Chuckawalla Valley State Prison Medical Inspection Report Cycle 5

Roy W. Wesley Office of the Inspector General Inspector General Chuckawalla Valley State Prison Medical Inspection Results Cycle 5 March 2018 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 5 Roy W. Wesley Inspector General Bryan B. Beyer Chief Deputy Inspector General Shaun R. Spillane Public Information Officer March 2018 T C ABLE OF ONTENTS Foreword ........................................................................................................................................ i Executive Summary ...................................................................................................................... iii Overall Rating: Adequate ........................................................................................................... iii Clinical Case Review and OIG Clinician Inspection Results .............................................. v Compliance Testing Results .............................................................................................. v Recommendations ........................................................................................................... vii Population-Based Metrics ................................................................................................ vii Introduction ................................................................................................................................... 1 About the Institution ................................................................................................................... 1 Objectives, Scope, and Methodology.............................................................................................. 3 Case Reviews ............................................................................................................................. 4 Patient Selection for Retrospective Case Reviews .............................................................. 4 Benefits and Limitations of Targeted Subpopulation Review ............................................. 5 Case Reviews Sampled ...................................................................................................... 6 Compliance Testing .................................................................................................................... 7 Sampling Methods for Conducting Compliance Testing..................................................... 7 Scoring of Compliance Testing Results.............................................................................. 8 Overall Quality Indicator Rating for Case Reviews and Compliance Testing ............................... 8 Population-Based Metrics ........................................................................................................... 8 Medical Inspection Results ............................................................................................................ 9 Access to Care ............................................................................................................ 11 Case Review Results ....................................................................................................... 11 Compliance Testing Results ............................................................................................ 14 Diagnostic Services .................................................................................................... 16 Case Review Results ....................................................................................................... 16 Compliance Testing Results ............................................................................................ 17 Emergency Services .................................................................................................... 19 Case Review Results ....................................................................................................... 19 Health Information Management ................................................................................ 22 Case Review Results ....................................................................................................... 22 Compliance Testing Results ............................................................................................ 23 Health Care Environment ........................................................................................... 25 Compliance Testing Results ............................................................................................ 25 Inter- and Intra-System Transfers ............................................................................... 28 Case Review Results ....................................................................................................... 28 Compliance Testing Results ............................................................................................ 30 Pharmacy and Medication Management ..................................................................... 32 Case Review Results ....................................................................................................... 32 Compliance Testing Results ............................................................................................ 33 Chuckawalla Valley State Prison, Cycle 5 Medical Inspection Table of Contents Office of the Inspector General State of California Prenatal and Post-Delivery Services ........................................................................... 37 Preventive Services ..................................................................................................... 38 Compliance Testing Results ............................................................................................ 38 Quality of Nursing Performance................................................................................ 40 Case Review Results ....................................................................................................... 40 Quality of Provider Performance .............................................................................. 43 Case Review Results ....................................................................................................... 43 Reception Center Arrivals ......................................................................................... 47 Specialized Medical Housing .................................................................................... 48 Specialty Services ..................................................................................................... 49 Case Review Results ....................................................................................................... 49 Compliance Testing Results ............................................................................................ 51 Administrative Operations (Secondary) ..................................................................... 53 Compliance Testing Results ............................................................................................ 53 Recommendations ........................................................................................................................ 56 Population-Based Metrics ............................................................................................................ 57 Appendix A — Compliance Test Results ..................................................................................... 60 Appendix B — Clinical Data ....................................................................................................... 73 Appendix C — Compliance Sampling Methodology .................................................................... 77 California Correctional Health Care Services’ Response .............................................................. 90 Chuckawalla Valley State Prison, Cycle 5 Medical Inspection Table of Contents Office of the Inspector General State of California L T F IST OF ABLES AND IGURES CVSP Executive Summary Table .................................................................................................. iv CVSP Health Care Staffing Resources as of July 2017 .................................................................... 2 CVSP Master Registry Data as of July 17, 2017 ............................................................................. 2 CVSP Results Compared to State and National HEDIS Scores...................................................... 59 Table B-1: CVSP Sample Sets ...................................................................................................... 73 Table B-2: CVSP Chronic Care Diagnoses ................................................................................... 74 Table B-3: CVSP Event – Program ............................................................................................... 