Chuckawalla Valley State Prison Medical Inspection Report Cycle 4

Robert A. Barton Office of the Inspector General Inspector General Chuckawalla Valley State Prison Medical Inspection Results Cycle 4 September 2015 Medical Inspection Unit Page 1 Office of the Inspector General State of California Office of the Inspector General CHUCKAWALLA VALLEY STATE PRISON Medical Inspection Results Cycle 4 Robert A. Barton Inspector General Roy W. Wesley Chief Deputy Inspector General Shaun R. Spillane Public Information Officer September 2015 TABLE OF CONTENTS Executive Summary ............................................................................................................................. i Overall Assessment: Adequate ....................................................................................... iii Clinical Case Review and OIG Clinician Inspection Results ......................................... iii Compliance Testing Results ........................................................................................... iv Population-Based Metrics ............................................................................................... ix Introduction ......................................................................................................................................... 1 About the Institution............................................................................................................................ 1 Objectives, Scope, and Methodology .................................................................................................. 4 Case Reviews ................................................................................................................................ 5 Patient Selection for Retrospective Case Reviews ................................................................. 5 Benefits and Limitations of Targeted Subpopulation Review ............................................... 6 Case Reviews Sampled .......................................................................................................... 7 Compliance Testing ...................................................................................................................... 8 Sampling Methods for Conducting Compliance Testing ....................................................... 8 Scoring of Compliance Testing Results ................................................................................. 8 Dashboard Comparisons ........................................................................................................ 9 Overall Quality Indicator Rating for Case Reviews and Compliance Testing ............................. 9 Population-Based Metrics ........................................................................................................... 10 Medical Inspection Results ............................................................................................................... 11 Primary (Clinical) Quality Indicators of Health Care ................................................................. 11 Access to Care ...................................................................................................................... 12 Case Review Results...................................................................................................... 12 Compliance Testing Results .......................................................................................... 12 CCHCS Dashboard Comparative Data .......................................................................... 14 Recommendation ........................................................................................................... 14 Diagnostic Services .............................................................................................................. 15 Case Review Results...................................................................................................... 15 Compliance Testing Results .......................................................................................... 15 Recommendation ........................................................................................................... 16 Emergency Services ............................................................................................................. 17 Case Review Results...................................................................................................... 17 Recommendations.......................................................................................................... 18 Health Information Management (Medical Records) .......................................................... 19 Case Review Results...................................................................................................... 19 Compliance Testing Results .......................................................................................... 20 CCHCS Dashboard Comparative Data .......................................................................... 22 Recommendations.......................................................................................................... 23 Health Care Environment .................................................................................................... 24 Compliance Testing Results .......................................................................................... 24 Recommendations.......................................................................................................... 27 Inter- and Intra-System Transfers ........................................................................................ 28 Chuckawalla Valley State Prison, Cycle 4 Medical Inspection Table of Contents Office of the Inspector General State of California Case Review Results...................................................................................................... 28 Compliance Testing Results .......................................................................................... 30 Recommendations.......................................................................................................... 31 Pharmacy and Medication Management ............................................................................. 32 Case Review Results...................................................................................................... 32 Compliance Testing Results .......................................................................................... 33 CCHCS Dashboard Comparative Data .......................................................................... 36 Recommendations.......................................................................................................... 36 Preventive Services .............................................................................................................. 38 Compliance Testing Results .......................................................................................... 38 CCHCS Dashboard Comparative Data .......................................................................... 39 Recommendations.......................................................................................................... 39 Quality of Nursing Performance .......................................................................................... 40 Case Review Results...................................................................................................... 40 Recommendations.......................................................................................................... 41 Quality of Provider Performance ......................................................................................... 42 Case Review Results...................................................................................................... 42 Recommendations.......................................................................................................... 45 Specialty Services ................................................................................................................. 46 Case Review Results...................................................................................................... 46 Compliance Testing Results .......................................................................................... 47 Recommendations.......................................................................................................... 48 Secondary (Administrative) Quality Indicators of Health Care ................................................. 49 Internal Monitoring, Quality Improvement, and Administrative Operations ...................... 50 Compliance Testing Results .......................................................................................... 50 CCHCS Dashboard Comparative Data .......................................................................... 52 Recommendations.......................................................................................................... 52 Job Performance, Training, Licensing, and Certifications .................................................. 53 Compliance Testing Results .......................................................................................... 53 Recommendations.......................................................................................................... 54 Population-Based Metrics ........................................................................................................... 55 Appendix A—Compliance Test Results ........................................................................................... 60 Appendix B—Clinical Data .............................................................................................................. 74 Appendix C—Compliance Sampling Methodology ......................................................................... 77 California Correctional Health Care Services’ Response ................................................................. 82 Chuckawalla Valley State Prison, Cycle 4 Medical Inspection Table of Contents Office of the Inspector General State of California LIST OF TABLES AND FIGURES Health Care Quality Indicators ............................................................................................................ ii CVSP Executive Summary Table ....................................................................................................... x CVSP Health Care Staffing Resources—May 2015 ........................................................................... 2 CVSP Master Registry Data as of June 15, 2015 ................................................................................ 2 Abbreviations Used in This Report ..................................................................................................... 3 Access to Care—CVSP Dashboard and OIG Compliance Results ................................................... 14 Health Information Management—CVSP Dashboard and OIG Compliance Results ...................... 22 Pharmacy and Medication Management—CVSP Dashboard and OIG Compliance Results .......... 36 Preventive Services—CVSP Dashboard and OIG Compliance Results ........................................... 39 Internal Monitoring, Quality Improvement, and Administrative Operations— CVSP Dashboard and OIG Compliance Results ........................................................................ 52 Table 1—CVSP Results Compared to State and National HEDIS Scores........................................ 58 Table 2—CVSP Results Compared to Medi-Cal Minimum and Maximum Performance ............... 59 Chuckawalla Valley State Prison, Cycle 4 Medical Inspection List of Tables and Figures Office of the Inspector General State of California EXECUTIVE SUMMARY Under the authority of California Penal Code Section 6126, which assigns the Office of the Inspector General (OIG) responsibility for oversight of the California Department of Corrections and Rehabilitation (CDCR), the OIG conducts a comprehensive inspection program to evaluate the delivery of medical care at each of CDCR’s 35 adult prisons. The OIG explicitly makes no determination regarding the constitutionality of care in the prison setting. That determination is left to the Receiver and the federal court. The assessment of care by the OIG is just one factor in the court’s determination whether care in the prison meets constitutional standards. The court may find that an institution that the OIG found to be providing adequate care still does not meet constitutional standards, depending on the analysis of the underlying data provided by the OIG. Likewise, an institution that has been rated inadequate by the OIG could still be found to pass constitutional muster with the implementation of remedial measures if the underlying data were to reveal easily mitigated deficiencies. The OIG’s inspections are mandated by the Penal Code and not aimed at specifically resolving the court’s questions on constitutional care. To the degree that they provide another factor for the court to consider, the OIG is pleased to provide added value to the taxpayers of California. To augment further the breadth and quality of the OIG’s medical inspection program, for this fourth cycle of inspections the OIG added a clinical case review component and significantly enhanced the compliance portion of the inspection process from that used in prior cycles. In addition, the OIG added a population-based metric comparison of selected Healthcare Effectiveness Data Information Set (HEDIS) measures from other State and national health care organizations and compared that data to similar results for Chuckawalla Valley State Prison (CVSP). The OIG performed its Cycle 4 medical inspection at CVSP from May to July 2015. The inspection included in-depth reviews of 62 inmate-patient files conducted by clinicians as well as reviews of documents from 369 inmate-patient files, covering 87 objectively scored tests of compliance with policies and procedures applicable to the delivery of medical care. The OIG assessed the case review and compliance results at CVSP using 13 health care quality indicators applicable to the institution, made up of 11 primary clinical indicators and 2 secondary administrative indicators. Of the 11 primary indicators, 6 were rated by both case review clinicians and compliance inspectors, 3 were rated by case review clinicians only, and 2 were rated by compliance inspectors only; both secondary indicators were rated by compliance inspectors only. See the Health Care Quality Indicators table on page ii. Based on that analysis, OIG experts made a considered and measured overall opinion that the quality of health care was adequate. Chuckawalla Valley State Prison, Cycle 4 Medical Inspection Page i Office of the Inspector General State of California Health Care Quality Indicators All Institutions– CVSP Fourteen Primary Indicators (Clinical) Applicability Applicability Both case review 1–Access to Care All institutions and compliance Both case review 2–Diagnostic Services All institutions and compliance 3–Emergency Services All institutions Case review only 4–Health Information Management Both case review All institutions (Medical Records) and compliance 5–Health Care Environment All institutions Compliance only Both case review 6–Inter- and Intra-System Transfers All institutions and compliance Both case review 7–Pharmacy and Medication Management All institutions and compliance Female institutions 8–Prenatal and Post-Delivery Services Not Applicable only 9–Preventive Services All institutions Compliance only 10–Quality of Nursing Performance All institutions Case review only 11–Quality of Provider Performance All institutions Case review only Institutions with 12–Reception Center Arrivals Not Applicable reception centers All institutions with 13–Specialized Medical Housing an OHU, CTC, SNF, Not Applicable (OHU, CTC, SNF, Hospice) or Hospice Both case review 14–Specialty Services All institutions and compliance Two Secondary Indicators All Institutions– CVSP (Administrative) Applicability Applicability 15–Internal Monitoring, Quality Improvement, and Administrative All institutions Compliance only Operations 16–Job Performance, Training, Licensing, All institutions Compliance only and Certifications Chuckawalla Valley State Prison, Cycle 4 Medical Inspection Page ii Office of the Inspector General State of California Overall Assessment: Adequate Based on the clinical case reviews, compliance testing, and population-based metrics, the OIG’s overall assessment rating for Overall Assessment CVSP was adequate. For the 11 primary (clinical) quality Rating: indicators applicable to CVSP, the OIG found one proficient, eight adequate, and two inadequate. For the two secondary Adequate (administrative) quality indicators, the OIG found one adequate and one inadequate. To determine the overall assessment for CVSP, the OIG considered individual clinical ratings and individual compliance question scores within each of the indicator categories, putting emphasis on the primary indicators. Based on that analysis, OIG experts made a considered and measured overall opinion about the quality of health care observed at CVSP. Clinical Case Review and OIG Clinician Inspection Results The OIG’s clinical case review results contributed to CVSP’s overall rating of adequate. The clinicians’ case reviews sampled patients with high medical needs and included a review of 853 patient care events. For the 11 primary indicators applicable to CVSP, 9 were evaluated by clinician case review; 2 were proficient, and 7 were adequate. When determining the overall adequacy of care, the OIG placed extra emphasis on the clinical nursing and provider quality indicators, as adequate health care staff can sometimes overcome suboptimal processes and programs. However, the opposite is not true; inadequate health care staff cannot provide adequate care, even though the established processes and programs onsite may be adequate. Program Strengths  Medical management at Chuckawalla Valley State Prison led with a strong commitment to excellence and continuous quality improvement. Providers and nurses felt their management team supported them.  The institution employed providers of sufficient quality to mitigate many of the deficiencies identified in this report.  During the period of review, CVSP provided excellent access to primary care services.  During the period of review, CVSP provided excellent diagnostic services; staff performed diagnostic tests, providers reviewed results, and patients were notified of results in a timely manner.  During the period of review, CVSP providers routinely updated patients’ problem lists. Chuckawalla Valley State Prison, Cycle 4 Medical Inspection Page iii Office of the Inspector General State of California Program Weaknesses  Providers reported not having access to patients’ electronic unit health records (eUHR) when on call (after hours). This was evident on several occasions when on-call providers unfamiliar with patients’ medical histories prescribed inappropriate medications. Providers did not use the previous eUHR laptop access primarily because of the long time required to obtain medical records. The future electronic medical record system has an opportunity to provide a more practical after-hours access.  A pattern of practice creating a potential for medication errors upon patients’ returning from hospitalization was noted. The medications at this institution were not discontinued when transferring a patient to a community hospital for admission. As such, there were instances when medication changes by the hospital were missed. Discussion with CVSP’s medical management revealed that plans were already being made to remedy this issue.  CVSP’s Emergency Medical Response Review Committee (EMRRC) did not appropriately audit all nonscheduled ground transports. Additionally, the committee did not routinely follow up on recommendations by the EMRRC, e.g., training.  Several indicators showed a pattern of incomplete patient assessment or incomplete documentation of health care records by nursing staff.  CVSP currently acts as the “hub” for patients returning from California Out-of-State Correctional Facilities (COCF). As CVSP’s infrastructure was not designed to handle this additional load of inmate-patients, it causes strain on CVSP’s resources. This is further described in the Inter- and Intra-System Transfers section. Compliance Testing Results The OIG’s compliance testing results contributed to CVSP’s overall rating of adequate. Of the 13 total indicators of health care applicable to CVSP, compliance inspectors evaluated 10. There were 87 individual compliance questions within those 10 indicators that tested CVSP’s compliance with California Correctional Health Care Services (CCHCS) policies and procedures.1 Those 87 questions are detailed in Appendix A—Compliance Test Results. The institution’s inspection scores for the 10 applicable indicators ranged from 39.8 percent to 90.8 percent, with the secondary (administrative) indicator Internal Monitoring, Quality Improvement, and Administrative Operations receiving the lowest score, and the primary (clinical) indicator Inter- and Intra-System Transfers receiving the highest. For the eight primary indicators applicable to compliance testing, 1 The OIG used its own clinicians to provide clinical expert guidance for testing compliance in certain areas where CCHCS policies and procedures did not specifically address an issue. Chuckawalla Valley State Prison, Cycle 4 Medical Inspection Page iv Office of the Inspector General State of California the OIG rated three proficient, three adequate, and two inadequate. For the two secondary indicators, which involve administrative health care functions, one was rated adequate and the other inadequate. Program Strengths As the CVSP Executive Summary Table on page x indicates, the institution’s compliance scores were in the proficient range for the following three indicators: Diagnostic Services (86.4 percent), Inter- and Intra-System Transfers (90.8 percent), and Specialty Services (87.9 percent). The following are some of CVSP’s strengths based on its compliance scores for individual questions within all primary health care indicators:  Nursing staff timely reviewed patient health service requests and timely completed face-to-face visits.  Inmate-patients seen by a provider received a recommended follow-up appointment within the provider’s ordered time frame.  The institution ensured that inmate-patients timely received their radiology and laboratory diagnostic services. In addition, providers reviewed and communicated radiology and laboratory services test results to the inmate-patients within the required time frames.  Health information management staff timely scanned non-dictated progress notes, initial health screening forms, and health care service request forms into patients’ health record files. They also timely scanned medication administration records for patients who received chronic care medications.  CVSP ensured clinical health care areas were appropriately disinfected, cleaned, and sanitary; clinics contained operable sinks and had sufficient quantities of hygiene supplies.  Clinical staff followed proper hand hygiene practices during patient encounters.  For patients who transferred into CVSP from another CDCR institution, nursing staff completed the assessment and disposition section of the Initial Health Screening (Form 7277) on the same day medical staff completed an initial screening of the patient.  CVSP ensured transfer packets prepared for inmate-patients transferring out of the facility included required medications and related documentation.  The institution timely dispensed chronic care medications to inmate-patients with chronic illnesses. Chuckawalla Valley State Prison, Cycle 4 Medical Inspection Page v Office of the Inspector General State of California  Nursing staff timely administered newly ordered prescriptions to patients and ensured that patients who transferred from one housing unit to another received their prescribed medications without interruption.  Clinic and medication line storage locations properly stored non-refrigerated, non-narcotic medications.  Nursing staff practiced appropriate administrative controls and protocols when they prepared medication for patients.  