Chuckawalla Valley State Prison Cycle 6 Medical Inspection Report

Amarik K. Singh, Inspector General Neil Robertson, Chief Deputy Inspector General OFFICE of the OIG INSPECTOR GENERAL Independent Prison Oversight January 2023 Cycle 6 Medical Inspection Report Chuckawalla Valley State Prison Report revised and republished on 2-13-23: On page 5, the first paragraph was edited to clarify the OIG clinicians found one adverse event during this inspection. Electronic copies of reports published by the Office of the Inspector General are available free in portable document format (PDF) on our website. We also offer an online subscription service. For information on how to subscribe, visit www.oig.ca.gov. For questions concerning the contents of this report, please contact Shaun Spillane, Public Information Officer, at 916-288-4233. Cycle 6, Chuckawalla Valley State Prison | iii Contents Illustrations iv Introduction 1 Summary 3 Overall Rating: Adequate 3 Medical Inspection Results 7 Deficiencies Identified During Case Review 7 Case Review Results 7 Compliance Testing Results 8 Population-Based Metrics 9 HEDIS Results 9 Recommendations 12 Indicators 16 Access to Care 14 Diagnostic Services 20 Emergency Services 25 Health Information Management 29 Health Care Environment 35 Transfers 42 Medication Management 48 Preventive Services 55 Nursing Performance 58 Provider Performance 63 Specialized Medical Housing 67 Specialty Services 72 Administrative Operations 78 Appendix A. Methodology 81 Case Reviews 82 Compliance Testing 85 Indicator Ratings and the Overall Medical Quality Rating 86 Appendix B. Case Review Data 87 Appendix C. Compliance Sampling Methodology 90 California Correctional Health Care Services’ Response 99 Office of the Inspector General, State of California Inspection Period: July 2021 – December 2021 Report Issued: January 2023 Cycle 6, Chuckawalla Valley State Prison | iv Illustrations Tables 1. CVSP Summary Table 3 2. CVSP Policy Compliance Scores 4 3. CVSP Master Registry Data as of February 2022 5 4. CVSP Health Care Staffing Resources as of February 2022 6 5. CVSP Results Compared With State HEDIS Scores 11 6. Access to Care 17 7. Other Tests Related to Access to Care 18 8. Diagnostic Services 23 9. Health Information Management 32 10. Other Tests Related to Health Information Management 33 11. Health Care Environment 40 12. Transfers 45 13. Other Tests Related to Transfers 46 14. Medication Management 52 15. Other Tests Related to Medication Management 53 16. Preventive Services 56 17. Specialized Medical Housing 70 18. Specialty Services 75 19. Other Tests Related to Specialty Services 76 20. Administrative Operations 79 A–1. Case Review Definitions 82 B–1. CVSP Case Review Sample Sets 87 B–2. CVSP Case Review Chronic Care Diagnoses 88 B–3. Case Review Events by Program 89 B–4. Case Review Sample Summary 89 Figures A–1. Inspection Indicator Rating Distribution for CVSP 81 A–2. Case Review Testing 84 A–3. Compliance Sampling Methodology 85 Photographs 1. Outdoor Patient Waiting Area 35 2. Indoor Patient Waiting Area 36 3. Individual Patient Waiting Modules 36 4. Expired Medical Supplies Dated July 2018 37 5. Cleaning Materials Stored With Medical Supplies 37 Cover: Rod of Asclepius courtesy of Thomas Shafee Office of the Inspector General, State of California Inspection Period: July 2021 – December 2021 Report Issued: January 2023 Cycle 6, Chuckawalla Valley State Prison | 1 Introduction Pursuant to California Penal Code section 6126 et seq., the Office of the Inspector General (the OIG) is responsible for periodically reviewing and reporting on the delivery of the ongoing medical care provided to incarcerated persons1 in the California Department of Corrections and Rehabilitation (the department).2 In Cycle 6, the OIG continues to apply the same assessment methodologies used in Cycle 5, including clinical case review and compliance testing. These methods provide an accurate assessment of how the institution’s health care systems function regarding patients with the highest medical risk who tend to access services at the highest rate. This information helps to assess the performance of the institution in providing sustainable, adequate care.3 We continue to review institutional care using 15 indicators, as in prior cycles. Using each of these indicators, our compliance inspectors collect data in answer to compliance- and performance-related questions as established in the medical inspection tool (MIT) available on the OIG’s website.4 We determine a total compliance score for each applicable indicator and consider the MIT scores in the overall conclusion of the institution’s performance. In addition, our clinicians complete document reviews of individual cases and also perform on-site inspections, which include interviews with staff. In reviewing the cases, our clinicians examine whether providers used sound medical judgment in the course of caring for a patient. In the event we find errors, we determine whether such errors were clinically significant or led to a significantly increased risk of harm to the patient.5 At the same time, our clinicians examine whether the institution’s medical system mitigated the error. The OIG rates the indicators as proficient, adequate, or inadequate. The OIG has adjusted Cycle 6 reporting in two ways. First, commencing with this reporting period, we interpret compliance and case review results together, providing a more holistic assessment of the care; and second, we consider whether institutional medical processes lead to identifying and correcting provider or system errors. The review assesses the institution’s medical care on both system and provider levels. 1 In this report, we use the terms patient and patients to refer to incarcerated persons. 2 The OIG’s medical inspections are not designed to resolve questions about the constitutionality of care, and the OIG explicitly makes no determination regarding the constitutionality of care the department provides to its population. 3 In addition to our own compliance testing and case reviews, the OIG continues to offer selected Healthcare Effectiveness Data and Information Set (HEDIS) measures for comparison purposes. 4 The department regularly updates its policies. The OIG updates our policy-compliance testing to reflect the department’s updates and changes. 5 If we learn of a patient needing immediate care, we notify the institution’s chief executive officer. Office of the Inspector General, State of California Inspection Period: July 2021 – December 2021 Report Issued: January 2023 Cycle 6, Chuckawalla Valley State Prison | 2 As we did during Cycle 5, our office is continuing to inspect both those institutions remaining under federal receivership and those delegated back to the department. There is no difference in the standards used for assessing a delegated institution versus an institution not yet delegated. At the time of the Cycle 6 inspection of Chuckawalla Valley State Prison, the institution had been delegated back to the department by the receiver. We completed our sixth inspection of Chuckawalla Valley State Prison, and this report presents our assessment of the health care provided at that institution during the inspection period between July 2021 and December 2021.6 The data we obtained for CVSP, and the on-site inspections occurred during the COVID-19 pandemic.7 Chuckawalla Valley State Prison (CVSP) is located in Blythe, in Riverside County; the institution became operational in 1988. CVSP primarily houses medium-security Level II male patients. The institution runs multiple clinics where medical staff members handle nonurgent requests for medical services. CVSP 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). CCHCS has designated CVSP as a basic care prison, an institution located in a rural area, away from tertiary care centers and specialty care providers whose services would likely be used frequently by higher-risk patients. 6 Samples are obtained per case review methodology shared with stakeholders in prior cycles. The case reviews include transfer reviews between April 2021 and December 2021. 7 As of September 21, 2022, the department reports on its public tracker that 93% of its incarcerated population at CVSP is fully vaccinated while 68% of CVSP staff are fully vaccinated: www.cdcr.ca.gov/covid19/population-status-tracking. Office of the Inspector General, State of California Inspection Period: July 2021 – December 2021 Report Issued: January 2023 Cycle 6, Chuckawalla Valley State Prison | 3 Summary We completed the Cycle 6 inspection of CVSP in June 2022. OIG inspectors monitored the institution’s delivery of medical care that occurred between July and December 2021. The OIG rated the overall quality of health care at CVSP as adequate. We list the individual indicators and ratings applicable for this institution in Table 1 below. Table 1. CVSP Summary Table Cycle 6 Cycle 6 Cycle 6 Change Health Care Indicators Case Review Compliance Overall Since Rating Rating Rating Cycle 5 Access to Care Proficient Proficient Proficient Diagnostic Services Inadequate Inadequate Inadequate Emergency Services Adequate N/A Adequate Health Information Management Proficient Proficient Proficient Health Care Environment N/A Inadequate Inadequate Transfers Adequate Adequate Adequate Medication Management Adequate Inadequate Inadequate Prenatal and Postpartum Care N/A N/A N/A N/A Preventive Services N/A Adequate Adequate Nursing Performance Adequate N/A Adequate Provider Performance Adequate N/A Adequate Reception Center N/A N/A N/A N/A Specialized Medical Housing Inadequate Inadequate Inadequate N/A Specialty Services Adequate Inadequate Inadequate Administrative Operations† N/A Inadequate Inadequate * The symbols in this column correspond to changes that occurred in indicator ratings between the medical inspections conducted during Cycle 5 and Cycle 6. The equals sign means there was no change in the rating. The single arrow means the rating rose or fell one level, and the double arrow means the rating rose or fell two levels (green, from inadequate to proficient; pink, from proficient to inadequate). † Administrative Operations is a secondary indicator and is not considered when rating the institution’s overall medical quality. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: July 2021 – December 2021 Report Issued: January 2023 Cycle 6, Chuckawalla Valley State Prison | 4 To test the institution’s policy compliance, our compliance inspectors, (a team of registered nurses) monitored the institution’s compliance with its medical policies by answering a standardized set of questions that measure specific elements of health care delivery. Our compliance inspectors examined 354 patient records and 1,064 data points and used the data to answer 90 policy questions. In addition, we observed CVSP processes during an on-site inspection in March 2022. Table 2 below lists CVSP’s average scores from Cycles 4, 5, and 6. Table 2. CVSP Policy Compliance Scores Scoring Ranges 100%–85.0% 84.9%–75.0% 74.9%–0 Medical Cycle 4 Cycle 5 Cycle 6 Inspection Policy Compliance Category Average Average Average Tool (MIT) Score Score Score 1 Access to Care 83.6% 77.6% 88.3% 2 Diagnostic Services 86.4% 66.5% 65.0% 4 Health Information Management 68.6% 71.0% 91.3% 5 Health Care Environment 66.4% 59.7% 55.4% 6 Transfers 90.8% 72.4% 83.8% 7 Medication Management 80.7% 70.4% 62.8% 8 Prenatal and Postpartum Care N/A N/A N/A 9 Preventive Services 84.9% 80.8% 82.7% 12 Reception Center N/A N/A N/A 13 Specialized Medical Housing N/A N/A 42.5% 14 Specialty Services 87.9% 74.9% 72.4% 15 Administrative Operations* 58.7% 90.0% 71.2% * In Cycle 4, there were two secondary (administrative) indicators, and this score reflects the average of those two scores. In Cycle 5 and moving forward, the two indicators were merged into one, with only one score as the result. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: July 2021 – December 2021 Report Issued: January 2023 Cycle 6, Chuckawalla Valley State Prison | 5 The OIG clinicians (a team of physicians and nurse consultants) reviewed 41 cases, which contained 904 patient-related events. After examining the medical records, our clinicians conducted a follow-up on-site inspection in June 2022 to verify their initial findings. The OIG physicians rated the quality of care for 20 comprehensive case reviews. Of these 20 cases, our physicians rated 18 adequate and two inadequate. Our physicians found one adverse event during this inspection at CVSP. The OIG then considered the results from both case review and compliance testing, and drew overall conclusions, which we report in the 13 health care indicators.8 Multiple OIG physicians and nurses performed quality control reviews; their subsequent collective deliberations ensured consistency, accuracy, and thoroughness. Our clinicians acknowledged institutional structures that catch and resolve mistakes that may occur throughout the delivery of care. As noted above, we listed the individual indicators and ratings applicable for this institution in Table 1, the CVSP Summary Table. In February 2022, the Health Care Services Master Registry showed that CVSP had a total population of 2,449. A breakdown of the medical risk level of the CVSP population as determined by the department is set forth in Table 3 below.9 Table 3. CVSP Master Registry Data as of February 2022 Medical Risk Level Number of Patients Percentage High 1 39 1.6% High 2 129 5.3% Medium 434 17.7% Low 1,847 75.4% Total 2,449 100% Source: Data for the population medical risk level were obtained from the CCHCS Master Registry dated 02-18-22. 8 The indicators for Reception Center and Prenatal Care do not apply to CVSP. 9 For a definition of medical risk, see CCHCS HCDOM 1.2.14, Appendix 1.9. Office of the Inspector General, State of California Inspection Period: July 2021 – December 2021 Report Issued: January 2023 Cycle 6, Chuckawalla Valley State Prison | 6 Based on staffing data the OIG obtained from California Correctional Health Care Services (CCHCS), as identified in Table 4 below, CVSP had one vacant executive leadership position, one vacant primary care provider, vacancies of 0.2 positions among nursing supervisors, and 18.8 vacant nursing staff positions. Table 4. CVSP Health Care Staffing Resources as of February 2022 Executive Primary Care Nursing Nursing Positions Leadership* Providers Supervisors Staff† Total Authorized Positions 6.0 5.5 10.7 64.0 86.2 Filled by Civil Service 5.0 4.5 10.5 45.2 65.2 Vacant 1.0 1.0 0.2 18.8 21.0 Percentage Filled by Civil Service 83.3% 81.8% 98.1% 70.6% 75.6% Filled by Telemedicine 0.0 1.0 0.0 0.0 1.0 Percentage Filled by Telemedicine 0.0% 18.2% 0.0% 0.0% 1.2% Filled by Registry 0.0 0.0 0.0 5.0 5.0 Percentage Filled by Registry 0.0% 0.0% 0.0% 7.8% 5.8% Total Filled Positions 5.0 5.5 10.5 50.2 71.2 Total Percentage Filled 83.3% 100.0% 98.1% 78.4% 82.6% Appointments in Last 12 Months 1.0 0.5 2.5 11.0 15.0 Redirected Staff 0.0 0.0 0.0 0.0 0.0 Staff on Extended Leave‡ 0.0 1.0 0.0 3.0 4.0 Adjusted Total: Filled Positions 5.0 4.5 10.5 47.2 67.2 Adjusted Total: Percentage Filled 83.3% 81.8% 98.1% 73.8% 78.0% * Executive Leadership includes the Chief Physician and Surgeon. † Nursing Staff includes Senior Psychiatric Technician and Psychiatric Technician. ‡ In Authorized Positions. Notes: The OIG does not independently validate staffing data received from the department. Positions are based on fractional time base equivalents. Source: Cycle 6 medical inspection preinspection questionnaire staffing matrix received February 8, 2022, from California Correctional Health Care Services. Office of the Inspector General, State of California Inspection Period: July 2021 – December 2021 Report Issued: January 2023 Cycle 6, Chuckawalla Valley State Prison | 7 Medical Inspection Results Deficiencies Identified During Case Review Deficiencies are medical errors that increase the risk of patient harm. Deficiencies can be minor or significant, depending on the severity of the deficiency. An adverse event occurs when the deficiency caused harm to the patient. All major health care organizations identify and track adverse events. We identify deficiencies and adverse events to highlight concerns regarding the provision of care and for the benefit of the institution’s quality improvement program to provide an impetus for improvement.10 The OIG identified one adverse event in the case review at CVSP: • In case 17, the patient had elevated finger stick blood glucose level of 360 mg/dL, with symptoms of dizziness, loss of appetite, and frequent urination.11 However, the provider did not order an urgent diabetic confirmatory test to make the diagnosis of new onset diabetes and to start diabetic treatment. Instead, the provider ordered the diabetic confirmatory test in three days and a provider follow-up appointment in 14 days. The oversight placed the patient at risk of serious diabetic complications, such as diabetic ketoacidosis.12 Case Review Results OIG case reviewers (a team of physicians and nurse consultants) assessed ten of the 13 indicators applicable to CVSP. Of these ten indicators, OIG clinicians rated two proficient, six adequate and two inadequate. The OIG physicians also rated the overall adequacy of care for each of the 20 detailed case reviews they conducted. Of these 20 cases, 18 were adequate and two were inadequate. In the 904 events reviewed, there were 151 deficiencies, 26 of which the OIG clinicians considered to be of such magnitude that, if left unaddressed, would likely contribute to patient harm. Our clinicians found the following strengths at CVSP: • Staff performed well with access to care, as most appointments were completed in a timely manner. 10 For a definition of an event, see Table A–1. 11 A normal finger stick blood sugar level ranges from 60 to 99 mg/dL. Mg/dL is milligrams per deciliter, which is unit of measure that shows the concentration of a substance in a specific amount of fluid. 12 Diabetic ketoacidosis is a diabetic complication in which the patient’s body produces excess blood acids called ketones. This condition can be life-threatening and requires the patient to be hospitalized for treatment. Office of the Inspector General, State of California Inspection Period: July 2021 – December 2021 Report Issued: January 2023 Cycle 6, Chuckawalla Valley State Prison | 8 • CVSP had a proficient health information management process, as the medical staff timely retrieved and scanned most hospital records, specialty reports, diagnostic tests, and pathology reports. Our clinicians found the following weaknesses at CVSP: • The staff performed poorly in diagnostic services, as laboratory tests were not completed as requested, and the providers did not always thoroughly communicate test results to their patients. • The staff performed poorly with specialized medical housing, as nursing staff did not always perform thorough assessments or initiate care plans reflecting patients’ needs. Compliance Testing Results Our compliance inspectors assessed 10 of the 13 indicators applicable to CVSP. Of these 10 indicators, our compliance inspectors rated two proficient, two adequate, and six inadequate. We tested policy compliance in the Health Care Environment, Preventive Services, and Administrative Operations, as these indicators do not have a case review component. CVSP demonstrated a high rate of policy compliance in the following areas: • Staff performed well in scanning community hospital discharge reports, specialty services reports, and requests for health care services into patient’s electronic medical records within required time frames. • Providers provided timely appointments for patients returning from hospitalization and from specialty services. Moreover, patients were referred within required time frames to their providers upon arrival at the institution. • Nursing staff reviewed health care services request forms and conducted face-to-face encounters within required time frames. In addition, CVSP housing units contained adequate supplies of health care request forms. • The institution performed well in offering immunizations to their patients and providing preventive services, such as influenza vaccination, annual testing for tuberculosis (TB), and colorectal cancer screenings. CVSP demonstrated a low rate of policy compliance in the following areas: • Patients did not always receive their chronic care medications within the required time frames. There was poor medication continuity for patients returning from hospitalization, for patients admitted to the specialized medical housing unit, and for patients laying over at CVSP. Office of the Inspector General, State of California Inspection Period: July 2021 – December 2021 Report Issued: January 2023 Cycle 6, Chuckawalla Valley State Prison | 9 • Health care staff did not follow hand hygiene precautions before or after patient encounters. • The institution did not consistently provide routine and STAT (immediate) laboratory services within the specified time frames. • The institution did not always ensure that approved specialty services were provided timely to patients upon arrival at CVSP. Population-Based Metrics In addition to our own compliance testing