75 Table B-4: CVSP Review Sample Summary ................................................................................. 76 Chuckawalla Valley State Prison, Cycle 5 Medical Inspection List of Tables and Figures Office of the Inspector General State of California This page intentionally left blank. Chuckawalla Valley State Prison, Cycle 5 Medical Inspection Office of the Inspector General State of California F OREWORD Pursuant to California Penal Code Section 6126 et seq., which assigns the Office of the Inspector General (OIG) responsibility for oversight of the California Department of Corrections and Rehabilitation (CDCR), the OIG conducts a comprehensive inspection program to evaluate the delivery of medical care at each of CDCR’s 35 adult prisons. The OIG explicitly makes no determination regarding the constitutionality of care in the prison setting. That determination is left to the Receiver and the federal court. The assessment of care by the OIG is just one factor in the court’s determination whether care in the prisons meets constitutional standards. The OIG’s inspections are mandated by the Penal Code and not aimed at specifically resolving the court’s questions on constitutional care. To the degree that they provide another factor for the court to consider, the OIG is pleased to provide added value to the taxpayers of California. In Cycle 5, for the first time, the OIG will be inspecting institutions delegated back to CDCR from the Receivership. There is no difference in the standards used for assessment of a delegated institution versus an institution not yet delegated. The Receiver delegated Chuckawalla Valley State Prison back to CDCR in May 2016. This fifth cycle of inspections will continue evaluating the areas addressed in Cycle 4, which included clinical case review, compliance testing, and a population-based metric comparison of selected Healthcare Effectiveness Data Information Set (HEDIS) measures. In agreement with stakeholders, the OIG made changes to both the case review and compliance components. The OIG found that in every inspection in Cycle 4, larger samples were taken than were needed to assess the adequacy of medical care provided. As a result, the OIG reduced the number of case reviews and sample sizes for compliance testing. Also, in Cycle 4, compliance testing included two secondary (administrative) indicators (Internal Monitoring, Quality Improvement, and Administrative Operations; and Job Performance, Training, Licensing, and Certifications). For Cycle 5, these have been combined into one secondary indicator, Administrative Operations. Chuckawalla Valley State Prison, Cycle 5 Medical Inspection Page i Office of the Inspector General State of California This page intentionally left blank. Chuckawalla Valley State Prison, Cycle 5 Medical Inspection Page ii Office of the Inspector General State of California E S XECUTIVE UMMARY The OIG performed its Cycle 5 medical inspection at Chuckawalla Valley State Prison (CVSP) from July to October of 2017. The OVERALL inspection included in-depth reviews of 41 patient files conducted RATING: by clinicians, as well as reviews of documents from 370 patient files, covering 84 objectively scored tests of compliance with Adequate policies and procedures applicable to the delivery of medical care. The OIG assessed the case review and compliance results at CVSP using 12 health care quality indicators applicable to the institution. To conduct clinical case reviews, the OIG employs a clinician team consisting of a physician and a registered nurse consultant, while a team of registered nurses trained in monitoring medical policy compliance conducts compliance testing. Both case review clinicians and compliance inspectors rated six of the indicators; only case review clinicians rated three of the indicators; and only compliance inspectors scored three of the indicators. The CVSP Executive Summary Table on the following page identifies the applicable individual indicators and scores for this institution. Chuckawalla Valley State Prison, Cycle 5 Medical Inspection Page iii Office of the Inspector General State of California CVSP Executive Summary Table Cycle 5 Cycle 4 Case Review Compliance Inspection Indicators Overall Overall Rating Rating Rating Rating 1—Access to Care Adequate Adequate Adequate Adequate 2—Diagnostic Services Proficient Inadequate Adequate Proficient 3—Emergency Services Adequate Not Applicable Adequate Adequate 4—Health Information Proficient Inadequate Adequate Inadequate Management 5—Health Care Environment Not Applicable Inadequate Inadequate Inadequate 6—Inter- and Intra-System Inadequate Inadequate Inadequate Adequate Transfers 7—Pharmacy and Medication I Adequate Inadequate Adequate n Adequate Management a 8—Prenatal and Post-Delivery Not Applicable Not Applicable Not Applicable Not Applicable Services 9—Preventive Services Not Applicable Adequate Adequate Adequate 10—Quality of Nursing Adequate Not Applicable Adequate Adequate Performance 11—Quality of Provider Adequate Not Applicable Adequate Adequate Performance 12—Reception Center Arrivals Not Applicable Not Applicable Not Applicable Not Applicable 13—Specialized Medical Housing Not Applicable Not Applicable Not Applicable Not Applicable 14—Specialty Services Adequate Inadequate Adequate Adequate 15—Administrative Operations Not Applicable Proficient Proficient Inadequate* (Secondary) *In Cycle 4, there were two secondary (administrative) indicators. This score reflects the average of those two scores. Chuckawalla Valley State Prison, Cycle 5 Medical Inspection Page iv Office of the Inspector General State of California Clinical Case Review and OIG Clinician Inspection Results The clinicians’ case reviews sampled patients with high medical needs and included a review of 600 patient care events.1 Case review clinician evaluated nine of the 12 indicators applicable to CVSP. Two indicators’ case review ratings were proficient, six were adequate, and one was inadequate. When determining the overall adequacy of care, the OIG paid particular attention to the clinical nursing and provider quality indicators, as adequate health care staff can sometimes overcome suboptimal processes and programs. However, the opposite is not true; inadequate health care staff cannot provide adequate care, even though the established processes and programs onsite may be adequate. The OIG clinicians identify inadequate medical care based on the risk of significant harm to the patient, not the actual outcome. Program Strengths — Clinical • During the review period, CVSP provided excellent diagnostic services. Staff timely performed diagnostic tests and providers reviewed the results and notified patients promptly. • Specialty reports were readily available for provider review. Even though providers did not always sign the specialty reports, CVSP staff retrieved and scanned them promptly into the electronic medical record. Program Weaknesses — Clinical • CVSP’s provider follow-up process after specialty appointments was poor. There were multiple occurrences of delayed provider appointments after a specialty consultation. • The institution performed poorly with patients who transferred into CVSP. Most deficiencies involved poor nursing assessment and interventions, and the receiving and release (R&R) nurses’ failure to promptly refer patients to providers. • CVSP providers sometimes did not review emergency room and specialty reports. Too often, providers performed superficial reviews and ignored important recommendations. Compliance Testing Results Of the 12 health care indicators applicable to CVSP, the compliance team scored nine.2 One indicator’s compliance score was proficient, two indicators’ compliance scores were adequate, and six indicators’ compliance scores were inadequate. There were 84 individual compliance 1 Each OIG clinician team consists of a board-certified physician and a registered nurse consultant with experience in correctional and community medical settings. 