The main pharmacy was secure, organized, and clean; it properly stored refrigerated and non-refrigerated medications and maintained an accurate record of custody over narcotic medications. The pharmacist-in-charge followed key medication error reporting protocols for identified errors.  The institution timely administered anti-tuberculosis medication to patients with tuberculosis and was prompt in offering patients required preventive services, such as influenza vaccinations and screenings for colorectal cancer. In addition, health care staff timely offered required immunizations to patients suffering from chronic care illnesses.  High-priority and routine specialty service appointments occurred timely. In addition, PCPs reviewed high-priority specialty service consultant reports timely.  When clinical staff denied specialty service requests, they processed those denials timely. Also, providers communicated the denials to the inmate-patients within required time frames. The following are some of the strengths identified within the two secondary administrative indicators:  The institution processed inmate medical appeals timely during the last 12 months. In addition, the institution’s second-level medical appeal responses addressed all of the patients’ appealed issues.  Providers, the pharmacist-in-charge, and the pharmacy had current licenses and registrations.  Supervising nurses conducted required periodic reviews of sampled nursing staff.  Sampled nursing staff were current on training requirements, licenses, and certifications. Chuckawalla Valley State Prison, Cycle 4 Medical Inspection Page vi Office of the Inspector General State of California  All staff were current with required medical emergency response certifications. Program Weaknesses The institution received ratings in the inadequate range for the following primary indicators: Health Information Management (68.6 percent) and Health Care Environment (66.4 percent). The institution also received an inadequate rating in the secondary indicator Internal Monitoring, Quality Improvement, and Administrative Operations (39.8 percent). The following are some of the weaknesses identified, based on CVSP’s compliance scores for individual questions within all primary health care indicators:  When inmate-patients who transferred into CVSP were referred to a PCP for a routine appointment based on nursing staff’s initial health care screening, the institution did not always ensure the patient was seen timely.  Many sampled inmate-patients under providers’ care for one or more chronic conditions received untimely appointments with PCPs; PCP follow-up visits subsequent to patients’ specialty appointments were also untimely.  The institution did not always obtain final pathology reports; providers did not always provide evidence of their review of the reports and did not always communicate the results of diagnostic pathology reports to patients.  Health information management staff incorrectly labeled some of the health care documents in patients’ eUHRs. In addition, the institution did not always timely scan specialty service consultant reports, community hospital discharge documents, and transcribed provider progress notes into patients’ eUHRs. Further, clinical staff did not always legibly sign or print their names on health care documents.  In some clinics, reusable invasive and non-invasive medical equipment was not properly sterilized or disinfected. In addition, clinics were missing equipment and supplies needed to properly conduct comprehensive exams and manage contaminated waste; some emergency response bags were either missing supplies or contained expired supplies, and oxygen tanks were not fully charged. Also, the space or configuration of furniture in some exam rooms was not optimal for conducting clinical exams or other health screenings.  Some patients failed to receive their community hospital discharge medications within one calendar day of their return to CVSP. In addition, if inmate-patients had a temporary layover at the institution, CVSP often failed to administer their medications without interruption. Chuckawalla Valley State Prison, Cycle 4 Medical Inspection Page vii Office of the Inspector General State of California  At half of the medication line locations inspected, nursing staff exhibited poor medication security controls over narcotic medications. Also, several medication administration locations where patients waited in line outdoors to receive their medication lacked covered areas providing patients protection from extreme weather.  Refrigerator temperature logs for the storage of non-narcotic medications at some clinic and medication line locations revealed the institution failed to maintain temperatures within policy guidelines. In some instances, daily temperature logs were not completed.  Patients’ annual tuberculosis screening results were read and documented by a licensed vocational nurse rather than a registered nurse, public health nurse, or provider. Also, for patients who received anti-tuberculosis medications, the institution did not always timely scan relevant monitoring information into the patients’ eUHRs.  The institution did not always provide timely specialty service appointments to inmate-patients who transferred into CVSP with previously approved or scheduled specialty appointments at the sending institution. Further, PCPs did not always review specialty service consultant reports within three business days after the service. The following are some of the weaknesses identified within the two secondary administrative indicators:  Quality Management Committee (QMC) meeting minutes did not demonstrate the institution evaluated clinical program performance or discussed steps taken to validate the accuracy of the performance data reported.  CVSP did not improve performance, reach its performance objectives, or identify the status of performance objectives for all quality improvement initiatives identified in its 2014 Performance Improvement Work Plan.  The warden and the chief executive officer (CEO) did not sign the Emergency Medical Response Review Committee (EMRRC) meeting minutes as required by policy.  Medical emergency response drill packets did not include all required documentation.  Providers did not always timely conduct required probationary or annual appraisals.  CVSP did not provide job-duty-specific new employee orientation training to nursing staff hired within the last year. Chuckawalla Valley State Prison, Cycle 4 Medical Inspection Page viii Office of the Inspector General State of California Population-Based Metrics In general, CVSP performed well for population-based metrics. For the comprehensive diabetes care, CVSP outperformed other State and national organizations in each of the measures, with one exception. For monitoring of diabetic patients, the U.S. Department of Veterans Affairs (VA) scored just two percentage points higher than CVSP’s score of 97 percent. CVSP outperformed Kaiser Permanente’s (statewide) rates, typically one of the highest-scoring health organizations in California. With regard to immunization measures, CVSP’s rates were higher than those reported by Kaiser Permanente and national commercial health plans (based on data obtained from health maintenance organizations). When compared to the VA’s rates, CVSP received higher scores for influenza shots, but underperformed significantly with regard to pneumococcal vaccinations. CVSP’s rates for colorectal cancer screening were lower than both Kaiser (statewide) and the VA, but higher than the commercial and Medicaid scores. This low percentage was largely due to a high rate of refusals by CVSP’s patient population. Overall, CVSP’s performance demonstrated by the population-based metrics indicated that the chronic care program was well run and operating as intended. The CVSP Executive Summary Table on the following page lists the quality indicators the OIG inspected and assessed during the clinical case reviews and objective compliance tests, and provides the institution’s rating in each area. The overall indicator ratings were based on a consensus decision by the OIG’s clinicians and non-clinical inspectors. Chuckawalla Valley State Prison, Cycle 4 Medical Inspection Page ix Office of the Inspector General State of California CVSP Executive Summary Table Case Compliance Overall Indicator Primary Indicators (Clinical) Review Score Rating Rating Access to Care Proficient 83.6% Adequate Diagnostic Services Proficient 86.4% Proficient Emergency Services Adequate Not Applicable Adequate Health Information Management Adequate 68.6% Inadequate (Medical Records) Health Care Environment Not Applicable 66.4% Inadequate Inter- and Intra-System Transfers Adequate 90.8% Adequate Pharmacy and Medication Management Adequate 80.7% Adequate Preventive Services Not Applicable 84.9% Adequate Quality of Nursing Performance Adequate Not Applicable Adequate Quality of Provider Performance Adequate Not Applicable Adequate Specialty Services Adequate 87.9% Adequate Note: Prenatal and Post-Delivery Services, Reception Center Arrivals, and Specialized Medical Housing (OHU, CTC, SNF, Hospice) indicators did not apply to this institution. Case Compliance Overall Indicator Secondary Indicators (Administrative) Review Score Rating Rating Internal Monitoring, Quality Improvement, Not Applicable 39.8% Inadequate and Administrative Operations Job Performance, Training, Licensing, and Not Applicable 77.5% Adequate Certifications Ratings for quality indicators are proficient (greater than 85.0 percent), adequate (75.0 percent to 85.0 percent), or inadequate (below 75.0 percent). Chuckawalla Valley State Prison, Cycle 4 Medical Inspection Page x Office of the Inspector General State of California INTRODUCTION Under the authority of California Penal Code Section 6126, which assigns the Office of the Inspector General (OIG) responsibility for oversight of the California Department of Corrections and Rehabilitation (CDCR), and at the request of the federal Receiver, the OIG developed a comprehensive medical inspection program to evaluate the delivery of medical care at each of CDCR’s 35 adult prisons. For this fourth cycle of inspections, the OIG augmented the breadth and quality of its inspection program used in prior cycles, adding a clinical case review component and significantly enhancing the compliance component of the program. Chuckawalla Valley State Prison (CVSP) was the sixth medical inspection of Cycle 4. During the inspection process, the OIG assessed the delivery of medical care to patients for 11 primary clinical health care indicators and 2 secondary administrative health care indicators applicable to the institution. It is important to note that while the primary quality indicators represent the clinical care being provided by the institution at the time of the inspection, the secondary quality indicators are purely administrative and are not reflective of the actual clinical care provided. The OIG is committed to reporting on each institution’s delivery of medical care to assist in identifying areas for improvement, but the federal court will ultimately determine whether any institution’s medical care meets constitutional standards. ABOUT THE INSTITUTION Chuckawalla Valley State Prison primarily houses medium security Level II male inmates. Two of the four Level II facilities at CVSP house inmates classified as having “sensitive needs.” The other two are general population Level II yards. The institution runs seven medical clinics where staff handle non-urgent requests for medical services. CVSP also treats inmates needing urgent or emergency care in its triage and treatment area. CVSP has been designated as a “basic care prison,” located in a rural area away from tertiary care centers and specialty care providers whose services are likely to be used frequently by higher-risk patients. Based on staffing data the OIG obtained from the institution, CVSP’s vacancy rate among licensed medical managers, primary care providers (PCPs), supervisors, and rank-and-file nurses was 10 percent in May 2015, with the highest vacancy percentages among nursing supervisors (24 percent) and nursing staff (9 percent). At the time of the OIG’s inspection, one supervising registered nurse II (SRN II) position was pending a start date; another 1.5 SRN II positions were on hold for hiring. This contributed to the high vacancy rate reflected for nursing supervisors. Of the four vacant nursing positions, one had been recently advertised; all four vacancies were covered by contracted registry staff. Chuckawalla Valley State Prison, Cycle 4 Medical Inspection Page 1 Office of the Inspector General State of California CVSP Health Care Staffing Resources—May 2015 Primary Care Nursing Management Nursing Staff Totals Providers Supervisors Description Number % Number % Number % Number % Number % Authorized 1 2% 5 8% 10.5 17% 45.8 74% 62.3 100% Positions Filled Positions 1 100% 5 100% 8 76% 41.8 91% 55.8 90% Vacancies 0 0% 0 0% 2.5 24% 4 9% 6.5 10% Recent Hires (within 12 0 0% 2 40% 2 25% 10 24% 14 25% months) Staff Utilized 0 0% 0 0% 0 0% 4 10% 4 7% from Registry Redirected Staff (to Non-Patient 0 0% 0 0% 0 0% 0 0% 0 0% Care Areas) Staff under Disciplinary 0 0% 1 20% 2 25% 3 7% 6 11% Review Staff on Long-term 0 0% 0 0% 1 13% 5 12% 6 11% Medical Leave Note: CVSP Health Care Staffing Resources data was not validated by the OIG. As of September 22, 2015, California Correctional Health Care Services (CCHCS) data showed that CVSP had 1,871 inmate-patients. Within that total population, 0.9 percent were designated as high-risk Level 1, and 4.3 percent were designated as high-risk Level 2. High-risk patients are at greater risk for poor health outcomes than average patients. The chart below illustrates the inmate-patient breakdown. CVSP Master Registry Data as of September 22, 2015 Risk Level # of Inmate-Patients Percentage High 1 16 0.9% High 2 81 4.3% Medium 506 27.0% Low 1,268 67.8% Total 1,871 100% Chuckawalla Valley State Prison, Cycle 4 Medical Inspection Page 2 Office of the Inspector General State of California Abbreviations Used in This Report ACLS Advanced Cardiovascular Life Support HIV Human Immunodeficiency Virus AHA American Heart Association HTN Hypertension ASU Administrative Segregation Unit INH Isoniazid (anti-tuberculosis medication) BLS Basic Life Support IV Intravenous CBC Complete Blood Count KOP Keep-on-Person (in taking medications) CC Chief Complaint LPT Licensed Psychiatric Technician CCHCS California Correctional Health Care Services LVN Licensed Vocational Nurse CCP Chronic Care Program MAR Medication Administration Record California Department of Corrections and CDCR MRI Magnetic Resonance Imaging Rehabilitation CEO Chief Executive Officer MD Medical Doctor CHF Congestive Heart Failure NA Nurse Administered (in taking medications) CME Chief Medical Executive N/A Not Applicable CMP Comprehensive Metabolic (Chemistry) Panel NP Nurse Practitioner CNA Certified Nursing Assistant OB Obstetrician CNE Chief Nurse Executive OHU Outpatient Housing Unit C/O Complains of OIG Office of the Inspector General COPD Chronic Obstructive Pulmonary Disease P&P Policies and Procedures (CCHCS) CP&S Chief Physician and Surgeon PA Physician Assistant CPR Cardio-Pulmonary Resuscitation PCP Primary Care Provider CSE Chief Support Executive POC Point of Contact CT Computerized Tomography PPD Purified Protein Derivative CTC Correctional Treatment Center PRN As Needed (in taking medications) DM Diabetes Mellitus RN Registered Nurse Directly Observed Therapy (in taking DOT Rx Prescription medications) Dx Diagnosis SNF Skilled Nursing Facility Subjective, Objective, Assessment, Plan, EKG Electrocardiogram SOAPE Education ENT Ear, Nose and Throat SOMS Strategic Offender Management System ER Emergency Room S/P Status post eUHR electronic Unit Health Record TB Tuberculosis FTF Face-to-Face TTA Triage and Treatment Area History and Physical (reception center H&P UA Urinalysis examination) HIM Health Information Management UM Utilization Management Chuckawalla Valley State Prison, Cycle 4 Medical Inspection Page 3 Office of the Inspector General State of California OBJECTIVES, SCOPE, AND METHODOLOGY In designing the medical inspection program, the OIG reviewed CCHCS policies and procedures, relevant court orders, and guidance developed by the American Correctional Association. The OIG also reviewed professional literature on correctional medical care; reviewed standardized performance measures used by the health care industry; consulted with clinical experts; and met with stakeholders from the court, the Receiver’s office, CDCR, the Office of the Attorney General, and the Prison Law Office to discuss the nature and scope of the OIG’s inspection program. With input from these stakeholders, the OIG developed a medical inspection program that evaluates medical care delivery by combining clinical case reviews of patient files, objective tests of compliance with policies and procedures, and an analysis of outcomes for certain population-based metrics. To maintain a metric-oriented inspection program that evaluates medical care delivery consistently at each State prison, the OIG identified 14 primary (clinical) and 2 secondary (administrative) quality indicators of health care to measure. The primary quality indicators cover clinical categories directly relating to the health care provided to patients, whereas the secondary quality indicators address the administrative functions that support a health care delivery system. The 14 primary quality indicators are Access to Care, Diagnostic Services, Emergency Services, Health Information Management (Medical Records), Health Care Environment, Inter- and Intra-System Transfers, Pharmacy and Medication Management, Prenatal and Post-Delivery Services, Preventive Services, Quality of Nursing Performance, Quality of Provider Performance, Reception Center Arrivals, Specialized Medical Housing (OHU, CTC, SNF, Hospice), and Specialty Services. The two secondary quality indicators are Internal Monitoring, Quality Improvement, and Administrative Operations; and Job Performance, Training, Licensing, and Certifications. The OIG rates each of the quality indicators applicable to the institution under inspection based on case reviews conducted by OIG clinicians and compliance tests conducted by OIG deputy inspectors general. The ratings may be derived from the case review results alone, the compliance test results alone, or a combination of both these information sources. For example, the ratings for the primary quality indicators Quality of Nursing Performance and Quality of Provider Performance are derived entirely from the case review results, while the ratings for both of the secondary quality indicators are derived entirely from compliance test results. As another example, primary quality indicators such as Diagnostic Services and Specialty Services receive ratings derived from both sources. At CVSP, 13 of the quality indicators were applicable, consisting of 11 primary clinical indicators and 2 secondary administrative indicators. Of the 11 primary indicators, 6 were rated by both case review clinicians and compliance inspectors, 3 were rated by case review clinicians only, and 2 were rated by compliance inspectors only; both secondary indicators were rated by compliance inspectors only. Chuckawalla Valley State Prison, Cycle 4 Medical Inspection Page 4 Office of the Inspector General State of California Consistent with the OIG’s agreement with the Receiver, the report only addresses the conditions found related to medical care criteria. The OIG does not review for efficiency and economy of operations. Moreover, if the OIG learns of an inmate-patient needing immediate care, the OIG notifies the chief executive officer of health care services and requests a status report. Additionally, if the OIG learns of significant departures from community standards, it may report such departures to the institution’s chief executive officer or to CCHCS. Because these matters involve confidential medical information protected by State and federal privacy laws, specific identifying details related to any such cases are not included in the OIG’s public report. In all areas, the OIG is alert for opportunities to make appropriate recommendations for improvement. Such opportunities may be present regardless of the score awarded to any particular quality indicator; therefore, recommendations for improvement should not necessarily be interpreted as indicative of deficient medical care delivery. CASE REVIEWS The OIG has added case reviews to the Cycle 4 medical inspections at the recommendation of its stakeholders. At the conclusion of Cycle 3, the federal Receiver and the Inspector General determined that the health care provided at the institutions was not fully evaluated by the compliance tool alone, and that the compliance tool was not designed to provide comprehensive qualitative assessments. Accordingly, the OIG added case reviews in which OIG physicians and nurses evaluate selected cases in detail to determine the overall quality of health care provided to the inmate-patients. The OIG’s clinicians perform a retrospective chart review of selected patient files to evaluate the care given by an institution’s primary care providers and nurses. Retrospective chart review is a well-established review process used by health care organizations that perform peer reviews and patient death reviews. Currently CCHCS uses retrospective chart review as part of its death review process and in its pattern-of-practice reviews. CCHCS also uses a more limited form of retrospective chart review when performing appraisals of individual primary care providers. PATIENT SELECTION FOR RETROSPECTIVE CASE REVIEWS Because retrospective chart review is time consuming and requires qualified health care professionals to perform it, OIG clinicians must carefully sample patient records. Accordingly, the group of patients the OIG targeted for chart review carried the highest clinical risk and utilized the majority of medical services. A majority of the patients selected for retrospective chart review were classified by CCHCS as high-risk patients. The reason the OIG targeted these patients for review is twofold: 1. The goal of retrospective chart review is to evaluate all aspects of the health care system. Statewide, high-risk and high-utilization patients consume medical services at a disproportionate rate; 9 percent of the total patient population are considered high-risk and Chuckawalla Valley State Prison, Cycle 4 Medical Inspection Page 5 Office of the Inspector General State of California account for more than half of the institution’s pharmaceutical, specialty, community hospital, and emergency costs. 2. Selecting this target group for chart review provides a significantly greater opportunity to evaluate all the various aspects of the health care delivery system at an institution. Underlying the choice of high-risk patients for detailed case review are three assumptions: 1. If the institution is able to provide adequate clinical care to the most challenging patients with multiple complex and interdependent medical problems, it will be providing adequate care to patients with less complicated health care issues. Because clinical expertise is required to determine whether the institution has provided adequate clinical care, the OIG utilizes experienced correctional physicians and registered nurses to perform this analysis. 2. The health of less complex patients is more likely to be affected by processes such as timely appointment scheduling, medication management, routine health screening, and immunizations. To review these processes, the OIG simultaneously performs a broad compliance review. 