and case reviews, as noted above, the OIG presents selected measures from the Healthcare Effectiveness Data and Information Set (HEDIS) for comparison purposes. The HEDIS is a set of standardized quantitative performance measures designed by the National Committee for Quality Assurance to ensure that the public has the data it needs to compare the performance of health care plans. Because the Veterans Administration no longer publishes its individual HEDIS scores, we removed them from our comparison for Cycle 6. However, through the California Department of Health Care Services’ Medi-Cal Managed Care Technical Report, the OIG obtained Kaiser Medi-Cal and Kaiser HEDIS scores to use in conducting our analysis, and we present them here for comparison. HEDIS Results We considered CVSP’s performance with population-based metrics to assess the macroscopic view of the institution’s health care delivery. CVSP’s results compared favorably with those found in State health plans for diabetic care measures. We list the nine HEDIS measures in Table 5. Comprehensive Diabetes Care Statewide comparison data is only available for three of the five diabetic measures. When compared with statewide Medi-Cal programs—California Medi-Cal, Kaiser Northern California (Medi-Cal), and Kaiser Southern California (Medi-Cal)—CVSP performed better than Medi-Cal and Kaiser in all three comparative measures: HbA1c screening, poor HbA1c control, and blood pressure control. We include HbA1c control, blood pressure control, and eye examination data for informational purposes. Immunizations Statewide comparative data were not available for immunization measures; however, we include this data for informational purposes. CVSP had a 67 percent influenza immunization rate for adults 18 to 64 years old, and a 97 percent immunization rate for adults 65 years and older. The pneumococcal vaccine rate was 87 percent.13 13 The pneumococcal vaccines administered are the 13, 15, and 20 valent pneumococcal vaccines (PCV13, PCV 15, and PCV 20), or the 23 valent pneumococcal vaccine (PPSV 23), depending on the patient’s medical conditions. For the adult population, the influenza or Office of the Inspector General, State of California Inspection Period: July 2021 – December 2021 Report Issued: January 2023 Cycle 6, Chuckawalla Valley State Prison | 10 Colorectal Cancer Screening Statewide comparative data were not available for colorectal cancer screening; however, we include these data for informational purposes. CVSP had an 81 percent colorectal cancer screening rate. pneumococcal vaccine may have been administered at an institution other than the one in which the patient was housed during the inspection period. Office of the Inspector General, State of California Inspection Period: July 2021 – December 2021 Report Issued: January 2023 Cycle 6, Chuckawalla Valley State Prison | 11 Table 5. CVSP Results Compared With State HEDIS Scores California California CVSP Kaiser Kaiser California NorCal SoCal Cycle 6 Medi-Cal Medi-Cal Medi-Cal HEDIS Measure Results* 2018† 2018 † 2018 † HbA1c Screening 97% 90% 94% 96% Poor HbA1c Control (> 9.0%) ‡, § 7% 34% 25% 18% HbA1c Control (< 8.0%) ‡ 85% – – – Blood Pressure Control (< 140/90) ‡ 94% 65% 78% 84% Eye Examinations 62% – – – Influenza – Adults (18–64) 67% – – – Influenza – Adults (65+) || 97% – – – Pneumococcal – Adults (65+) || 87% – – – Colorectal Cancer Screening 81% – – – Notes and Sources * Unless otherwise stated, data were collected in March 2022 by reviewing medical records from a sample of CVSP’s population of applicable patients. These random statistical sample sizes were based on a 95 percent confidence level with a 15 percent maximum margin of error. † HEDIS Medi-Cal data were obtained from the California Department of Health Care Services publication titled Medi-Cal Managed Care External Quality Review Technical Report, (published April 2021). ‡ For this indicator, the entire applicable CVSP population was tested. § For this measure only, a lower score is better. Source: Institution information provided by the California Department of Corrections and Rehabilitation. Health Care plan data were obtained from the CCHCS Master Registry. Office of the Inspector General, State of California Inspection Period: July 2021 – December 2021 Report Issued: January 2023 Cycle 6, Chuckawalla Valley State Prison | 12 Recommendations As a result of our assessment of CVSP’s performance, we offer the following recommendations to the department: Diagnostic Services • Medical leadership should ascertain the causes of the untimely provision of routine and STAT laboratory services and should implement remedial measures as appropriate. • Medical leadership should consider developing strategies to ensure that the institution receives STAT results timely and that the appropriate nursing staff communicates the results to the provider within the required time frame. • The department should also consider developing strategies to ensure that providers create patient letters when test results are endorsed and that patient letters contain all elements required by CCHCS policy. Health Care Environment • Medical leadership should remind staff to follow universal hand hygiene precautions. Implementing random spot checks could improve compliance. • Nursing leadership should consider performing random spot checks to ensure that staff follow equipment and medical supply management protocols. • Nursing leadership should direct each clinic nurse supervisor to review the monthly emergency medical response bag (EMRB) and treatment cart logs to ensure that the EMRBs and treatment carts are regularly inventoried and sealed. Transfers • Nursing leadership should develop and implement internal auditing of staff to ensure the complete and thorough assessments of patients returning from hospitalizations. Medication Management • The institution should consider developing and implementing measures to ensure that staff timely make available and administer medications to patients and that staff document their actions in the medication administration record as required by CCHCS policy and procedures. Office of the Inspector General, State of California Inspection Period: July 2021 – December 2021 Report Issued: January 2023 Cycle 6, Chuckawalla Valley State Prison | 13 Specialized Medical Housing • Nursing leadership should ensure that the initial outpatient housing unit (OHU) assessments are completed within the time frame required by CCHCS policy. • Nursing leadership should ensure that OHU nurses perform thorough assessments and initiate care plans reflecting patients’ needs. • Nursing leadership should determine the root cause of challenges to patients’ receiving all ordered medications within the time frame required and should implement remedial measures as appropriate. Specialty Services • CVSP leadership should ensure that remote telemedicine equipment is working appropriately. • Medical leadership should determine the root cause(s) of challenges to the timely provision of specialty appointments and specialty service follow-up visits and should implement remedial measures as appropriate. • Medical leadership should identify why preapproved specialty appointments were missed for transfer-in patients; leadership should implement remedial measures as appropriate. Office of the Inspector General, State of California Inspection Period: July 2021 – December 2021 Report Issued: January 2023 Cycle 6, Chuckawalla Valley State Prison | 14 Access to Care In this indicator, OIG inspectors evaluated the institution’s performance in providing patients with timely clinical appointments. Our inspectors Overall reviewed the scheduling and appointment timeliness for newly arrived Rating patients, sick call, and nurse follow-up appointments. We examined Proficient referrals to primary care providers, provider follow-ups, and specialists. Furthermore, we evaluated the follow-up appointments for patients who Case Review received specialty care or returned from an off-site hospitalization. Rating Proficient Results Overview Compliance Score CVSP performed well with access to care. CVSP timely completed Proficient appointments with clinic providers after specialty services and (88.3%) hospitalization, specialized medical housing providers and clinic nurses. The compliance testing had an overall access to care score of 88.3 percent. CVSP’s excellent performances in both case review and compliance testing contributed to the OIG’s rating this indicator proficient. Case Review and Compliance Testing Results Our clinicians reviewed 378 provider, nursing, urgent or emergent care, specialty, and hospital events that required the institution to generate appointments. We found 11 deficiencies related to access to care; five were significant.14 Access to Care Providers Compliance testing found poor completion of chronic care follow-up and provider-ordered sick call follow-up appointments (MIT 1.001, 60.0%; MIT 1.006, 66.7%); however, the institution performed well in nurse-to-provider appointments (MIT 1.005, 86.7%). Our clinicians reviewed 91 clinic provider appointments and identified two deficiencies: • In case 2, a sick call nurse evaluated the patient for a complaint and indicated that the patient would be referred to the provider. However, the nurse did not order the appointment. • In case 19, a nurse evaluated the patient for right arm pain and requested a provider follow-up appointment in 14 days. Instead, the appointment occurred in 21 days. Access to Clinic Nurses CVSP performed well in access for nurse sick calls and provider-to-nurse referrals. Compliance testing found that all nurse sick call requests were reviewed on the same day they were received (MIT 1.003, 100%). Moreover, 14 Deficiencies occurred five times in case 16 and once in cases 2, 4, 12, 14, 19, and 30. Cases 2, 4, 12, 16, and 30 had significant deficiencies. Office of the Inspector General, State of California Inspection Period: July 2021 – December 2021 Report Issued: January 2023 Cycle 6, Chuckawalla Valley State Prison | 15 the nurses evaluated 93.3 percent of their patients within the required one business day (MIT 1.004). Our clinicians identified seven deficiencies related to clinic nurse access; three were significant, which are discussed below:15 • In case 12, the provider requested finger stick blood sugar (FSBS) checks three times weekly for 12 weeks; however, the nursing staff performed FSBS checks only five times in two weeks. • In case 16, the patient had a skin abscess requiring wound care. On three occasions, the nurse performed wound care and indicated that the patient was to have a nursing follow-up in two days for wound care; however, the appointments did not occur as indicated. • In case 30, the sick call nurse triaged a patient with an ankle pain and initiated a next-day visit; however, the appointment did not occur until five days later. Access to Specialty Services Compliance testing found that 60.0 percent of the initial high-priority specialty appointments (MIT 14.001), 80.0 percent of the initial medium- priority specialty appointments (MIT 14.004), and 93.3 percent of the initial routine-priority specialty appointments (MIT 14.007) occurred within the required time frames. The institution performed adequately in follow-up specialty appointments (MIT 14.003, 50.0%; MIT 14.006, 100%; and MIT 14.009, 70.0%). Our clinicians reviewed 77 specialty events and identified two deficiencies.16 These deficiencies are discussed in the Specialty Services indicator. Follow-Up After Specialty Services CVSP performed well in ensuring that patients saw their providers after specialty appointments. Compliance testing revealed that 95.8 percent of provider appointments after specialty services occurred within the required time frames (MIT 1.008). Our clinicians did not identify any missed or delayed provider appointments. Follow-Up After Hospitalization CVSP performed well in ensuring that patients saw their providers within the required time frames after hospitalizations. Compliance testing found that 100 percent of provider appointments occurred within the required time frames (MIT 1.007). Our clinicians reviewed 20 hospital returns and did not identify any missed or delayed provider appointments. 15 Deficiencies occurred five times in case 16 and once in cases 12 and 30. Significant deficiencies occurred in cases 12, 16, and 30. 16 Deficiencies occurred in cases 4 and 14. Office of the Inspector General, State of California Inspection Period: July 2021 – December 2021 Report Issued: January 2023 Cycle 6, Chuckawalla Valley State Prison | 16 Follow-Up After Urgent or Emergent Care (TTA) Providers generally saw their patients following a triage-and-treatment area (TTA) event as requested. Our clinicians assessed 21 TTA events and did not identify any deficiencies. Follow-Up After Transferring Into the Institution Compliance testing found that 92.0 percent of provider appointments for newly arrived patients occurred within the required time frames (MIT 1.002). Our clinicians evaluated seven transfer-in events and did not identify any missed or delayed provider appointments. Clinician On-Site Inspection CVSP has four main clinics: A, B, C and D. Each clinic had an assigned provider and an office technician who attended the morning huddles and ensured that provider appointments were met. Each provider saw about 10 patients per day. At the time of the clinician on-site inspection, there were 20 provider appointments backlogged for the four clinics. Our clinicians discussed the missed or delayed appointments with the office technician supervisor, and the supervisor acknowledged that most of the missed or delayed appointments were due to human errors, as the medical staff did not order or incorrectly ordered the appointments. The office technician supervisor also mentioned that the office technicians assigned to specific clinics are no longer able to review provider and nursing progress notes to ensure that appointments are appropriately placed as documented in the progress notes. Thus, this may have contributed to the missed appointments. Office of the Inspector General, State of California Inspection Period: July 2021 – December 2021 Report Issued: January 2023 Cycle 6, Chuckawalla Valley State Prison | 17 Compliance Testing Results TTaabbllee 66.. AAcccceessss ttoo CCaarree Scored Answer Compliance Questions Yes No N/A Yes % Chronic care follow-up appointments: Was the patient’s most recent chronic care visit within the health care guideline’s maximum 15 10 0 60.0% allowable interval or within the ordered time frame, whichever is shorter? (1.001) * For endorsed patients received from another CDCR institution: Based on the patient’s clinical risk level during the initial health 23 2 0 92.0% screening, was the patient seen by the clinician within the required time frame? (1.002) * Clinical appointments: Did a registered nurse review the patient’s 30 0 0 100% request for service the same day it was received? (1.003) * Clinical appointments: Did the registered nurse complete a face-to- face visit within one business day after the CDCR Form 7362 was 28 2 0 93.3% reviewed? (1.004) * Clinical appointments: If the registered nurse determined a referral to a primary care provider was necessary, was the patient seen within 13 2 15 86.7% the maximum allowable time or the ordered time frame, whichever is the shorter? (1.005) * Sick call follow-up appointments: If the primary care provider ordered a follow-up sick call appointment, did it take place within the time 2 1 27 66.7% frame specified? (1.006) * Upon the patient’s discharge from the community hospital: Did the patient receive a follow-up appointment within the required time 21 0 4 100% frame? (1.007) * Specialty service follow-up appointments: Did the clinician follow-up visits occur within required time frames? (1.008) *,† 23 1 21 95.8% Clinical appointments: Do patients have a standardized process to 6 0 0 100% obtain and submit health care services request forms? (1.101) Overall percentage (MIT 1): 88.3% * The OIG clinicians considered these compliance tests along with their case review findings when determining the quality rating for this indicator. † CCHCS changed its specialty policies in April 2019, removing the requirement for primary care physician follow-up visits following specialty services. As a result, we tested MIT 1.008 only for high-priority specialty services or when staff ordered follow-ups. The OIG continued to test the clinical appropriateness of specialty follow-ups through its case review testing. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: July 2021 – December 2021 Report Issued: January 2023 Cycle 6, Chuckawalla Valley State Prison | 18 TTaabbllee 77.. OOtthheerr T Teestsst sR Reelalatetedd t oto A Acccecsess sto t oC aCraere Scored Answer Compliance Questions Yes No N/A Yes % For patients received from a county jail: If, during the assessment, the nurse referred the patient to a provider, was the patient seen within the N/A N/A N/A N/A required time frame? (12.003) * For patients received from a county jail: Did the patient receive a history and physical by a primary care provider within seven calendar N/A N/A N/A N/A days? (12.004) * For CTC and SNF only (effective 4/2019, include OHU): Was a written history and physical examination completed within the required time 9 1 0 90.0% frame? (13.002) * For OHU, CTC, SNF, and Hospice (applicable only for samples prior to 4/2019): Did the primary care provider complete the Subjective, Objective, N/A N/A 10 N/A Assessment, and Plan notes on the patient at the minimum intervals required for the type of facility where the patient was treated? (13.003) *,† Did the patient receive the high-priority specialty service within 14 calendar days of the primary care provider order or the Physician 9 6 0 60.0% Request for Service? (14.001) * Did the patient receive the subsequent follow-up to the high-priority specialty service appointment as ordered by the primary care provider? 5 5 5 50.0% (14.003) * Did the patient receive the medium-priority specialty service within 15-45 calendar days of the primary care provider order or the Physician 12 3 0 80.0% Request for Service? (14.004) * Did the patient receive the subsequent follow-up to the medium- priority specialty service appointment as ordered by the primary care 5 0 10 100% provider? (14.006) * Did the patient receive the routine-priority specialty service within 90 calendar days of the primary care provider order or Physician 14 1 0 93.3% Request for Service? (14.007) * Did the patient receive the subsequent follow-up to the routine-priority specialty service appointment as ordered by the primary care provider? 7 3 5 70.0% (14.009) * * The OIG clinicians considered these compliance tests along with their case review findings when determining the quality rating for this indicator. † CCHCS changed its policies and removed mandatory minimum rounding intervals for patients located in specialized medical housing. After April 2, 2019, MIT 13.003 only applied to CTCs that still had state- mandated rounding intervals. OIG case reviewers continued to test the clinical appropriateness of provider follow-ups within specialized medical housing units through case reviews. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: July 2021 – December 2021 Report Issued: January 2023 Cycle 6, Chuckawalla Valley State Prison | 19 Recommendations The OIG offers no recommendations for this indicator. Office of the Inspector General, State of California Inspection Period: July 2021 – December 2021 Report Issued: January 2023 Cycle 6, Chuckawalla Valley State Prison | 20 Diagnostic Services In this indicator, OIG inspectors evaluated the institution’s performance in timely complete radiology, laboratory, and pathology tests. Our inspectors Overall determined whether the institution properly retrieved the resultant reports Rating and whether providers reviewed the results correctly. In addition, in Cycle Inadequate 6, we examined the institution’s performance in timely completing and reviewing immediate (STAT) laboratory tests. Case Review Rating Inadequate Results Overview Compliance Overall, CVSP performed poorly in this indicator. Although CVSP performed Score well in completing radiology tests, it performed poorly in completing Inadequate laboratory tests including STAT laboratory tests. Furthermore, the providers (65.0%) did not thoroughly communicate laboratory results to their patients. The institution performed well in retrieving pathology reports; however, the providers did not always communicate the pathology results to their patients. Taking into considerations of both case review rating and compliance results, we rated this indicator inadequate. Case Review and Compliance Testing Results Our clinicians reviewed 221 diagnostic events and identified 22 deficiencies, two of which were significant.17 There were deficiencies related to laboratory tests not completed timely, a pathology report not retrieved, and poor communication of test results to the patients. Test Completion CVSP performed well in completing radiology tests. Compliance testing showed that the institution completed 100 percent of radiology tests within the required time frames (MIT 2.001). Our clinicians reviewed 18 radiology tests and found all tests completed as requested. CVSP performed poorly in completing laboratory tests. Compliance testing found that 20.0 percent of laboratory tests were completed as requested (MIT 2.004). Our clinicians reviewed 187 laboratory tests and identified 10 deficiencies related to early or late laboratory completion18 Three examples follow: • In case 4, the patient was taking a blood thinner, and an INR lab test was completed two days early.19 17 Deficiencies occurred three times in cases 6 and 12, twice in cases 9, 18, and 19, and once in cases 1, 4, 5, 7, 8, 10, 14, 15, 16, and 17. Significant deficiencies occurred in cases 1 and 19. 