2 The OIG’s compliance team consists of inspectors who are registered nurses with expertise in CDCR policies regarding medical staff and processes. Chuckawalla Valley State Prison, Cycle 5 Medical Inspection Page v Office of the Inspector General State of California questions within those nine indicators, generating 1,004 data points, that tested CVSP’s compliance with California Correctional Health Care Services (CCHCS) policies and procedures.3 Appendix A — Compliance Test Results details those 84 questions. Program Strengths — Compliance • Nursing staff reviewed patient health care service requests the same day they received the requests, and nurses conducted face-to-face encounters with patients within required time frames. In addition, the institution had health care services request forms available to patients in housing units. • The institution provided radiology and laboratory services to patients within required time frames. • CVSP clinic locations were appropriately clean, sanitary, and free of infectious agents. • CVSP ensured that patients who transferred among yards within the institution received their medications at their scheduled dosing times. • The institution provided patients influenza immunizations and colorectal cancer screenings within required time frames. Program Weaknesses — Compliance • The institution’s providers did not always communicate the results of diagnostic tests to patients within required time frames. • CVSP staff did not always accurately scan documents into the electronic medical record. In addition, the institution did not always receive a completed discharge report from a community hospital, or providers did not properly review the hospital discharge reports. • Several clinic locations did not follow appropriate medical supply storage and management protocols, and not every clinic location had essential core medical equipment and supplies. In addition, several clinic examination rooms did not have adequate space to allow clinicians to perform an appropriate patient examination. • The institution did not always properly store refrigerated and non-refrigerated medications at medication line and clinic locations. • Providers did not always review routine specialty service reports, or reviewed the reports late. In addition, the institution did not always provide patients transferring into CVSP from 3 The OIG used its own clinicians to provide clinical expert guidance for testing compliance in certain areas for which CCHCS policies and procedures did not specifically address an issue. Chuckawalla Valley State Prison, Cycle 5 Medical Inspection Page vi Office of the Inspector General State of California another CDCR institution with their previously scheduled specialty service within required time frames. Recommendations The OIG recommends the following: • CVSP nursing managers should develop guidelines, implement training, and establish job performance monitoring strategies for licensed vocational nurse (LVN) care coordinators. Population-Based Metrics In general, CVSP performed sufficiently as measured by population-based metrics. In comprehensive diabetes care, the institution outperformed state and national health care plans in four of the five diabetic measures, with CVSP scoring lower in diabetic eye exams compared to most of the health care plans. With regard to immunizations, CVSP outperformed all applicable health care plans for influenza immunizations for both younger and older adults, but scored lower than all applicable health care plans for pneumococcal immunizations. For colorectal cancer screening, the institution’s score was mixed, scoring higher than two health care plans but slightly lower than three other applicable health care plans. Patient refusals for both pneumococcal immunizations and colorectal cancer screening negatively affected CVSP’s score for these measures. Overall, CVSP’s population-based metrics performance reflected a well-functioning chronic care program, compared to the other state and national health care entities reviewed. The institution may improve its scores for pneumococcal immunizations and colorectal cancer screening by educating patients about the benefits of these services. Chuckawalla Valley State Prison, Cycle 5 Medical Inspection Page vii Office of the Inspector General State of California This page intentionally left blank. Chuckawalla Valley State Prison, Cycle 5 Medical Inspection Page viii Office of the Inspector General State of California I NTRODUCTION Pursuant to California Penal Code Section 6126 et seq., which assigns the Office of the Inspector General (OIG) responsibility for oversight of the California Department of Corrections and Rehabilitation (CDCR), and at the request of the federal Receiver, the OIG developed a comprehensive medical inspection program to evaluate the delivery of medical care at each of CDCR’s 35 adult prisons. The OIG conducted a clinical case review and a compliance inspection, ensuring a thorough, end-to-end assessment of medical care within CDCR. Chuckawalla Valley State Prison (CVSP) was the 21st medical inspection of Cycle 5. During the inspection process, the OIG assessed the delivery of medical care to patients using the primary clinical health care indicators applicable to the institution. The Administrative Operations indicator is secondary because it does not reflect the actual clinical care provided. ABOUT THE INSTITUTION CVSP is located in Blythe, in Riverside County, and the institution became operational in 1988. CVSP primarily houses medium-security Level II male patients. The institution runs multiple clinics where medical staff members handle non-urgent requests for medical services. CVSP also treats patients needing urgent or emergent care in its triage and treatment area (TTA). CCHCS has designated CVSP as a “basic care prison,” an institution located in a rural area away from tertiary care centers and specialty care providers whose services would likely be used frequently by higher- risk patients. In August of 2014, the institution received national accreditation from the Commission on Accreditation for Corrections and was re-accredited in April 2017. This accreditation program is a professional peer review process based on national standards set by the American Correctional Association. Based on staffing data the OIG obtained from the institution as identified in the CVSP Health Care Staffing Resources as of July 2017 table below, CVSP’s vacancy rate among medical managers, primary care providers, supervisors, and rank-and-file nurses was 15 percent in July 2017, with the highest vacancy percentages among management at 40 percent. At the time of the OIG’s inspection, there were six health care staff members on long-term medical leave. Chuckawalla Valley State Prison, Cycle 5 Medical Inspection Page 1 Office of the Inspector General State of California CVSP Health Care Staffing Resources as of July 2017 Primary Care Nursing Management Nursing Staff Totals Providers Supervisors Description Number % Number % Number % Number % Number % Authorized 5 7% 5 7% 10.5 14% 55.6 73% 76.1 100% Positions Filled Positions 3 60% 3.6 72% 10.5 100% 47.8 86% 64.9 85% Vacancies 2 40% 1.4 28% 0 0% 7.8 14% 11.2 15% Recent Hires (within 12 1 33% 3 83% 4 38% 7 15% 15 23% months) Staff Utilized 0 0% 1 28% 0 0% 0 0% 1 2% from Registry Redirected Staff (to Non-Patient 0 0% 0 0% 0 0% 0 0% 0 0% Care Areas) Staff on Long-term 1 33% 0 0% 1 10% 4 8% 6 9% Medical Leave Note: CVSP Health Care Staffing Resources data was not validated by the OIG. As of July 17, 2017, the Master Registry for CVSP showed that the institution had a total population of 2,791. Within that total population, 0.1 percent was designated as high medical risk, Priority 1 (High 1), and 2.0 percent was designated as high medical risk, Priority 2 (High 2). Patients’ assigned risk levels are based on the complexity of their required medical care related to their specific diagnoses, frequency of higher levels of care, age, and abnormal laboratory results and procedures. High 1 has at least two high-risk conditions; High 2 has only one. Patients at high medical risk are more susceptible to poor health outcomes than those at medium or low medical risk. Patients at high medical risk also typically require more health care services than do patients with lower assigned risk levels. The chart below illustrates the breakdown of the institution’s medical risk levels at the start of the OIG medical inspection. CVSP Master Registry Data as of July 17, 2017 Medical Risk Level Number of Patients Percentage High 1 3 0.1% High 2 55 2.0% Medium 502 18.0% Low 2,231 79.9% Total 2,791 100% Chuckawalla Valley State Prison, Cycle 5 Medical Inspection Page 2 Office of the Inspector General State of California O , S , M BJECTIVES COPE AND ETHODOLOGY In designing the medical inspection program, the OIG reviewed CCHCS policies and procedures, relevant court orders, and guidance developed by the American Correctional Association. The OIG also reviewed professional literature on correctional medical care; reviewed standardized performance measures used by the health care industry; consulted with clinical experts; and met with stakeholders from the court, the Receiver’s office, CDCR, the Office of the Attorney General, and the Prison Law Office to discuss the nature and scope of the OIG’s inspection program. With input from these stakeholders, the OIG developed a medical inspection program that evaluates medical care delivery by combining clinical case reviews of patient files, objective tests of compliance with policies and procedures, and an analysis of outcomes for certain population-based metrics. To maintain a metric-oriented inspection program that evaluates medical care delivery consistently at each state prison, the OIG identified 15 indicators (14 primary (clinical) indicators and one secondary (administrative) indicator) of health care to