3. Patient charts generated during death reviews, sentinel events (an unexpected occurrence involving death or serious injury, or risk thereof), and hospitalizations are mostly of high-risk patients. BENEFITS AND LIMITATIONS OF TARGETED SUBPOPULATION REVIEW Because the selected patients utilize the broadest range of services offered by the health care system, the OIG’s retrospective chart review provides adequate data for a qualitative assessment of the most vital system processes (referred to as “primary quality indicators”). Retrospective chart review provides an accurate qualitative assessment of the relevant primary quality indicators as applied to the targeted subpopulation of high-risk and high-utilization patients. While this targeted subpopulation does not represent the prison population as a whole, the ability of the institution to provide adequate care to this subpopulation is a crucial and vital indicator of how the institution provides health care to its whole patient population. Simply put, if the institution’s medical system does not adequately care for those patients needing the most care, then it is not fulfilling its obligations, even if it takes good care of patients with less complex medical needs. Since the targeted subpopulation does not represent the institution’s general prison population, the OIG cautions against inappropriate extrapolation of conclusions from the retrospective chart reviews to the general population. For example, if the high-risk diabetic patients reviewed have poorly-controlled diabetes, one cannot conclude that the entire diabetic population is inadequately controlled. Similarly, if the high-risk diabetic patients under review have poor outcomes and require significant specialty interventions, one cannot conclude that the entire diabetic population is having similarly poor outcomes. Chuckawalla Valley State Prison, Cycle 4 Medical Inspection Page 6 Office of the Inspector General State of California Nonetheless, the health care system’s response to this subpopulation can be accurately evaluated and yields valuable systems information. In the above example, if the health care system is providing appropriate diabetic monitoring, medication therapy, and specialty referrals for the high-risk patients reviewed, then it can be reasonably inferred that the health care system is also providing appropriate diabetic services to the entire diabetic subpopulation. However, if these same high-risk patients needing monitoring, medications, and referrals are generally not getting those services, it is likely that the health care system is not providing appropriate diabetic services to the greater diabetic subpopulation. CASE REVIEWS SAMPLED As indicated in Appendix B, Table B-4, CVSP Case Review Sample Summary, the OIG clinicians evaluated medical charts for 62 unique inmate-patients. Both nurses and physicians reviewed charts for 12 of those patients, for 74 reviews in total. Physicians performed detailed reviews of 30 charts, and nurses performed detailed reviews for 10 charts, totaling 40 detailed reviews. For detailed case reviews, the clinicians looked at all encounters occurring in approximately six months of medical care. Nurses also performed a limited or focused review of medical records for an additional 34 inmate-patients. These generated 853 clinical events for review (Appendix B, Table B - 3, CVSP Event-Program). The reporting format provides details on whether the encounter was adequate or had significant deficiencies, and identifies deficiencies by programs and processes to help the institution focus on improvement areas. While the sample method specifically pulled only 6 chronic care patient records, i.e. 4 diabetes patients and 2 anticoagulation patients (Appendix B, Table B-1, CVSP Sample Sets), the 62 unique inmate-patients sampled included patients with 110 chronic care diagnoses, including 8 additional patients with diabetes (for a total of 12) (Appendix B, Table B-2, CVSP Chronic Care Diagnoses). The OIG’s sample selection tool evaluated many chronic care programs because the complex and high-risk patients selected from the different categories often had multiple medical problems. While the OIG did not evaluate every chronic disease or health care staff member, the OIG did assess the overall operation of the institution’s system and staff for adequacy. The OIG’s case review methodology and sample size matched other qualitative research. The empirical findings, supported by expert statistical consultants, showed adequate conclusions after 10 to 15 charts had undergone full clinician review. In qualitative statistics, this phenomenon is known as “saturation.” The OIG asserts that the sample size of over 30 detailed reviews certainly far exceeds the saturation point necessary for an adequate qualitative review. With regard to reviewing charts from different providers, the case review is not intended to be a focused search for poorly performing providers; rather, it is focused on how the system cares for those patients who need the most care. Nonetheless, while not sampling cases by each provider at the institution, the OIG’s pilot inspections adequately reviewed most providers. Providers would only escape OIG case review if institutional management successfully mitigated patient risk by having the more poorly performing PCPs care for the less Chuckawalla Valley State Prison, Cycle 4 Medical Inspection Page 7 Office of the Inspector General State of California complicated, low-utilizing, and lower-risk patients. The OIG’s clinicians concluded the sample size was adequate to assess the quality of services provided. Based on the collective results of clinicians’ case reviews, the OIG rated each quality indicator as either proficient (excellent), adequate (passing), inadequate (failing), or not applicable. A separate confidential CVSP Supplemental Medical Inspection Results: Individual Case Review Summaries report details the case reviews OIG clinicians conducted and is available to specific stakeholders. For further details regarding the sampling methodologies and counts, see Appendix B – Clinical Data, Table B-1; Table B-2; Table B-3; and Table B-4. COMPLIANCE TESTING SAMPLING METHODS FOR CONDUCTING COMPLIANCE TESTING From May to July 2015, deputy inspectors general attained answers to 87 objective medical inspection test (MIT) questions designed to assess the institution’s compliance with critical policies and procedures applicable to the delivery of medical care. To conduct most tests, inspectors randomly selected samples of inmate-patients for whom the testing objectives were applicable and reviewed their electronic unit health records. In some cases, inspectors used the same samples to conduct more than one test. In total, inspectors reviewed health records for 369 individual inmate-patients and analyzed specific transactions within their records for evidence that critical events occurred. Inspectors also reviewed management reports and meeting minutes to assess certain administrative operations. In addition, during the week of May 18, 2015, field inspectors conducted a detailed onsite inspection of CVSP’s medical facilities and clinics; interviewed key institutional employees; and reviewed employee records, logs, medical appeals, death reports, and other documents. This generated 1,164 scored data points to assess care. In addition to the scored questions, the OIG obtained information from the institution that it did not score. This included, for example, information about CVSP’s plant infrastructure, protocols for tracking medical appeals and local operating procedures, and staffing resources. For details of the compliance results, see Appendix A—Compliance Test Results. For details of the OIG’s compliance sampling methodology, see Appendix C—Compliance Sampling Methodology. SCORING OF COMPLIANCE TESTING RESULTS The OIG rated the institution in the following eight primary (clinical) and two secondary (administrative) quality indicators applicable to the institution for compliance testing: Chuckawalla Valley State Prison, Cycle 4 Medical Inspection Page 8 Office of the Inspector General State of California  Primary indicators: Access to Care, Diagnostic Services, Health Information Management (medical records), Health Care Environment, Inter- and Intra-System Transfers, Pharmacy and Medication Management, Preventive Services, and Specialty Services.  Secondary indicators: Internal Monitoring, Quality Improvement, and Administrative Operations; and Job Performance, Training, Licensing, and Certifications. After compiling the answers to the 87 questions, the OIG derived a score for each primary and secondary quality indicator identified above by calculating the percentage score of all Yes answers for each of the questions applicable to a particular indicator, then averaging those scores. Based on those results, the OIG assigned a rating to each quality indicator of proficient, adequate, or inadequate. DASHBOARD COMPARISONS For some of the individual compliance questions, the OIG identified where similar metrics were available within the CCHCS Dashboard. There is not complete parity between the metrics due to time frames when data was collected. As a result, there is some difference between the OIG’s findings and the Dashboard metrics. The OIG compared its compliance test results with the institution’s Dashboard results and reported on that comparative data under various applicable quality indicators within the Medical Inspection Results section of this report. OVERALL QUALITY INDICATOR RATING FOR CASE REVIEWS AND COMPLIANCE TESTING The OIG derived the final rating for each quality indicator by combining the ratings from the case reviews and from the compliance testing, as applicable. When combining these ratings, the case review evaluations and the compliance testing results usually agreed, but there were instances when the rating differed for a particular quality indicator. In those instances, the inspection team assessed the quality indicator based on the collective ratings from both components. Specifically, the OIG clinicians and deputy inspectors general discussed the nature of individual exceptions found within that indicator category and considered the overall effect on the ability of patients to receive adequate medical care. To derive an overall assessment rating for the institution’s medical inspection, the OIG evaluated the various rating categories assigned to each of the quality indicators applicable to the institution, giving more weight to the rating results for the primary quality indicators, which directly relate to the health care provided to inmate-patients. Based on that analysis, OIG experts made a considered and measured overall opinion about the quality of health care observed. Chuckawalla Valley State Prison, Cycle 4 Medical Inspection Page 9 Office of the Inspector General State of California POPULATION-BASED METRICS The OIG identified a subset of HEDIS measures applicable to the CDCR inmate-patient population. To identify outcomes for CVSP, the OIG reviewed some of the compliance testing results, randomly sampled additional inmate-patients’ records, and obtained CVSP data from the CCHCS Master Registry. The OIG compared those results to metrics reported by other State and federal agencies. Chuckawalla Valley State Prison, Cycle 4 Medical Inspection Page 10 Office of the Inspector General State of California MEDICAL INSPECTION RESULTS PRIMARY (CLINICAL) QUALITY INDICATORS OF HEALTH CARE The primary quality indicators assess the clinical aspects of health care. As shown on the Health Care Quality Indicators table on page ii of this report, 11 of the OIG’s primary indicators were applicable to CVSP. Of those 11 indicators, both the case review and compliance components of the inspection rated 6, the case review component alone rated 3, and the compliance component alone rated 2. Summary of Case Review Results: Clinicians reviewed 30 cases, rating the adequacy of care for each case. Of these 30 cases, 25 were adequate, and 5 were inadequate. For the 853 events reviewed, there were 217 deficiencies, of which the reviewers determined 16 to be of such magnitude that, if left unaddressed, they would likely contribute to patient harm. Adverse Events Identified During Case Review: Medical care is a complex dynamic process, and subject to human error even within the best health care organizations. All major health care organizations identify and track adverse events for the purpose of quality improvement. They are not generally representative of medical care delivered by the organization. The OIG identified adverse events for the dual purposes of quality improvement and the illustration of problematic patterns of practice found during the inspection. Because of the anecdotal description of these events, the OIG cautions against drawing inappropriate conclusions regarding the institution based solely on adverse events. There was one adverse event identified in the case reviews, but it was not reflective of the overall medical care provided at CVSP. In case 9, an on-call provider prescribed ibuprofen for a patient complaining of headache. The provider should not have prescribed ibuprofen to this diabetic patient with renal impairment and episodes of hyperkalemia as ibuprofen can worsen renal impairment and cause increased hyperkalemia. The Quality of Provider Performance indicator noted this case. Compliance Results: The compliance component assessed 8 of the 11 primary (clinical) indicators applicable to CVSP. This section of the report includes a summary of the results of those assessments. The test questions used by the inspectors to assess compliance for each indicator are detailed in Appendix A. Chuckawalla Valley State Prison, Cycle 4 Medical Inspection Page 11 Office of the Inspector General State of California ACCESS TO CARE This indicator evaluates the institution’s ability to provide Case Review Rating: inmate-patients with timely clinical appointments. Areas specific to Proficient inmate-patients’ access to care are reviewed, such as initial Compliance Score: assessments of newly arriving inmates, acute and chronic care 83.6% follow-ups, face-to-face nurse appointments when an inmate-patient Overall Rating: requests to be seen, provider referrals from nursing lines, and Adequate follow-ups after hospitalization or specialty care. Compliance testing for this indicator also evaluates whether inmate-patients have Health Care Services Request forms (CDCR Form 7362) available in their housing units. Case Review Results The OIG clinicians reviewed over 535 provider and nurse encounters and they identified seventeen minor deficiencies relating to Access to Care. Health care staff did not see the patients in the ordered time frames for 11 of these deficiencies. Six deficiencies related to delays in provider follow-up after hospitalization or specialty care. Overall, the OIG found no significant problems with Access to Care. Appointments were overall timely in all aspects reviewed, including nurse-to-provider sick call referrals, triage and treatment area (TTA) and hospital follow-ups, intra-system transfers, specialty appointment follow-ups, and outpatient provider and nursing follow-ups. CVSP performed very well with regard to Access to Care, and the indicator rating was thus proficient. Compliance Testing Results The institution performed in the adequate range in the Access to Care indicator, with an overall score of 83.6 percent. While CVSP scored well in four of the nine tests conducted, it performed only adequately in two areas and inadequately in three other key areas. As indicated below, CVSP scored proficiently in four areas, achieving 100 percent in two of the areas tested:  Inmates had access to Health Care Services Request forms (CDCR Form 7362) at all six housing units inspected, receiving a score of 100 percent for this test (MIT 1.101).  Inspectors sampled 30 Health Care Services Request forms (CDCR Form 7362) submitted by inmate-patients across all facility clinics. As documented on the forms, nursing staff reviewed all 30 (100 percent) of the request forms on the same day they were received (MIT 1.003). Additionally, in all but one instance (97 percent), nursing staff completed a Chuckawalla Valley State Prison, Cycle 4 Medical Inspection Page 12 Office of the Inspector General State of California face-to-face encounter with the inmate-patient within one business day of reviewing the request; in the one exception, the RN conducted the visit one day late (MIT 1.004).  Of the eight inmate-patients who nursing staff referred to a primary care provider (PCP) and for whom the PCP determined a follow-up sick call appointment was necessary, seven patients (88 percent) received a timely appointment. One patient never received his follow-up appointment; the patient paroled 27 days after the ordered appointment date (MIT 1.006). The institution performed adequately in the following areas:  For 18 health care service requests sampled where the nursing staff referred the inmate-patient for a PCP appointment, 15 of the inmate-patients (83 percent) received a timely appointment. In two instances the follow-up appointment occurred one and four days late, respectively. For another inmate-patient, the follow-up visit, while timely, was with a registered nurse and not a PCP as required (MIT 1.005).  When inspectors sampled 28 inmate-patients who had been discharged from a community hospital, they found that 23 (82 percent) received or were offered a follow-up appointment with a PCP within five days of discharge. The five untimely appointments were from one to nine days late (MIT 1.007). The following areas were rated inadequate:  Of 23 inmate-patients sampled who transferred into CVSP from other institutions and were referred to a PCP for a routine appointment based on nursing staff’s initial health care screening of the patient, only 14 of them (61 percent) were seen timely. Appointments were from two to nine days late for five patients, and from 21 to 52 days late for four other patients (MIT 1.002).  When the OIG reviewed recent appointments for 30 inmate-patients with chronic care conditions, only 21 of the patients (70 percent) received timely appointments. Untimely appointments for seven patients occurred from one to 11 days late. For two other patients, inspectors did not find evidence that an appointment had occurred at all (MIT 1.001).  Inspectors also sampled 25 inmate-patients who received a specialty service and found that 18 (72 percent) received a timely follow-up appointment with a PCP. Five patients received appointments that were only one day late; however, two other patients saw a PCP for a specialty service follow-up six and seven days late, respectively (MIT 1.008). Chuckawalla Valley State Prison, Cycle 4 Medical Inspection Page 13 Office of the Inspector General State of California CCHCS Dashboard Comparative Data The Dashboard uses the average of nine medical access measure indicators to calculate the score for access to medical services. The OIG compared CVSP compliance scores with that Dashboard average score. As indicated in the table below, the OIG based its compliance results on current documents as well as documents dating up to nine months back; CVSP’s May Dashboard data reflected only the institution’s April 2015 results. Nevertheless, both the OIG and Dashboard results were consistent and within the proficient range. Access to Care—CVSP Dashboard and OIG Compliance Results CVSP DASHBOARD RESULTS OIG COMPLIANCE RESULTS Scheduling & Access to Care: Access to Care (1.001, 1.004, 1.005, 1.007) Medical Services Diagnostic Services (2.001, 2.004) Specialty Services (14.001, 14.003) May 2015 July 2014 – April 2015 92% 89% Note: The CCHCS Dashboard data includes access to care for inmate-patients returning from CDCR inpatient housing units and emergency departments. The OIG does not specifically test follow-up appointments for these patients. Recommendation No specific recommendations. The institution scored within the proficient or adequate range for most areas addressed by this indicator; staff can easily address areas needing improvement by adhering to established policy and procedure. Chuckawalla Valley State Prison, Cycle 4 Medical Inspection Page 14 Office of the Inspector General State of California DIAGNOSTIC SERVICES This indicator addresses several types of diagnostic services. Case Review Rating: Specifically, it addresses whether radiology and laboratory Proficient services were timely provided to inmate-patients, whether the Compliance Score: primary care provider (PCP) timely reviewed the results, and 86.4% whether the results were communicated to the inmate-patient within the required time frames. In addition, for pathology Overall Rating: services, the OIG determines whether the institution received a Proficient final pathology report and whether the PCP timely reviewed and communicated the pathology results to the patient. The case reviews also factor in the appropriateness, accuracy, and quality of the diagnostic test(s) ordered and the clinical response to the results. Case Review Results The OIG clinicians reviewed 122 diagnostic events and found 21 minor deficiencies; the majority related to health information management (discussed in the Health Information Management indicator). The OIG found no significant problems with diagnostic services. Overall, diagnostic services were successfully completed and performed timely, reports were available and reviewed timely by the primary care providers, and providers notified patients of the test results quickly. CVSP performed very well with regard to diagnostic services, and the indicator rating was thus proficient. Compliance Testing Results The institution received an overall score of 86.4 percent in the Diagnostic Services indicator, which encompasses radiology, laboratory, and pathology services. For clarity, each type of diagnostic service is discussed separately below: Radiology Services  For all ten of the radiology services sampled (100 percent), inspectors found the services were timely performed, the diagnostic report results were timely reviewed by the ordering provider, and the test results were timely communicated to the inmate-patients (MIT 2.001, 2.002, 2.003). Laboratory Services  For nine of ten laboratory services sampled (90 percent), inspectors found the services were performed timely. The one exception was a service performed one day late (MIT 2.004). Also, nine of those ten sampled inmate-patients’ eUHR files (90 percent) included the Chuckawalla Valley State Prison, Cycle 4 Medical Inspection Page 15 Office of the Inspector General State of California laboratory diagnostic report with evidence the provider had reviewed the diagnostic test results timely. For one patient, the provider reviewed the test results two days late (MIT 2.005). Finally, inspectors found that providers communicated nine of the ten diagnostic studies to the inmate-patient timely (90 percent). The only exception was when a PCP communicated results to the patient two days late (MIT 2.006). Pathology Services  The institution documented the timely receipt of a final pathology report in the eUHR for only seven of ten inmate-patients sampled (70 percent). For one patient, the institution received the pathology report for an urgent service 14 days late; for two other patients, there was no evidence the institution ever received a final pathology report (MIT 2.007). Providers timely reviewed the pathology results for six of the eight sampled patients with final reports, resulting in a score of 75 percent. For two patients, providers failed to initial the report, evidencing their review of the final results (MIT 2.008). Further, inspectors found that providers communicated the final pathology results to only five of the eight inmate-patients sampled (63 percent). For two patients, there was no evidence the provider met with the patient after the pathology service was performed, and for one patient the provider met with the inmate-patient to discuss the pathology results three days late (MIT 2.009). Recommendation No specific recommendations. Except for its performance in pathology services, the institution scored within the proficient range for this indicator; staff can easily address areas needing improvement regarding pathology services by adhering to established policy and procedure. Chuckawalla Valley State Prison, Cycle 4 Medical Inspection Page 16 Office of the Inspector General State of California EMERGENCY SERVICES An emergency medical response system is essential to providing Case Review Rating: effective and timely emergency medical response, assessment, Adequate treatment, and transportation 24 hours per day. Provision of Compliance Score: urgent/emergent care is based on a patient’s emergency situation, Not Applicable clinical condition, and need for a higher level of care. The OIG reviews emergency response services including first aid, basic life Overall Rating: support (BLS), and advanced cardiac life support (ACLS) Adequate consistent with the American Heart Association guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiovascular care, and the provision of services by knowledgeable staff appropriate to each individual’s training, certification, and authorized scope of practice. The OIG evaluates this quality indicator entirely through clinicians’ reviews of case files and conducts no separate compliance testing element. Case Review Results The OIG clinicians reviewed 59 urgent/emergent events and found 26 deficiencies, mainly in the area of nursing care. The majority of these deficiencies were minor and did not contribute to patient harm. A few notable exceptions are listed below. In general, CVSP performed well with emergency response times, BLS and ACLS care, and 9-1-1 call activation times. Despite the deficiencies noted, the case reviews showed that most patients requiring urgent or emergent services received timely and adequate care. Provider Performance The triage and treatment area (TTA) provider generally made appropriate triage decisions, and sent patients to the appropriate levels of care. Onsite discussions revealed the TTA sometimes lacked a provider during business hours. During such times, however, a provider was always available by phone (similar to non-business hours with a provider on call). The few provider deficiencies relating to emergency services were due to documentation or transcription issues. Nursing Performance Nurses did not always perform thorough assessments, promptly initiate care, or communicate with providers when necessary.  