18 Deficiencies occurred in cases 4, 5, 7, 9, 12, 15, 17, and 18. 19 The INR is a lab test to measure the body’s blood clotting. This time-sensitive laboratory test is used to monitor the effectiveness of blood thinning medications. Office of the Inspector General, State of California Inspection Period: July 2021 – December 2021 Report Issued: January 2023 Cycle 6, Chuckawalla Valley State Prison | 21 • In case 12, laboratory tests were completed one day late. • In case 15, laboratory tests were completed four days early. CVSP performed poorly in collecting and retrieving STAT laboratory tests (MIT 2.007, zero). The nursing staff also did not notify the providers of STAT laboratory results within the required time frames (MIT 2.008, zero). CVSP performed satisfactorily in completing electrocardiograms (EKG). Our clinicians reviewed seven EKGs and found two deficiencies: • In case 1, an EKG was completed 30 days late. • In case 12, an EKG was completed four days late. Health Information Management Compliance testing showed providers endorsed most radiology and laboratory reports timely (MIT 2.002, 100%, and MIT 2.005, 90.0%). Our clinicians identified one deficiency, related to lacking an endorsement of a laboratory test.20 Compliance testing showed providers thoroughly communicated the results of radiology studies to their patients (MIT 2.003, 90.0%). However, providers did not always thoroughly communicate laboratory results to their patients (MIT 2.006, 40.0%). Our clinicians found that on one occasion, the provider did not thoroughly communicate a radiology result, and on four occasions, the provider did not thoroughly communicate laboratory results to the patient.21 Examples include the following: • In case 6, the provider sent a patient letter informing the patient of laboratory results but did not include all the required elements, such as whether the results were within normal limits. • In case 18, the provider sent a patient letter informing the patient of X-ray results but did not include all the required elements, such as the test date. Compliance testing showed that CVSP retrieved 90.0 percent of pathology reports within the required time frames (MIT 2.010). Providers endorsed the pathology reports within the required time frames (MIT 2.011, 100%); however, providers did not always send pathology result letters to their patients within the required time frames (MIT 2.012, 50.0%). Our clinicians reviewed nine events associated with pathology reports and found three deficiencies, two of which are described below:22 • In case 6, a provider endorsed a gastric biopsy result report but did not send the patient result letter. 20 Deficiencies occurred in cases 8 and 15. 21 Deficiencies occurred twice in case 6 and once in cases 8, 9, and 18. 22 Deficiencies occurred in cases 6, 14, and 19. Office of the Inspector General, State of California Inspection Period: July 2021 – December 2021 Report Issued: January 2023 Cycle 6, Chuckawalla Valley State Prison | 22 • In case 19, a dermatologist performed a skin biopsy, and the pathology result report was not retrieved or scanned into the medical record during the review period. Clinician On-Site Inspection CVSP had three full-time phlebotomists assigned to the four main clinics. Our clinicians discussed the early completion of laboratory tests, and the diagnostic supervisor explained that each clinic has a dedicated day of the week in which laboratory tests were collected. Due to this schedule, laboratory tests were completed early. The supervisor acknowledged the delays in the completion of EKGs and informed our clinicians that CVSP is in the process of obtaining EKG machines for each of the four main clinics. The nursing staff will be able to complete EKGs in the clinic rather than send patients to the TTA for EKGs. As for the pathology reports, the utilization management nurse or the specialty nurse reviewed specialists’ records and requested pathology reports when indicated. Office of the Inspector General, State of California Inspection Period: July 2021 – December 2021 Report Issued: January 2023 Cycle 6, Chuckawalla Valley State Prison | 23 Compliance Testing Results TTaabblele 88.. DDiiaaggnnoossttiicc SSeerrvviicceess Scored Answer Compliance Questions Yes No N/A Yes % Radiology: Was the radiology service provided within the time frame 10 0 0 100% specified in the health care provider’s order? (2.001) * Radiology: Did the ordering health care provider review and endorse 10 0 0 100% the radiology report within specified time frames? (2.002) * Radiology: Did the ordering health care provider communicate the results of the radiology study to the patient within specified time 9 1 0 90.0% frames? (2.003) Laboratory: Was the laboratory service provided within the time 2 8 0 20.0% frame specified in the health care provider’s order? (2.004) * Laboratory: Did the health care provider review and endorse the 9 1 0 90.0% laboratory report within specified time frames? (2.005) * Laboratory: Did the health care provider communicate the results of the laboratory test to the patient within specified time frames? 4 6 0 40.0% (2.006) Laboratory: Did the institution collect the STAT laboratory test and 0 2 0 0 receive the results within the required time frames? (2.007) * Laboratory: Did the provider acknowledge the STAT results, OR did nursing staff notify the provider within the required time frames? 0 2 0 0 (2.008) * Laboratory: Did the health care provider endorse the STAT laboratory 2 0 0 100% results within the required time frames? (2.009) Pathology: Did the institution receive the final pathology report 9 1 0 90.0% within the required time frames? (2.010) * Pathology: Did the health care provider review and endorse the 10 0 0 100% pathology report within specified time frames? (2.011) * Pathology: Did the health care provider communicate the results of the pathology study to the patient within specified time frames? 5 5 0 50.0% (2.012) Overall percentage (MIT 2): 65.0% * The OIG clinicians considered these compliance tests along with their case review findings when determining the quality rating for this indicator. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: July 2021 – December 2021 Report Issued: January 2023 Cycle 6, Chuckawalla Valley State Prison | 24 Recommendations • Medical leadership should ascertain the causes of the untimely provision of routine and STAT laboratory services and should implement remedial measures as appropriate. • Medical leadership should consider developing strategies to ensure that the institution receives STAT results timely and that the appropriate nursing staff communicates the results to the provider within the required time frame. • The department should also consider developing strategies to ensure that providers create patient letters when test results are endorsed and that patient letters contain all elements required by CCHCS policy. Office of the Inspector General, State of California Inspection Period: July 2021 – December 2021 Report Issued: January 2023 Cycle 6, Chuckawalla Valley State Prison | 25 Emergency Services In this indicator, OIG clinicians evaluated the quality of emergency medical care. Our clinicians reviewed emergency medical services by examining the Overall timeliness and appropriateness of clinical decisions made during medical Rating emergencies. Our evaluation included examining the emergency medical Adequate response, cardiopulmonary resuscitation (CPR) quality, triage and treatment area (TTA) care, provider performance, and nursing Case Review performance. Our clinicians also evaluated the Emergency Medical Rating Response Review Committee’s (EMRRC) performance in identifying Adequate problems with its emergency services. The OIG assessed the institution’s emergency services mainly through case review. Compliance Score Results Overview (N/A) In this cycle, CVSP’s performance improved in emergency services as compared to its performance in Cycle 5. Overall, CVSP had fewer deficiencies in this cycle, only one of which was considered significant. Providers and nurses generally performed well. The nursing staff responded timely to emergencies and performed appropriate triage decisions. Most of the identified deficiencies were related to incomplete nursing assessments. However, the emergency medical response review committee (EMRRC) did not thoroughly review emergency events; there were missing elements in the incident package. We rated this indicator adequate. Case Review Results We reviewed 21 urgent or emergent events and found 16 emergency care deficiencies. Of these 16 deficiencies, one was significant.23 Emergency Medical Response CVSP performed well in emergency medical response. Our clinicians reviewed 12 emergency response events and found that nurses timely responded when a medical alarm was activated. Nursing staff also responded promptly to emergencies throughout the institution. They made appropriate triage decisions, activated emergency medical services (EMS), and notified TTA staff in a timely manner. Cardiopulmonary Resuscitation During our review period, CVSP staff did not have any events during which cardiopulmonary resuscitation (CPR) was performed. Consequently, we were not able to assess the CPR process at CVSP. 23 Deficiencies occurred five times in case 3, three times in case 16, twice in cases 1 and 39, and once in cases 2, 12, 17, and 18. A significant deficiency occurred in case 12. Office of the Inspector General, State of California Inspection Period: July 2021 – December 2021 Report Issued: January 2023 Cycle 6, Chuckawalla Valley State Prison | 26 Provider Performance Providers performed well in urgent and emergent events. The providers were available for consultation from the TTA staff. Providers made appropriate decisions, transferred patients to community hospitals when necessary, and generally documented these events thoroughly. Our clinicians identified one deficiency, related to lacking a provider progress note for an emergency event.24 Nursing Performance Nurses performed well during urgent and emergency events. The TTA nurses promptly responded when a medical alarm was activated, made sound medical decisions, and timely consulted a provider. However, opportunities for improvement were identified when nurses did not always provide a thorough patient assessment or reassessment. The following are examples: • In case 12, the registered nurse evaluated a patient with a complaint of low back pain but did not assess the patient’s lower extremity strength and range of motion. • In case 16, the registered nurse administered a medication for pain but did not reassess the patient’s pain level prior to releasing the patient back to his housing. Nursing Documentation TTA nurses usually documented emergent events thoroughly. Our clinicians identified four deficiencies related to incomplete documentation.25 These deficiencies did not affect overall patient care. Emergency Medical Response Review Committee The EMRRC met monthly. Our compliance team found that the incident review packages did not contain all required elements (MIT 15.003, zero). Our clinicians found that clinical reviews were frequently performed by the nursing supervisors, and that on two occasions, there was no evidence that the chief medical executive (CME) or designee conducted a clinical review.26 Clinician On-Site Inspection At CVSP, the TTA had three examination rooms. One room was reserved for observation, while the other two rooms were used for emergency care or for assessing patients who returned from a community hospital or specialist appointment. The TTA was staffed with two registered nurses for all shifts. The TTA nurses responded to all the medical alarms and the licensed vocational nurses (LVNs) generally served as the first medical responders. 24 A deficiency occurred in case 16. 25 Deficiencies in nursing documentation occurred in cases 2, 12, 16, and 18. 26 The CME or designee did not conduct a clinical review in cases 1 and 17. Office of the Inspector General, State of California Inspection Period: July 2021 – December 2021 Report Issued: January 2023 Cycle 6, Chuckawalla Valley State Prison | 27 The TTA nurses also evaluated each patient who returned from a community hospital or specialist appointment. On the weekends and on holidays, they ensured that patients who were paroling received their medications. During the on-site visit, our clinicians observed a TTA huddle. The utilization manager, off-site specialty nurses, and specialized medical housing nurses attended the huddle. The TTA nurses discussed patients who were seen in the TTA. The participants also discussed the status of hospitalized patients and the off-site specialty appointments scheduled for that day. Office of the Inspector General, State of California Inspection Period: July 2021 – December 2021 Report Issued: January 2023 Cycle 6, Chuckawalla Valley State Prison | 28 Recommendations The OIG offers no recommendations for this indicator. Office of the Inspector General, State of California Inspection Period: July 2021 – December 2021 Report Issued: January 2023 Cycle 6, Chuckawalla Valley State Prison | 29 Health Information Management In this indicator, OIG inspectors evaluated the flow of health information, a crucial link in high-quality medical care delivery. Our inspectors examined Overall whether the institution retrieved and scanned critical health information Rating (progress notes, diagnostic reports, specialist reports, and hospital- Proficient discharge reports) into the medical record in a timely manner. Our inspectors also tested whether clinicians adequately reviewed and Case Review endorsed those reports. In addition, our inspectors checked whether staff Rating labeled and organized documents in the medical record correctly. Proficient Compliance Results Overview Score Proficient CVSP performed excellent in retrieving and scanning hospital records, (91.3%) specialty reports, diagnostic tests, and pathology reports. Nurses and providers recorded urgent and emergent events thoroughly. With a case a review rating of proficient and a compliance score of 91.3 percent, the institution earned a proficient rating in this indicator. Case Review and Compliance Testing Results During the period of review, our clinicians found 12 deficiencies related to health information management, one of which was significant.27 Hospital Discharge Reports CVSP performed well in retrieving and scanning hospital records. Compliance testing found that CVSP staff scanned most hospital discharge records within the required time frames (MIT 4.003, 90.0%). Most discharge records included the important physician discharge summary, and providers endorsed the reports within five days (MIT 4.005, 84.0%). Our clinicians reviewed 20 hospital events and identified one deficiency: • In case 41, a provider did not endorse a hospital record until two weeks after the record was scanned into the medical record. Specialty Reports CVSP did not always receive or review the high-priority, medium-priority, and routine-priority specialty reports within the required time frames (MIT 14.002, 86.7%; MIT 14.005, 60.0%; and MIT 14.008, 73.3%). However, CVSP performed well in scanning the specialty reports, as compliance testing showed that 86.7 percent of specialty reports were scanned within the required time frame (MIT 4.002). Our clinicians reviewed 76 specialty reports and did not identify any deficiencies. 27 Deficiencies occurred three times in case 6, twice in cases 14 and 19, and once in cases 8, 9, 16, 18, and 41. A significant deficiency occurred in case 19. Office of the Inspector General, State of California Inspection Period: July 2021 – December 2021 Report Issued: January 2023 Cycle 6, Chuckawalla Valley State Prison | 30 Diagnostic Reports Compliance testing showed that providers endorsed most radiology and laboratory reports timely (MIT 2.002, 100%, and MIT 2.005, 90.0%). Compliance testing showed that providers thoroughly communicated the results of radiology studies to their patients (MIT 2.003, 90.0%). However, providers did not always communicate laboratory results to their patients (MIT 2.006, 40.0%). Our clinicians identified one deficiency related to lacking an endorsement of a laboratory test and five deficiencies related to lacking thorough communication of laboratory results to the patients.28 CVSP performed very well in retrieving pathology reports (MIT 2.010, 90.0%). Providers endorsed all pathology reports within the required time frames (MIT 2.011, 100%) but did not always send pathology result letters to their patients within the required time frames (MIT 2.012, 50.0%). Our clinicians reviewed nine events associated with pathology reports and found three deficiencies.29 These deficiencies are discussed in the Diagnostic Services indicator. Urgent and Emergent Records Our clinicians reviewed 21 emergency care events and found that the nurses and providers recorded these events sufficiently. Our clinicians did not identify any deficiencies. Scanning Performance CVSP performed well in the scanning process. Compliance testing showed that the institution scanned and labeled medical files accurately (MIT 4.004, 95.8%). Our clinicians identified two mislabeled documents.30 An example follows: • In case 19, the date of a radiology test was mislabeled. Clinician On-Site Inspection CVSP medical record staff scanned records as they received them. Most patients returning from community hospitals had their hospital records with them. Triage and treatment center (TTA) nurses were instructed to contact the hospital directly for any missing hospital records. For on-site specialty reports, the on-site specialty nurses scanned the reports on the same day the visit occurred. For off-site specialty reports, the medical record staff scanned the handwritten reports on the day the visit occurred and scanned the formal specialty reports as they received them. 28 Deficiencies occurred twice in case 6 and once in cases 8, 9, 16 and 18. 29 Deficiencies occurred in cases 6, 14, and 19. 30 Mislabeled documents were identified in cases 14 and 19. Office of the Inspector General, State of California Inspection Period: July 2021 – December 2021 Report Issued: January 2023 Cycle 6, Chuckawalla Valley State Prison | 31 The specialty nurses also contacted the specialists directly for any missing specialty reports. Office of the Inspector General, State of California Inspection Period: July 2021 – December 2021 Report Issued: January 2023 Cycle 6, Chuckawalla Valley State Prison | 32 Compliance Testing Results Table 9. Health Information Management Table 9. Health Information Management Scored Answer Compliance Questions Yes No N/A Yes % Are health care service request forms scanned into the patient’s electronic health record within three calendar days of the encounter 20 0 0 100% date? (4.001) Are specialty documents scanned into the patient’s electronic health 26 4 15 86.7% record within five calendar days of the encounter date? (4.002) * Are community hospital discharge documents scanned into the patient’s electronic health record within three calendar days of 18 2 5 90.0% hospital discharge? (4.003) * During the inspection, were medical records properly scanned, 23 1 0 95.8% labeled, and included in the correct patients’ files? (4.004) * For patients discharged from a community hospital: Did the preliminary or final hospital discharge report include key elements 21 4 0 84.0% and did a provider review the report within five calendar days of discharge? (4.005) * Overall percentage (MIT 4): 91.3% * The OIG clinicians considered these compliance tests along with their case review findings when determining the quality rating for this indicator. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: July 2021 – December 2021 Report Issued: January 2023 Cycle 6, Chuckawalla Valley State Prison | 33 TTaabbllee 1100.. OOtthheerr TTeessttss RReellaatteedd ttoo HHeeaaltlthh I nInfoformrmaatitoionn M Mananagagememenetnt Scored Answer Compliance Questions Yes No N/A Yes % Radiology: Did the ordering health care provider review and endorse 10 0 0 100% the radiology report within specified time frames? (2.002) * Laboratory: Did the health care provider review and endorse the 9 1 0 90.0% laboratory report within specified time frames? (2.005) * Laboratory: Did the provider acknowledge the STAT results, OR did nursing staff notify the provider within the required time frame? 