measure. The primary quality indicators cover clinical categories directly relating to the health care provided to patients, whereas the secondary quality indicator addresses the administrative functions that support a health care delivery system. The CVSP Executive Summary Table on page iv of this report identifies these 15 indicators. The OIG rates each of the quality indicators applicable to the institution under inspection based on case reviews conducted by OIG clinicians and compliance tests conducted by OIG registered nurses. The case review results alone, the compliance test results alone, or a combination of both of these information sources may influence an indicator’s overall rating. For example, the OIG derives the ratings for the primary quality indicators Quality of Nursing Performance and Quality of Provider Performance entirely from the case review done by clinicians, while the ratings for the primary quality indicators Health Care Environment and Preventive Services are derived entirely from compliance testing done by registered nurse inspectors. As another example, primary quality indicators such as Diagnostic Services and Specialty Services receive ratings derived from both sources. Consistent with the OIG’s agreement with the Receiver, this 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 a patient needing immediate care, the OIG notifies the chief executive officer of health care services and requests a status report. Additionally, if the OIG learns of significant departures from community standards, it may report such departures to the institution’s chief executive officer or to CCHCS. Because these matters involve confidential medical information protected by state and federal privacy laws, the OIG does not include specific identifying details related to any such cases in the public report. Chuckawalla Valley State Prison, Cycle 5 Medical Inspection Page 3 Office of the Inspector General State of California In all areas, the OIG is alert for opportunities to make appropriate recommendations for improvement. Such opportunities may be present regardless of the score awarded to any particular quality indicator; therefore, recommendations for improvement are not necessarily indicative of deficient medical care delivery. CASE REVIEWS The OIG added case reviews to the Cycle 4 medical inspections at the recommendation of its stakeholders, which continues in the CASE REVIEW Cycle 5 medical inspections. The text box provides additional An appraisal of the medical care provided to one patient detail that describes this process. over a specific period, which can comprise either a The OIG’s clinicians perform a retrospective chart review of detailed case review or a selected patient files to evaluate the care given by an institution’s focused case review. primary care providers and nurses. Retrospective chart review is a Detailed Case Review well-established review process used by health care organizations A review that includes all that perform peer reviews and patient death reviews. Currently, aspects of one patient’s medical care assessed over a CCHCS uses retrospective chart review as part of its death review six-month period. This process and in its pattern-of-practice reviews. CCHCS also uses a review allows the OIG more limited form of retrospective chart review when performing clinicians to examine many areas of health care appraisals of individual primary care providers. delivery, such as access to care, diagnostic services, Patient Selection for Retrospective Case Reviews health information management, and specialty services. Because retrospective chart review is time consuming and requires qualified health care professionals to perform it, OIG clinicians Focused Case Review must carefully select a sample of patient records. Accordingly, the A review that focuses on one specific aspect of group of patients the OIG targeted for chart review carried the medical care. This review highest clinical risk and utilized the majority of medical services. tends to concentrate on a As only 58 patients at CVSP were classified by CCHCS as High 1 singular facet of patient care, such as the sick call or High 2, the majority of patients selected for retrospective chart process or the institution’s review were high-utilizing patients with chronic care illnesses who emergency medical response. were classified as high or medium risk. 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; 11 percent of the total patient population is high-risk and accounts for more than half of the institution’s pharmaceutical, specialty, community hospital, and emergency costs. 2. Selecting this target group for chart review provides a significantly greater opportunity to evaluate all the various aspects of the health care delivery system at an institution. Chuckawalla Valley State Prison, Cycle 5 Medical Inspection Page 4 Office of the Inspector General State of California Underlying the choice of high-risk patients for detailed case review, the OIG clinical experts made the following three assumptions: 1. If the institution is able to provide adequate clinical care to the most challenging patients with multiple complex and interdependent medical problems, it is more likely to provide adequate care to patients with less complicated health care issues. Because clinical expertise is required to determine whether the institution has provided adequate clinical care, the OIG utilizes experienced correctional physicians and registered nurses to perform this analysis. 2. The health of less complex patients is more likely 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 from death reviews, sentinel events (unexpected occurrences involving death or serious injury, or risk thereof), and hospitalizations are more likely to comprise high-risk patients. Benefits and Limitations of Targeted Subpopulation Review Because the patients selected utilize the broadest range of services offered by the health care system, the OIG’s retrospective 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. 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 is reasonable to infer that the health care system is also providing appropriate diabetic services to the entire diabetic subpopulation. However, if these same Chuckawalla Valley State Prison, Cycle 5 Medical Inspection Page 5 Office of the Inspector General State of California 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-1: CVSP Sample Sets, the OIG clinicians evaluated medical charts for 41 unique patients. Appendix B, Table B-4: CVSP Case Review Sample Summary clarifies that both nurses and physicians reviewed charts for 11 of those patients, for 52 reviews in total. Physicians performed detailed reviews of 20 charts, and nurses performed detailed reviews of 9 charts, totaling 29 detailed reviews. For detailed case reviews, physicians or nurses 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 21 patients. These generated 600 clinical events for review (Appendix B, Table B-3: CVSP Event – Program). The inspection tool 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., 6 diabetes patients (Appendix B, Table B-1: CVSP Sample Sets), the 41 unique patients sampled included patients with 105 chronic care diagnoses, including 6 additional patients with diabetes (for a total of 12) (Appendix B, Table B-2: CVSP Chronic Care Diagnoses). The OIG’s sample selection tool allowed evaluation of many chronic care programs because the complex and high-risk patients selected from the different categories often had multiple medical problems. While the OIG did not evaluate every chronic disease or health care staff member, the OIG did assess for adequacy the overall operation of the institution’s system and staff. The OIG’s case review methodology and sample size matched those of 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 found the Cycle 4 medical inspection sample size of 30 for detailed physician reviews far exceeded the saturation point necessary for an adequate qualitative review. At the end of Cycle 4 inspections, the case review results were re-analyzed using 50 percent of the cases; there were no significant differences in the ratings. To improve inspection efficiency while preserving the quality of the inspection, the OIG reduced in number the samples for Cycle 5 medical inspections. In Cycle 5, for basic institutions with small high-risk populations, the case review team will use a sample size of detailed physician-reviewed cases 67 percent as large as that used in Cycle 4. For intermediate institutions and basic institutions housing many high-risk patients, the case review team will use a sample 83 percent as large as that in Cycle 4. Finally, for the most medically complex institution, California Health Care Facility (CHCF), the OIG will continue to use a sample size equal to that used in Cycle 4. CVSP is a basic facility, and the physician sample was 67 percent (20 physician-detailed