In cases 1, 19, and 20, patients presented with cardiac complaints. The nurses failed to thoroughly assess or promptly implement care.  In cases 3 and 4, nursing delayed the taking of initial vital signs. Chuckawalla Valley State Prison, Cycle 4 Medical Inspection Page 17 Office of the Inspector General State of California  In case 1, the nurse failed to contact the provider-on-call when the patient’s chest pain worsened, his blood pressure increased, and the ground ambulance was delayed. Emergency Medical Response Review Committee  The committee failed to perform detailed reviews in three cases when transportation occurred by ground ambulance.  In case 1 the committee recognized custody staff’s delay in initiating CPR but did not follow up or ensure training was completed.  In case 2 the EMRRC records indicated the patient was initially transported to the medical clinic by custody staff, while the medical records stated that health care staff went to the housing unit and transported the patient by wheelchair to the medical clinic. The committee failed to recognize the disparity in the records, the lack of first medical responder documentation, and the incomplete assessment performed by the clinic RN. The committee recommended the TTA nurse receive training, but this did not occur. Conclusion CVSP staff provided adequate emergency services to patients during the time frame reviewed. The majority of deficiencies found relating to emergency services were due to inadequate assessment or documentation by nursing and did not significantly affect patient care. Recommendations Although Emergency Services scored adequate overall, strategies for improvement are clearly indicated. The OIG recommends CVSP adhere to current policy and procedure and implement the following specific recommendations:  Develop TTA-specific nursing expectations.  Pro-actively evaluate the TTA nursing assessments, interventions, and documentation. Review the deficiencies with the nurse and implement institutional training.  Implement a tracking method to ensure EMRRC recommendations are promptly completed and reported back to the committee.  Ensure compliance with the current CCHCS Emergency Medical Response: Post-Event Review Procedure Policy (IMSP&P Volume 4, Chapter 12). Chuckawalla Valley State Prison, Cycle 4 Medical Inspection Page 18 Office of the Inspector General State of California HEALTH INFORMATION MANAGEMENT (MEDICAL RECORDS) Health information management is a crucial link in the delivery of Case Review Rating: medical care. Medical personnel require accurate information in Adequate order to make sound judgments and decisions. This indicator Compliance Score: examines whether the institution adequately manages its health care 68.6% information. This includes determining whether the information is correctly labeled and organized and available in the electronic unit Overall Rating: Inadequate health record (eUHR); whether the various medical records (internal and external, e.g., hospital and specialty reports and progress notes) are obtained and scanned timely into the inmate-patient’s eUHR; whether records routed to clinicians include legible signatures or stamps; and whether hospital discharge reports include key elements and are timely reviewed by providers. Case Review Results Chuckawalla Valley State Prison’s Health Information Management deficiencies were present at a low-to-moderate rate during case review. Out of the 217 deficiencies for all indicators identified from the case reviews, 39 related to this indicator. With the majority of the deficiencies considered not likely to contribute to patient harm, the Health Information Management indicator rating was adequate. The noted deficiencies were subcategorized as follows. Inter-Departmental Transmission  A small number of deficiencies related to intended orders not carried through across various departments. Examples included ordered test results not found in the eUHR (unclear if the tests were performed) and specialty visits not scheduled as requested. Hospital Records  Four deficiencies related to hospital records. These deficiencies included hospital reports not retrieved and reviewed in a timely manner. These deficiencies did not result in harm to patients. Specialty Services  Seven Health Information Management deficiencies related to specialty services. Most were due to providers not signing reports or staff not scanning reports into the eUHR in a timely manner. There was also one instance when specialty results were not available for the specialist to review at the time of the patient’s next appointment, and one instance of a misfiled specialty note. These findings are also discussed in the Specialty Services indicator. Chuckawalla Valley State Prison, Cycle 4 Medical Inspection Page 19 Office of the Inspector General State of California Diagnostic Reports  The majority of the eleven Health Information Management deficiencies related to the eUHR lacking diagnostic reports. One chart contained labs belonging to another patient. Three studies lacked completion by the time frame requested. Urgent/Emergent Records  The small number of Health Information Management deficiencies related to urgent/emergent records not found in the eUHR. Scanning Performance  While scanning times for all documents were adequate overall, the OIG clinicians found some deficiencies relating to scanning performance. As already noted, some documents were mislabeled or misfiled. Legibility  There were occasional issues relating to illegibility of notes and signatures (without name stamps) for some of the providers. This could pose a significant medical risk to patients, especially when other staff review these notes, such as with patient transfers to another care team or another institution. Miscellaneous  There were several instances when the eUHR lacked provider and nursing notes (and sometimes referral documents). The OIG also noted some deficiencies dealing with transcription errors. Compliance Testing Results The institution received an overall score of 68.6 percent in the Health Information Management (Medical Records) indicator. There are opportunities to improve in the following areas:  The institution scored 17 percent in its labeling and filing of documents scanned into inmate-patients’ electronic unit health records. The most common error was mislabeled documents where staff incorrectly named the actual scanned document, i.e., the file label used to identify the document in the chart did not agree with the actual document name (MIT 4.006).  The institution scored 55 percent for the timely scanning of dictated or transcribed provider progress notes into inmate-patients’ eUHR files. Inspectors found that staff scanned only 11 Chuckawalla Valley State Prison, Cycle 4 Medical Inspection Page 20 Office of the Inspector General State of California of the 20 sampled documents within five days of the PCP visit with the patient. All nine exceptions were scanned between one and ten days late (MIT 4.002).  Of the 20 specialty services consultant reports reviewed by the OIG, staff scanned only 12 of them (60 percent) into the inmate-patient’s eUHR file within five days of the appointment (or service). Inspectors found eight specialty reports that were scanned between one and five days late (MIT 4.003). Similarly, community hospital discharge reports or treatment records were not always scanned into the inmate-patient’s eUHR within three calendar days of the hospital discharge. Only 14 of the 20 sampled reports (70 percent) were timely scanned, while 6 other sampled reports were scanned between one and nine days late (MIT 4.004). The institution performed adequately in the following areas:  Providers did not always review community hospital discharge reports or treatment records for CVSP inmate-patients who were sent or admitted to the hospital within three calendar days of discharge. The institution scored 82 percent for this test. When the OIG reviewed eUHR files for 28 patients, 23 were compliant. There was no evidence a provider reviewed the discharge report for one patient, and the provider reviewed the report from one to seven days late in four other instances (MIT 4.008).  When the OIG reviewed various medical documents such as hospital discharge reports, initial health screening forms, certain medication records, and specialty services reports to ensure that clinical staff legibly documented their names on the forms, only 24 of 32 samples (75 percent) showed compliance (MIT 4.007). The institution performed well in its scanning of the following health care documents:  Inspectors found that staff timely scanned medication administration records into the inmate-patient’s eUHR files. The institution scored 100 percent for this test (MIT 4.005).  Most miscellaneous non-dictated documents, including providers’ progress notes, inmate-patients’ initial health screening forms, and requests for health care services were scanned timely. Of the 20 documents sampled, 18 (90 percent) were scanned into the patient’s eUHR within three calendar days of the patient’s encounter. Of the two untimely scanned documents, one was scanned one day late and the other, two days late (MIT 4.001). Chuckawalla Valley State Prison, Cycle 4 Medical Inspection Page 21 Office of the Inspector General State of California CCHCS Dashboard Comparative Data As indicated below, for two of the four comparative measures, the OIG’s compliance results for CVSP were inconsistent with the May 2015 CVSP Dashboard results. The OIG test results were based on a review of current documents as well as documents dating up to eight months back; CVSP’s May Dashboard data reflected only the institution’s April 2015 results. Given these disparate time frames, the OIG’s compliance scores were only consistent with CVSP’s Dashboard results for miscellaneous non-dictated and dictated documents. For specialty documents and community hospital documents, CVSP’s Dashboard results were much higher than the OIG’s results. Health Information Management— CVSP Dashboard and OIG Compliance Results CVSP DASHBOARD RESULTS OIG COMPLIANCE RESULTS Availability of Health Information: Health Information Management (4.001) Non-Dictated Documents Non-Dictated Medical Documents May 2015 September 2014 – April 2015 93% 90% Note: The Dashboard results were obtained from the Non-Dictated Documents Drilldown data for “Medical Documents 3 Days.” CVSP DASHBOARD RESULTS OIG COMPLIANCE RESULTS Availability of Health Information: Health Information Management (4.002) Dictated Documents Dictated Documents May 2015 December 2014 – May 2015 57% 55% Note: The Dashboard results were obtained from the Dictated Documents Drilldown data for “Medical Dictated Documents 5 Days.” CVSP DASHBOARD RESULTS OIG COMPLIANCE RESULTS Availability of Health Information: Health Information Management (4.003) Specialty Notes Specialty Documents May 2015 September 2014 – February 2015 87% 60% Note: The Dashboard measure includes specialty notes from dental, optometry, and physical therapy appointments, which the OIG omits from its sample. Chuckawalla Valley State Prison, Cycle 4 Medical Inspection Page 22 Office of the Inspector General State of California CVSP DASHBOARD RESULTS OIG COMPLIANCE RESULTS Availability of Health Information: Health Information Management (4.004) Community Hospital Records Community Hospital Discharge Documents May 2015 September 2014 – March 2015 88% 70% Recommendations The OIG found numerous issues related to Health Information Management. CVSP can address these issues by adhering to established policy and procedure and implementing the following specific recommendations:  CVSP has the opportunity to improve on the timeliness of hospital discharge and specialty reports by implementing an audit system. This system should identify when these reports were received and by what method, i.e., downloaded hospital records, records returned with patients, faxed reports, mailed reports, etc. Trends that may cause delay should be identified, including receipt of records, provider review, and timeliness of scanning into the eUHR. These trends should be appropriately addressed.  Providers should time-stamp notes and orders and thoroughly review transcribed notes.  Clinicians who review medical documents, including hospital discharge reports, should print their names or utilize name stamps in addition to their signatures or initials to improve legibility on all health care documents. Chuckawalla Valley State Prison, Cycle 4 Medical Inspection Page 23 Office of the Inspector General State of California HEALTH CARE ENVIRONMENT This indicator addresses the general operational aspects of the Case Review Rating: institution’s clinics, including certain elements of infection control Not Applicable and sanitation, medical supplies and equipment management, the Compliance Score: availability of both auditory and visual privacy for inmate-patient 66.4% visits, and the sufficiency of facility infrastructure to conduct comprehensive medical examinations. Rating of this component is Overall Rating: based entirely on the compliance testing results from the visual Inadequate observations inspectors make at the institution during their onsite visit. Compliance Testing Results The institution received an overall score of 66.4 percent in the Health Care Environment indicator, and improvement is possible in several test areas, as described below:  When inspecting for proper protocols to mitigate exposure to blood-borne pathogens and contaminated waste, the OIG inspectors found only one of the eight clinics (13 percent) was compliant. In five of the clinics, a sharps container was either not present in an exam room or not present anywhere in the clinic. Also, the TTA staff did not have access to disinfectant supplies in the event of biohazard spills occurring after hours, and both the TTA and receiving and release (R&R) clinic did not have adequate supplies of personal protective equipment accessible to staff (MIT 5.105).  The OIG inspected exam rooms in CVSP’s eight clinics to determine if appropriate space, configuration, supplies, and equipment allowed clinicians to perform a proper clinical exam. Inspectors found that only two of the eight clinical exam rooms or treatment spaces (25 percent) were sufficient—the remaining six had deficiencies. The most common deficiency, found in four clinics, was the placement of exam tables that did not allow the patient to lie in a fully extended supine position. Further, as shown in Figure 1, in one of these same exam rooms, the placement of the biohazard can and small work table impeded the PCP’s access to the patient. The available floor Figure 1: Poor table placement space in the R&R clinic exam room where nurses Chuckawalla Valley State Prison, Cycle 4 Medical Inspection Page 24 Office of the Inspector General State of California conducted patient health screenings was not sufficient to conduct physical exams of patients. Finally, as Figure 2 illustrates, the exam table in the CVSP’s specialty clinic had several large tears in the vinyl cover, which could harbor infectious agents (MIT 5.110).  In only three of seven applicable clinics inspected (43 percent), clinical health care staff ensured that reusable invasive and non-invasive medical equipment was properly sterilized or disinfected. In CVSP’s specialty clinic, Figure 2: Exam table with torn vinyl inspectors observed that staff did not disinfect the exam table prior to the start of each shift. According to staff, the contractor, Prison Industry Authority, cleans the clinic and its exam table nightly. In three other clinics, the packaging notation on medical equipment items indicated the equipment items were sterilized; however, the sterilization of the equipment was not tracked and recorded in the medical equipment sterilization log (MIT 5.102).  Clinic common areas and exam rooms were often missing essential supplies and core equipment necessary to conduct a comprehensive exam. As a result, only four of the eight clinics (50 percent) received a passing score for this test. Some PCP exam rooms were missing glucometers, nebulization units, peak flow meters, and hemoccult cards with developers. In addition, one clinic did not have a medication refrigerator nor a permanent distance marker for the Snellen vision chart. Inspectors also observed that the R&R clinic lacked an exam table and the automated external defibrillator had not been calibrated within the prior 12 months (MIT 5.108).  Inspectors examined emergency response bags to determine if they were inspected daily and inventoried monthly, and whether they contained all essential items. The OIG inspectors found that emergency response bags were compliant in only three of the six clinical locations where bags were stored (50 percent). Specifically, one bag was missing glucose tubes and another had expired glucose tubes. In addition, two oxygen tanks were not fully charged; when inspectors brought this to the attention of staff, they replaced both oxygen tanks without delay (MIT 5.111). CVSP received an adequate score in the following area:  Inspectors found that six of the eight clinics (75 percent) followed adequate medical supply storage and management protocols. In one clinic, while staff had stored bulk medical Chuckawalla Valley State Prison, Cycle 4 Medical Inspection Page 25 Office of the Inspector General State of California supplies in an orderly manner in clinic room cabinets, the cabinets themselves were not labeled for easy identification of the supplies. Inspectors also found a staff member’s personal water bottle being stored in a refrigerator intended for the bulk storage of medications (MIT 5.107). The institution scored at the proficient level in the five areas described below, receiving a score of 100 percent for three of the tests:  All eight clinics (100 percent) had operable sinks and sufficient quantities of hygiene supplies in clinical areas (MIT 5.103).  OIG inspectors observed clinicians’ encounters with patients in six clinics and found that all clinicians (100 percent) followed good hand hygiene practices (MIT 5.104).  The non-clinic bulk medical supply storage area located in CVSP’s Facility A met the supply management process and supported the needs of the medical health care program, resulting in a score of 100 percent (MIT 5.106).  When inspectors reviewed cleaning logs for the eight clinics, they found that some areas of the Facility C clinic did not receive comprehensive cleaning for one week in the month of April 2015. As a result, the institution received a score of 88 percent for this test. (MIT 5.101).  Seven of CVSP’s eight clinics (88 percent) had an adequate environment conducive to providing medical services. One clinic lacked adequate auditory privacy for inmate-patients during their encounters with nurses. Patient privacy was compromised because inmate-patients in the waiting area could overhear the nurse communicating with the patient being assessed (MIT 5.109). Other Information Obtained from Non-Scored Results The OIG gathered information to determine if the institution’s physical infrastructure supports health care management’s ability to provide timely or adequate health care. The OIG did not score this question. When OIG inspectors interviewed health care management, management discussed possible issues regarding the facility’s potential for adding a specialized medical housing unit. While CVSP does not currently have an activated specialized medical housing unit, according to the CEO, CVSP currently lacks a positive air pressure room and any properly-constructed mental health crisis rooms; if CVSP activated a specialized housing unit, it would need both items. At the time of the OIG onsite visit, CVSP sent all inmate-patients needing inpatient or mental health care to its sister institution, Ironwood State Prison. Chuckawalla Valley State Prison, Cycle 4 Medical Inspection Page 26 Office of the Inspector General State of California The institution does have two significant infrastructure projects approved and scheduled to begin in June 2016: remodeling CVSP’s central health building, and expanding health clinics in each of the institution’s yards (MIT 5.999). Recommendations While many scores were within the proficient or adequate range for this indicator, the institution performed in the inadequate range in several areas and could easily improve its overall score by adhering to recognized health care guidelines and implementing the following specific recommendations:  To mitigate exposure to blood-borne pathogens and contaminated waste, the institution should stock all clinical areas with sharps containers, disinfectant supplies, and adequate supplies of personal protective equipment.  The institution should take measures to properly maintain and stock its clinic areas with a full complement of core equipment, including a glucometer, nebulization unit, peak flow meter, refrigerators, and permanent distance markers for Snellen vision charts. The institution should stock exam rooms where providers work with hemoccult cards and a developer. Also, clinic staff should ensure that they store personal beverage items separately from stored medical supplies.  Staff should monitor calibration expiration dates for applicable medical equipment to ensure equipment items are calibrated within required timeframes.  The institution should position exam tables in its exam rooms so that patients can lie fully extended on the exam table and clinicians can have unimpeded access to the patient. In addition, CVSP should either repair tears on exam tables or replace the tables. Chuckawalla Valley State Prison, Cycle 4 Medical Inspection Page 27 Office of the Inspector General State of California INTER- AND INTRA-SYSTEM TRANSFERS This indicator focuses on the management of inmate-patients’ Case Review Rating: medical needs and continuity of patient care during the inter- and Adequate intra-facility transfer process. The OIG review includes evaluation Compliance Score: of the institution’s ability to provide and document health 90.8% screening assessments (including tuberculosis screening), initiation Overall Rating: of relevant referrals based on patient needs, and the continuity of Adequate medication delivery to patients arriving from another institution. For those patients, the clinicians also review the timely completion of pending health appointments, tests, and requests for specialty services. For inmate-patients who transfer out of the facility, the OIG evaluates the ability of the institution to document transfer information that includes pre-existing health conditions, pending appointments, tests and requests for specialty services, medication transfer packages, and medication administration prior to transfer. The patients reviewed for Inter- and Intra-System Transfers include inmates received from other CDCR facilities and inmates transferring out of CVSP to another CDCR facility. Case Review Results The OIG clinicians reviewed 25 encounters relating to Inter- and Intra-System Transfers, including information from both the sending and receiving institutions. The OIG clinicians reviewed 35 hospitalization events, each of which resulted in a transfer back to the institution. In general, the inter- and intra-system transfer processes at CVSP were adequate, with the majority of transferring inmates receiving timely continuity of health care services. Although there were rarely any major issues found in the cases reviewed, there were deficiencies found regarding nursing assessment and the thorough completion of transfer forms. Specific examples of case review findings are listed below. Transfers In Deficiencies found with patients arriving to CVSP were largely due to nursing processes.  