0 2 0 0 (2.008) * Pathology: Did the institution receive the final pathology report within 9 1 0 90.0% the required time frames? (2.010) * Pathology: Did the health care provider review and endorse the 10 0 0 100% pathology report within specified time frames? (2.011) * Pathology: Did the health care provider communicate the results of the 5 5 0 50.0% pathology study to the patient within specified time frames? (2.012) Did the institution receive and did the primary care provider review the high-priority specialty service consultant report within the required time 13 2 0 86.7% frame? (14.002) * Did the institution receive and did the primary care provider review the medium-priority specialty service consultant report within the required 9 6 5 60.0% time frame? (14.005) * Did the institution receive and did the primary care provider review the routine-priority specialty service consultant report within the required 11 4 0 73.3% time frame? (14.008) * * The OIG clinicians considered these compliance tests along with their case review findings when determining the quality rating for this indicator. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: July 2021 – December 2021 Report Issued: January 2023 Cycle 6, Chuckawalla Valley State Prison | 34 Recommendations The OIG offers no recommendations for this indicator. Office of the Inspector General, State of California Inspection Period: July 2021 – December 2021 Report Issued: January 2023 Cycle 6, Chuckawalla Valley State Prison | 35 Health Care Environment In this indicator, OIG compliance inspectors tested clinics’ waiting areas, infection control, sanitation procedures, medical supplies, equipment Overall management, and examination rooms. Inspectors also tested clinics’ Rating performance in maintaining auditory and visual privacy for clinical Inadequate encounters. Compliance inspectors asked the institution’s health care administrators to comment on their facility’s infrastructure and its ability to Case Review support health care operations. The OIG rated this indicator solely on the Rating compliance score, using the same scoring thresholds as in the Cycle 4 and (N/A) Cycle 5 medical inspections. Our case review clinicians do not rate this indicator. Compliance Score Inadequate Results Overview (55.4%) In this cycle, multiple aspects of CVSP’s health care environment needed improvement: multiple clinics contained expired medical supplies; multiple clinics lacked medical supplies or contained improperly calibrated medical equipment; emergency medical response bag (EMRB) logs either were missing staff verification or inventory was not performed; and staff did not regularly sanitize their hands before or after examining patients. These factors resulted in an inadequate rating for this indicator. Compliance Testing Results Outdoor Waiting Areas We examined outdoor patient waiting areas (see Photo 1, right). Health care and custody staff reported existing waiting areas had sufficient seating capacity. The staff reported that the outdoor waiting area was only used when the indoor waiting area was at capacity. Also, staff reported that they only call patients close to their appointment time during inclement weather. Photo 1. Outdoor patient waiting area (photographed on 3-17-22). Office of the Inspector General, State of California Inspection Period: July 2021 – December 2021 Report Issued: January 2023 Cycle 6, Chuckawalla Valley State Prison | 36 Indoor Waiting Areas We inspected indoor waiting areas (see Photo 2). Patients had enough seating capacity while waiting for their appointments. Depending on the population, patients were either placed in a holding area or held in individual modules to await their medical appointments (see Photo 3, below). Health care and custody staff reported that existing waiting areas contained sufficient seating capacity. During our inspection, we did not observe overcrowding or noncompliance with social distancing requirements in any of the clinics’ indoor waiting areas. Photo 2. Indoor patient waiting area (photographed on 3-16-22). Clinic Environment Seven of eight clinic environments were sufficiently conducive to medical care. They provided reasonable auditory privacy, appropriate waiting areas, wheelchair accessibility, and nonexamination room workspace (MIT 5.109, 87.5%). In one clinic, however, the examination room configuration did not allow sufficient space to accommodate a wheelchair. Of the eight clinics we observed, six contained appropriate space, configuration, supplies, and equipment to allow clinicians to perform proper clinical examinations (MIT 5.110, 75.0%). In one clinic, the examination room was not free of unnecessary clutter at the time our inspection. The remaining clinic’s examination room configurations did not have sufficient space either for clinicians to conduct proper patient examination or for patients to lie fully extended on the examination table without obstructions. Photo 3. Individual patient waiting modules (photographed on 3-15-22). Office of the Inspector General, State of California Inspection Period: July 2021 – December 2021 Report Issued: January 2023 Cycle 6, Chuckawalla Valley State Prison | 37 Clinic Supplies Only one of the eight clinics followed adequate medical supply storage and management protocols (MIT 5.107, 12.5%). We found one or more of the following deficiencies in seven clinics: expired medical supplies (see Photo 4, left), unidentified medical supplies, cleaning materials stored with medical supplies (see Photo 5, below), staff members’ food stored long-term in the medical supply storage room, and compromised sterile medical supply packaging. Photo 4. Expired medical supplies dated July 2018 (photographed on 3-16-22). Photo 5. Cleaning materials stored with medical supplies (photographed on 3-17-22). Office of the Inspector General, State of California Inspection Period: July 2021 – December 2021 Report Issued: January 2023 Cycle 6, Chuckawalla Valley State Prison | 38 Only two of the eight clinics met requirements for essential core medical equipment and supplies (MIT 5.108, 25.0%). The remaining six clinics lacked medical supplies or contained improperly calibrated or nonfunctional equipment. The missing items included an examination table disposable paper, weight scale, lubricating jelly, tongue depressors, peak flow meter and tips, glucometer control solution, nebulization unit, and oto- ophthalmoscope and tips. The staff had not properly calibrated an automated external defibrillator (AED). We found a nonfunctional oto- ophthalmoscope. CVSP staff inaccurately logged the results of the glucometer daily quality control test within 30 days prior to the on-site inspection. We examined emergency medical response bags (EMRBs) to determine whether they contained all essential items. We checked whether staff inspected the bags daily and inventoried them monthly. None of the five EMRBs passed our test (MIT 5.111, zero). We found one or more of the following deficiencies with all the EMRBs: staff failed to ensure that the EMRB’s compartments were sealed and intact; staff had not inventoried the EMRBs when seal tags were replaced or had not inventoried the EMRBs within 30 days prior to the on-site inspection; staff inaccurately logged the results of the EMRB glucometer daily quality control test within 30 days prior to the on-site inspection; and we found an expired glucometer quality control solution. The treatment cart in the TTA did not meet the minimum inventory level, and several supplies were not placed in the correct drawer, as indicated in the inventory log. Medical Supply Management All the medical supply storage areas located outside the medical clinics stored medical supplies adequately (MIT 5.106, 100%). According to the chief executive officer (CEO), CVSP did not have any concerns about the medical supplies process. Health care managers and medical warehouse managers expressed no concerns about the medical supply chain or their communication process with the existing system. Infection Control and Sanitation Staff appropriately disinfected, cleaned, and sanitized four of eight clinics (MIT 5.101, 50.0%). In three clinics, biohazard waste was not emptied after each clinic day. In the remaining clinic, we found the cabinet under the sink to be unsanitary. Staff in five of seven clinics properly sterilized or disinfected medical equipment (MIT 5.102, 71.4%). In two clinics, staff did not mention disinfecting the examination table as part of their daily start-up protocol. We found operating sinks and hand hygiene supplies in the examination rooms in six of eight clinics (MIT 5.103, 75.0%). The patient restrooms in two clinics lacked either antiseptic soap or disposable hand towels. Office of the Inspector General, State of California Inspection Period: July 2021 – December 2021 Report Issued: January 2023 Cycle 6, Chuckawalla Valley State Prison | 39 We observed patient encounters in four clinics. In three clinics, clinicians did not wash their hands before or after examining their patients, before applying gloves, or after performing blood draws (MIT 5.104, 25.0%). Health care staff in seven of eight clinics followed proper protocols to mitigate exposure to bloodborne pathogens and contaminated waste (MIT 5.105, 87.5%). In one clinic, the examination room lacked a sharps container. Physical Infrastructure CVSP’s health care management and plant operations manager reported that all clinical areas infrastructures were in good working order and did not hinder health care services. At the time of our medical inspection, the institution reported the Health Care Facility Improvement Program (HCFIP) project was renovating the Facility B primary clinic that started January 16, 2022. The institution estimated that the project would be completed by November 2022. In addition, the renovation of the Facility A clinic, Pharmacy, and Central Health Services Building were expected to begin between October and December 2022 and the projects were estimated to be completed between February 2023 and August 2023 (MIT 5.999). Office of the Inspector General, State of California Inspection Period: July 2021 – December 2021 Report Issued: January 2023 Cycle 6, Chuckawalla Valley State Prison | 40 Compliance Testing Results TTaabbllee 1111.. HHeeaalltthh CCaarree EEnnvviirroonnmmeenntt Scored Answer Compliance Questions Yes No N/A Yes % Infection control: Are clinical health care areas appropriately 4 4 0 50.0% disinfected, cleaned, and sanitary? (5.101) Infection control: Do clinical health care areas ensure that reusable invasive and noninvasive medical equipment is properly sterilized or 5 2 1 71.4% disinfected as warranted? (5.102) Infection control: Do clinical health care areas contain operable sinks 6 2 0 75.0% and sufficient quantities of hygiene supplies? (5.103) Infection control: Does clinical health care staff adhere to universal 1 3 4 25.0% hand hygiene precautions? (5.104) Infection control: Do clinical health care areas control exposure to 7 1 0 87.5% blood-borne pathogens and contaminated waste? (5.105) Warehouse, conex, and other nonclinic storage areas: Does the medical supply management process adequately support the needs 1 0 0 100% of the medical health care program? (5.106) Clinical areas: Does each clinic follow adequate protocols for 1 7 0 12.5% managing and storing bulk medical supplies? (5.107) Clinical areas: Do clinic common areas and exam rooms have 2 6 0 25.0% essential core medical equipment and supplies? (5.108) Clinical areas: Are the environments in the common clinic areas 7 1 0 87.5% conducive to providing medical services? (5.109) Clinical areas: Are the environments in the clinic exam rooms 6 2 0 75.0% conducive to providing medical services? (5.110) Clinical areas: Are emergency medical response bags and emergency crash carts inspected and inventoried within required time frames, 0 5 3 0 and do they contain essential items? (5.111) Does the institution’s health care management believe that all clinical This is a nonscored test. Please areas have physical plant infrastructures that are sufficient to provide see the indicator for discussion of adequate health care services? (5.999) this test. Overall percentage (MIT 5): 55.4% * The OIG clinicians considered these compliance tests along with their case review findings when determining the quality rating for this indicator. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: July 2021 – December 2021 Report Issued: January 2023 Cycle 6, Chuckawalla Valley State Prison | 41 Recommendations • Medical leadership should remind staff to follow universal hand hygiene precautions. Implementing random spot checks could improve compliance. • Nursing leadership should consider performing random spot checks to ensure that staff follow equipment and medical supply management protocols. • Nursing leadership should direct each clinic nurse supervisor to review the monthly emergency medical response bag (EMRB) and treatment cart logs to ensure that the EMRBs and treatment carts are regularly inventoried and sealed. Office of the Inspector General, State of California Inspection Period: July 2021 – December 2021 Report Issued: January 2023 Cycle 6, Chuckawalla Valley State Prison | 42 Transfers In this indicator, OIG inspectors examined the transfer process for those patients who transferred into the institution as well as for those who Overall transferred to other institutions. For newly arrived patients, our inspectors Rating assessed the quality of health screenings and the continuity of provider Adequate appointments, specialist referrals, diagnostic tests, and medications. For patients who transferred out of the institution, inspectors checked whether Case Review staff reviewed patient medical records and determined the patient’s need Rating for medical holds. They also assessed whether staff transferred patients Adequate with their medical equipment and gave correct medications before patients left. In addition, our inspectors evaluated the performance of staff in Compliance communicating vital health transfer information, such as preexisting health Score conditions, pending appointments, tests, and specialty referrals; inspectors Adequate also confirmed whether staff sent complete medication transfer packages to (83.8%) the receiving institution. For patients who returned from off-site hospitals or emergency rooms, inspectors reviewed whether staff appropriately implemented the recommended treatment plans, administered necessary medications, and scheduled appropriate follow-up appointments. Results Overview CVSP performed adequately in the transfer process. Compared with Cycle 5, OIG clinicians found fewer deficiencies. For patients transferring into CVSP, nurses and providers generally performed timely initial evaluations and staff ensured good medication continuity. For patients transferring out of CVSP, nurses completed the transfer packages, and the patients received their medications prior to the transfers. The institution performed satisfactorily in both case review and compliance testing; thus, we rated this indicator adequate. Case Review and Compliance Testing Results We reviewed 50 events in 18 cases in which patients transferred into or out of the institution, including returns from community hospitals. We identified 16 deficiencies, of which two were significant.31 Transfers In The transfer-in process was sufficient. Although the receiving and releasing (R&R) nurses did not always complete the initial health screening form thoroughly (MIT 6.001, 64.0%), the nurses did well in completing the assessment and disposition section (MIT 6.002, 100%). Our clinicians reviewed seven transfer-in events and found that the R&R nurses evaluated newly arrived patients and ordered provider appointments within the required time frames. 31 Deficiencies occurred in cases 1, 21, 22, 23, 24, 26, 39, and 41. Cases 24 and 39 had significant deficiencies. Office of the Inspector General, State of California Inspection Period: July 2021 – December 2021 Report Issued: January 2023 Cycle 6, Chuckawalla Valley State Prison | 43 The compliance team found that CVSP scored high for medication continuity at the time of transfer (MIT 6.003, 87.5%). Our clinicians found two deficiencies related to medication continuity.32 These deficiencies are discussed in the Medication Management indicator. CVSP also performed well in medication continuity for patients transferred within the institution (MIT 7.005, 100%). Both compliance testing and case review found that newly arrived patients were seen by a provider within the necessary time frames (MIT 1.002, 92.0%). However, compliance testing found that only 35.0 percent of preapproved specialty appointments were completed timely (MIT 14.010). Our clinicians did not identify any missed or delayed preapproved specialty appointments. Transfers Out The CVSP transfer-out process was satisfactory. Our clinicians found that R&R nurses evaluated patients, completed the transfer packages, and ensured adequate supply of medications prior to patients’ transferring out of the institution. In the five transfer-out events, our clinicians found three deficiencies, one of which was significant:33 • In case 24, prior to transfer from CVSP, a COVID-19 screening test was not completed. At the time of the compliance on-site inspection, CVSP did not have any patient movement (MIT 6.101, N/A). Hospitalizations The compliance team found that CVSP performed very well in ensuring that patients had timely follow up appointments after hospitalizations or emergency room visits (MIT 1.007, 100%). CVSP also performed well in retrieving and scanning hospital records (MIT 4.003, 90.0%). Our clinicians reviewed 20 events in which patients returned from a hospitalization or emergency room visit and identified one deficiency related to the late endorsement of a hospital record and five deficiencies related to inadequate nursing assessments.34 An example follows: • In case 1, the patient returned from the hospital and had an abnormal rapid heart rate; however, the nurse did not reassess the heart rate or consult a provider. CVSP performed poorly in medication continuity when patients returned from hospitalization (MIT 7.003, 65.2%). Our clinicians identified two deficiencies related to medication continuity, one of which was considered 32 Medication continuity was interrupted in cases 21 and 23. 33 Deficiencies occurred in cases 24 and 26. A significant deficiency occurred in case 24. 34 Deficiencies occurred in cases 1, 39, and 41. Office of the Inspector General, State of California Inspection Period: July 2021 – December 2021 Report Issued: January 2023 Cycle 6, Chuckawalla Valley State Prison | 44 significant.35 These deficiencies are discussed in the Medication Management indicator. Clinician On-Site Inspection Our inspectors toured CVSP’s R&R unit, which had two examination rooms allocated for medical evaluation. The unit was staffed with a registered nurse who was knowledgeable about the transfer process, including medication availability, provider appointment timelines, completion of screening questions, and specialty appointment continuity. The nurse indicated that since the COVID-19 pandemic, there were fewer patients arriving and leaving. 35 Deficiencies occurred in cases 1 and 39. A significant deficiency occurred in case 39. Office of the Inspector General, State of California Inspection Period: July 2021 – December 2021 Report Issued: January 2023 Cycle 6, Chuckawalla Valley State Prison | 45 Compliance Testing Results TTaabblele 1 122. .T Trraannssffeerrss Scored Answer Compliance Questions Yes No N/A Yes % For endorsed patients received from another CDCR institution or COCF: Did nursing staff complete the initial health screening and 16 9 0 64.0% answer all screening questions within the required time frame? (6.001) * For endorsed patients received from another CDCR institution or COCF: When required, did the RN complete the assessment and disposition section of the initial health screening form; refer the 23 0 2 100% patient to the TTA if TB signs and symptoms were present; and sign and date the form on the same day staff completed the health screening? (6.002) For endorsed patients received from another CDCR institution or COCF: If the patient had an existing medication order upon arrival, 7 1 17 87.5% were medications administered or delivered without interruption? (6.003) * For patients transferred out of the facility: Do medication transfer packages include required medications along with the corresponding N/A N/A N/A N/A transfer packet required documents? (6.101) * Overall percentage (MIT 6): 83.8% * The OIG clinicians considered these compliance tests along with their case review findings when determining the quality rating for this indicator. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: July 2021 – December 2021 Report Issued: January 2023 Cycle 6, Chuckawalla Valley State Prison | 46 TTaabblele 1 133.. OOtthheerr TTeessttss RReellaatteedd ttoo TTrraannssffeerrss Scored Answer Compliance Questions Yes No N/A Yes % For endorsed patients received from another CDCR institution: Based on the patient’s clinical risk level during the initial health screening, was the 23 2 0 92.0% patient seen by the clinician within the required time frame? (1.002) * Upon the patient’s discharge from the community hospital: Did the patient receive a follow-up appointment with a primary care provider 21 0 4 100% within the required time frame? (1.007) * Are community hospital discharge documents scanned into the patient’s electronic health record within three calendar days of hospital 18 2 5 90.0% discharge? (4.003) * For patients discharged from a community hospital: Did the preliminary or final hospital discharge report include key elements and did a 21 4 0 84.0% provider review the report within five calendar days of discharge? (4.005) * Upon the patient’s discharge from a community hospital: Were all ordered medications administered, made available, or delivered to the 15 8 2 65.2% patient within required time frames? (7.003) * Upon the patient’s transfer from one housing unit to another: Were 25 0 0 100% medications continued without interruption? (7.005) * For patients en route who lay over at the institution: If the temporarily housed patient had an existing medication order, were medications 5 3 0 62.5% administered or delivered without interruption? (7.006) * For endorsed patients received from another CDCR institution: If the patient was approved for a specialty services appointment at the 7 13 0 35.0% sending institution, was the appointment scheduled at the receiving institution within the required time frames? (14.010) * * The OIG clinicians considered these compliance tests along with their case review findings when determining the quality rating for this indicator. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: July 2021 – December 2021 Report Issued: January 2023 Cycle 6, Chuckawalla Valley State Prison | 47 Recommendations • Nursing leadership should develop and implement internal auditing of staff to ensure the complete and thorough assessments of patients returning from hospitalizations. Office of the Inspector General, State of California Inspection Period: July 2021 – December 2021 Report Issued: January 2023 Cycle 6, Chuckawalla Valley State Prison | 48 Medication Management In this indicator, OIG inspectors evaluated the institution’s performance in administering prescription medications on time and without interruption. Overall The inspectors examined this process from the time a provider prescribed Rating medication until the nurse administered the medication to the patient. Inadequate When rating this indicator, the OIG emphasized the compliance test results, which tested medication processes to a much greater degree than case Case Review review testing. In addition to examining medication administration, our Rating compliance inspectors also tested many other processes, including Adequate medication handling, storage, error reporting, and other pharmacy processes. Compliance Score Inadequate Results Overview (62.8%) CVSP performed poorly in chronic medication continuity, hospital discharge medications, specialized medical housing medications, and medication administration; the institution had an overall compliance score of 62.8 percent. However, it performed well in new medication prescriptions and medication continuity for transferred patients. Our clinicians found significant deficiencies related to chronic care medications, new medications, and hospital discharge medications. We considered all aspects of medication management and rated this indicator inadequate. Case Review and Compliance Testing Results We reviewed 113 events related to medications and found seven medication deficiencies, of which four were significant.36 New Medication Prescriptions CVSP performed well in delivering newly prescribed medications, as compliance testing showed that most newly prescribed medications were completed within the required time frames (MIT 7.002, 96.0%). Our clinicians also found that most patients received their newly prescribed medications timely. However, we identified one significant deficiency related to a newly prescribed medication: • In case 14, the patient had left wrist surgery and did not receive his newly prescribed medication for pain relief. Chronic Medication Continuity During this review period, compliance testing found that most patients did not receive their chronic care medications within the required time frames 36 Deficiencies occurred in cases 1, 11, 12, 14, 21, 23, and 39. Cases 11, 12, 14, and 39 had significant deficiencies. Office of the Inspector General, State of California Inspection Period: July 2021 – December 2021 Report Issued: January 2023 Cycle 6, Chuckawalla Valley State Prison | 49 (MIT 7.001, 5.0%). Our clinicians found two delays related to chronic medication continuity. One of the delays was considered significant:37 • In case 11, the patient received his glaucoma medication six days late. Hospital Discharge Medications CVSP performed poorly in ensuring that patients receive their medications when they return from an off-site hospital or emergency room. The compliance team found that 65.2 percent of the patients receive their medications within the required time frames (MIT 7.003). Our clinicians reviewed 20 hospital returns and identified two medication management deficiencies, one of which was considered significant:38 • In case 39, the patient returned from the hospital with a diagnosis of coronary artery disease, and the patient received his antianginal cardiac medication 22 days late. Specialized Medical Housing Medications CVSP performed poorly in medication management for patients in the Outpatient Housing Unit (OHU), as medications were not consistently administered timely (MIT 13.004, 30.0%). Transfer Medications Compliance testing found that CVSP performed well in ensuring that patients who transferred into the institution received their medications timely (MIT 6.003, 87.5%). Patients who were temporarily housed at the facility did not always receive their medications within the required time frames (MIT 7.006, 62.5%). However, compliance testing found superb medication continuity for patients transferring from yard to yard (MIT 7.005, 100.0%). Our clinicians found two deficiencies related to medication continuity for patients who transferred into the institution, one of which is described as follows:39 • In case 21, the patient with hypertension transferred into CVSP and received his blood pressure medication one day late. CVSP performed well in ensuring that patients who transferred out of the institution received their medications. Our clinicians did not identify any deficiencies. 37 Delays occurred in cases 11 and 12. A significant deficiency occurred in case 11. 38 Deficiencies occurred in cases 1 and 39. A significant deficiency occurred in case 39. 39 Deficiencies occurred in cases 21 and 23. Office of the Inspector General, State of California Inspection Period: July 2021 – December 2021 Report Issued: January 2023 Cycle 6, Chuckawalla Valley State Prison | 50 Medication Administration Compliance testing showed that nurses administered tuberculosis (TB) medications within the required time frames (MIT 9.001, 100%). However, the institution did not thoroughly monitor patients taking TB medications, as required by policy (MIT 9.002, 20.0%). Our clinicians did not identify any deficiencies related to TB medications. Clinician On-Site Inspection Our clinicians interviewed the medication nurses and found they were knowledgeable about the medication administration process. The medication nurses attended clinic huddles and notified providers of expiring medications. The medication rooms were clean and organized, and there were no backlogs of keep-on-person medication delivery. Our clinicians attended huddles in A clinic and D clinic. During the huddles, the care teams discussed medication compliance, including medication nonadherence, and medication continuity for patients transferring into the institution, arriving from another yard, or returning from the hospital. Compliance Testing Results Medication Practices and Storage Controls The institution adequately stored and secured narcotic medications in six of seven clinic and medication line locations (MIT 7.101, 85.7%). In one location, a medication nurse did not describe the appropriate narcotic medication discrepancy reporting process. CVSP appropriately stored and secured nonnarcotic medications in three of six clinic and medication line locations (MIT 7.102, 50.0%). In three locations, we observed one or both of the following deficiencies: the medication area lacked a clearly labeled designated area for medications that were to be returned to the pharmacy, and the crash cart log was missing daily security check entries for the past 30 days. Staff did not keep medications protected from physical, chemical, and temperature contamination in any clinic and medication line locations (MIT 7.103, zero). In seven locations, we found one or more of the following deficiencies: staff did not record the room temperatures for medications stored in the RN examination room; staff did not consistently record the refrigerator temperatures; the medication refrigerator was unsanitary; and staff did not store oral and topical medications separately. Staff successfully stored valid and unexpired medications in five of the six applicable medication line locations (MIT 7.104, 83.3%). In one location, a medication was stored beyond the expiration date. Nurses exercised proper hand hygiene and contamination control protocols in four of six locations (MIT 7.105, 66.7%). In one location, some nurses neglected to wash or sanitize their hands before each subsequent regloving. In another location, although the medication nurse was wearing gloves Office of the Inspector General, State of California Inspection Period: July 2021 – December 2021 Report Issued: January 2023 Cycle 6, Chuckawalla Valley State Prison | 51 when administering medication to patients for comsumption, we observed that the fingertips on the nurse’s gloves were purposely ripped for the convenience of accessing and retrieving medications from the automated medication dispensing machine. Staff in five of six medication preparation and administration areas demonstrated appropriate administrative controls and protocols (MIT 7.106, 83.3%). In one location, medication nurses did not maintain unissued medication in its original labeled packaging. Staff in all medication areas used appropriate administrative controls and protocols when distributing medications to their patients (MIT 7.107, 100%). Pharmacy Protocols Pharmacy staff followed general security, organization, and cleanliness management protocols in CVSP’s main pharmacy (MIT 7.108, 100%) and properly stored nonrefrigerated medications (MIT 7.109, 100%). The institution did not properly store refrigerated or frozen medications in the pharmacy. We found the pharmacy’s refrigerator to be unsanitary (MIT 7.110, zero). The pharmacist-in-charge (PIC) did not thoroughly review monthly inventories of controlled substances in the institution’s clinic and medication storage locations. Specifically, the nurses present at the time of the medication area inspection did not correctly complete several medication area inspection checklists (CDCR form 7477). These errors resulted in a score of zero for this test (MIT 7.111). We examined 10 medication error reports. The PIC timely or correctly processed only seven of these 10 reports (MIT 7.112, 70.0%). In three reports, we found one or more of the following deficiencies: the PIC did not document pertinent data relating where the error occurred within the pharmacy process; the PIC notified the patient and provider untimely; and the report did not contain the PIC’s determinations or findings regarding the error. Nonscored Tests In addition to testing the institution’s self-reported medication errors, our inspectors also followed up on any significant medication errors found during compliance testing. We did not score this test; we provide these results for informational purposes only. At CVSP, the OIG did not find any applicable medication errors (MIT 7.998). Office of the Inspector General, State of California Inspection Period: July 2021 – December 2021 Report Issued: January 2023 Cycle 6, Chuckawalla Valley State Prison | 52 Compliance Testing Results Table 14. Medication Management Table 14. Medication Management Scored Answer Compliance Questions Yes No N/A Yes % Did the patient receive all chronic care medications within the required time frames or did the institution follow departmental policy for refusals or 1 19 5 5.0% no-shows? (7.001) * Did health care staff administer, make available, or deliver new order 24 1 0 96.0% prescription medications to the patient within the required time frames? (7.002) Upon the patient’s discharge from a community hospital: Were all ordered medications administered, made available, or delivered to the patient within 15 8 2 65.2% required time frames? (7.003) * For patients received from a county jail: Were all medications ordered by the institution’s reception center provider administered, made available, or N/A N/A N/A N/A delivered to the patient within the required time frames? (7.004) * Upon the patient’s transfer from one housing unit to another: Were 25 0 0 100% medications continued without interruption? (7.005) * For patients en route who lay over at the institution: If the temporarily housed patient had an existing medication order, were medications administered or 5 3 0 62.5% delivered without interruption? (7.006) * All clinical and medication line storage areas for narcotic medications: Does the institution employ strong medication security controls over narcotic 6 1 3 85.7% medications assigned to its storage areas? (7.101) All clinical and medication line storage areas for nonnarcotic medications: Does the institution properly secure and store nonnarcotic medications in the 3 3 4 50.0% assigned storage areas? (7.102) All clinical and medication line storage areas for nonnarcotic medications: Does the institution keep nonnarcotic medication storage locations free of 0 7 3 0 contamination in the assigned storage areas? (7.103) All clinical and medication line storage areas for nonnarcotic medications: Does the institution safely store nonnarcotic medications that have yet to expire in 5 1 4 83.3% the assigned storage areas? (7.104) Medication preparation and administration areas: Do nursing staff employ and follow hand hygiene contamination control protocols during medication 4 2 4 66.7% preparation and medication administration processes? (7.105) Medication preparation and administration areas: Does the institution employ appropriate administrative controls and protocols when preparing medications 5 1 4 83.3% for patients? (7.106) Medication preparation and administration areas: Does the institution employ appropriate administrative controls and protocols when administering 6 0 4 100% medications to patients? (7.107) Pharmacy: Does the institution employ and follow general security, organization, and cleanliness management protocols in its main and remote 1 0 0 100% pharmacies? (7.108) Pharmacy: Does the institution’s pharmacy properly store nonrefrigerated 1 0 0 100% medications? (7.109) Pharmacy: Does the institution’s pharmacy properly store refrigerated or frozen 0 1 0 0 medications? (7.110) Pharmacy: Does the institution’s pharmacy properly account for narcotic 0 1 0 0 medications? (7.111) Pharmacy: Does the institution follow key medication error reporting 7 3 0 70.0% protocols? (7.112) Pharmacy: For Information Purposes Only: During compliance testing, did the This is a nonscored test. Please OIG find that medication errors were properly identified and reported by the see the indicator for discussion of institution? (7.998) this test. Pharmacy: For Information Purposes Only: Do patients in restricted housing This is a nonscored test. Please units have immediate access to their KOP prescribed rescue inhalers and see the indicator for discussion of nitroglycerin medications? (7.999) this test. Overall percentage (MIT 7): 62.8% * The OIG clinicians considered these compliance tests along with their case review findings when determining the quality rating for this indicator. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: July 2021 – December 2021 Report Issued: January 2023 Cycle 6, Chuckawalla Valley State Prison | 53 TTaabbllee 1155.. OOtthheerr TTeessttss R Reelalatetedd t oto M Medediciactaiotino nM Manaangaegmemenetnt Scored Answer Compliance Questions Yes No N/A Yes % For endorsed patients received from another CDCR institution or COCF: If the patient had an existing medication order upon arrival, 7 1 17 87.5% were medications administered or delivered without interruption? (6.003) * For patients transferred out of the facility: Do medication transfer packages include required medications along with the corresponding N/A N/A N/A N/A transfer-packet required documents? (6.101) * Patients prescribed TB medication: Did the institution administer the 15 0 0 100% medication to the patient as prescribed? (9.001) * Patients prescribed TB medication: Did the institution monitor the patient per policy for the most recent three months he or she was on 3 12 0 20.0% the medication? (9.002) * Upon the patient’s admission to specialized medical housing: Were all medications ordered, made available, and administered to the patient 3 7 0 30.0% within required time frames? (13.004) * * The OIG clinicians considered these compliance tests along with their case review findings when determining the quality rating for this indicator. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: July 2021 – December 2021 Report Issued: January 2023 Cycle 6, Chuckawalla Valley State Prison | 54 Recommendations • The institution should consider developing and implementing measures to ensure that staff timely make available and administer medications to patients and that staff document their actions in the medication administration record as required by CCHCS policy and procedures. Office of the Inspector General, State of California Inspection Period: July 2021 – December 2021 Report Issued: January 2023 Cycle 6, Chuckawalla Valley State Prison | 55 Preventive Services In this indicator, OIG compliance inspectors tested whether the institution Overall offered or provided cancer screenings, tuberculosis (TB) screenings, Rating influenza vaccines, and other immunizations. If the department designated Adequate the institution as at high risk for coccidioidomycosis (valley fever), we tested the institution’s performance in transferring out patients quickly. The OIG rated this indicator solely according to the compliance score, using the Case Review same scoring thresholds used in the Cycle 4 and Cycle 5 medical Rating inspections. Our case review clinicians do not rate this indicator. (N/A) Compliance Results Overview Score Adequate CVSP staff performed well in administering TB medications as prescribed, (82.7%) screening patients annually for TB, offering patients an influenza vaccine for the most recent influenza season, offering colorectal cancer screening for all patients ages 45 through 75, and offering required immunizations to chronic care patients. The institution faltered in monitoring patients who were taking prescribed TB medications. These findings are set forth in the table on the next page. Overall, we rated this indicator adequate. Office of the Inspector General, State of California Inspection Period: July 2021 – December 2021 Report Issued: January 2023 Cycle 6, Chuckawalla Valley State Prison | 56 Compliance Testing Results Table 16. Preventive Services Table 16. Preventive Services Scored Answer Compliance Questions Yes No N/A Yes % Patients prescribed TB medication: Did the institution administer the 15 0 0 100% medication to the patient as prescribed? (9.001) Patients prescribed TB medication: Did the institution monitor the patient per policy for the most recent three months he or she was on 3 12 0 20.0% the medication? (9.002) † Annual TB screening: Was the patient screened for TB within the last 25 0 0 100% year? (9.003) Were all patients offered an influenza vaccination for the most recent 24 1 0 96.0% influenza season? (9.004) All patients from the age of 45 through the age of 75: Was the 25 0 0 100% patient offered colorectal cancer screening? (9.005) Female patients from the age of 50 through the age of 74: Was the N/A N/A N/A N/A patient offered a mammogram in compliance with policy? (9.006) Female patients from the age of 21 through the age of 65: Was N/A N/A N/A N/A patient offered a pap smear in compliance with policy? (9.007) Are required immunizations being offered for chronic care patients? 8 2 15 80.0% (9.008) Are patients at the highest risk of coccidioidomycosis (valley fever) N/A N/A N/A N/A infection transferred out of the facility in a timely manner? (9.009) Overall percentage (MIT 9): 82.7% * The OIG clinicians considered these compliance tests along with their case review findings when determining the quality rating for this indicator. † In April 2020, after our review but before this report was published, CCHCS reported adding the symptom of fatigue into the electronic health record system (EHRS) PowerForm for tuberculosis (TB)-symptom monitoring. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: July 2021 – December 2021 Report Issued: January 2023 Cycle 6, Chuckawalla Valley State Prison | 57 Recommendations The OIG offers not recommendations for this indicator. Office of the Inspector General, State of California Inspection Period: July 2021 – December 2021 Report Issued: January 2023 Cycle 6, Chuckawalla Valley State Prison | 58 Nursing Performance In this indicator, the OIG clinicians evaluated the quality of care delivered by Overall the institution’s nurses, including registered nurses (RNs), licensed Rating vocational nurses (LVNs), psychiatric technicians (PTs), and certified Adequate nursing assistants (CNAs). Our clinicians evaluated nurses’ performance in making timely and appropriate assessments and interventions. We also evaluated the institution’s nurses’ performance in many clinical settings and Case Review processes, including sick call, outpatient care, care coordinating and Rating management, emergency services, specialized medical housing, Adequate hospitalizations, transfers, specialty services, and medication management. Compliance The OIG assessed nursing care through case review only and performed no Score compliance testing for this indicator. (N/A) When summarizing overall nursing performance, our clinicians understand that nurses perform numerous aspects of medical care. As such, specific nursing quality issues are discussed in other indicators, such as Emergency Services, Specialty Services, and Specialized Medical Housing. Results Overview Nurses generally provided appropriate nursing care. We identified 40 more deficiencies during this cycle that we did during Cycle 5; however, we also reviewed 106 more nursing events. Four of the 10 significant deficiencies we identified occurred in the Outpatient Housing Unit (OHU), which was reactivated in July 2021. Taking all aspects of nursing care into consideration, we rated this indicator adequate. Case Review Results We reviewed 260 nursing encounters in 41 cases. Of the nursing encounters we reviewed, 155 occurred in the outpatient setting. We identified 91 nursing performance deficiencies, of which 10 were significant.40 Nursing Assessment and Interventions A critical component of nursing care is the quality of nursing assessment, which includes both subjective elements, such as patient interviews, and objective elements, such as observation and examination. Nurses generally provided appropriate nursing assessments and interventions. However, nursing assessments in the outpatient and specialized medical housing units showed room for improvement. Nursing Documentation Complete and accurate nursing documentation is an essential component of patient care. Without proper documentation, health care staff can overlook 40 Deficiencies occurred in cases 1, 2, 3, 10, 11, 12, 14, 15, 16, 17, 18, 19, 21, 22, 23, 24, 26, 27, 29, 31, 32, 33, 34, 36, 38, 39, 40, and 41. Significant deficiencies occurred cases 12, 14, 16, 17, 24, 31, 39, 40, and 41. Office of the Inspector General, State of California Inspection Period: July 2021 – December 2021 Report Issued: January 2023 Cycle 6, Chuckawalla Valley State Prison | 59 changes in patients’ conditions. CVSP staff generally documented care appropriately. However, the following are examples of outpatient documentation deficiencies: • In case 16, the nurse did not document consulting a provider about the need for wound care orders. • In case 31, the sick call nurse evaluated the patient for a complaint of a foreign object in the eye; however, the nurse did not document the eye’s appearance. Nursing Sick Call Our clinicians reviewed 45 sick call requests and identified 23 deficiencies.41 Most nurses triaged sick calls appropriately and performed timely evaluations. Many of the deficiencies we identified were related to incomplete nursing assessments. Examples include the following: • In case 1, the patient complained of low back and hip pain. The sick call nurse did not assess the patient’s lower extremity strength. • In case 3, the nurse evaluated the patient for a complaint of dizziness but did not perform a thorough assessment to ensure that the patient’s symptoms were not cardiac related. Case Management Our clinicians reviewed five visits in which patients were evaluated by a case manager.42 Each of the medical clinics also had an LVN clinic coordinator who focused on chronic care management, such as diabetic care. Our clinicians did not identify any deficiencies related to case management. Wound Care Our clinicians reviewed three cases involving wound care and found nine deficiencies.43 Two cases were in an outpatient setting and one case was in the OHU. Although each case had wound care deficiencies, most of the deficiencies were identified within one case: • In case 16, on three occasions, nurses evaluated the patient who had a draining wound and acknowledged that the patient required daily wound care; however, the nurses did not order wound care. 41 Nursing sick call deficiencies occurred in cases 1, 3, 10, 11, 14, 15, 16, 17, 23, 27, 29, 31, 32, 33, 34, 36, and 37. 42 Patients were evaluated by the care manager in cases 6, 7, and 10. 43 Cases 16, 33, and 41 had wound care deficiencies. Office of the Inspector General, State of California Inspection Period: July 2021 – December 2021 Report Issued: January 2023 Cycle 6, Chuckawalla Valley State Prison | 60 Emergency Services We reviewed 21 urgent or emergent events. Nurses responded promptly to emergent events and generally provided good care. However, we identified opportunities for improvement, which we discuss in the Emergency Services indicator. Hospital Returns We reviewed 20 events that involved returns from off-site hospitals or emergency rooms. Most nurses performed sufficient nursing assessments; however, there were deficiencies related to inadequate nursing assessments, which we discuss in the Transfers indicator. Transfers We reviewed 12 events involving transfer-in and transfer-out processes. Opportunities for improvement are discussed in the Transfers indicator. Specialized Medical Housing We reviewed three OHU cases with a total of 20 nursing deficiencies. Our clinicians found that nurses did not always perform thorough assessments or initiate patient care plans. We discuss these deficiencies in the Specialized Medical Housing indicator. Specialty Services We reviewed 77 events in which patients received specialty procedures or consultations. Our clinicians evaluated 21 events related to nurses’ evaluations after a specialty appointment. Our clinicians identified ten nursing deficiencies. We provide additional details in the Specialty Services indicator. Medication Management Our clinicians found lapses in medication continuity. We discuss the details in the Medication Management indicator. Clinician On-Site Inspection Our clinicians spoke with nurses and nurse managers in the TTA, OHU, R&R, specialty, and outpatient clinics and medication areas, and attended huddles in the medical clinics and central health building. We found that the clinic staff were knowledgeable and familiar with their patient population. Since the Cycle 5 inspection, medical clinics C and D have been remodeled. The medical staff reported that they were pleased with the additional clinic space, which allowed the nursing care coordinator a private space to conduct patient interviews and exams. Office of the Inspector General, State of California Inspection Period: July 2021 – December 2021 Report Issued: January 2023 Cycle 6, Chuckawalla Valley State Prison | 61 At the time of the on-site inspection, medical clinic B was under construction. Thus, medical evaluations at that clinic were conducted in a mobile trailer. The staff indicated that after medical clinic B was completed, medical clinic A would be renovated. During the on-site visit, the CNE expressed concerns with the 30 percent of nurse positions that were not filled. Nursing morale was low, and in general, nurses were tired after the multiple COVID-19 outbreaks, with the recent outbreak occurring in January 2022. Our clinicians discussed the case review questions with nursing leadership, who agreed with some of the findings and had begun nursing training to address those findings. The CNE and OHU SRN II acknowledged that since the reactivation of their OHU in July 2021, training issues were identified, and training was ongoing. Office of the Inspector General, State of California Inspection Period: July 2021 – December 2021 Report Issued: January 2023 Cycle 6, Chuckawalla Valley State Prison | 62 Recommendations The OIG offers no recommendations for this indicator. Office of the Inspector General, State of California Inspection Period: July 2021 – December 2021 Report Issued: January 2023 Cycle 6, Chuckawalla Valley State Prison | 63 Provider Performance In this indicator, OIG case review clinicians evaluated the quality of care Overall delivered by the institution’s providers: physicians, physician assistants, Rating and nurse practitioners. Our clinicians assessed the providers’ performance Adequate in evaluating, diagnosing, and managing their patients properly. We examined provider performance across several clinical settings and programs, including sick call, emergency services, outpatient care, chronic Case Review care, specialty services, intake, transfers, hospitalizations, and specialized Rating medical housing. We assessed provider care through case review only and Adequate performed no compliance testing for this indicator. Compliance Score Results Overview (N/A) CVSP providers delivered generally good care, similar with their performance in Cycle 5. They generally made appropriate assessments and decisions, managed chronic medical conditions effectively, reviewed medical records thoroughly, and addressed the specialists’ recommendations adequately. We rated this indicator adequate. Case Review Results Our clinicians reviewed 116 medical provider encounters and identified 10 deficiencies, five of which were significant.44 Our physicians also rated the overall adequacy of care for each of the 20 detailed case reviews they conducted. Of these 20 cases, 18 were adequate and two were inadequate. Assessment and Decision-Making Providers generally made appropriate assessments and sound medical plans for their patients. They diagnosed medical conditions correctly, ordered appropriate tests, and coordinated effective treatment plans for their patients. However, there was one significant deficiency related to poor decision making: • In case 16, the provider diagnosed the patient with a right gluteal abscess but did not place the patient on the recommended antibiotic covering for methicillin-resistant Staphylococcus aureus (MRSA) bacteria. The provider also did not order close provider follow-up to reassess the abscess and to perform the recommended incision and drainage, the primary treatment for an abscess. Review of Records For patients returned from hospitalizations, CVSP providers performed well in reviewing medical records and addressing the hospitalists’ recommendations. The providers also performed well in reviewing the 44 Deficiencies occurred three times in case 16, twice in cases 6, 17, and 39, and once in case 18. Significant deficiencies occurred twice in case 39 and once in cases 6, 16, and 17. Office of the Inspector General, State of California Inspection Period: July 2021 – December 2021 Report Issued: January 2023 Cycle 6, Chuckawalla Valley State Prison | 64 medication administration record (MAR) and reconciling the patients’ medications. Emergency Care Providers made appropriate triage decisions when patients arrived at the TTA for emergency treatment. In addition, providers were available for consultation with the TTA nursing staff. We identified one deficiency, related to lacking a provider progress note for an emergent event. Chronic Care Providers performed well in managing chronic medical conditions such as hypertension, diabetes, asthma, hepatitis C infection, and cardiovascular disease. For patients with diabetes, providers regularly monitored the patients’ blood glucose levels and adjusted diabetic medications. However, our clinicians identified two significant deficiencies related to diabetic care.45 An example follows: • In case 17, the patient complained of dizziness, loss of appetite, and frequent urination, and had an abnormally high finger stick blood sugar level of 360 mg/dL.46 Thus, the patient had new onset diabetes and had hyperglycemic symptoms, and the provider did not order an urgent confirmatory test nor initiate diabetic treatment with close follow-up. Specialty Services Providers appropriately referred to specialists, timely reviewed specialty reports, and adequately addressed the specialists’ recommendations. Our clinicians did not identify any provider deficiencies related to specialty services. Documentation Quality Providers generally documented outpatient and TTA encounters on the same day of the encounter. Our clinicians did not identify any deficiencies related to documentation quality. Specialized Medical Housing Providers completed their admission history and physical exams and conducted rounds at clinically appropriate intervals. Our clinicians examined 16 provider encounters and identified two significant 45 Deficiencies occurred in cases 6 and 17. A significant deficiency occurred in case 17. 46 A normal finger stick blood sugar level ranges from 60 to 99 mg/dL. Mg/dL is milligrams per deciliter, which is unit of measure that shows the concentration of a substance in a specific amount of fluid. Office of the Inspector General, State of California Inspection Period: July 2021 – December 2021 Report Issued: January 2023 Cycle 6, Chuckawalla Valley State Prison | 65 deficiencies, which we discuss in the Specialized Medical Housing indicator. Clinician On-Site Inspection CVSP had four full-time providers and two vacancies. The providers were enthusiastic about their work and generally satisfied with nursing, diagnostic, and specialty services. Provider meetings occur every workday morning. Our clinicians also attended morning huddles, where the clinic team discussed patients returning from hospitalization or specialty appointments with recommendations. The nurses informed the providers of the scheduled appointments, expiring medications, and new arrivals from other institutions. Our clinicians attended a population health management meeting for clinic A. The medical staff discussed delays in chronic care appointments and strategized solutions to eliminate these delays. The medical staff reviewed health care metrics, such as hemoglobin A1c, and discussed ways to achieve diabetic care goals.47 The medical staff also reviewed preventive health screening guidelines and identified required screening services, such as screening colonoscopies. Our clinicians identified one provider who was responsible for 70 percent of the provider deficiencies, including the single adverse event; however, this provider was no longer working for CVSP. Thus, the chief physician and surgeon (CP&S) addressed the provider’s deficiencies. The CP&S reported he was not aware of any clinical issues with the provider. 47 Hemoglobin A1c is a blood test that measures the average plasma glucose over the previous 12 weeks. Office of the Inspector General, State of California Inspection Period: July 2021 – December 2021 Report Issued: January 2023 Cycle 6, Chuckawalla Valley State Prison | 66 Recommendations The OIG offers no recommendations for this indicator. Office of the Inspector General, State of California Inspection Period: July 2021 – December 2021 Report Issued: January 2023 Cycle 6, Chuckawalla Valley State Prison | 67 Specialized Medical Housing In this indicator, OIG inspectors evaluated the quality of care in the Overall specialized medical housing units. We evaluated the performance of the Rating medical staff in assessing, monitoring, and intervening for medically Inadequate complex patients requiring close medical supervision. Our inspectors also evaluated the timeliness and quality of provider and nursing intake assessments and care plans. We assessed staff members’ performance in Case Review responding promptly when patients’ conditions deteriorated and looked for Rating good communication when staff consulted with one another while Inadequate providing continuity of care. Our clinicians also interpreted relevant Compliance compliance results and incorporated them into this indicator. At the time of Score our inspection, CVSP’s specialized medical housing consisted of an Inadequate Outpatient Housing Unit (OHU). (42.5%) Results Overview CVSP delivered poor care in the OHU. The OHU nurses did not always complete timely admission exams, often did not perform thorough assessments, and did not always initiate care plans reflecting patients’ needs. OHU medical staff also performed poorly in medication administration. However, we found that the OHU providers generally completed timely admission exams and delivered good care. Overall, we rated this indicator inadequate. Case Review and Compliance Testing Results Our clinicians reviewed three OHU cases that included both provider and nursing events and identified 26 deficiencies, six of which were significant.48 Provider Performance Providers generally delivered good care in the OHU. Our clinicians and compliance team found that CVSP providers performed timely admission history and physical exams (MIT 13.002, 90.0%). Providers also completed their rounds at clinically appropriate intervals. Our clinicians examined 16 provider encounters and identified two significant deficiencies: • In case 39, the patient with coronary artery disease returned from the hospital. The provider acknowledged that the patient had coronary artery disease but did not place the patient on the hospitalist’s recommended daily aspirin. • Also in case 39, the provider saw the patient returned from a heart catheterization procedure and acknowledged that the patient had severe triple vessel disease and that the cardiologist recommended 48 Deficiencies occurred in cases 39, 40, and 41. Significant deficiencies occurred in cases 39, 40, and 41. Office of the Inspector General, State of California Inspection Period: July 2021 – December 2021 Report Issued: January 2023 Cycle 6, Chuckawalla Valley State Prison | 68 antianginal medications. However, the provider did not order antianginal medications for the patient. Nursing Performance The compliance team found that nurses did not always perform timely admission assessments (MIT 13.001, 50.0%). Our clinicians did not identify any delays in admission assessments but found that nurses frequently did not perform thorough assessments and did not always reassess patients who had abnormal findings. In addition, the nurses did not ensure that patients’ care plans reflected the patients’ medical needs. There were 20 deficiencies related to poor nursing performance, four of which were significant.49 The following are examples: • In case 39, the patient was placed in the OHU for close observation, as the patient had severe coronary artery disease and waited for coronary bypass surgery. The patient returned from the hospital, where he had been admitted for chest pain, and the OHU nurse did not review the hospital discharge recommendations or update the patient’s care plan. Furthermore, the patient had multiple episodes of chest pain and the RNs did not always perform complete assessments. • In case 40, this patient had rectal bleeding and anemia, and the provider noted that the patient should not be taking any nonsteroidal anti-inflammatory drugs (NSAIDs). However, the RN inappropriately administered the patient ibuprofen, an NSAID, without a provider’s order. • In case 41, this patient was admitted to the OHU after a cervical spinal surgery. The patient wore a cervical collar and had neurological deficits. Throughout the review, the patient complained of neck and back pains, but the nurses did not perform thorough assessments. In addition, when the patient developed a wound, the nurses did not initiate a wound care plan. Medication Administration The OHU staff performed poorly in medication administration. The compliance team found that only 30.0 percent of newly admitted patients received their medications within the required time frames (MIT 13.004). Our clinicians did not identify any medication administration deficiencies. Clinician On-Site Inspection At the time of our clinicians’ inspection, the 14-bed OHU was occupied with four patients. Of the four OHU patients, three were from CVSP and one from Kern Valley State Prison (KVSP). Our clinicians learned that the institution’s OHU reopened in July 2021. The OHU was staffed with one registered nurse, 49 Deficiencies occurred eight times in cases 39 and 41, and four times in case 40. Significant deficiencies occurred twice in case 39 and once in cases 40 and 41. Office of the Inspector General, State of California Inspection Period: July 2021 – December 2021 Report Issued: January 2023 Cycle 6, Chuckawalla Valley State Prison | 69 who indicated that one RN worked on the unit on the day shifts and one LVN worked on the evening and night shifts. CVSP did not have a designated OHU provider. Instead, the providers who were assigned to the patients in the housing unit where they lived prior to being in the OHU also cared for them in the OHU. The case review team also attended the central health morning huddle. The OHU RN participated in the huddle, along with nurses from the TTA, specialty services, and utilization management. A supervising registered nurse and a representative from the radiology department also attended the huddle. The OHU RN discussed the status of the OHU patients, including their upcoming specialty appointments. The nursing leadership indicated that shortly after the re-opening of the OHU, they identified that nurses were not thoroughly documenting their assessments. Subsequently, the nursing leadership-initiated training on the admission and discharge processes. The OHU supervising registered nurse also indicated that nurses were trained on actions that they were expected to take when call lights were not functioning. Compliance Testing Results At the time of on-site inspection, the OHU clinic had a nonfunctional call light communication system (MIT 13.102, zero). The staff did not maintain a patient safety check log, as specified in the institution’s local operating procedure in the event the call light system is inoperable. Office of the Inspector General, State of California Inspection Period: July 2021 – December 2021 Report Issued: January 2023 Cycle 6, Chuckawalla Valley State Prison | 70 Compliance Testing Results Table 17. Specialized Medical Housing Table 17. Specialized Medical Housing Scored Answer Compliance Questions Yes No N/A Yes % For OHU, CTC, and SNF: Prior to 4/2019: Did the registered nurse complete an initial assessment of the patient on the day of admission, or within eight hours of admission to CMF’s Hospice? 