reviews) of the Cycle 4 sample. Chuckawalla Valley State Prison, Cycle 5 Medical Inspection Page 6 Office of the Inspector General State of California With regard to reviewing charts from different providers, the OIG does not intend for the case review to be a focused search for poorly performing providers; rather, the OIG intends for the case review to focus on how the system cares for those patients who need care the most. Nonetheless, while not sampling cases by each provider at the institution, the OIG inspections adequately review most providers. Providers would only escape OIG case review if institutional management successfully mitigated patient risk by having the more poorly performing providers care for the less complicated, low-utilizing, and lower-risk patients. The OIG’s clinicians concluded that the case review sample size was more than adequate to assess the quality of services provided. Based on the collective results of clinicians’ case reviews, the OIG rated each quality indicator 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 July to October 2017, registered nurse inspectors obtained answers to 84 objective medical inspection test (MIT) questions designed to assess the institution’s compliance with critical policies and procedures applicable to the delivery of medical care. To conduct most tests, inspectors randomly selected samples of patients for whom the testing objectives were applicable and reviewed their electronic medical records. In some cases, inspectors used the same samples to conduct more than one test. In total, inspectors reviewed health records for 370 individual patients and analyzed specific transactions within their records for evidence that critical events occurred. Inspectors also reviewed management reports and meeting minutes to assess certain administrative operations. In addition, during the week of July 31, 2017, registered nurse 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 1,004 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 Cycle 5 medical inspection testing, the OIG reduced the number of compliance samples tested for 18 indicator tests from a sample of 30 patients to a sample of 25 patients. The OIG also removed some inspection tests upon stakeholder agreement that either the compliance testing duplicated in the case reviews or had limited value. Lastly, for Cycle 4 medical inspections, the OIG tested two secondary (administrative) indicators; Internal Monitoring, Quality Improvement, and Chuckawalla Valley State Prison, Cycle 5 Medical Inspection Page 7 Office of the Inspector General State of California Administrative Operations; and Job Performance, Training, Licensing, and Certifications, and the OIG has combined these tests into one Administrative Operations indicator for Cycle 5 inspections. For details of the compliance results, see Appendix A — Compliance Test Results. For details of the OIG’s compliance sampling methodology, see Appendix C — Compliance Sampling Methodology. Scoring of Compliance Testing Results After compiling the answers to the 84 questions for the nine indicators for which compliance testing was applicable, the OIG compliance team derived a score for each quality indicator by calculating the percentage score of all Yes answers for each of the questions applicable to a particular indicator, then averaging those scores. Based on those results, the OIG assigned a rating to each quality indicator of proficient (greater than 85 percent), adequate (between 75 percent and 85 percent), or inadequate (less than 75 percent). OVERALL QUALITY INDICATOR RATING FOR CASE REVIEWS AND COMPLIANCE TESTING The OIG derived the final rating for each quality indicator by combining the ratings from the case reviews and from the compliance testing, as applicable. When combining these ratings, the case review evaluations and the compliance testing results usually agreed, but there were instances when the rating differed for a particular quality indicator. In those instances, the inspection team assessed the quality indicator based on the collective ratings from both components. Specifically, the OIG clinicians and registered nurse inspectors discussed the nature of individual exceptions found within that indicator category and considered the overall effect on the ability of patients to receive adequate medical care. To derive an overall assessment rating of the institution’s medical inspection, the OIG evaluated the various rating categories assigned to each of the quality indicators applicable to the institution, giving more weight to the rating results of the primary quality indicators, which directly relate to the health care provided to patients. Based on that analysis, OIG experts made a considered and measured overall opinion about the quality of health care observed. POPULATION-BASED METRICS The OIG identified a subset of Healthcare Effectiveness Data Information Set (HEDIS) measures applicable to the CDCR patient population. To identify outcomes for CVSP, the OIG reviewed some of the compliance testing results, randomly sampled additional patients’ records, and obtained CVSP data from the CCHCS Master Registry. The OIG compared those results to HEDIS metrics reported by other statewide and national health care organizations. Chuckawalla Valley State Prison, Cycle 5 Medical Inspection Page 8 Office of the Inspector General State of California M I R EDICAL NSPECTION ESULTS The quality indicators assess the clinical aspects of health care. The CVSP Executive Summary Table on page iv of this report identifies the 12 applicable individual indicators and scores for this institution. Both case review clinicians and compliance inspectors rated six of the indicators; only case review clinicians rated three of the indicators; and only compliance inspectors scored three of the indicators. The Administrative Operations indicator is a secondary indicator; therefore, the OIG did not rely upon this indicator when determining the institution’s overall score. Based on the analysis and results in all the primary indicators, the OIG experts made a considered and measured opinion that the quality of health care at CVSP was adequate. Summary of Case Review Results: The clinical case review component assessed 9 of the 12 primary (clinical) indicators applicable to CVSP. Of these nine indicators, OIG clinicians rated two proficient, six adequate, and one inadequate. The OIG physicians rated the overall adequacy of care for each of the 20 detailed case reviews they conducted. Of these 20 cases, 3 were proficient, 12 were adequate, and 5 were inadequate. In the 600 events reviewed, there were 167 deficiencies, 66 of which were considered to be of such magnitude that, if left unaddressed, they would likely contribute to patient harm. Adverse Events Identified During Case Review: Adverse events are medical errors that cause serious patient harm. Medical care is a complex and dynamic process with many moving parts, subject to human error even within the best health care organizations. All major health care organizations typically 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 nature of these events, the OIG cautions against drawing inappropriate conclusions regarding the institution based solely on adverse events. OIG clinicians identified one adverse event in the case reviews at CVSP: • In case 5, the patient had cancer. When the cancer was first discovered in a hospital, the oncologist recommended an urgent 7-day follow-up to determine the next course of action. The patient did not see the oncologist for 40 days. The oncology specialist then recommended an urgent biopsy procedure. The oncology specialist needed this biopsy to identify the patient’s type of metastatic cancer and to formulate the most appropriate treatment plan. The CVSP provider overlooked the oncologist’s urgent recommendations four times before ordering the biopsy. These errors resulted in a nearly 2-month delay in obtaining this vital test. The Quality of Provider Performance indicator also addresses this deficiency. Chuckawalla Valley State Prison, Cycle 5 Medical Inspection Page 9 Office of the Inspector General State of California Summary of Compliance Results: The compliance component assessed 9 of the 12 indicators applicable to CVSP. Of these nine indicators, OIG inspectors rated one proficient, two adequate, and six inadequate. The test questions used to assess compliance for each indicator are in Appendix A at the end of this report. Chuckawalla Valley State Prison, Cycle 5 Medical Inspection Page 10 Office of the Inspector General State of California ACCESS TO CARE This indicator evaluates the institution’s ability to provide patients Case Review Rating: with timely clinical appointments. Compliance and case review Adequate teams review areas specific to patients’ access to care, such as initial Compliance Score: assessments of newly arriving patients, acute and chronic care