In cases 26 and 27, the nurse failed to assess abnormal findings.  In case 28, the nurse failed to initiate a provider appointment.  In case 9, the patient failed to receive his blood pressure medication on the day of arrival or the following morning. Chuckawalla Valley State Prison, Cycle 4 Medical Inspection Page 28 Office of the Inspector General State of California Transfers Out Deficiencies found with inmates transferring out of CVSP were minimal. All deficiencies were due to incomplete or inaccurate nursing documentation of significant medical information on the Health Care Transfer Information Form (CDCR Form 7371).  In case 4, the RN did not document the patient’s history of chronic hepatitis C virus.  In case 31, the RN incorrectly documented a history of asthma. Hospitalizations Patients returning from hospitalizations are some of the highest risk encounters due to two factors. First, these patients are generally hospitalized for a severe illness or injury. Second, they are at risk due to potential lapses in care that can occur during any transfer. The TTA nurse at CVSP processed hospital return patients in a timely manner, and the primary care provider followed up with the patients in a timely manner. This process worked well for the majority of hospitalization events reviewed. However, the OIG identified some deficiencies in nursing assessment documentation.  In cases 2, 9, 19, and 23, the nurse failed to document receipt and review of hospital records or discharge recommendations. Onsite Visit During the onsite visit, the OIG clinicians learned CVSP is a “hub” for patients returning from California Out-of-State Correctional Facilities (COCF). Per CVSP staff, for almost a year, these patients (not endorsed to CVSP) had been housed in CVSP’s administrative segregation unit (ASU) en route to their endorsed facilities. Medical staff have indicated these patients’ stays, which were supposed to be days in length, have turned out to be months. This has been challenging to CVSP in several ways:  CVSP’s staff had to transfer their own ASU patients to Ironwood State Prison’s ASU because COCF patients occupied CVSP’s ASU.  Because COCF patients do not always arrive with medical records, or they arrive with paper records that are incomplete, unlabeled, or uncategorized, providers and staff report that thorough and appropriate review of records continues to be a tedious process.  Each of the COCF patients requires a provider to complete a medical classification chrono (MCC).  Patients often arrive without prescribed medications, which impacts nursing and pharmacy.  When care or medications are delayed, multiple Health Care Service Request forms (CDCR Form 7362) are submitted. Chuckawalla Valley State Prison, Cycle 4 Medical Inspection Page 29 Office of the Inspector General State of California During the month of March 2015, records reviewed revealed CVSP’s ASU logged over 170 COCF patients. As CVSP’s infrastructure was not designed to house returning COCF patients, the staffing requirements to fulfill the needs of these patients have been overwhelming. Compliance Testing Results The institution obtained a proficient score of 90.8 percent in the Inter- and Intra-System Transfers indicator, scoring within the proficient range in four of the five areas tested, as described below:  The institution scored 100 percent when the OIG tested four inmate-patients who transferred out of the institution during the onsite inspection to determine whether their transfer packages included required medications and related documentation (MIT 6.101).  Inspectors tested 30 inmate-patients who transferred into CVSP from another CDCR institution to determine if nursing staff completed the assessment and disposition section of the Initial Health Screening (CDCR Form 7277) on the same day staff completed an initial screening of the patient. Inspectors found one exception, resulting in a score of 97 percent. For one patient, the registered nurse neglected to sign and date the Initial Health Screening (MIT 6.002).  The institution scored 88 percent when OIG tested 16 inmate-patients who transferred out of CVSP to another CDCR institution to determine whether CVSP listed the patients’ pending specialty service appointments on the Health Care Transfer Information form (CDCR Form 7371). The institution failed to include specialty service appointments on the transfer forms for two patients (MIT 6.004).  The OIG also reviewed the Initial Health Screening for 30 inmate-patients who transferred into CVSP from another CDCR institution to determine whether they received a complete initial health screening from nursing staff on their day of arrival. Inspectors found nursing staff timely completed the screening for 26 of the patients sampled (87 percent). For three patients, inspectors identified health screenings that were not complete, as nurses neglected to answer all the form’s screening questions. For another patient, the nurse completed the health screening two days late (MIT 6.001). The institution scored within the adequate range for the following test:  Six of the sampled inmate-patients who transferred into CVSP had an existing medication order upon arrival. Inspectors tested those patients’ records to determine if they received their medications without interruption and found that five of the six patients (83 percent) received them timely. For one patient who did not arrive at CVSP with his self-administered keep-on-person (KOP) medication, nursing staff failed to reissue the medication to the patient upon arrival (MIT 6.003). Chuckawalla Valley State Prison, Cycle 4 Medical Inspection Page 30 Office of the Inspector General State of California Recommendations The institution can easily improve its overall rating of adequate for this indicator by adhering to established policy and procedure and implementing the following specific recommendation:  CVSP should implement formal training along with audits and competency testing for nurses who complete Initial Health Screening forms (CDCR Form 7277) and Health Care Transfer Information forms (CDCR Form 7371). Chuckawalla Valley State Prison, Cycle 4 Medical Inspection Page 31 Office of the Inspector General State of California PHARMACY AND MEDICATION MANAGEMENT This indicator is an evaluation of the institution’s ability to provide appropriate pharmaceutical administration and security Case Review Rating: management, encompassing the process from the written Adequate prescription to the administration of the medication. By combining Compliance Score: 80.7% both a quantitative compliance test with case review analysis, this assessment identifies issues in various stages of the medication Overall Rating: management process, including ordering and prescribing, Adequate transcribing and verifying, dispensing and delivering, administering, and documenting and reporting. Because effective medication management is affected by numerous entities across various departments, this assessment considers internal review and approval processes, pharmacy, nursing, health information systems, custody processes, and actions taken by the PCP prescriber, staff, and patient. Based on results from pilot inspections, the OIG has found that the most accurate evaluation of this indicator is derived largely from a detailed analysis of the OIG compliance scores in addition to the clinical case reviews. The case reviews often add specific examples of the findings revealed by the compliance scores and identify problems in other processes that may not be evident when viewed solely from a compliance standpoint. Case Review Results The OIG clinicians evaluated Pharmacy and Medication Management as secondary processes as they relate to the quality of clinical care provided. Compliance testing took a more targeted approach, which the OIG heavily relied upon for the overall rating for this indicator. Case review indicated that for the majority of cases, patients received their medications timely and as prescribed. CVSP adequately maintained medication continuity for patients returning from a hospitalization. However, the OIG clinicians did find a pattern of practice creating a potential risk for medication errors. The institution failed to discontinue medications when patients transferred back to CVSP after a hospital admission. As such, there were occasional instances when staff missed medication changes.  In case 9, the patient’s hospital discharge medications included one new and one previously prescribed blood pressure medication, and three other blood pressure medications to be discontinued. However, while the provider correctly ordered the new medication, the three prior medications were inappropriately continued. This created a potential for severely low blood pressure. Chuckawalla Valley State Prison, Cycle 4 Medical Inspection Page 32 Office of the Inspector General State of California Conclusion The OIG rated overall pharmacy and medication administration performance adequate. Compliance Testing Results The institution received an overall score of 80.7 percent for the Pharmacy and Medication Management indicator. For discussion purposes below, this indicator is divided into three sub-indicators that consist of medication administration; observed medication practices and storage controls; and pharmacy protocols. Medication Administration For this sub-indicator, the institution received an average score of 83 percent and performed well in the following areas:  CVSP scored 100 percent when the OIG sampled 30 patients to determine if they timely received their newly ordered prescriptions (MIT 7.002).  The institution timely dispensed chronic care medications to 28 of the 29 inmate-patients sampled (97 percent). One patient missed one day’s dose of his nurse administered medication during a three-month test period (MIT 7.001).  The institution also performed well in ensuring that inmate-patients who transferred from one housing unit to another received their medications without interruption, receiving a score of 95 percent for this test. One of the 20 inmate-patients sampled missed one day’s dose of his nurse administered medication (MIT 7.005). CVSP received a marginally adequate score in the following area:  The institution timely provided hospital discharge medications to 21 of 28 patients sampled who had returned from a community hospital (75 percent). While three patients received their medication one day late, the institution delivered medication for a fourth patient 18 days late. Additionally, for three patients, inspectors found no evidence that patients had either received or refused their medication (MIT 7.003). Opportunities for improvement exist in the following medication administration area:  When the OIG sampled six inmate-patients who were en route to another institution and temporarily laid over at CVSP, inspectors found that only three (50 percent) received their nurse administered or KOP medications without interruption (MIT 7.006). Chuckawalla Valley State Prison, Cycle 4 Medical Inspection Page 33 Office of the Inspector General State of California Observed Medication Practices and Storage Controls For this sub-indicator, the institution received a score of 64 percent. As described below, CVSP scored 100 percent in two areas but received suboptimal scores in four others:  The institution properly stored non-narcotic medications that do not require refrigeration at all 13 of the applicable clinics and medication line storage locations sampled (100 percent) (MIT 7.102).  Inspectors observed nursing staff following appropriate administrative controls during medication preparation at all six (100 percent) of the sampled medication and preparation administration locations (MIT 7.105). Nursing staff at five of the six locations (83 percent) followed proper hand hygiene contamination control protocols during the medication preparation and administration processes. The nurse at one location’s medication line (pill line), did not always sanitize her hands between glove changes (MIT 7.104).  The institution employed strong medication security controls over narcotic medications in only three of its six clinic and medication line locations that stored narcotics (50 percent). In medication areas, policy requires that two licensed nurses perform a controlled substance physical inventory at every shift change. In addition, nurses should ensure that controlled substances are securely maintained and locked up; only one nurse per shift should maintain the keys. OIG inspectors observed noncompliant practices in three clinic locations; at two clinics a single LVN conducted a controlled substance physical inventory at the shift change; at one of those same clinics and at another clinic, both an RN and an LVN possessed keys to one narcotics locker during the same shift (MIT 7.101).  When observing the medication distribution process at six pill line locations, inspectors found that only three (50 percent) were compliant with appropriate administrative controls and protocols. Inspectors observed exceptions for three pill line windows at CVSP; each lacked an overhang or shade protection. Figure 3 shows one example of a pill line window where patients can be exposed to extreme heat or inclement weather when waiting outdoors to receive their medication. However, OIG’s onsite inspectors were told that plans were Figure 3: Unprotected medication in place to build an overhang at each of the three pickup window outdoor pill line locations (MIT 7.106). Chuckawalla Valley State Prison, Cycle 4 Medical Inspection Page 34 Office of the Inspector General State of California  The institution failed to properly store non-narcotic medications that require refrigeration in its clinics and medication line storage locations. When inspectors tested daily temperature logs for refrigerators and freezers in six applicable clinics, they found that staff did not always maintain historical temperature logs or that logs revealed refrigerator temperatures outside policy thresholds. As a result, the institution scored 0 percent for this test (MIT 7.103). Pharmacy Protocols For this sub-indicator, the OIG evaluated the main pharmacy. The institution received an average score of 98 percent. As described below, CVSP scored no less than 92 percent in all five areas.  In its main pharmacy, the institution follows general security, organization, and cleanliness management protocols; properly stores non-refrigerated medications; properly stores refrigerated or frozen medications; and maintains adequate controls and properly accounts for narcotic medications. CVSP scored 100 percent in each of these areas (MIT 7.107, 7.108, 7.109, 7.110).  Also, CVSP’s pharmacist-in-charge (PIC) properly processed 23 of 25 medication error reports tested (92 percent). For one reported incident, the PIC did not complete the medication error follow-up review within five business days from when the error was reported by staff, the review was conducted 13 days late; for a second incident, inspectors found no evidence the medication error follow-up report was distributed timely to the appropriate institutional subcommittees (MIT 7.111). Other Information Obtained from Non-Scored Results In addition to testing reported medication errors, OIG inspectors follow up on any significant medication errors found during the case reviews or compliance testing to determine whether staff properly identified and reported the errors. At CVSP, the OIG did not find any applicable medication errors (MIT 7.998). The OIG tested inmate-patients housed in isolation units to determine if they had immediate access to their prescribed KOP rescue inhalers and nitroglycerin medications. Each of the three applicable inmates interviewed indicated he had possession of his asthmatic inhaler (MIT 7.999). Chuckawalla Valley State Prison, Cycle 4 Medical Inspection Page 35 Office of the Inspector General State of California CCHCS Dashboard Comparative Data The Dashboard uses performance measures from the Medication Administration Process Improvement Program (MAPIP) audit tool to calculate the average score for its Medication Administration measure. The OIG compared similar CVSP compliance scores with applicable May 2015 Dashboard results. As noted in the table below, the OIG based its compliance results on a review of current documents as well as documents dating up to nine months back; CVSP’s May Dashboard data reflected only the institution’s April 2015 results. The Dashboard and OIG scores were both in the proficient range. Pharmacy and Medication Management— CVSP Dashboard and OIG Compliance Results CVSP DASHBOARD RESULTS OIG COMPLIANCE RESULTS Medication Management: Medication Administration (7.001, 7.002) Medication Administration (Chronic Care & New Meds) Preventive Services (9.001) May 2015 (Administering INH Medication) August 2014 – May 2015 100% 98% Note: The Dashboard results were obtained from the Medication Administration Drilldown data for Chronic Care Meds—Medical, New Outpatient Orders—Medical, New Outpatient Orders—Psychiatric, and Administration—TB Medications. Variances may exist because CCHCS includes medication administration of KOP medications only for the first two drilldown measures, while the OIG tests KOP, DOT, and nurse administered (NA) medication administration. Recommendations While the overall rating for this indicator was adequate, the OIG found some deficiencies that CVSP can remedy by adhering to established policy and procedure and implementing the following specific recommendations:  CVSP should create a special hospital return medication order that discontinues all prior outpatient medications and specifies the medication, dose, route, frequency, duration, and start time for each new prescription. When given verbally, nurses can expect to verify each prescription in detail with read-back with the ordering physician.  Nurses should remove pre-hospitalization medication administration records from the medication binder or clearly mark pre-hospital medications as discontinued. Chuckawalla Valley State Prison, Cycle 4 Medical Inspection Page 36 Office of the Inspector General State of California  Nursing staff should conduct a controlled substance physical inventory with two licensed nurses at each shift change; one nurse per shift should maintain sole custody of the keys to the controlled substance cabinet or locker. Chuckawalla Valley State Prison, Cycle 4 Medical Inspection Page 37 Office of the Inspector General State of California PREVENTIVE SERVICES This indicator assesses whether the institution offers or provides Case Review Rating: various preventive medical services to inmate-patients. These Not Applicable include cancer screenings, tuberculosis screenings, and influenza Compliance Score: and chronic care immunizations. This indicator also assesses 84.9% whether certain institutions take preventive actions to relocate Overall Rating: inmate-patients identified as being at higher risk for contracting Adequate coccidioidomycosis (valley fever). Compliance Testing Results The institution performed in the adequate range in the Preventive Services indicator, with an overall score of 84.9 percent. The institution scored at the proficient level in four of the six tests. The stronger areas are described below:  The OIG sampled 30 inmate-patients to determine if CVSP timely offered them an influenza vaccine; all 30 patients (100 percent) received or were offered influenza vaccinations during the most recent influenza season (MIT 9.004).  The institution scored 97 percent for administering anti-tuberculosis medication (INH) to inmate-patients with tuberculosis. Twenty-eight of 29 patients sampled received all required doses of INH medication timely when inspectors reviewed their records for a three-month testing period (MIT 9.001).  The institution offered colorectal cancer screenings to 27 of 30 sampled inmate-patients subject to the annual screening requirement (90 percent). For three patients, inspectors found no evidence the patient either was offered a fecal occult blood test within the previous twelve months or received a normal colonoscopy within the previous ten years (MIT 9.005).  The OIG tested whether the institution offered vaccinations for influenza, pneumonia, and hepatitis to its patients who suffer from a chronic care condition. At CVSP, 14 of the 16 chronic care inmate-patients sampled (88 percent) received all recommended vaccinations at the required interval, while only two patients were not offered one or more of the vaccinations (MIT 9.008). The institution scored low in the following two key preventive services tests:  When the OIG reviewed the institution’s monthly monitoring of 29 sampled patients who received INH medication over a three-month period, the institution was in compliance for Chuckawalla Valley State Prison, Cycle 4 Medical Inspection Page 38 Office of the Inspector General State of California only 18 of those patients (62 percent). The institution completed the required monitoring for ten patients, but failed to scan each month’s monitoring results separately into the patient’s eUHR file. CVSP monitored one other patient for only one of the two months during which he received INH medication prior to his parole. (MIT 9.002).  The institution scored 73 percent for conducting annual tuberculosis screenings. All 30 inmate-patients sampled were screened for tuberculosis within the prior year. However, eight inmate-patients identified as Code 22 (requiring a tuberculosis skin test in addition to screening of signs and symptoms) had their tuberculosis test results read by a licensed vocational nurse, rather than by a registered nurse, public health nurse, or primary care provider (MIT 9.003). CCHCS Dashboard Comparative Data As indicated below, the OIG’s proficient compliance results for colon cancer screening as of May 2015 were consistent with the data reported within the CCHCS Dashboard for CVSP. Preventive Services—CVSP Dashboard and OIG Compliance Results CVSP DASHBOARD RESULTS OIG COMPLIANCE RESULTS Colon Cancer Screening Colon Cancer Screening (9.005) May 2015 May 2015 98% 90% Recommendations No specific recommendations. The institution scored at the proficient level for most areas tested within this indicator; staff can easily address areas needing improvement by adhering to established policy and procedure. Chuckawalla Valley State Prison, Cycle 4 Medical Inspection Page 39 Office of the Inspector General State of California QUALITY OF NURSING PERFORMANCE The Quality of Nursing Performance indicator is a qualitative Case Review Rating: evaluation of nursing services performed entirely by OIG nursing Adequate clinicians within the case review process, and, therefore, does not Compliance Score: have a score under the compliance testing component. The OIG Not Applicable nurses conduct case reviews that include reviewing face-to-face encounters related to nursing sick call requests identified on the Overall Rating: Health Care Services Request form (CDCR Form 7362), urgent Adequate walk-in visits, referrals for medical services by custody staff, RN case management, RN utilization management, clinical encounters by licensed vocational nurses (LVNs) and licensed psychiatric technicians (LPTs), and any other nursing service performed on an outpatient basis. The OIG case review also includes activities and processes performed by nursing staff that are not considered direct patient encounters, such as the initial receipt and review of CDCR Form 7362 service requests and follow-up with primary care providers and other staff on behalf of the patient. Key focus areas for evaluation of outpatient nursing care include appropriateness and timeliness of patient triage and assessment, identification and prioritization of health care needs, use of the nursing process to implement interventions including patient education and referrals, and documentation that is accurate, thorough, and legible. Nursing services provided in the outpatient housing unit (OHU), correctional treatment center (CTC), or other inpatient units are reported under Specialized Medical Housing. Nursing services provided in the triage and treatment area (TTA) or related to emergency medical responses are reported under Emergency Services. Case Review Results The OIG evaluated 225 nursing encounters for CVSP case reviews; 150 of these were outpatient nursing encounters. For the 150 encounters, the OIG identified 39 deficiencies. Most deficiencies were minor, with only one, case 44, being significant. Case review findings showed that most triage RNs provided necessary interventions for patients presenting with medical issues in the outpatient RN clinics. However, case reviews also revealed patterns of assessment and documentation deficiencies. OIG nursing clinicians rated the overall Quality of Nursing Performance at CVSP adequate. Nursing Assessment/Documentation  In case 44, a patient submitted a complaint for “difficulty breathing.” The RN performed the paper triage, but failed to perform a face-to-face assessment. Failure to perform face-to-face assessments also occurred in cases 11, 12, and 52. Chuckawalla Valley State Prison, Cycle 4 Medical Inspection Page 40 Office of the Inspector General State of California  In case 49, a face-to-face assessment occurred for complaints of abdominal pain, rectal bleeding, and nose bleed. The nurse failed to perform an adequate subjective assessment. The objective assessment did not include thorough abdominal or nasal and sinus assessments. Additional examples of incomplete assessments were seen in cases 23, 48, and 51.  