5 5 0 50.0% Effective 4/2019: Did the registered nurse complete an initial assessment of the patient at the time of admission? (13.001) * For CTC and SNF only (effective 4/2019, include OHU): Was a written history and physical examination completed within the required time 9 1 0 90.0% frame? (13.002) * For OHU, CTC, SNF, and Hospice (applicable only for samples prior to 4/2019): Did the primary care provider complete the Subjective, Objective, Assessment, and Plan notes on the patient at the N/A N/A 10 N/A minimum intervals required for the type of facility where the patient was treated? (13.003) *,† Upon the patient’s admission to specialized medical housing: Were all medications ordered, made available, and administered to the 3 7 0 30.0% patient within required time frames? (13.004) * For OHU and CTC only: Do inpatient areas either have properly working call systems in its OHU & CTC or are 30-minute patient 0 0 1 N/A welfare checks performed; and do medical staff have reasonably unimpeded access to enter patient’s cells? (13.101) * For specialized health care housing (CTC, SNF, Hospice, OHU): Do health care staff perform patient safety checks according to 0 1 0 0 institution’s local operating procedure or within the required time frames? (13.102) * Overall percentage (MIT 13): 42.5% * The OIG clinicians considered these compliance tests along with their case review findings when determining the quality rating for this indicator. † CCHCS changed its policies and removed mandatory minimum rounding intervals for patients located in specialized medical housing. After April 2, 2019, MIT 13.003 only applied to CTCs that still have state-mandated rounding intervals. OIG case reviewers continued to test the clinical appropriateness of provider follow-ups within specialized medical housing units through case reviews. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: July 2021 – December 2021 Report Issued: January 2023 Cycle 6, Chuckawalla Valley State Prison | 71 Recommendations • Nursing leadership should ensure that the initial OHU assessments are completed within the time frame required by CCHCS policy. • Nursing leadership should ensure that OHU nurses perform thorough assessments and initiate care plans reflecting patients’ needs. • Nursing leadership should determine the root cause of challenges to patients’ receiving all ordered medications within the time frame required and should implement remedial measures as appropriate. Office of the Inspector General, State of California Inspection Period: July 2021 – December 2021 Report Issued: January 2023 Cycle 6, Chuckawalla Valley State Prison | 72 Specialty Services In this indicator, OIG inspectors evaluated the quality of specialty services. The OIG clinicians focused on the institution’s performance in providing Overall needed specialty care. Our clinicians also examined specialty appointment Rating scheduling, providers’ specialty referrals, and medical staff’s retrieval, Inadequate review, and implementation of any specialty recommendations. Case Review Results Overview Rating Adequate CVSP had a mixed performance in this indicator. Staff often completed Compliance medium-priority and routine-priority specialty appointments. The specialty Score nurses also coordinated specialty appointments and assessed patients Inadequate returned from specialty appointments. However, staff performed poorly in (72.4%) completing high-priority and preapproved specialty appointments. Considering both the case review rating and compliance testing, we rated this indicator inadequate. Case Review and Compliance Testing Results Our clinicians reviewed 98 events related to specialty services, including 77 specialty consultations and procedures, and found 14 deficiencies, one of which was significant.50 Access to Specialty Services Compliance testing showed that CVSP generally completed the initial medium-priority and routine-priority specialty appointments within the required time frames (MIT 14.004, 80.0%, and MIT 14.007, 93.3%). The institution performed adequately in completing the follow-up medium- priority and routine-priority specialty appointments (MIT 14.006, 100%, and MIT 14.009, 70.0%). However, the institution performed poorly in completing the initial and follow-up high-priority specialty appointments (MIT 14.001, 60.0%, and MIT 14.003, 50.0%). The institution also performed poorly in completing preapproved specialty appointments for patients transferring into CVSP (MIT 14.010, 35.0%). Our clinicians identified two deficiencies related to specialty appointments, one of which was significant:51 • In case 4, a provider requested a screening colonoscopy within 87 days; however, the specialty appointment did not occur. Provider Performance Providers generally referred appropriately, reviewed specialty reports within the recommended time frames, and addressed the specialists’ 50 Deficiencies occurred three times in cases 12 and 14, twice in cases 1 and 19, and once in cases 2, 4, 6, and 41. A significant deficiency occurred in case 4. 51 Deficiencies occurred in case 4 and 14. A significant deficiency occurred in case 4. Office of the Inspector General, State of California Inspection Period: July 2021 – December 2021 Report Issued: January 2023 Cycle 6, Chuckawalla Valley State Prison | 73 recommendations. We did not identify any deficiencies related to provider performance. Nursing Performance Specialty nurses reviewed requests for specialty services and arranged for specialty appointments. The nurses performed nursing assessments when patients returned from their specialty appointments. They reviewed the specialists’ findings and recommendations and communicated those results to the providers. The nurses also requested provider follow-up appointments. We reviewed 21 nursing encounters related to specialty services and identified 10 deficiencies.52 These deficiencies related to inadequate nursing assessments after the patients returned from their specialty appointments. Two examples follow: • In case 1, the patient was seen by an oncologist for lung cancer. The patient had an elevated heart rate and complained of shortness of breath; however, the specialty nurse did not reassess the heart rate nor obtain an oxygen saturation reading. • In case 2, the patient returned from a colonoscopy, and the specialty nurse did not document an abdomen exam. Health Information Management Compliance testing showed that 86.7 percent of specialty reports were scanned within the required time frames (MIT 4.002). However, the institution did not always receive or review the high-priority, medium- priority, and routine-priority specialty reports within the required time frames (MIT 14.002, 86.7%; MIT 14.005, 60.0%; and MIT 14.008, 73.3%). Our clinicians did not identify deficiencies related to scanning or retrieving specialty reports. Patient Care Environment The telemedicine staff generally maintained the video, audio, and remote medical equipment, such as stethoscope and otoscope, so the telemedicine specialists can effectively assess their patients. However, there was a deficiency related to broken remote medical equipment: • In case 6, the telemedicine cardiologist and the specialty nurse acknowledged that the remote stethoscope was not working. Clinician On-Site Inspection The institution employed multiple nurses for on-site, off-site, and telemedicine specialty services. The nurses reviewed specialty requests, 52 Deficiencies occurred three times in case 12, twice in cases 1 and 19, and once in cases 2, 14, and 41. Office of the Inspector General, State of California Inspection Period: July 2021 – December 2021 Report Issued: January 2023 Cycle 6, Chuckawalla Valley State Prison | 74 contacted the specialist for available appointments, and scheduled the appointments. The specialty nurses also obtained the diagnostic tests requested by the specialists and forwarded these tests to the specialists on the days of their appointments. Medical record staff informed the OIG clinicians that the specialists occasionally did not forward their reports to CVSP within the required time frames. In those events, the specialty nurses would contact the specialists and request the reports. Office of the Inspector General, State of California Inspection Period: July 2021 – December 2021 Report Issued: January 2023 Cycle 6, Chuckawalla Valley State Prison | 75 Compliance Testing Results TaTabblele 1 188. .S Sppeecciaialtlyty S Seervrviciceess Scored Answer Compliance Questions Yes No N/A Yes % Did the patient receive the high-priority specialty service within 14 calendar days of the primary care provider order or the Physician 9 6 0 60.0% Request for Service? (14.001) * Did the institution receive and did the primary care provider review the high-priority specialty service consultant report within the 13 2 0 86.7% required time frame? (14.002) * Did the patient receive the subsequent follow-up to the high-priority specialty service appointment as ordered by the primary care 5 5 5 50.0% provider? (14.003) * Did the patient receive the medium-priority specialty service within 15-45 calendar days of the primary care provider order or Physician 12 3 0 80.0% Request for Service? (14.004) * Did the institution receive and did the primary care provider review the medium-priority specialty service consultant report within the 9 6 5 60.0% required time frame? (14.005) * Did the patient receive the subsequent follow-up to the medium- priority specialty service appointment as ordered by the primary care 5 0 10 100% provider? (14.006) * Did the patient receive the routine-priority specialty service within 90 calendar days of the primary care provider order or Physician 14 1 0 93.3% Request for Service? (14.007) * Did the institution receive and did the primary care provider review the routine-priority specialty service consultant report within the 11 4 0 73.3% required time frame? (14.008) * Did the patient receive the subsequent follow-up to the routine- priority specialty service appointment as ordered by the primary care 7 3 5 70.0% provider? (14.009) * For endorsed patients received from another CDCR institution: If the patient was approved for a specialty services appointment at the 7 13 0 35.0% sending institution, was the appointment scheduled at the receiving institution within the required time frames? (14.010) * Did the institution deny the primary care provider’s request for 14 6 0 70.0% specialty services within required time frames? (14.011) Following the denial of a request for specialty services, was the patient informed of the denial within the required time frame? 18 2 0 90.0% (14.012) Overall percentage (MIT 14): 72.4% * The OIG clinicians considered these compliance tests along with their case review findings when determining the quality rating for this indicator. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: July 2021 – December 2021 Report Issued: January 2023 Cycle 6, Chuckawalla Valley State Prison | 76 TTaabblele 1 199.. OOtthheerr TTeessttss RReellaatteedd ttoo SSppeecciaialtltyy S Seervrviciceess Scored Answer Compliance Questions Yes No N/A Yes % Specialty service follow-up appointments: Did the clinician follow-up 23 1 21 95.8% visits occur within required time frames? (1.008) *, † Are specialty documents scanned into the patient’s electronic health 26 4 15 86.7% record within five calendar days of the encounter date? (4.002) * * The OIG clinicians considered these compliance tests along with their own case review findings when determining the quality rating for this indicator. † CCHCS changed its specialty policies in April 2019, removing the requirement for primary care physician follow-up visits following most specialty services. As a result, we test 1.008 only for high-priority specialty services or when the staff orders PCP or PC RN follow-ups. The OIG continues to test the clinical appropriateness of specialty follow-ups through its case review testing. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: July 2021 – December 2021 Report Issued: January 2023 Cycle 6, Chuckawalla Valley State Prison | 77 Recommendations • CVSP leadership should ensure that remote telemedicine equipment is working appropriately. • Medical leadership should determine the root cause(s) of challenges to the timely provision of specialty appointments and specialty service follow-up visits and should implement remedial measures as appropriate. • Medical leadership should identify why preapproved specialty appointments were missed for transfer-in patients; leadership should implement remedial measures as appropriate. Office of the Inspector General, State of California Inspection Period: July 2021 – December 2021 Report Issued: January 2023 Cycle 6, Chuckawalla Valley State Prison | 78 Administrative Operations In this indicator, OIG compliance inspectors evaluated health care administrative processes. Our inspectors examined the timeliness of the Overall medical grievance process and checked whether the institution followed Rating reporting requirements for adverse or sentinel events and patient deaths. Inadequate Inspectors checked whether the Emergency Medical Response Review Committee (EMRRC) met and reviewed incident packages. We investigated Case Review and determined whether the institution conducted the required emergency Rating response drills. Inspectors also assessed whether the Quality Management (N/A) Committee (QMC) met regularly and addressed program performance adequately. In addition, the inspectors determined whether the institution Compliance provided training and job performance reviews for its employees. We Score checked whether staff possessed current, valid professional licenses, Inadequate certifications, and credentials. The OIG rated this indicator solely according (71.2%) to the compliance score, using the same scoring thresholds used in the Cycle 4 and Cycle 5 medical inspections. Our case review clinicians do not rate this indicator. Because none of the tests in this indicator affected clinical patient care directly (it is a secondary indicator), the OIG did not consider this indicator’s rating when determining the institution’s overall quality rating. Results Overview CVSP’s performance declined compared with its performance in Cycle 5. The Emergency Medical Response Review Committee (EMRRC) did not always review cases within the required time frames, did not always include case review minutes, or did not always complete the required checklists. In addition, the institution conducted medical emergency response drills with incomplete documentation and incomplete custody participation. Physician managers did not always complete annual or probationary performance appraisals in a timely manner. At the time of our inspection, the nurse educator was not able to provide sufficient documentation that newly hired staff received their onboarding training. These findings are set forth in the table on the next page. Overall, we rated this indicator inadequate. Nonscored Results CVSP did not report any adverse sentinel events requiring root cause analysis during our inspection period (MIT 15.001). CVSP did not report any deaths at the time of our inspection (MIT 15.998). Office of the Inspector General, State of California Inspection Period: July 2021 – December 2021 Report Issued: January 2023 Cycle 6, Chuckawalla Valley State Prison | 79 Compliance Testing Results TTaabbllee 2200.. AAddmmiinniissttrraattiivvee OOppeerraattiioonnss Scored Answer Compliance Questions Yes No N/A Yes % For health care incidents requiring root cause analysis (RCA): Did the N/A N/A N/A N/A institution meet RCA reporting requirements? (15.001) * Did the institution’s Quality Management Committee (QMC) meet 6 0 0 100% monthly? (15.002) For Emergency Medical Response Review Committee (EMRRC) reviewed cases: Did the EMRRC review the cases timely, and did 0 12 0 0 the incident packages the committee reviewed include the required documents? (15.003) For institutions with licensed care facilities: Did the Local Governing Body (LGB) or its equivalent meet quarterly and discuss local N/A N/A N/A N/A operating procedures and any applicable policies? (15.004) Did the institution conduct medical emergency response drills during each watch of the most recent quarter, and did health care and 1 2 0 33.3% custody staff participate in those drills? (15.101) Did the responses to medical grievances address all of the inmates’ 10 0 0 100% appealed issues? (15.102) Did the medical staff review and submit initial inmate death reports N/A N/A N/A N/A to the CCHCS Death Review Unit on time? (15.103) Did nurse managers ensure the clinical competency of nurses who 10 0 0 100% administer medications? (15.104) Did physician managers complete provider clinical performance 2 2 0 50.0% appraisals timely? (15.105) Did the providers maintain valid state medical licenses? (15.106) 8 0 0 100% Did the staff maintain valid Cardiopulmonary Resuscitation (CPR), Basic Life Support (BLS), and Advanced Cardiac Life Support (ACLS) 2 0 1 100% certifications? (15.107) Did the nurses and the pharmacist-in-charge (PIC) maintain valid professional licenses and certifications, and did the pharmacy 5 0 2 100% maintain a valid correctional pharmacy license? (15.108) Did the pharmacy and the providers maintain valid Drug Enforcement 1 0 0 100% Agency (DEA) registration certificates? (15.109) Did nurse managers ensure their newly hired nurses received the 0 1 0 0 required onboarding and clinical competency training? (15.110) This is a nonscored test. Please Did the CCHCS Death Review Committee process death review refer to the discussion in this reports timely? (15.998) indicator. This is a nonscored test. Please What was the institution’s health care staffing at the time of the OIG refer to Table 4 for CCHCS- medical inspection? (15.999) provided staffing information. Overall percentage (MIT 15): 71.2% * Effective March 2021, this test was for informational purposes only. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: July 2021 – December 2021 Report Issued: January 2023 Cycle 6, Chuckawalla Valley State Prison | 80 Recommendations The OIG offers no recommendations for this indicator. Office of the Inspector General, State of California Inspection Period: July 2021 – December 2021 Report Issued: January 2023 Cycle 6, Chuckawalla Valley State Prison | 81 Appendix A. Methodology In designing the medical inspection program, the OIG met with stakeholders to review CCHCS policies and procedures, relevant court orders, and guidance developed by the American Correctional Association. We also reviewed professional literature on correctional medical care; reviewed standardized performance measures used by the health care industry; consulted with clinical experts; and met with stakeholders from the court, the receiver’s office, the department, the Office of the Attorney General, and the Prison Law Office to discuss the nature and scope of our inspection program. With input from these stakeholders, the OIG developed a medical inspection program that evaluates the delivery of medical care by combining clinical case reviews of patient files, objective tests of compliance with policies and procedures, and an analysis of outcomes for certain population- based metrics. We rate each of the quality indicators applicable to the institution under inspection based on case reviews conducted by our clinicians or compliance tests conducted by our registered nurses. Figure A–1 below depicts the intersection of case review and compliance. Figure A–1. Inspection Indicator Rating Distribution for CVSP Office of the Inspector General, State of California Inspection Period: July 2021 – December 2021 Report Issued: January 2023 Cycle 6, Chuckawalla Valley State Prison | 82 Case Reviews The OIG added case reviews to the Cycle 4 medical inspections at the recommendation of its stakeholders, which continues in the Cycle 6 medical inspections. Below, Table A–1 provides important definitions that describe this process. Table A–1. Case Review Definitions Office of the Inspector General, State of California Inspection Period: July 2021 – December 2021 Report Issued: January 2023 Cycle 6, Chuckawalla Valley State Prison | 83 The OIG eliminates case review selection bias by sampling using a rigid methodology. No case reviewer selects the samples he or she reviews. Because the case reviewers are excluded from sample selection, there is no possibility of selection bias. Instead, nonclinical analysts use a standardized sampling methodology to select most of the case review samples. A randomizer is used when applicable. For most basic institutions, the OIG samples 20 comprehensive physician review cases. For institutions with larger high-risk populations, 25 cases are sampled. For the California Health Care Facility, 30 cases are sampled. Case Review Sampling Methodology We obtain a substantial amount of health care data from the inspected institution and from CCHCS. Our analysts then apply filters to identify clinically complex patients with the highest need for medical services. These filters include patients classified by CCHCS with high medical risk, patients requiring hospitalization or emergency medical services, patients arriving from a county jail, patients transferring to and from other departmental institutions, patients with uncontrolled diabetes or uncontrolled anticoagulation levels, patients requiring specialty services or who died or experienced a sentinel event (unexpected occurrences resulting in high risk of, or actual, death or serious injury), patients requiring specialized medical housing placement, patients requesting medical care through the sick call process, and patients requiring prenatal or postpartum care. After applying filters, analysts follow a predetermined protocol and select samples for clinicians to review. Our physician and nurse reviewers test the samples by performing comprehensive or focused case reviews. Case Review Testing Methodology An OIG physician, a nurse consultant, or both review each case. As the clinicians review medical records, they record pertinent interactions between the patient and the health care system. We refer to these interactions as case review events. Our clinicians also record medical errors, which we refer to as case review deficiencies. Deficiencies can be minor or significant, depending on the severity of the deficiency. If a deficiency caused serious patient harm, we classify the error as an adverse event. On the next page, Figure A–2 depicts the possibilities that can lead to these different events. After the clinician inspectors review all the cases, they analyze the deficiencies, then summarize their findings in one or more of the health care indicators in this report. Office of the Inspector General, State of California Inspection Period: July 2021 – December 2021 Report Issued: January 2023 Cycle 6, Chuckawalla Valley State Prison | 84 Figure A–2. Case Review Testing Office of the Inspector General, State of California Inspection Period: July 2021 – December 2021 Report Issued: January 2023 Cycle 6, Chuckawalla Valley State Prison | 85 Compliance Testing Compliance Sampling Methodology Our analysts identify samples for both our case review inspectors and compliance inspectors. Analysts follow a detailed selection methodology. For most compliance questions, we use sample sizes of approximately 25 to 30. Figure A–3 below depicts the relationships and activities of this process. Figure A–3. Compliance Sampling Methodology Compliance Testing Methodology Our inspectors answer a set of predefined medical inspection tool (MIT) questions to determine the institution’s compliance with CCHCS policies and procedures. Our nurse inspectors assign a Yes or a No answer to each scored question. OIG headquarters nurse inspectors review medical records to obtain information, allowing them to answer most of the MIT questions. Our regional nurses visit and inspect each institution. They interview health care staff, observe medical processes, test the facilities and clinics, review employee records, logs, medical grievances, death reports, and other documents, and obtain information regarding plant infrastructure and local operating procedures. Office of the Inspector General, State of California Inspection Period: July 2021 – December 2021 Report Issued: January 2023 Cycle 6, Chuckawalla Valley State Prison | 86 Scoring Methodology Our compliance team calculates the percentage of all Yes answers for each of the questions applicable to a particular indicator, then averages the scores. The OIG continues to rate these indicators based on the average compliance score using the following descriptors: proficient (85.0 percent or greater), adequate (between 84.9 percent and 75.0 percent), or inadequate (less than 75.0 percent). Indicator Ratings and the Overall Medical Quality Rating To reach an overall quality rating, our inspectors collaborate and examine all the inspection findings. We consider the case review and the compliance testing results for each indicator. After considering all the findings, our inspectors reach consensus on an overall rating for the institution. Office of the Inspector General, State of California Inspection Period: July 2021 – December 2021 Report Issued: January 2023 Cycle 6, Chuckawalla Valley State Prison | 87 Appendix B. Case Review Data Table B–1. CVSP Case Review Sample Sets Sample Set Total Anticoagulation 3 CTC / OHU 3 Diabetes 3 Emergency Services – Non-CPR 3 High Risk 4 Hospitalization 5 Intra-system Transfers-In 3 Intra-system Transfers-Out 3 RN Sick Call 12 Specialty Services 2 41 Office of the Inspector General, State of California Inspection Period: July 2021 – December 2021 Report Issued: January 2023 Cycle 6, Chuckawalla Valley State Prison | 88 Table B–2. CVSP Case Review Chronic Care Diagnoses Diagnosis Total Anemia 4 Anticoagulation 2 Arthritis/Degenerative Joint Disease 5 Asthma 4 COVID-19 3 Cancer 4 Cardiovascular Disease 7 Chronic Kidney Disease 1 Chronic Pain 15 Cirrhosis/End-Stage Liver Disease 2 Deep Venous Thrombosis/Pulmonary Embolism 2 Diabetes 8 Gastroesophageal Reflux Disease 11 Hepatitis C 6 Hyperlipidemia 21 Hypertension 18 Mental Health 3 Substance Abuse 4 Thyroid Disease 2 122 Office of the Inspector General, State of California Inspection Period: July 2021 – December 2021 Report Issued: January 2023 Cycle 6, Chuckawalla Valley State Prison | 89 Table B–3. Case Review Events by Program Program Total Diagnostic Services 238 Emergency Care 26 Hospitalization 39 Intra-system Transfers-In 16 Intra-system Transfers-Out 6 Outpatient Care 395 Specialized Medical Housing 65 Specialty Services 119 904 Table B–4. Case Review Sample Summary MD Reviews Detailed 20 MD Reviews Focused 0 RN Reviews Detailed 13 RN Reviews Focused 19 Total Reviews 52 Total Unique Cases 41 Overlapping Reviews (MD & RN) 11 Office of the Inspector General, State of California Inspection Period: July 2021 – December 2021 Report Issued: January 2023 Cycle 6, Chuckawalla Valley State Prison | 90 Appendix C. Compliance Sampling Methodology Chuckawalla Valley State Prison Quality No. of Indicator Sample Category Samples Data Source Filters Access to Care MIT 1.001 Chronic Care 25 Master Registry • Chronic care conditions (at least Patients one condition per patient—any risk level) • Randomize MIT 1.002 Nursing Referrals 25 OIG Q: 6.001 • See Transfers MITs 1.003–006 Nursing Sick Call 30 Clinic Appointment • Clinic (each clinic tested) (6 per clinic) List • Appointment date (2–9 months) • Randomize MIT 1.007 Returns From 25 OIG Q: 4.005 • See Health Information Community Management (Medical Records) Hospital (returns from community hospital) MIT 1.008 Specialty Services 45 OIG Q: 14.001, • See Specialty Services Follow-Up 14.004 & 14.007 MIT 1.101 Availability of 6 OIG on-site review • Randomly select one housing unit Health Care from each yard Services Request Forms Diagnostic Services MITs 2.001–003 Radiology 10 Radiology Logs • Appointment date (90 days–9 months) • Randomize • Abnormal MITs 2.004–006 Laboratory 10 Quest • Appt. date (90 days–9 months) • Order name (CBC or CMPs only) • Randomize • Abnormal MITs 2.007–009 Laboratory STAT 2 Quest • Appt. date (90 days–9 months) • Order name (CBC or CMPs only) • Randomize • Abnormal MITs 2.010–012 Pathology 10 InterQual • Appt. date (90 days–9 months) • Service (pathology related) • Randomize Office of the Inspector General, State of California Inspection Period: July 2021 – December 2021 Report Issued: January 2023 Cycle 6, Chuckawalla Valley State Prison | 91 Quality No. of Indicator Sample Category Samples Data Source Filters Health Information Management (Medical Records) MIT 4.001 Health Care Services 20 OIG Qs: 1.004 • Nondictated documents Request Forms • First 20 IPs for MIT 1.004 MIT 4.002 Specialty Documents 45 OIG Qs: 14.002, • Specialty documents 14.005 & 14.008 • First 10 IPs for each question MIT 4.003 Hospital Discharge 25 OIG Q: 4.005 • Community hospital discharge Documents documents • First 20 IPs selected MIT 4.004 Scanning Accuracy 24 Documents for any • Any misfiled or mislabeled tested inmate document identified during OIG compliance review (24 or more = No) MIT 4.005 Returns From 25 CADDIS Off-site • Date (2–8 months) Community Hospital Admissions • Most recent 6 months provided (within date range) • Rx count • Discharge date • Randomize Health Care Environment MITs 5.101–105 Clinical Areas 8 OIG inspector • Identify and inspect all on-site MITs 5.107–111 on-site review clinical areas. Transfers MITs 6.001–003 Intrasystem Transfers 25 SOMS • Arrival date (3–9 months) • Arrived from (another departmental facility) • Rx count • Randomize MIT 6.101 Transfers Out 0 OIG inspector • R&R IP transfers with medication on-site review Office of the Inspector General, State of California Inspection Period: July 2021 – December 2021 Report Issued: January 2023 Cycle 6, Chuckawalla Valley State Prison | 92 Quality No. of Indicator Sample Category Samples Data Source Filters Pharmacy and Medication Management MIT 7.001 Chronic Care 25 OIG Q: 1.001 See Access to Care Medication • At least one condition per patient—any risk level • Randomize MIT 7.002 New Medication 25 Master Registry • Rx count Orders • Randomize • Ensure no duplication of IPs tested in MIT 7.001 MIT 7.003 Returns From 25 OIG Q: 4.005 • See Health Information Community Hospital Management (Medical Records) (returns from community hospital) MIT 7.004 RC Arrivals— N/A at this OIG Q: 12.001 • See Reception Center Medication Orders institution MIT 7.005 Intrafacility Moves 25 MAPIP transfer • Date of transfer (2–8 months) data • To location/from location (yard to yard and to/from ASU) • Remove any to/from MHCB • NA/DOT meds (and risk level) • Randomize MIT 7.006 En Route 8 SOMS • Date of transfer (2–8 months) • Sending institution (another departmental facility) • Randomize • NA/DOT meds MITs 7.101–103 Medication Storage Varies OIG inspector • Identify and inspect clinical Areas by test on-site review & med line areas that store medications MITs 7.104–107 Medication Varies OIG inspector • Identify and inspect on-site Preparation and by test on-site review clinical areas that prepare and Administration Areas administer medications MITs 7.108–111 Pharmacy 1 OIG inspector • Identify & inspect all on-site on-site review pharmacies MIT 7.112 Medication Error 10 Medication error • All medication error reports with Reporting reports Level 4 or higher • Select total of 25 medication error reports (recent 12 months) MIT 7.999 Restricted Unit 0 On-site active • KOP rescue inhalers & KOP Medications medication listing nitroglycerin medications for IPs housed in restricted units Office of the Inspector General, State of California Inspection Period: July 2021 – December 2021 Report Issued: January 2023 Cycle 6, Chuckawalla Valley State Prison | 93 Quality No. of Indicator Sample Category Samples Data Source Filters Prenatal and Postpartum Care MITs 8.001–007 Recent Deliveries N/A at this OB Roster • Delivery date (2–12 months) institution • Most recent deliveries (within date range) Pregnant Arrivals N/A at this OB Roster • Arrival date (2–12 months) institution • Earliest arrivals (within date range) Preventive Services MITs 9.001–002 TB Medications 15 Maxor • Dispense date (past 9 months) • Time period on TB meds (3 months or 12 weeks) • Randomize MIT 9.003 TB Evaluation, 25 SOMS • Arrival date (at least 1 year prior Annual Screening to inspection) • Birth month • Randomize MIT 9.004 Influenza 25 SOMS • Arrival date (at least 1 year prior Vaccinations to inspection) • Randomize • Filter out IPs tested in MIT 9.008 MIT 9.005 Colorectal Cancer 25 SOMS • Arrival date (at least 1 year prior Screening to inspection) • Date of birth (51 or older) • Randomize MIT 9.006 Mammogram N/A at this SOMS • Arrival date (at least 2 yrs. prior institution to inspection) • Date of birth (age 52–74) • Randomize MIT 9.007 Pap Smear N/A at this SOMS • Arrival date (at least three yrs. institution prior to inspection) • Date of birth (age 24–53) • Randomize MIT 9.008 Chronic Care 25 OIG Q: 1.001 • Chronic care conditions (at least Vaccinations 1 condition per IP—any risk level) • Randomize • Condition must require vaccination(s) MIT 9.009 Valley Fever N/A at this Cocci transfer • Reports from past 2–8 months institution status report • Institution • Ineligibility date (60 days prior to inspection date) • All Office of the Inspector General, State of California Inspection Period: July 2021 – December 2021 Report Issued: January 2023 Cycle 6, Chuckawalla Valley State Prison | 94 Quality No. of Indicator Sample Category Samples Data Source Filters Reception Center MITs 12.001–008 RC N/A at this SOMS • Arrival date (2–8 months) institution • Arrived from (county jail, return from parole, etc.) • Randomize Specialized Medical Housing MITs 13.001–004 Specialized Health 10 CADDIS • Admit date (2–8 months) Care Housing Unit • Type of stay (no MH beds) • Length of stay (minimum of 5 days) • Rx count • Randomize MITs 13.101–102 Call Buttons All OIG inspector • Specialized Health Care Housing on-site review • Review by location Specialty Services MITs 14.001–003 High-Priority 15 Specialty Services • Approval date (3–9 months) Initial and Follow-Up Appointments • Remove consult to audiology, RFS chemotherapy, dietary, Hep C, HIV, orthotics, gynecology, consult to public health/Specialty RN, dialysis, ECG 12-Lead (EKG), mammogram, occupational therapy, ophthalmology, optometry, oral surgery, physical therapy, physiatry, podiatry, and radiology services • Randomize Office of the Inspector General, State of California Inspection Period: July 2021 – December 2021 Report Issued: January 2023 Cycle 6, Chuckawalla Valley State Prison | 95 MITs 14.004–006 Medium-Priority 15 Specialty Services • Approval date (3–9 months) Initial and Follow-Up Appointments • Remove consult to audiology, RFS chemotherapy, dietary, Hep C, HIV, orthotics, gynecology, consult to public health/Specialty RN, dialysis, ECG 12-Lead (EKG), mammogram, occupational therapy, ophthalmology, optometry, oral surgery, physical therapy, physiatry, podiatry, and radiology services • Randomize MITs 14.007–009 Routine Initial and 15 Specialty Services • Approval date (3–9 months) Follow-Up RFS Appointments • Remove consult to audiology, chemotherapy, dietary, Hep C, HIV, orthotics, gynecology, consult to public health/Specialty RN, dialysis, ECG 12-Lead (EKG), mammogram, occupational therapy, ophthalmology, optometry, oral surgery, physical therapy, physiatry, podiatry, and radiology services • Randomize MIT 14.010 Specialty Services 20 Specialty Service • Arrived from (other departmental Arrivals Arrivals institution) • Date of transfer (3–9 months) • Randomize MITs 14.011–012 Denials 20 InterQual • Review date (3–9 months) • Randomize N/A IUMC/MAR • Meeting date (9 months) Meeting Minutes • Denial upheld • Randomize Office of the Inspector General, State of California Inspection Period: July 2021 – December 2021 Report Issued: January 2023 Cycle 6, Chuckawalla Valley State Prison | 96 Quality No. of Indicator Sample Category Samples Data Source Filters Administrative Operations MIT 15.001 Adverse/sentinel 0 Adverse/sentinel • Adverse/sentinel events events (ASE) events report (2–8 months) MIT 15.002 QMC Meetings 6 Quality • Meeting minutes (12 months) Management Committee meeting minutes MIT 15.003 EMRRC 12 EMRRC meeting • Monthly meeting minutes minutes (6 months) MIT 15.004 LGB N/A at LGB meeting • Quarterly meeting minutes this minutes (12 months) institution MIT 15.101 Medical Emergency 3 On-site summary • Most recent full quarter Response Drills reports & • Each watch documentation for ER drills MIT 15.102 Institutional Level 10 On-site list of • Medical grievances closed Medical Grievances grievances/closed (6 months) grievance files MIT 15.103 Death Reports 0 Institution-list of • Most recent 10 deaths deaths in prior • Initial death reports 12 months MIT 15.104 Nursing Staff 10 On-site nursing • On duty one or more years Validations education files • Nurse administers medications • Randomize MIT 15.105 Provider Annual 4 On-site • All required performance Evaluation Packets provider evaluation documents evaluation files MIT 15.106 Provider Licenses 8 Current provider • Review all listing (at start of inspection) MIT 15.107 Medical Emergency All On-site • All staff Response certification ◦ Providers (ACLS) Certifications tracking logs ◦ Nursing (BLS/CPR) • Custody (CPR/BLS) MIT 15.108 Nursing Staff and All On-site tracking • All required licenses and Pharmacist in Charge system, logs, or certifications Professional Licenses employee files and Certifications Office of the Inspector General, State of California Inspection Period: July 2021 – December 2021 Report Issued: January 2023 Cycle 6, Chuckawalla Valley State Prison | 97 Quality No. of Indicator Sample Category Samples Data Source Filters Administrative Operations MIT 15.109 Pharmacy and All On-site listing • All DEA registrations Providers’ Drug of provider DEA Enforcement Agency registration #s (DEA) Registrations & pharmacy registration document MIT 15.110 Nursing Staff New All Nursing staff • New employees (hired within last Employee Orientations training logs 12 months) MIT 15.998 Death Review 0 OIG summary log: • Between 35 business days & Committee deaths 12 months prior • California Correctional Health Care Services death reviews Office of the Inspector General, State of California Inspection Period: July 2021 – December 2021 Report Issued: January 2023 Cycle 6, Chuckawalla Valley State Prison | 98 (This page left blank for reproduction purposes.) Office of the Inspector General, State of California Inspection Period: July 2021 – December 2021 Report Issued: January 2023 Cycle 6, Chuckawalla Valley State Prison | 99 California Correctional Health Care Services’ Response  
 

       January 19, 2023 Amarik Singh, Inspector General Office of the Inspector General 10111 Old Placerville Road, Suite 110 Sacramento, CA 95827 Dear Ms. Singh: The Office of the Receiver has reviewed the draft Medical Inspection Report for Chuckawalla Valley State Prison (CVSP) conducted by the Office of the Inspector General (OIG) from July to December 2021. California Correctional Health Care Services (CCHCS) acknowledges the OIG findings. Thank you for preparing the report. Your efforts have advanced our mutual objective of ensuring transparency and accountability in CCHCS operations. If you have any questions or concerns, please contact me at (916) 896-6780. Sincerely, Robin Hart Associate Director Policy and Risk Management Services California Correctional Health Care Services cc: Diana Toche, D.D.S., Undersecretary, Health Care Services, CDCR Clark Kelso, Receiver Directors, CCHCS Roscoe Barrow, Chief Counsel, CCHCS Office of Legal Affairs Renee Kanan, M.D., Deputy Director, Medical Services, CCHCS Barbara Barney-Knox, R.N., Deputy Director, Nursing Services, CCHCS Annette Lambert, Deputy Director, Quality Management, CCHCS DeAnna Gouldy, Deputy Director, Policy and Risk Management Branch, CCHCS Regional Executives, Region IV, CCHCS Chief Executive Officer, CVSP Katherine Tebrock, Chief Assistant Inspector General, OIG Doreen Pagaran, R.N., Nurse Consultant Program Review, OIG Misty Polasik, Staff Services Manager I, OIG P.O. Box 588500 Elk Grove, CA 95758 Office of the Inspector General, State of California Inspection Period: July 2021 – December 2021 Report Issued: January 2023 Cycle 6 Medical Inspection Report for Chuckawalla Valley State Prison OFFICE of the INSPECTOR GENERAL Amarik K. Singh Inspector General Neil Robertson Chief Deputy Inspector General STATE of CALIFORNIA January 2023 OIG