Adequate follow-ups, face-to-face nurse appointments when patients request (77.6%) to be seen, provider referrals from nursing lines, and follow-ups Overall Rating: after hospitalization or specialty care. Compliance testing for this Adequate indicator also evaluates whether patients have Health Care Services Request forms (CDCR Form 7362) available in their housing units. Case Review Results The OIG clinicians reviewed 369 provider, nurse, specialty, and hospital events that required follow-up appointments, and identified 28 deficiencies relating to access to care, 15 of which were significant. Provider-to-Provider Follow-up Appointments CVSP’s performance with provider-ordered appointments was good. Failure to carry out provider-ordered appointments can result in lapses of care; however, these occurred rarely. OIG clinicians reviewed 151 outpatient provider appointments. There were only six deficiencies in this area, five of which were significant. The following three cases provide examples: • In case 6, the provider ordered a 30-day follow-up appointment for a patient who had received an abnormal laboratory result that suggested a bacterial gastrointestinal infection. The appointment did not occur for more than three months. This treatment delay could have led to him developing gastrointestinal ulcers. • In case 8, the institution sent the patient to the hospital for a rectal abscess. The provider ordered a 4-day follow-up, but the appointment did not occur for 13 days. Failure to promptly monitor the abscess could have led to a worsening infection. • In case 17, a provider should have seen this diabetic patient to discuss laboratory results and a recent change in diabetic medication. The provider ordered a two-week follow-up, but the patient was not seen for more than six weeks later. RN Sick Call Access CVSP nursing sick call access was good. The RNs performed sick call triage timely. Staff quickly scanned health care services request forms into the electronic medical record. Most (non-urgent) face-to-face nursing assessments occurred the same day the nurse reviewed the patient’s sick call request or by the next business day. OIG clinicians reviewed 41 sick call requests. Sick call nurses Chuckawalla Valley State Prison, Cycle 5 Medical Inspection Page 11 Office of the Inspector General State of California failed to see only three patients with symptomatic complaints by the next business day. For two patients, delays occurred because staff incorrectly entered the appointment scheduling orders into the electronic medical record as “asymptomatic.” Fortunately, nursing staff discovered these two errors promptly, and nursing staff promptly scheduled the patients for sick call nurse appointments between one and three days later. The third error resulted in a one-day delay of the nursing sick call appointment. All of these delays were minor, and none resulted in poor outcomes. RN-to-Provider Referrals CVSP ensured timely provider visits after nurse referrals. The nurses made 25 referrals; three deficiencies occurred regarding appointment delays ranging from one day to eight weeks. Provider Follow-up After Specialty Services The process of providers following up after specialty appointments was poor. A follow-up appointment after a specialist consultation allows the provider to consider the specialty recommendations and to implement interventions timely. Occasionally, specialty consultants discover medical problems that require aggressive management. In these situations, prompt provider follow-up is critical. The OIG clinicians identified seven deficiencies, four of which were significant. The following two cases are pertinent examples: • In case 8, a gastrointestinal specialist evaluated the patient who had worsening symptoms from inflammatory bowel disease (frequent stools, rectal fullness, and rectal abscesses). The provider follow-up should have occurred within two weeks, but it did not occur for nearly a month. • In case 25, a cardiologist evaluated the patient for cardiovascular disease and recommended further cardiac testing. The institution should have scheduled the provider follow-up appointment within two weeks, but the appointment occurred five weeks after the specialty appointment. The institution correspondingly delayed the patient’s cardiac testing. Intra-System Transfers Patients arriving at CVSP from other CDCR institutions often did not see a provider timely. This was primarily due to the R&R nurse’s failure to timely initiate provider appointments when patients arrived at CVSP. The Inter- and Intra-System Transfer indicator also discusses these findings. Follow-up After Hospitalization CVSP ensured that providers saw their patients after the patients returned from outside hospitals or emergency departments. The institution had 16 hospitalizations and outside emergency events. There were no deficiencies regarding access to care for these patients. Chuckawalla Valley State Prison, Cycle 5 Medical Inspection Page 12 Office of the Inspector General State of California Follow-up After Urgent/Emergent Care Providers at CVSP offered timely follow-up evaluations for patients seen in the TTA. Of the 20 encounters reviewed, only one significant deficiency occurred: • In case 24, the patient had acute right knee pain and swelling. The provider ordered a five-day RN follow-up appointment, which did not occur. The patient’s pain persisted for several weeks, and the institution eventually sent the patient to a community hospital emergency department (ED) for evaluation of a possible blood clot in his leg. Specialty Access and Follow-up CVSP performed satisfactorily with both specialty access and follow-up. The Specialty Services indicator also addresses performance in this area. Diagnostic Results Follow-up The institution’s providers offered a sufficient level of follow-up after initially discussing diagnostic results with their patients. The providers frequently reviewed abnormal results and ordered appropriate follow-ups. The OIG clinicians identified two significant deficiencies, including the following: • In case 25, the patient received an abdominal ultrasound to investigate concerns about a mass in his abdomen. CVSP did not schedule a provider follow-up appointment, and the patient transferred out of the institution a month later without a re-evaluation. Clinician Onsite Inspection During their onsite inspection, the OIG clinicians learned that CVSP had approximately 2,700 patients with no provider backlogs in any of the clinics. The institution’s medical leadership attributed the lack of any backlogs to the new providers CVSP recently hired. CVSP’s providers saw an average of 10 to 14 patients per day, and, additionally, they had sufficient time to address any walk-in patient needs that arose. Furthermore, the providers customarily worked four ten-hour days per week and collaborated to ensure coverage. Case Review Conclusion CVSP performed satisfactorily regarding Access to Care. However, case review revealed certain areas where improvement is needed, such as provider follow-up after specialty services and transfer-in appointments. Nevertheless, access to care for the majority of patients was good, including during critical periods when patients needed follow-up after visiting outside hospitals or the TTA. The OIG clinicians rated this indicator adequate. Chuckawalla Valley State Prison, Cycle 5 Medical Inspection Page 13 Office of the Inspector General State of California Compliance Testing Results The institution performed in the adequate range in the Access to Care indicator, with a compliance score of 77.6 percent, scoring in the proficient range in the tests below: • Inspectors sampled 30 health care services request forms submitted by patients across all facility clinics. Nurses reviewed all such forms on the same day nursing staff received them (MIT 1.003). • Patients had access to health care services request forms at all six housing units that the OIG inspected (MIT 1.101). • For 26 of the 30 sampled patients who submitted health care services request forms (87 percent), the RN conducted a face-to-face encounter with the patient within one business day of reviewing the form. For three patients, the RN conducted the encounter one day late, and for one patient, the OIG inspectors found no evidence the face-to-face encounter occurred (MIT 1.004). The following tests received scores in the adequate range: • Of the ten applicable health care services request forms sampled for which the nurse referred the patient to a provider appointment, eight patients (80 percent) received timely appointments. For one patient, the follow-up appointment occurred one day late, and for another patient, no evidence showed that the appointment occurred at all (MIT 1.005). • Of the four sampled patients nursing staff referred to a provider and for whom the provider subsequently ordered a follow-up appointment, three (75 percent) received