In case 11, the patient finished a course of antibiotics and requested a refill. The nurse conducted a face-to-face encounter but failed to perform an assessment and to provide accurate medication education.  In case 19, the RN failed to review records and instead advised the patient to continue a medication not prescribed. The provider had discontinued this medication nine days prior. Recommendations Although the case reviews revealed outpatient nursing care was adequate, there is room for improvement in a few areas. The institution can improve those areas by adhering to established policy and procedure and implementing the following specific recommendation:  CVSP should review the quality of nursing sick call audits. The OIG case reviews found the current system did not address the lack in assessment, documentation, and face-to-face encounters. Chuckawalla Valley State Prison, Cycle 4 Medical Inspection Page 41 Office of the Inspector General State of California QUALITY OF PROVIDER PERFORMANCE In this indicator, the OIG physicians provide a qualitative Case Review Rating: evaluation of the adequacy of provider care at the institution. Adequate Appropriate evaluation, diagnosis, and management plans are Compliance Score: reviewed for programs including, but not limited to, nursing sick Not Applicable call, chronic care programs, TTA, specialized medical housing, and specialty services. The assessment of provider care is Overall Rating: performed entirely by OIG physicians. There is no compliance Adequate testing component associated with this quality indicator. Case Review Results The OIG clinicians reviewed 295 CVSP medical provider encounters and identified 58 deficiencies related to provider performance. Ten deficiencies were considered likely to contribute to patient harm, and of those, five were associated with a provider no longer working at CVSP. As a whole, CVSP provider performance was rated adequate. Assessment and Decision-Making The large majority of provider encounters reviewed demonstrated adequate assessment and sound medical decision-making. However, the OIG noted some concerns regarding the quality of provider care during the case review.  Providers, especially when on-call, sometimes appeared to be unaware of the patient’s history. They inappropriately ordered or renewed certain medications such as narcotics and non-steroidal anti-inflammatory medications (cases 6, 9, and 19).  In case 11, the provider failed to urgently order diagnostic tests to evaluate testicular pain with swelling, redness, and induration. After the provider diagnosed orchitis (inflammation of the testicle), the provider failed to prescribe appropriate treatment consistent with guidelines.  In case 34, after blood tests and a bronchoscopy were negative for lung cancer, the provider noted that the CT scan showed bullae, but failed to comment on that lung mass or its diagnosis.  There were several instances when providers failed to provide complete evaluations or documentation. For example, there was no documentation for multiple knee exams for knee pain (cases 16, 21, and 23), a skin exam after surgery (case 32), and a neurological exam for weakness and paresthesia (case 35). Chuckawalla Valley State Prison, Cycle 4 Medical Inspection Page 42 Office of the Inspector General State of California  In case 34, the provider prescribed the wrong medication to a patient. A provider mistakenly ordered a blood pressure medication when the intended medication was for itching. Other health care staff quickly caught and rectified the error. Review of Records Providers generally reviewed diagnostic reports, specialty reports, and hospital reports in a timely manner when available, and with adequate thoroughness ( discussed more in the Health Information Management indicator). Providers also routinely updated problem lists. However, there were a few notable exceptions:  In case 6, when a CVSP provider saw the patient on the day of discharge, the hospital-recommended referral for a hemorrhoidectomy was not addressed.  In cases 34 and 37, providers failed to reorder certain diagnostic tests due to laboratory processing problems.  In cases 9, 13, 33, and 40, providers failed to adequately address medications upon the patient’s return from a hospitalization or specialty visit.  In case 15, the provider failed to renew blood pressure medications when the medications were about to run out.  In cases 18 and 36, providers erroneously noted diagnostic results as being “within normal limits” when, in fact, they were not. Notably, in case 2, the provider noticed a possible discrepancy with a computed tomography (CT) report in the patient’s medical history. Although the patient had a partial prostatectomy in the past, the CT report noted a normal prostate. The OIG commends this provider for taking the time and making the effort to contact the radiologist for clarification. Emergency Care Providers made appropriate triage decisions when patients presented emergently to the TTA. The overall emergency care provided was adequate. Chronic Care Chronic care performance was adequate overall. Appropriate monitoring, assessments, and interventions were the rule rather than the exception. Sometimes, providers failed to order appropriate chronic care follow-up intervals, and a few other negative patterns emerged: Chuckawalla Valley State Prison, Cycle 4 Medical Inspection Page 43 Office of the Inspector General State of California  The management of anticoagulation was sometimes inadequate (cases 14 and 21).  The providers failed to manage some patient’s blood pressure as well as possible. This was seen in case 2 and on multiple occasions in case 15. Specialty Services Reviews of the specialty services referrals revealed that, overall, CVSP providers requested specialty services appropriately. When providers saw patients for follow-up after specialty services, the reports were adequately reviewed and appropriate actions were taken. There were a few exceptions:  In case 6, also discussed previously, the provider deferred the referral for hemorrhoidectomy (for extensive hemorrhoids) to address the patient’s more pressing issue. However, once that issue was resolved, the provider failed to submit the referral for a hemorrhoidectomy.  Providers submitted a few referrals with incomplete information (seen several times in case 34).  Cases 32, 33, and 37 had late pre-operative orders to stop certain medications. Health Information Management As noted in the Health Information Management indicator, the eUHR lacked a few provider notes and had a few transcription errors. Onsite Inspection The OIG found the CVSP providers were generally content with their work, leadership, and ancillary services. The providers felt well supported by a medical management team with a strong commitment to excellence and continuous quality improvement. They felt their workload was appropriate and manageable. Providers shared their on-call coverage with providers at the neighboring Ironwood State Prison (ISP). Discussion with some of the providers revealed the lack of access to the eUHR when on call. Discussion with medical management revealed prior on-call access had slow connectivity issues. With these connectivity issues now much improved, CVSP medical management will revisit the provider on-call access to the eUHR. Chuckawalla Valley State Prison, Cycle 4 Medical Inspection Page 44 Office of the Inspector General State of California Pharmacy and Medication Management While CVSP satisfactorily maintained medication continuity for patients returning from a hospitalization in most cases reviewed, the OIG clinicians noted a pattern of practice creating a potential for medication errors. Case reviews revealed that providers at CVSP failed to discontinue chronic medications upon hospitalization and that the medications automatically resumed upon the patients’ return from the hospital. While the CVSP providers usually made medication changes recommended at hospital discharge, there were several instances when errors occurred. During discussion with the OIG, the CVSP administration explained that it had already completed a review of the issue and proposed changes (also noted in the Pharmacy and Medication Management indicator). Conclusion Of the 30 cases reviewed, 25 were adequate, and five were inadequate. After taking all factors into consideration, the OIG rated CVSP provider performance as adequate. Recommendations The OIG recommends the following regarding provider performance:  On-call providers should have access to the eUHR to avoid prescribing inappropriate medications or interventions.  On-call providers should be encouraged to question the contacting nurse regarding the patient’s full medical history.  When patients return from an outside hospital, providers should review all medications individually, rather than writing “continue prior medications.” Chuckawalla Valley State Prison, Cycle 4 Medical Inspection Page 45 Office of the Inspector General State of California SPECIALTY SERVICES This indicator focuses on specialist care from the time a Case Review Rating: physician’s request for services or order for specialist care is Adequate completed to the time related recommendations are received from Compliance Score: specialists. This indicator also evaluates whether providers timely 87.9% review specialist records and document the patients’ care plans, including the course of care when specialists do not order Overall Rating: recommendations, and whether providers communicate the results Adequate of specialists’ reports to the patients. For specialty services denied by the institution, the OIG determines whether the denials are timely and appropriate, and whether the provider updates the inmate-patient on the plan of care. Case Review Results The OIG clinicians reviewed 124 events related to Specialty Services, the majority of which were specialty consultations and procedures. They found 28 deficiencies in this category, with almost half due to specialty service appointments not occurring as ordered (or requested). Two deficiencies within specialty services were significant. Access to Specialty Services  Urgent and routine specialty services were generally timely and adequate, though there were occasional minor delays in specialty follow-up appointments. Nursing Performance  Nursing performance for specialty services was adequate. Provider Performance  The OIG found seven provider deficiencies. Three related to pre-operative orders not being given in a timely manner; two related to medication recommendations not being followed (or lack of documentation as to why recommendations were not followed); and two related to referral requests not being completely filled out. Health Information Management  Six of the deficiencies found in specialty services were related to health information management. Four of these deficiencies were due to a delay in specialty reports being retrieved, reviewed by a provider, or scanned into the eUHR. One deficiency related to a provider referral submitted but not found in the eUHR. One deficiency was due to diagnostic Chuckawalla Valley State Prison, Cycle 4 Medical Inspection Page 46 Office of the Inspector General State of California results not being available to the specialist during a follow-up consultation. These deficiencies are also noted in the Health Information Management section. Onsite Inspection Onsite discussions revealed that specialty visits that take place via telemedicine were coordinated centrally (at CCHCS), and not by CVSP staff. Certain specialists offered a finite number of hours or visits per week or month. As a result, CVSP staff reported that timely access to specialty care was challenging at times. Additionally, processes for telemedicine appeared to differ from face-to-face (offsite) specialty follow-up appointments and recommendations. Telemedicine specialty recommendations and follow-up were noted by nursing staff, who filled out an order form. A provider then reviewed and signed the orders. For offsite specialty recommendations and follow-up, providers reviewed the specialty report and wrote their own orders. These differences could cause confusion or result in failure to implement recommendations. Compliance Testing Results The institution received an overall proficient score of 87.9 percent in the Specialty Services indicator. CVSP scored in the proficient range for five tests but received an inadequate rating for two areas. The institution did well in the following areas:  For 13 of the 15 inmate-patients sampled (87 percent), their high-priority specialty services appointment occurred within 14 calendar days of the provider’s order. Two patients received their specialty service two days late (MIT 14.001). Following an inmate-patient’s high- priority specialty services appointment, providers reviewed the specialists’ reports within three business days of the service for all 13 applicable patients sampled (100 percent) (MIT 14.002).  For all 15 of the inmate-patients sampled (100 percent), their routine specialty services appointment occurred within 90 calendar days of the provider’s order (MIT 14.003).  The OIG tested the timeliness of CVSP’s denials of providers’ specialty services requests for 20 patients and found that 18 of the denials (90 percent) occurred within the required time frame. For two patients’ routine specialty services, the institution issued the denial two days late (MIT 14.006). Similarly, CVSP scored 95 percent regarding providers communicating the denial status to 19 of the 20 patients within 30 calendar days. The provider informed one patient of his denied specialty service ten days late (MIT 14.007). Chuckawalla Valley State Prison, Cycle 4 Medical Inspection Page 47 Office of the Inspector General State of California The institution has room for improvement in the following areas:  When the institution ordered routine specialty services, providers did not always review the specialists’ reports within three business days after the specialist performed the service. CVSP providers timely reviewed only 11 of the 15 reports sampled (73 percent). For three patients, the provider reviewed the specialist’s report only one day late; for another patient, the provider reviewed the specialist’s report 12 days late (MIT 14.004).  When staff approve or schedule patients for specialty services appointments at one institution, and then transfer to another institution, policy requires that the receiving institution ensure a patient’s appointment is timely rescheduled or held as scheduled. At CVSP, only 14 of the 20 patients sampled (70 percent) received their specialty services appointment within the required action date. Based on inspectors’ review, three patients received their optometry appointments two or three days late; one patient received his orthopedic appointment 40 days late; another, 52 days late. For one other patient, there was no evidence that his ordered optometry appointment occurred at all (MIT 14.005). Recommendations Generally, patients had adequate access to specialty visits or procedures, and the institution can easily address most areas needing improvement by adhering to established policy and procedure and implementing quality improvement training in the following areas:  When appointment barriers occur, health care staff should document the problem in the patient’s health record and document notification to the primary care provider and local leadership.  CCHCS providers should work with their specialists to ensure timely availability of (telemedicine) care for their patients. Chuckawalla Valley State Prison, Cycle 4 Medical Inspection Page 48 Office of the Inspector General State of California SECONDARY (ADMINISTRATIVE) QUALITY INDICATORS OF HEALTH CARE The last two quality indicators (Internal Monitoring, Quality Improvement, and Administrative Operations and Job Performance, Training, Licensing, and Certifications) involve health care administrative systems and processes. Testing in these areas applies only to the compliance component of the process. Therefore, there is no case review assessment associated with either of the two indicators. As part of the compliance component for the first of these two indicators, the OIG did not score several questions. Instead, the OIG presented the findings for informational purposes only. For example, the OIG described certain local processes in place at CVSP. To test both the scored and non-scored areas within these two secondary quality indicators, OIG inspectors interviewed key institutional employees and reviewed documents during their onsite visit to CVSP in May 2015. They also reviewed documents obtained from the institution and from CCHCS prior to the start of the inspection. Chuckawalla Valley State Prison, Cycle 4 Medical Inspection Page 49 Office of the Inspector General State of California INTERNAL MONITORING, QUALITY IMPROVEMENT, AND ADMINISTRATIVE OPERATIONS This indicator focuses on the institution’s administrative health care Case Review Rating: oversight functions. The OIG evaluates whether the institution Not Applicable promptly processes inmate-patient medical appeals and addresses Compliance Score: all appealed issues. Inspectors also verify that the institution follows 39.8% reporting requirements for adverse/sentinel events and inmate deaths, and whether the institution is making progress toward its Overall Rating: Inadequate Performance Improvement Work Plan initiatives. In addition, the OIG verifies that the Emergency Medical Response Review Committee (EMRRC) performs required reviews and that staff perform required emergency response drills. Inspectors also assess whether the Quality Management Committee (QMC) meets regularly and adequately addresses program performance. For those institutions with licensed facilities, inspectors also verify that required committee meetings are held. Compliance Testing Results The institution scored poorly in the Internal Monitoring, Quality Improvement, and Administrative Operations indicator, receiving an overall score of 39.8 percent. Although CVSP received a score of 100 percent in two of the eight test areas applicable to the institution, it scored 0 percent in four others. All low-scoring areas are described below:  Inspectors reviewed six recent months of Quality Management Committee (QMC) meeting minutes and confirmed that the institution’s QMC did meet monthly but it did not evaluate program performance or take action when improvement opportunities were identified, resulting in a score of 0 percent (MIT 15.003). In addition, CVSP did not take adequate steps to ensure the accuracy of its Dashboard data reporting. Specifically, the OIG did not find discussions of data validation, methodologies used when evaluating data, or communication of data accuracy. Consequently, the institution received a score of 0 percent for this test (MIT 15.004).  The OIG inspected meeting minutes and corresponding documentation for CVSP’s Emergency Medical Response Review Committee (EMRRC) meetings convened during the prior six months, and found there were two emergency medical response incidents requiring discussion. While CVSP reviewed the packets timely and included required forms and documentation, the warden and chief executive officer (CEO) did not sign either set of the meeting minutes reviewed. As a result, CVSP received a score of 0 percent for this test (MIT 15.007).  Inspectors reviewed the summary reports and related documentation for three medical emergency response drills conducted in the prior quarter and found that none included the Chuckawalla Valley State Prison, Cycle 4 Medical Inspection Page 50 Office of the Inspector General State of California Medical Report of Injury or Unusual Occurrence (CDCR Form 7219). Therefore, the institution received a score of 0 percent for this test (MIT 15.101).  CVSP improved or reached targeted performance objectives for only two of the seven quality improvement initiatives identified in its 2014 Performance Improvement Work Plan, resulting in a score of 29 percent (MIT 15.005). The institution performed in the proficient range in the following three test areas:  CVSP promptly processed all inmate medical appeals timely in each of the most recent 12 months (100 percent). Based on data received from the institution, there were no medical appeals categorized as overdue during that period (MIT 15.001).  Medical staff sent the Initial Inmate Death Report (CDCR Form 7229A) to CCHCS’s Death Review Unit timely for the one death that occurred within the OIG’s 12-month test period, resulting in a score of 100 percent (MIT 15.103).  For nine of the ten sampled second-level medical appeals (90 percent), the institution’s response addressed all of the patients’ appealed issues (MIT 15.102). Other Information Obtained From Non-Scored Areas  The OIG gathered non-scored data regarding the completion of death review reports and found that CCHCS’s Death Review Committee did not timely complete its death review summary for the one death that occurred during the testing period. The CCHCS Death Review Committee is required to complete a death review summary within 30 business days of the death and submit it to the institution’s CEO. However, for the one death tested, the committee completed its summary 29 days late (76 calendar days after the death) and submitted the summary to CVSP 9 days after that (MIT 15.996).  Inspectors met with the institution’s CEO to inquire about CVSP’s protocols for tracking appeals. The CEO stated that the medical appeals coordinator provides management with weekly oral reports and a monthly comprehensive written report from CCHCS that categorizes appeals by complaint category. The CEO indicated that management’s approach to reviewing appeals is proactive, and that CVSP is current in managing its medical appeals. The CEO evaluates appeals for timeliness and trends, and identified access to care, referrals, and medical accommodations as the most common three appealed issues. When management substantiates problematic areas, CVSP provides education and training to staff (MIT 15.997).  Non-scored data gathered regarding the institution’s practices for implementing local operating procedures (LOPs) indicated that the institution has a good process in place for Chuckawalla Valley State Prison, Cycle 4 Medical Inspection Page 51 Office of the Inspector General State of California developing LOPs. The health program specialist (HPS) monitors existing LOPs monthly to ensure they are current. The HPS also monitors new and revised CCHCS policies and procedures to determine whether they impact existing LOPs or require a new LOP. Supervisors and managers impacted by the change work with the HPS to draft new LOPs. The HPS presents new and revised LOPs to the institution’s Quality Management Committee meetings (and via the local governing body when the warden has a role in affecting policy). Once approved, the LOP is communicated to all applicable staff, including executive management, the public health nurse instructor, and supervisors of impacted areas. The HPS also distributes an on-the-job-training form to applicable staff, who then return it to the HPS as proof of practice that training occurred. Currently, the institution has implemented all 17 stakeholder recommended LOPs that were applicable to CVSP (100 percent) (MIT 15.998).  