their follow-up appointments timely. For one patient, the appointment was nine days late (MIT 1.006). The institution had room to improve in the following tests: • Only 12 of 25 applicable sampled patients who received a high priority or routine specialty service (48 percent) also received a timely follow-up appointment with a provider. Of the 13 patients who did not receive a timely follow-up appointment, 8 of them received appointments ranging from one to eight days late. Four other patients received appointments ranging from 61 to 78 days late, and one patient did not receive an appointment at all (MIT 1.008). • OIG inspectors sampled 25 patients who suffered from one or more chronic care conditions; only 16 patients timely received their provider-ordered follow-up appointments (64 percent). Nine other patients received their appointments late as follows: five patients’ appointments were from 3 to 7 days late; one patient’s appointment was 77 days late. For three patients, their appointments were more than four months late (MIT 1.001). Chuckawalla Valley State Prison, Cycle 5 Medical Inspection Page 14 Office of the Inspector General State of California • OIG inspectors tested 25 patients who were discharged from a community hospital to determine whether they received a provider follow-up appointment at CVSP within five calendar days of their return to the institution, or earlier if a TTA provider ordered that the appointment occur sooner. Only 18 of these patients (72 percent) received timely provider follow-up appointments. Five patients received their appointments from 2 to 17 days late; one patient received his appointment 36 days late; and for one final patient, no evidence showed that he received an appointment (MIT 1.007). • Among 22 applicable sampled patients who transferred into CVSP from other institutions and were referred to a provider based on the RNs’ initial health care screening assessments, providers saw only 16 of them timely (73 percent). Four patients’ provider appointments occurred from one to 12 days late, and two other patients’ appointments were 33 and 41 days late (MIT 1.002). Chuckawalla Valley State Prison, Cycle 5 Medical Inspection Page 15 Office of the Inspector General State of California DIAGNOSTIC SERVICES This indicator addresses several types of diagnostic services. Case Review Rating: Specifically, it addresses whether radiology and laboratory services Proficient were timely provided to patients, whether primary care providers Compliance Score: timely reviewed results, and whether providers communicated Inadequate results to the patient within required time frames. In addition, for (66.5%) pathology services, the OIG determines whether the institution Overall Rating: received a final pathology report and whether the provider timely Adequate 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. For this indicator, the case review and compliance review processes yielded different results, with the case review giving a proficient rating and the compliance review resulting in an inadequate score. While compliance testing found that providers did not timely sign the diagnostic results, the case reviews found that the providers’ clinical review of the results was appropriate. The compliance testing found concerns with providers communicating diagnostic services’ results to patients timely or not communicating the results to patients at all. However, case review found during their review that although providers may not have properly documented the communication process of diagnostic test results to patients, CVSP providers acted on test results and made appropriate decisions based on them. After considering the results of both the case review and the compliance testing, the OIG determined an overall rating of adequate was appropriate for this indicator. Case Review Results The OIG clinicians reviewed 112 diagnostic events and found six deficiencies, five of which were significant and are discussed here. Test Completion CVSP performed and completed electrocardiograms (EKGs) and X-rays timely. Case review clinicians reviewed 23 ordered radiologic exams, and the institution failed to complete only one of the imaging studies. • In case 4, the provider ordered a chest x-ray in preparation for the patient’s surgery, but the test was not performed. Four significant laboratory deficiencies occurred among the 91 the OIG reviewed, as follows: • In case 5, the patient had experienced a significant weight loss. A provider ordered laboratory tests to obtain preliminary data to help discover the reason for this loss, but the patient never received the tests. Chuckawalla Valley State Prison, Cycle 5 Medical Inspection Page 16 Office of the Inspector General State of California • Also in case 5, the patient was subsequently diagnosed with cancer. Urgent laboratory tests were ordered to identify baseline blood counts prior to chemotherapy, but they were not performed. Fortunately, this error did not delay the patient’s cancer treatment. • In case 13, the diabetic patient’s laboratory tests were not performed. These tests were ordered to monitor the patient’s control of his diabetes, and this error resulted in a delay in care. • In case 18, the patient had an elevated heart rate, and laboratory testing was ordered to investigate the cause. However, the tests were not performed until a provider reordered them three months later. Health Information Management CVSP’s diagnostic imaging studies and laboratory results were easily reviewable within the electronic medical record. When institution staff completed these tests, the EHRS (electronic health records system) automatically sent messages to the providers for review. The providers reviewed the results timely. The OIG identified no health information management deficiencies regarding diagnostic services. Pathology Services CVSP appeared to have sufficient pathology services. The OIG clinicians did not identify any deficiencies in this area. Clinician Onsite Inspection During the onsite inspection, CVSP providers expressed that they considered the institution’s diagnostic services satisfactory. The providers were easily able to access and review diagnostic results. CVSP’s leadership attributed three of the five significant deficiencies to temporary errors resulting from the transition from the prior medical record system to the EHRS. Case Review Conclusion CVSP completed diagnostic and laboratory services promptly. Diagnostic reports were readily available in the electronic medical record, and providers reviewed them and notified patients of their tests results quickly. CVSP performed well regarding the Diagnostic Services indicator, and the case review rating was thus proficient. Compliance Testing Results The institution received a compliance score of 66.5 percent in the Diagnostic Services indicator, which encompasses radiology, laboratory, and pathology services. For clarity, we discuss each type of diagnostic service separately below: Chuckawalla Valley State Prison, Cycle 5 Medical Inspection Page 17 Office of the Inspector General State of California Radiology Services • The institution timely performed radiology services for all eight of the applicable sampled patients (MIT 2.001). CVSP providers timely initialed and dated the diagnostic services reports as required by CCHCS policy for only four of the ten samples inspected (40 percent). Providers reviewed one report one day late; for the remaining five patients, no evidence showed that providers had reviewed their reports (MIT 2.002). Providers also timely communicated test results to only six of the ten patients (60 percent); for the remaining four patients, the provider never communicated the test results (MIT 2.003). Laboratory Services • All ten sampled patients received their provider-ordered laboratory services timely (MIT 2.004). In addition, CVSP’s providers reviewed eight of the nine applicable laboratory services reports within the required time frame (89 percent); but one report was reviewed six days late (MIT 2.005). Finally, providers timely communicated the results to only four of the ten sampled patients (40 percent). Providers communicated two patients’ results 6 and 13 days late, and one patient’s results 51 days late. Providers never communicated the other three patients’ results to them (MIT 2.006). Pathology Services • Clinicians at CVSP timely received the final pathology reports for seven of ten sampled patients (70 percent). The institution received two of the untimely reports 8 and 75 days late; and for the third report, OIG inspectors found no evidence in the electronic medical record concerning its timeliness (MIT 2.007). Providers timely reviewed the pathology results for eight of ten patients (80 percent). For one patient, the provider documented evidence of review four days late; and for another patient, OIG inspectors found no evidence of provider review in the