The OIG discusses the institution’s health care staffing resources in the About the Institution section on page 1 (MIT 15.999). CCHCS Dashboard Comparative Data Both the Dashboard and the OIG testing results show that CVSP demonstrates a high level of compliance for processing its medical appeals. Internal Monitoring, Quality Improvement, and Administrative Operations— CVSP Dashboard and OIG Compliance Results CVSP DASHBOARD RESULTS OIG COMPLIANCE RESULTS Timely Appeals Medical Appeals-Timely Processing (15.001) May 2015 12-months ending March 2015 100% 100% Note: The CCHCS Dashboard data includes appeal data for: American Disability Act (ADA), mental health, dental, and staff complaint areas, whereas the OIG excluded these appeal areas. Recommendations No specific recommendations. Although the institution scored within the inadequate range for many of the compliance tests included in this indicator, CVSP can easily improve those scores by adhering to established policy and procedure. Chuckawalla Valley State Prison, Cycle 4 Medical Inspection Page 52 Office of the Inspector General State of California JOB PERFORMANCE, TRAINING, LICENSING, AND CERTIFICATIONS In this indicator, the OIG examines whether the institution Case Review Rating: adequately manages its health care staffing resources by evaluating Not Applicable whether job performance reviews are completed as required; Compliance Score: specified staff possess current, valid credentials and professional 77.5% licenses or certifications; nursing staff receive new employee orientation training and annual competency testing; and clinical and Overall Rating: Adequate custody staff have current medical emergency response certifications. Compliance Testing Results The institution received an overall adequate score of 77.5 percent in the Job Performance, Training, Licensing, and Certifications indicator. For six of the eight tests in this indicator, the institution scored 100 percent. Those tests included the following:  All providers at CVSP possessed current professional licenses. Nursing staff and the pharmacist-in-charge also possessed current professional licenses and met all certification requirements (MIT 16.001, 16.105).  Nursing supervisors completed required nursing reviews for all five nurses the OIG sampled (MIT 16.101).  All ten nursing staff who administer medications had current clinical competency validations (MIT 16.102).  All provider, nursing, and custody staff had current emergency response certifications (MIT 16.104).  The institution’s pharmacy and providers who prescribe controlled substances were current with their Drug Enforcement Agency registration (MIT 16.106). While the institution scored well in areas above, the following two notable areas show opportunities to improve:  The institution does not perform complete timely structured clinical performance appraisals for its providers. As of the onsite inspection date, the OIG inspectors found that CVSP was timely with only one of five employees (20 percent) who were due for a probationary or annual review. Two providers had not received an annual review since March 2012 and July Chuckawalla Valley State Prison, Cycle 4 Medical Inspection Page 53 Office of the Inspector General State of California 2013, respectively. Another provider did not receive a third probationary review (of three required), and one other provider was overdue for a second and third probationary review (MIT 16.103).  When inspectors reviewed training records for 11 nursing staff hired within the last year, they found no evidence that nurses completed new employee orientation training specific to their job assignment. Consequently, the institution received a score of 0 percent for this test (MIT 16.107). Recommendations No specific recommendations. The institution scored 100 percent in all but two areas addressed by this indicator and can easily address areas needing improvement by adhering to established policy and procedure. Chuckawalla Valley State Prison, Cycle 4 Medical Inspection Page 54 Office of the Inspector General State of California POPULATION-BASED METRICS The compliance testing and the case reviews give an accurate assessment of how the institution’s health care systems are functioning with regard to the patients with the highest risk and utilization. This information is vital to assess the capacity of the institution to provide sustainable, adequate care. However, one significant limitation of the case review methodology is that it does not give a clear assessment of how the institution performs for the entire population. For better insight into this performance, the OIG has turned to population-based metrics. For comparative purposes, the OIG has selected several Healthcare Effectiveness Data and Information Set (HEDIS) measures for disease management to gauge the institution’s effectiveness in outpatient health care, especially chronic disease management. The Healthcare Effectiveness Data and Information Set is a set of standardized performance measures developed by the National Committee for Quality Assurance with input from over 300 organizations representing every sector of the nation’s health care industry. It is used by over 90 percent of the nation’s health plans as well as many leading employers and regulators. It was designed to ensure that the public (including employers, the Centers for Medicare and Medicaid Services, and researchers) has the information it needs to compare accurately the performance of health care plans. Healthcare Effectiveness Data and Information Set data is often used to produce health plan report cards, analyze quality improvement activities, and create performance benchmarks. Methodology For population-based metrics, the OIG used a subset of HEDIS measures applicable to the CDCR inmate-patient population. Selection of the measures was based on the availability, reliability, and feasibility of the data required for performing the measurement. The OIG collected data utilizing various information sources, including the eUHR, the Master Registry (maintained by CCHCS), as well as a random sample of patient records analyzed and abstracted by trained personnel. Data obtained from the CCHCS Master Registry and Diabetic Registry was not independently validated by the OIG and is presumed to be accurate. For some measures, the OIG used the entire population rather than statistically random samples. While the OIG is not a certified HEDIS compliance auditor, the OIG uses similar methods to ensure that measures are comparable to those published by other organizations. Comparison of Population-Based Metrics For Chuckawalla Valley State Prison, nine HEDIS measures were selected and are listed in Table 1—CVSP Results Compared to State and National HEDIS Scores on page 58. Multiple health plans publish their HEDIS performance measures at the State and national levels. The OIG has provided selected results for several health plans in both categories for comparative purposes. In addition, the OIG selected California’s Medi-Cal Managed Care Program as the population most similar to that Chuckawalla Valley State Prison, Cycle 4 Medical Inspection Page 55 Office of the Inspector General State of California of the CDCR inmate population. As indicated in Table 2—CVSP Results Compared to Medi-Cal Minimum and Maximum Performance on page 59, the California Department of Health Care Services (DHCS) annually establishes a high performance level (HPL) and a minimum performance level (MPL) for each of its required performance measures. Where applicable, the OIG compared CVSP’s results to the Medi-Cal HPL and MPL levels. Results of Population-Based Metric Comparison Comprehensive Diabetes Care For chronic care management, the OIG chose measures related to the management of diabetes. Diabetes is the most complex common chronic disease requiring a high level of intervention on the part of the health care system in order to produce optimal results. CVSP performed very well with its management of diabetes. When compared statewide, CVSP’s scores outperformed the Medi-Cal average scores (Table 1) as well as its HPL scores (Table 2) in each of the five diabetic measures selected. CVSP also outperformed Kaiser Permanente (Table 1) in all five diabetic measures. While most of CVSP’s scores were closely comparable to Kaiser Permanente, CVSP outperformed both the north and south Kaiser regions, by 25 percent and 12 percent, respectively, for diabetic eye examinations. When compared nationally, CVSP significantly outperformed averages for Medicaid, Medicare, and commercial health plans (based on data obtained from health maintenance organizations) in each of the five diabetic measures listed. Also when compared to the U.S. Department of Veterans Affairs (VA), CVSP outperformed the VA in all applicable measures except its monitoring of diabetic patients, where CVSP scored only two percentage points lower than the VA. Immunizations Comparative data for immunizations (Table 1) was only fully available for the VA, and partially available for Kaiser Permanente (north and south) and commercial (national). Regarding the administration of influenza shots, CVSP outperformed scores for Kaiser, commercial, and the VA. The OIG inspectors found that all CVSP patients tested were offered the immunization, but some had refused it. With respect to pneumococcal immunizations, CVSP’s performance was 17 percentage points lower than the VA. While the OIG inspectors found that 4 percent of CVSP’s patients were offered but refused the immunization, 20 percent of the patients sampled had no evidence of receiving (or refusing) a pneumococcal vaccination. Cancer Screening For colorectal cancer screening, CVSP performed slightly lower than Kaiser Permanente, north and south, and 7 percentage points lower than the VA. However, the institution performed higher than both commercial and Medicare, by 12 and 11 percentage points, respectively. While CVSP only Chuckawalla Valley State Prison, Cycle 4 Medical Inspection Page 56 Office of the Inspector General State of California scored 75 percent for colorectal cancer screening, the OIG found that the institution offered the cancer screening to all of the patients tested, but 25 percent of them subsequently refused it. Summary CVSP outperformed scores for all other health plans in six of the nine categories tested. For the remaining three measures, the institution scored 97 percent in diabetic patient monitoring, only 2 percentage points lower than the VA’s score of 99 percent. The institution’s lower score for colorectal cancer screening fell in the middle of the five comparable scores, and was due to patients’ refusal of services. However, the OIG only partially attributed CVSP’s lower score for pneumococcal vaccinations to patient refusals. Overall, CVSP’s performance reflects a high-performing chronic care program, corroborated by the institution’s adequate ratings in the Access to Care, Preventive Services, Quality of Nursing Performance, and Quality of Provider Performance indicators. With regard to CVSP’s performance in influenza shots, pneumococcal immunizations, and cancer screenings, the institution should make interventions to lower the rate of refusals. Chuckawalla Valley State Prison, Cycle 4 Medical Inspection Page 57 Office of the Inspector General State of California Table 1—CVSP Results Compared to State and National HEDIS Scores California National Kaiser Kaiser CVSP HEDIS (No.CA) (So.CA) HEDIS Clinical Measures Medi- HEDIS HEDIS HEDIS Com- HEDIS VA Cycle 4 Cal Scores Scores Medicaid mercial Medicare Average Results 2013 2014 2014 2013 2013 2013 2012 1 2 3 3 4 4 4 5 Comprehensive Diabetes Care HbA1c Testing (Monitoring) 97% 83% 95% 94% 84% 90% 92% 99% Poor HbA1c Control (>9.0%) 6,7 17% 40% 18% 21% 46% 31% 25% 19% HbA1c Control (<8.0%) 6 72% 49% 70% 67% 46% 59% 66% - Blood Pressure Control (<140/90) 87% 63% 82% 85% 60% 65% 66% 80% Eye Exams 94% 51% 69% 82% 54% 56% 69% 90% Immunizations Influenza Shots - Adults (18–64) 8 67% - 59% 55% - 50% - 65% Influenza Shots - Adults (65+) 80% - - - - - - 76% Immunizations: Pneumococcal 76% - - - - - - 93% Cancer Screening Colorectal Cancer Screening 75% - 78% 80% - 63% 64% 82% 1. Unless otherwise stated, data was collected in May 2015 by reviewing medical records from a sample of CVSP's population of applicable inmate-patients. These random statistical sample sizes were based on a 95 percent confidence level with a 15 percent maximum margin of error. 2. HEDIS Medi-Cal data was obtained from the California Department of Health Care Services 2013 HEDIS Aggregate Report for the Medi-Cal Managed Care Program. 3. Data was obtained from Kaiser Permanente November 2014 reports for the Northern and Southern California regions. 4. National HEDIS data for Medicaid, commercial, and Medicare was obtained from the 2014 State of Health Care Quality Report, available on the NCQA website: www.ncqa.org. The results for commercial were based on data received from various health maintenance organizations. 5. The Department of Veterans Affairs (VA) data was obtained from the VHA Facility Quality and Safety Report - Fiscal Year 2012 Data. 6. For this indicator, the entire applicable CVSP population was tested. 7. For this measure only, a lower score is better. For Kaiser, the OIG derived the Poor HbA1c Control indicator using the reported data for the <9.0% HbA1c control indicator. 8. The VA HEDIS data is for the age range 50–64. Chuckawalla Valley State Prison, Cycle 4 Medical Inspection Page 58 Office of the Inspector General State of California Table 2—CVSP Results Compared to Medi-Cal Minimum and Maximum Performance California HEDIS California HEDIS CVSP Medi-Cal High Medi-Cal Minimum Clinical Measures Cycle 4 Performance Level Performance Level Inspection Results 2013 2013 Comprehensive Diabetes Care HbA1c Testing (Monitoring) 97% 91% 79% Poor HbA1c Control (>9.0%) 17% 29% 50% *Lower score is better HbA1c Control (<8.0%) 72% 59% 42% Blood Pressure Control (<140/90) 87% 75% 54% Eye Exams 94% 70% 45% CVSP Cycle 4 Inspection - California HEDIS California HEDIS Average Results Medi-Cal High Medi-Cal Minimum Performance Level 2013 Performance Level 2013 97% 94% 91% 87% 79% 75% 72% 70% 59% 54% 50% 45% 42% 29% 17% HbA1c Testing Poor HbA1c Control HbA1c Control Blood Pressure Eye Exams (Monitoring) (>9.0%) (<8.0%) Control (<140/90) *Lower score is better Chuckawalla Valley State Prison, Cycle 4 Medical Inspection Page 59 Office of the Inspector General State of California APPENDIX A—COMPLIANCE TEST RESULTS Chuckawalla Valley State Prison Range of Summary Scores: 39.82% - 90.83% Indicator Overall Score (Yes %) Access to Care 83.61% Diagnostic Services 86.39% Emergency Services Not Applicable Health Information Management (Medical Records) 68.60% Health Care Environment 66.40% Inter- and Intra-System Transfers 90.83% Pharmacy and Medication Management 80.74% Prenatal and Post-delivery Services Not Applicable Preventive Services 84.91% Quality of Nursing Performance Not Applicable Quality of Provider Performance Not Applicable Reception Center Arrivals Not Applicable Specialized Medical Housing (OHU, CTC, SNF, Hospice) Not Applicable Specialty Services 87.86% Internal Monitoring, Quality Improvement, and Administrative 39.82% Operations Job Performance, Training, Licensing, and Certifications 77.50% Chuckawalla Valley State Prison, Cycle 4 Medical Inspection Page 60 Office of the Inspector General State of California Scored Answers Yes Reference + Number Access to Care Yes No No Yes % N/A 1.001 Chronic care follow-up appointments: Was the inmate- 21 9 30 70.00% 0 patient's most recent chronic care visit within the health care guideline's maximum allowable interval or within the ordered time frame, whichever is shorter? 1.002 For endorsed inmate-patients received from another 14 9 23 60.87% 7 CDCR institution: If the nurse referred the inmate-patient to a provider during the initial health screening, was the inmate-patient seen within the required time frame? 1.003 Clinical appointments: Did a registered nurse review the 30 0 30 100.00% 0 inmate-patient's request for service the same day it was received? 1.004 Clinical appointments: Did the registered nurse complete a 29 1 30 96.67% 0 face-to-face visit within one business day after the Form CDCR 7362 was reviewed? 1.005 Clinical appointments: If the registered nurse determined a 15 3 18 83.33% 12 referral to a primary care provider was necessary, was the inmate-patient seen within the maximum allowable time or the ordered time frame, whichever is the shorter? 1.006 Sick call follow-up appointments: If the primary care 7 1 8 87.50% 22 provider ordered a follow-up sick call appointment, did it take place within the time frame specified? 1.007 Upon the inmate-patient's discharge from the 23 5 28 82.14% 0 community hospital: Did the inmate-patient receive a follow-up appointment within the required time frame? 1.008 Specialty service follow-up appointments: Do specialty 18 7 25 72.00% 5 service primary care physician follow-up visits occur within required time frames? 1.101 Clinical appointments: Do inmate-patients have a 6 0 6 100.00% 0 standardized process to obtain and submit health care services request forms? Overall Percentage: 83.61% Chuckawalla Valley State Prison, Cycle 4 Medical Inspection Page 61 Office of the Inspector General State of California Scored Answers Yes Reference + Number Diagnostic Services Yes No No Yes % N/A 2.001 Radiology: Was the radiology service provided within the 10 0 10 100.00% 0 time frame specified in the provider's order? 2.002 Radiology: Did the primary care provider review and initial 10 0 10 100.00% 0 the diagnostic report within specified time frames? 2.003 Radiology: Did the primary care provider communicate the 10 0 10 100.00% 0 results of the diagnostic study to the inmate-patient within specified time frames? 2.004 Laboratory: Was the laboratory service provided within the 9 1 10 90.00% 0 time frame specified in the provider's order? 2.005 Laboratory: Did the primary care provider review and 9 1 10 90.00% 0 initial the diagnostic report within specified time frames? 2.006 Laboratory: Did the primary care provider communicate 9 1 10 90.00% 0 the results of the diagnostic study to the inmate-patient within specified time frames? 2.007 Pathology: Did the institution receive the final diagnostic 7 3 10 70.00% 0 report within the required time frames? 2.008 Pathology: Did the primary care provider review and initial 6 2 8 75.00% 2 the diagnostic report within specified time frames? 2.009 Pathology: Did the primary care provider communicate the 5 3 8 62.50% 2 results of the diagnostic study to the inmate-patient within specified time frames? Overall Percentage: 86.39% Chuckawalla Valley State Prison, Cycle 4 Medical Inspection Page 62 Office of the Inspector General State of California Emergency Services Scored Answers Assesses reaction times and responses to emergency situations. Not Applicable Scored Answers Yes Reference + Number Health Information Management (Medical Records) Yes No No Yes % N/A 4.001 Are non-dictated progress notes, initial health screening 18 2 20 90.00% 0 forms, and health care service request forms scanned into the eUHR within three calendar days of the inmate-patient encounter date? 4.002 Are dictated / transcribed documents scanned into the eUHR 11 9 20 55.00% 0 within five calendar days of the inmate-patient encounter date? 4.003 Are specialty documents scanned into the eUHR within five 12 8 20 60.00% 0 calendar days of the inmate-patient encounter date? 4.004 Are community hospital discharge documents scanned into 14 6 20 70.00% 0 the eUHR within three calendar days of the inmate-patient date of hospital discharge? 4.005 Are medication administration records (MARs) scanned into 20 0 20 100.00% 0 the eUHR within the required time frames? 4.006 During the eUHR review, did the OIG find that documents 2 10 12 16.67% 0 were correctly labeled and included in the correct inmate- patient's file? 4.007 Did clinical staff legibly sign health care records, when 24 8 32 75.00% 0 required? 4.008 For inmate-patient's discharged from a community 23 5 28 82.14% 0 hospital: Did the preliminary hospital discharge report include key elements and did a PCP review the report within three calendar days of discharge? Overall Percentage: 68.60% Chuckawalla Valley State Prison, Cycle 4 Medical Inspection Page 63 Office of the Inspector General State of California Scored Answers Yes Reference + Number Health Care Environment Yes No No Yes % N/A 5.101 Infection Control: Are clinical health care areas 7 1 8 87.50% 0 appropriately disinfected, cleaned and sanitary? 5.102 Infection control: Do clinical health care areas ensure that 3 4 7 42.86% 1 reusable invasive and non-invasive medical equipment is properly sterilized or disinfected as warranted? 5.103 Infection Control: Do clinical health care areas contain 8 0 8 100.00% 0 operable sinks and sufficient quantities of hygiene supplies? 5.104 Infection control: Does clinical health care staff adhere to 6 0 6 100.00% 2 universal hand hygiene precautions? 5.105 Infection control: Do clinical health care areas control 1 7 8 12.50% 0 exposure to blood-borne pathogens and contaminated waste? 5.106 Warehouse, Conex and other non-clinic storage areas: 1 0 1 100.00% 7 Does the medical supply management process adequately support the needs of the medical health care program? 5.107 Clinical areas: Does each clinic follow adequate protocols 6 2 8 75.00% 0 for managing and storing bulk medical supplies? 5.108 Clinical areas: Do clinic common areas and exam rooms 4 4 8 50.00% 0 have essential core medical equipment and supplies? 5.109 Clinical areas: Do clinic common areas have an adequate 7 1 8 87.50% 0 environment conducive to providing medical services? 5.110 Clinical areas: Do clinic exam rooms have an adequate 2 6 8 25.00% 0 environment conducive to providing medical services? 5.111 Emergency response bags: Are TTA and clinic emergency 3 3 6 50.00% 2 medical response bags inspected daily and inventoried monthly, and do they contain essential items? 5.999 For Information Purposes Only: Does the institution's health care management believe that all clinical areas have Information Only physical plant infrastructures sufficient to provide adequate health care services? Overall Percentage: 66.40% Chuckawalla Valley State Prison, Cycle 4 Medical Inspection Page 64 Office of the Inspector General State of California Scored Answers Yes Reference + Number Inter- and Intra-System Transfers Yes No No Yes % N/A 6.001 For endorsed inmate-patients received from another 26 4 30 86.67% 0 CDCR institution or COCF: Did nursing staff complete the initial health screening and answer all screening questions on the same day the inmate-patient arrived at the institution? 6.002 For endorsed inmate-patients received from another 29 1 30 96.67% 0 CDCR institution or COCF: When required, did the RN complete the assessment and disposition section of the health screening form; refer the inmate-patient to the TTA, if TB signs and symptoms were present; and sign and date the form on the same day staff completed the health screening? 6.003 For endorsed inmate-patients received from another 5 1 6 83.33% 24 CDCR institution or COCF: If the inmate-patient had an existing medication order upon arrival, were medications administered or delivered without interruption? 6.004 For inmate-patients transferred out of the facility: Were 14 2 16 87.50% 0 scheduled specialty service appointments identified on the Health Care Transfer Information Form 7371? 6.101 For inmate-patients transferred out of the facility: Do 4 0 4 100.00% 0 medication transfer packages include required medications along with the corresponding Medical Administration Record (MAR) and Medication Reconciliation? Overall Percentage: 90.83% Chuckawalla Valley State Prison, Cycle 4 Medical Inspection Page 65 Office of the Inspector General State of California Scored Answers Yes Reference + Number Pharmacy and Medication Management Yes No No Yes % N/A 7.001 Did the inmate-patient receive all chronic care medications 28 1 29 96.55% 1 within the required time frames or did the institution follow departmental policy for refusals or no-shows? 7.002 Did health care staff administer or deliver new order 30 0 30 100.00% 0 prescription medications to the inmate-patient within the required time frames? 7.003 Upon the inmate-patient's discharge from a community 21 7 28 75.00% 0 hospital: Were all medications ordered by the institution's primary care provider administered or delivered to the inmate-patient within one calendar day of return? 7.004 For inmate-patients received from a county jail: Were all medications ordered by the institution's reception center Not Applicable provider administered or delivered to the inmate-patient within the required time frames? 7.005 Upon the inmate-patient's transfer from one housing 19 1 20 95.00% 0 unit to another: Were medications continued without interruption? 7.006 For en route inmate-patients who lay over at the 3 3 6 50.00% 0 institution: If the temporarily housed inmate-patient had an existing medication order, were medications administered or delivered without interruption? 7.101 All clinical and medication line storage areas for narcotic 3 3 6 50.00% 8 medications: Does the institution employ strong medication security controls over narcotic medications assigned to its clinical areas? 7.102 All clinical and medication line storage areas for non- 13 0 13 100.00% 1 narcotic medications: Does the institution properly store non-narcotic medications that do not require refrigeration in assigned clinical areas? 7.103 All clinical and medication line storage areas for non- 0 6 6 0.00% 8 narcotic medications: Does the institution properly store non-narcotic medications that require refrigeration in assigned clinical areas? Chuckawalla Valley State Prison, Cycle 4 Medical Inspection Page 66 Office of the Inspector General State of California Scored Answers Yes Reference + Number Pharmacy and Medication Management Yes No No Yes % N/A 7.104 Medication preparation and administration areas: Do 5 1 6 83.33% 8 nursing staff employ and follow hand hygiene contamination control protocols during medication preparation and medication administration processes? 7.105 Medication preparation and administration areas: Does 6 0 6 100.00% 8 the institution employ appropriate administrative controls and protocols when preparing medications for inmate- patients? 7.106 Medication preparation and administration areas: Does 3 3 6 50.00% 8 the institution employ appropriate administrative controls and protocols when distributing medications to inmate- patients? 7.107 Pharmacy: Does the institution employ and follow general 1 0 1 100.00% 0 security, organization, and cleanliness management protocols in its main and satellite pharmacies? 7.108 Pharmacy: Does the institution's pharmacy properly store 1 0 1 100.00% 0 non-refrigerated medications? 7.109 Pharmacy: Does the institution's pharmacy properly store 1 0 1 100.00% 0 refrigerated or frozen medications? 7.110 Pharmacy: Does the institution's pharmacy properly 1 0 1 100.00% 0 account for narcotic medications? 7.111 Pharmacy: Does the institution follow key medication error 23 2 25 92.00% 0 reporting protocols? 7.998 For Information Purposes Only: During eUHR compliance testing and case reviews, did the OIG find that Information Only medication errors were properly identified and reported by the institution? 7.999 For Information Purposes Only: Do inmate-patients in isolation housing units have immediate access to their KOP Information Only prescribed rescue inhalers and nitroglycerin medications? Overall Percentage: 80.74% Chuckawalla Valley State Prison, Cycle 4 Medical Inspection Page 67 Office of the Inspector General State of California Prenatal and Post-delivery Services Scored Answers This indicator is not applicable to this institution. Not Applicable Scored Answers Yes Reference + Number Preventive Services Yes No No Yes % N/A 9.001 Inmate-patients prescribed INH: Did the institution 28 1 29 96.55% 0 administer the medication to the inmate-patient as prescribed? 9.002 Inmate-patients prescribed INH: Did the institution 18 11 29 62.07% 0 monitor the inmate-patient monthly for the most recent three months he or she was on the medication? 9.003 Annual TB Screening: Was the inmate-patient screened for 22 8 30 73.33% 0 TB within the last year? 9.004 Were all inmate-patients offered an influenza vaccination for 30 0 30 100.00% 0 the most recent influenza season? 9.005 All inmate-patients from the age 50 through the age of 27 3 30 90.00% 0 75: Was the inmate-patient offered colorectal cancer screening? 9.006 Female inmate-patients from the age of 50 through the age of 74: Was the inmate-patient offered a mammogram in Not Applicable compliance with policy? 9.007 Female inmate-patients from the age of 21 through the age of 65: Was the inmate-patient offered a pap smear in Not Applicable compliance with policy? 9.008 Are required immunizations being offered for chronic care 14 2 16 87.50% 0 inmate-patients? 9.009 Are inmate-patients at the highest risk of coccidioidomycosis (valley fever) infection transferred out Not Applicable of the facility in a timely manner? Overall Percentage: 84.91% Chuckawalla Valley State Prison, Cycle 4 Medical Inspection Page 68 Office of the Inspector General State of California Quality of Nursing Performance Scored Answers The quality of nursing performance will be assessed during case reviews, conducted by OIG clinicians, and is not applicable for the compliance portion of the medical inspection. The methodologies OIG clinicians use to Not Applicable evaluate the quality of nursing performance are presented in a separate inspection document entitled OIG MIU Retrospective Case Review Methodology. Quality of Provider Performance Scored Answers The quality of provider performance will be assessed during case reviews, conducted by OIG clinicians, and is not applicable for the compliance portion of the medical inspection. The methodologies OIG clinicians use to Not Applicable evaluate the quality of provider performance are presented in a separate inspection document entitled OIG MIU Retrospective Case Review Methodology. Reception Center Arrivals Scored Answers This indicator is not applicable to this institution. Not Applicable Specialized Medical Housing (OHU, CTC, SNF, Hospice) Scored Answers This indicator is not applicable to this institution. Not Applicable Chuckawalla Valley State Prison, Cycle 4 Medical Inspection Page 69 Office of the Inspector General State of California Scored Answers Yes Reference + Number Specialty Services Yes No No Yes % N/A 14.001 Did the inmate-patient receive the high priority specialty 13 2 15 86.67% 0 service within 14 calendar days of the PCP order? 14.002 Did the PCP review the high priority specialty service 13 0 13 100.00% 2 consultant report within three business days after the service was provided? 14.003 Did the inmate-patient receive the routine specialty service 15 0 15 100.00% 0 within 90 calendar days of the PCP order? 14.004 Did the PCP review the routine specialty service consultant 11 4 15 73.33% 0 report within three business days after the service was provided? 14.005 For endorsed inmate-patients received from another 14 6 20 70.00% 0 CDCR institution: If the inmate-patient was approved for a specialty services appointment at the sending institution, was the appointment scheduled at the receiving institution within the required time frames? 14.006 Did the institution deny the primary care provider request for 18 2 20 90.00% 0 specialty services within required time frames? 14.007 Following the denial of a request for specialty services, was 19 1 20 95.00% 0 the inmate-patient informed of the denial within the required time frame? Overall Percentage: 87.86% Chuckawalla Valley State Prison, Cycle 4 Medical Inspection Page 70 Office of the Inspector General State of California Scored Answers Yes Reference Internal Monitoring, Quality Improvement, and + Number Administrative Operations Yes No No Yes % N/A 15.001 Did the institution promptly process inmate medical appeals 12 0 12 100.00% 0 during the most recent 12 months? 15.002 Does the institution follow adverse/sentinel event reporting Not Applicable requirements? 15.003 Did the institution Quality Management Committee (QMC) 0 6 6 0.00% 0 meet at least monthly to evaluate program performance, and did the QMC take action when improvement opportunities were identified? 15.004 Did the institution's Quality Management Committee (QMC) 0 1 1 0.00% 0 or other forum take steps to ensure the accuracy of its Dashboard data reporting? 15.005 For each initiative in the Performance Improvement Work 2 5 7 28.57% 0 Plan (PIWP), has the institution performance improved or reached the targeted performance objective(s)? 15.006 For institutions with licensed care facilities: Does the local governing body (LGB), or its equivalent, meet Not Applicable quarterly and exercise its overall responsibilities for the quality management of patient health care? 15.007 Does the Emergency Medical Response Review Committee 0 2 2 0.00% 0 perform timely incident package reviews that include the use of required review documents? 15.101 Did the institution complete a medical emergency response 0 3 3 0.00% 0 drill for each watch and include participation of health care and custody staff during the most recent full quarter? 15.102 Did the institution's second level medical appeal response 9 1 10 90.00% 0 address all of the inmate-patient's appealed issues? 15.103 Did the institution's medical staff review and submit the 1 0 1 100.00% 0 initial inmate death report to the Death Review Unit in a timely manner? 15.996 For Information Purposes Only: Did the CCHCS Death Review Committee submit its inmate death review summary Information Only to the institution timely? Chuckawalla Valley State Prison, Cycle 4 Medical Inspection Page 71 Office of the Inspector General State of California Scored Answers Yes Reference Internal Monitoring, Quality Improvement, and + Number Administrative Operations Yes No No Yes % N/A 15.997 For Information Purposes Only: Identify the institution's protocols for tracking medical appeals. Information Only 15.998 For Information Purposes Only: Identify the institution's protocols for implementing health care local operating Information Only procedures. 15.999 For Information Purposes Only: Identify the institution's Information Only healthcare staffing resources. Overall Percentage: 39.82% Chuckawalla Valley State Prison, Cycle 4 Medical Inspection Page 72 Office of the Inspector General State of California Scored Answers Yes Reference + Number Job Performance, Training, Licensing, and Certifications Yes No No Yes % N/A 16.001 Do all providers maintain a current medical license? 7 0 7 100.00% 0 16.101 Does the institution's Supervising Registered Nurse conduct 5 0 5 100.00% 0 periodic reviews of nursing staff? 16.102 Are nursing staff who administer medications current on 10 0 10 100.00% 0 their clinical competency validation? 16.103 Are structured clinical performance appraisals completed 1 4 5 20.00% 1 timely? 16.104 Are staff current with required medical emergency response 3 0 3 100.00% 0 certifications? 16.105 Are nursing staff and the Pharmacist-in-Charge current with 5 0 5 100.00% 1 their professional licenses and certifications? 16.106 Do the institution's pharmacy and authorized providers who 1 0 1 100.00% 0 prescribe controlled substances maintain current Drug Enforcement Agency (DEA) registrations? 16.107 Are nursing staff current with required new employee 0 1 1 0.00% 0 orientation? Overall Percentage: 77.50% Chuckawalla Valley State Prison, Cycle 4 Medical Inspection Page 73 Office of the Inspector General State of California APPENDIX B—CLINICAL DATA Table B-1: CVSP Sample Sets Sample Set Total Anticoagulation 2 Death Review/Sentinel Events 1 Diabetes 4 Emergency Services - CPR 1 Emergency Services - Non-CPR 5 High Risk 6 Hospitalization 6 Intra-system Transfers-In 3 Intra-system Transfers-Out 3 RN Sick Call 25 Specialty Services 6 62 Chuckawalla Valley State Prison, Cycle 4 Medical Inspection Page 74 Office of the Inspector General State of California Table B-2 CVSP Chronic Care Diagnoses Diagnosis Total Anemia 3 Anticoagulation 2 Arthritis/Degenerative Joint Disease 9 Asthma 3 COPD 3 Cardiovascular Disease 4 Chronic Kidney Disease 2 Chronic Pain 3 Cirrhosis/End Stage Liver Disease 1 Diabetes 12 Gastroesophageal Reflux Disease 9 Gastrointestinal Bleed 1 Hepatitis C 12 Hyperlipidemia 9 Hypertension 33 Mental Health 1 Migraine Headaches 1 Seizure Disorder 1 Thyroid Disease 1 110 Chuckawalla Valley State Prison, Cycle 4 Medical Inspection Page 75 Office of the Inspector General State of California Table B-3 CVSP Event - Program Program Total Diagnostic Services 121 Emergency Care 59 Hospitalization 55 Intra-system Transfers-In 15 Intra-system Transfers-Out 10 Outpatient Care 439 Specialized Medical Housing 2 Specialty Services 152 853 Table B-4 CVSP Case Review Sample Summary Total MD Reviews Detailed 30 MD Reviews Focused 0 RN Reviews Detailed 10 RN Reviews Focused 34 Total Reviews 74 Total Unique Cases 62 Overlapping Reviews (MD & RN) 12 Chuckawalla Valley State Prison, Cycle 4 Medical Inspection Page 76 Office of the Inspector General State of California APPENDIX C—COMPLIANCE SAMPLING METHODOLOGY Chuckawalla Valley State Prison Sample Category Quality (number of Indicator patients) Data Source Filters Access to Care Chronic Care Master Registry  Chronic care conditions (at least one condition per (30—Basic Level) inmate-patient—any risk level) (40—Inter Level)  Randomize Nursing Sick Call MedSATS  Clinic (each clinic tested) (5 per clinic)  Appt. date (2–9 months) (minimum of 30)  Randomize Returns from Inpatient Claims  See Health Information Management (Medical Community Hospital Data Records) (returns from community hospital) (30) Diagnostic Radiology Radiology Logs  Appt. Date (90 days–9 months) Services (10)  Randomize  Abnormal Laboratory Quest  Appt. date (90 days–9 months) (10)  Order name (CBC or CMPs only)  Randomize  Abnormal Pathology InterQual  Appt. date (90 days–9 months) (10)  Service (pathology related)  Randomize Health Timely Scanning OIG Qs: 1.001,  Non-dictated documents Information (20 each) 1.002, 1.006, &  First 5 inmate-patients selected for each question Management 9.004 (Medical OIG Q: 1.001  Dictated documents Records)  First 20 inmate-patients selected OIG Qs: 14.002  Specialty documents & 14.004  First 10 inmate-patients selected for each question OIG Q: 4.008  Community hospital discharge documents  First 20 inmate-patients selected for the question OIG Q: 7.001  MARs  First 20 inmate-patients selected Legible Signatures OIG Qs: 4.008,  First 8 inmates sampled and Review 6.001/6.002,  One source document per inmate-patient (40) 7.001, 12.001/12.002, & 14.002 Complete and Documents for  Any incorrectly scanned eUHR document Accurate Scanning any tested inmate identified during OIG eUHR file review, e.g., mislabeled, misfiled, illegibly scanned, or missing Returns from Inpatient Claims  Date (2–8 months) Community Hospital Data  Most recent 6 months provided (within date range) (30)  Rx count  Discharge date  Randomize (each month individually)  First 5 inmate-patients from each of the 6 months (if not 5 in a month, supplement from another, as needed) Chuckawalla Valley State Prison, Cycle 4 Medical Inspection Page 77 Office of the Inspector General State of California Sample Category Quality (number of Indicator patients) Data Source Filters Health Care Clinical Areas OIG Inspector  Identify and inspect all onsite clinical areas. Environment (number varies by Onsite Review institution) Inter- and Intra-System SOMS  Arrival date (3–9 months) Intra-System transfers  Arrived from (another CDCR facility) Transfers (30)  Rx count  Randomize Specialty Service MedSATS  Date of Transfer (3–9 months) Send-outs  Randomize (20) Pharmacy and Chronic Care OIG Q: 1.001 See Access to Care Medication Medication  (At least one condition per inmate-patient—any Management (30—Basic Level) risk level) (40—Inter Level)  Randomize New Medication Master Registry  Rx Count Orders  Randomize (30—Basic Level)  Ensure no duplication of inmate-patients tested in (40—Inter Level) chronic care medications Intra-Facility moves MAPIP Transfer  Date of transfer (2–8 months) (30) Data  To location/from location (yard to yard and to/from ASU)  Remove any to/from MHCB  NA/DOT meds (high–low)–inmate-patient must have NA/DOT meds to qualify for testing  Randomize En Route SOMS  Date of transfer (2–8 months) (10)  Sending institution (another CDCR facility)  Randomize  Length of stay (minimum of 2 days)  NA/DOT meds Returns from Inpatient Claims  See Health Information Management (Medical Community Hospital Data Records) (returns from community hospital) (30) Medication OIG Inspector  Identify and inspect onsite clinical areas that Preparation and Onsite Review prepare and administer medications Administration Areas Pharmacy OIG Inspector  Identify and inspect onsite pharmacies Onsite Review Medication Error OIG Inspector  Any medication error identified during OIG eUHR Reporting Review file review, e.g., case reviews and/or compliance testing Prenatal and Recent Deliveries OB Roster  Delivery date (2–12 months) Post-delivery (5)  Most recent deliveries (within date range) Services N/A at this institution Pregnant Arrivals OB Roster  Arrival date (2–12 months) (5)  Earliest arrivals (within date range) N/A at this institution Chuckawalla Valley State Prison, Cycle 4 Medical Inspection Page 78 Office of the Inspector General State of California Sample Category Quality (number of Indicator patients) Data Source Filters Preventive Chronic Care OIG Q: 1.001  Chronic care conditions (at least 1 condition per Services Vaccinations inmate-patient—any risk level) (30—Basic Level)  Randomize (40—Inter Level)  Condition must require vaccination(s) Not all conditions require vaccinations INH Maxor  Dispense date (past 9 months) (all applicable up to  Time period on INH (at least a full 3 months) 30)  Randomize Colorectal Screening SOMS  Arrival date (at least 1 year prior to inspection) (30)  Date of birth (51 or older)  Randomize Influenza SOMS  Arrival date (at least 1 year prior to inspection) Vaccinations  Randomize (30)  Filter out inmate-patients tested in chronic care vaccination sample TB Code 22, annual SOMS  Arrival date (at least 1 year prior to inspection) TST  TB Code (22) (15)  Randomize TB Code 34, annual SOMS  Arrival date (at least 1 year prior to inspection) screening  TB Code (34) (15)  Randomize Mammogram SOMS  Arrival date (at least 2 years prior to inspection) (30)  Date of birth (age 52–74) N/A at this institution  Randomize Pap Smear SOMS  Arrival date (at least three years prior to (30) inspection) N/A at this institution  Date of birth (age 24–53)  Randomize Valley Fever Cocci Transfer  Reports from past 2–8 months (number will vary) Status Report  Institution  Ineligibility date (60 days prior to inspection date) N/A at this institution  All Reception RC SOMS  Arrival date (2–8 months) Center Arrivals (20)  Arrived from (county jail, return from parole, etc.)  Randomize N/A at this institution Specialized OHU, CTC, SNF, CADDIS  Admit date (1–6 months) Medical Hospice  Type of stay (no MH beds) Housing (10 per housing area)  Length of stay (minimum of 5 days)  Randomize N/A at this institution Chuckawalla Valley State Prison, Cycle 4 Medical Inspection Page 79 Office of the Inspector General State of California Sample Category Quality (number of Indicator patients) Data Source Filters Specialty High-Priority MedSATS  Appt. date (3–9 months) Services Access (10)  Randomize Routine MedSATS  Appt. date (3–9 months) (10)  Remove optometry, physical therapy or podiatry  Randomize Specialty Service MedSATS  Sending institution Arrivals  Date of transfer (3–9 months) (20)  Sent to (another CDCR facility)  Randomize Denials InterQual  Review date (3–9 months) (20)*  Randomize IUMC/MAR  Meeting date (9 months) *Ten InterQual Meeting Minutes  Denial upheld Ten MARs  Randomize Internal Medical Appeals Monthly Medical  Medical appeals (12 months) Monitoring, (all) Appeals Reports Quality Adverse/Sentinel Adverse/Sentinel  Adverse/sentinel events (2–8 months) Improvement, Events Events Report and (5) Administrative QMC Meetings Quality  Meeting minutes (12 months) Operations (12) Management Committee Meeting Minutes Performance Performance  Performance Improvement Work Plan with Improvement Plans Improvement updates (12 months) (12) Work Plan Local Governing Local Governing  Meeting minutes (12 months) Body Body Meeting (12) Minutes EMRRC EMRRC  Meeting minutes (6 months) (6) Meeting Minutes Medical Emergency OIG Inspector  Most recent full quarter Response Drills Onsite Review  Each watch (3) 2nd Level Medical OIG Inspector  Medical appeals denied (6 months) Appeals Onsite Review (10) Death Reports OIG Inspector  Death reports (12 months) (10) Onsite Review Local Operating OIG Inspector  Review all Procedures Onsite Review (all) Chuckawalla Valley State Prison, Cycle 4 Medical Inspection Page 80 Office of the Inspector General State of California Sample Category Quality (number of Indicator patients) Data Source Filters Job Performance RN Review OIG Inspector  Current Supervising RN reviews and Training, Evaluations Onsite Review Licensing, and (5) Certifications Nursing Staff OIG Inspector  Review annual competency validations Validations Onsite Review  Randomize (10) Provider Annual OIG Inspector  All required performance evaluation documents Evaluation Packets Onsite Review (all) Medical Emergency OIG Inspector  All staff Response Onsite Review o Providers (ACLS) Certifications o Nursing (BLS/CPR) (all) o Custody (CPR/BLS) Nursing staff and OIG Inspector  All licenses and certifications Pharmacist-in-charge Onsite Review Professional Licenses and Certifications (all) Pharmacy and OIG Inspector  All current DEA registrations Providers’ Drug Onsite Review Enforcement Agency (DEA) Registrations (all) Nursing Staff New OIG Inspector  New employees (within the last 12 months) Employee Onsite Review Orientations (all) Chuckawalla Valley State Prison, Cycle 4 Medical Inspection Page 81 Office of the Inspector General State of California C C ALIFORNIA ORRECTIONAL H C S ’ EALTH ARE ERVICES R ESPONSE Chuckawalla Valley State Prison, Cycle 4 Medical Inspection Page 82 Office of the Inspector General State of California September 17, 2015 Robert A. Barton, Inspector General Office of the Inspector General 10111 Old Placerville Road, Suite 110 Sacramento, CA 95827 Dear Mr. Barton: The purpose of this letter is to inform you that the Office of the Receiver has reviewed the draft report of the Office of the Inspector General (OIG) Medical Inspection Results for Chuckawalla Valley State Prison conducted from May 2015 to July 2015. California Correctional Health Care Services (CCHCS) acknowledges DIG's findings. Thank you for preparing the report. Your efforts have advanced our mutual objective of ensuring transparency and accountability in CCHCS operations. If you have any questions or concerns, please contact me at (916) 691-9573. Sincerely, a~~ JA~ET LEWIS Deputy Director Policy and Risk Management Services California Correctional Health Care Services cc: Clark Kelso, Receiver Diana Toche, Undersecretary, California Department of Corrections and Rehabilitation Richard Kirkland, Chief Deputy Receiver Jared Goldman, Counsel to the Receiver Christine Berthold, Deputy Inspector Generat Senior, OIG Scott Heatley, M.D., Ph.D., CCHP, Chief Physician and Surgeon, OIG Yulanda Mynhier, Director, Health Care Policy and Administration, CCHCS Roscoe Barrow, Chief Counsel, Receiver's Office of Legal Affairs, CCHCS R. Steven Tharratt, M.D., MPVM, FACP, Director, Health Care Operations, CCHCS Renee Kanan, M.D., Chief Quality Officer, Quality Management, CCHCS Ricki Barnett, M.D., Deputy Director, Medical Services, CCHCS Cheryl Schutt, R.N., Deputy Director, Nursing Services Branch, CCHCS Robert Herrick, Regional Health Care Executive, Region IV Elizabeth dos Santos Chen, D.O., Regional Deputy Medical Executive, Region IV Jorge Gomez R.N., Regional Chief Nursing Executive, Region IV Lara Saich, Chief, Risk Management Branch, CCHCS Dawn DeVore, SSM II, Program Compliance Section, CCHCS CALIFORNIA CORRECTIONAL P.O. Box 588500 HEALTH CARE SERVICES Elk Grove, CA 95758