electronic medical record (MIT 2.008). Finally, providers timely communicated the pathology results to only two of the ten sampled patients (20 percent). Providers communicated six patients’ results from 5 to 29 days late; a provider communicated one patient’s results more than three months late; and the provider failed to communicate one patient’s results (MIT 2.009). Chuckawalla Valley State Prison, Cycle 5 Medical Inspection Page 18 Office of the Inspector General State of California EMERGENCY SERVICES An emergency medical response system is essential to providing effective and timely emergency medical response, assessment, Case Review Rating: Adequate treatment, and transportation 24 hours per day. Provision of Compliance Score: urgent/emergent care is based on a patient’s emergent 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: Adequate support (BLS), and advanced cardiac life support (ACLS) consistent with the American Heart Association guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiovascular care, and the provision of services by knowledgeable staff appropriate to each individual’s training, certification, and authorized scope of practice. The OIG evaluates this quality indicator entirely through clinicians’ reviews of case files and conducts no separate compliance testing element. Case Review Results The OIG clinicians reviewed 20 urgent or emergent events and found 18 deficiencies within various aspects of emergency care, 7 of which were significant. Out of the 13 cases where the TTA staff evaluated patients, the majority of TTA encounters were adequate. The significant deficiencies were identified within only three cases. CPR Response The OIG clinicians reviewed one emergency CPR case and found the response to be excellent. CVSP medical staff intervened efficiently and appropriately. The documentation was comprehensive. Provider Performance TTA provider performance was adequate. In most TTA encounters, providers made proper assessments and devised reasonable plans of care. When needed, the CVSP providers transferred their patients to community hospitals. The OIG identified three provider deficiencies, one of which was significant: • In case 3, the patient complained of chest pain with left side numbness and shortness of breath. The patient was at high risk for heart disease, and his symptoms were worrisome due to the possibility of a heart attack. The provider failed to immediately order nitroglycerin or aspirin (medications allowing blood to reach the heart more efficiently if the patient were having a heart attack). The provider’s failure to emergently order those medications delayed oxygenation to the heart and could have led to heart damage or even death. Fortunately, the Chuckawalla Valley State Prison, Cycle 5 Medical Inspection Page 19 Office of the Inspector General State of California patient was transported to a community ER, and his chest pain was quickly relieved after he received the necessary medications. Nursing Performance The OIG clinicians discovered 11 nursing deficiencies, 3 of which were significant. Most nursing deficiencies involved incomplete nursing assessments and interventions, as identified in the following examples: • In case 3, the patient had chest pain. The TTA RN did not ask the patient about the onset of his pain or its severity, or whether the pain occurred during rest or with activity. Furthermore, the RN did not administer aspirin or nitroglycerin. Not administering these medications could have resulted in heart damage. • In case 9, the patient came to the TTA with an unusually slow heartbeat, nausea, vomiting, and dizziness, which are signs and symptoms of a possible stroke. Despite the presence of these warning signs, the TTA RN did not conduct an assessment for stroke until nearly one hour after the patient had arrived in the TTA. Management of stroke is time sensitive. Delays in recognizing the possible onset of stroke may result in brain damage or even death. Fortunately, the patient did not have a stroke and suffered no harm. • In case 10, the TTA nurse did not evaluate or treat the patient’s chest pain satisfactorily. The nurse did not conduct a thorough cardiac assessment, including asking the patient about the time of onset and severity of the chest pain, and timely administration of aspirin and nitroglycerin. Fortunately, this did not result in patient harm. Emergency Medical Response Review Committee (EMRRC) The CVSP EMRRC conducted regular reviews of urgent and emergent response cases. However, at the onsite inspection, the medical leadership acknowledged that the EMRRC did not identify the problems regarding initiating timely assessment and intervention in the three emergency cases (cases 3, 9, and 10) relating to cardiac and neurologic care. Clinician Onsite Inspection The OIG clinicians visited the TTA, which had two patient rooms. Each room was equipped with a bed and emergency equipment. The institution assigned two RNs to the TTA at all times. The chief physician and surgeon’s (CP&S’s) office was adjacent to the TTA, and the CP&S welcomed consultations during regular business hours. CVSP nursing staff contacted the provider on call (POC) by phone when they needed an after-hours consultation. While all POCs were accessible by phone, some were not available for face-to-face provider evaluations because they were geographically located too far away from the institution. The nurses normally used the CCHCS standardized nursing protocols to provide appropriate assessments and interventions to patients needing urgent/emergent care. During the OIG case review discussion, the SRNs agreed with the Chuckawalla Valley State Prison, Cycle 5 Medical Inspection Page 20 Office of the Inspector General State of California OIG case review findings, concurring that some nurses in the TTA did not provide comprehensive chest pain assessments and interventions. However, the nurse managers had not identified these deficiencies during the CVSP nursing emergency medical response reviews. The SRNs attributed many of the TTA nurses’ deficiencies to the new RNs working in the TTA areas who did not yet possess sufficient emergency nursing experience. The TTA SRN had identified the need for a training program for the TTA emergency nurses and, had developed a skills education and competency tool. Supervising nurses had recently developed additional training programs for the TTA nurses. This plan was awaiting administrative approval. The chief nurse executive planned to implement this training as soon as possible, and thereafter, annually. Case Review Conclusion CVSP’s patient population was mostly medically straightforward and uncomplicated. These lower-risk patients required routine services; thus, the OIG clinicians found the majority of the patients at CVSP received timely urgent/emergent services that were appropriate to the level of care needed by the patient. Nevertheless, CVSP was occasionally unable to recognize and treat serious emergency medical conditions, such as chest pain. The EMRRC sometimes did not recognize lapses in medical care. However, since most emergency services delivered were appropriate for the generally healthy CVSP population, the OIG clinicians rated the Emergency Services indicator adequate. Chuckawalla Valley State Prison, Cycle 5 Medical Inspection Page 21 Office of the Inspector General State of California HEALTH INFORMATION MANAGEMENT Health information management is a crucial link in the delivery of Case Review Rating: medical care. Medical personnel require accurate information in Proficient order to make sound judgments and decisions. This indicator Compliance Score: examines whether the institution adequately manages its health care Inadequate information. This includes determining whether the information is (71.0%) correctly labeled and organized and available in the electronic Overall Rating: medical record; whether the various medical records (internal and Adequate external, e.g., hospital and specialty reports and progress notes) are obtained and scanned timely into the patient’s electronic medical record; whether records routed to clinicians include legible signatures or stamps; and whether hospital discharge reports include key elements and are timely reviewed by providers. For this indicator, the case review and compliance review processes yielded different results, with the case review giving a proficient rating and the compliance review resulting in an inadequate score. While the case reviews found very few problems, the compliance testing identified problems with mislabeled and misfiled documents as well as problems with hospital discharge report processing. In the reviewed cases, providers properly reviewed and acted upon the hospital discharge reports, even though they sometimes failed to sign them. The OIG’s internal review process considered those factors that led to both scores, and since the identified deficiencies did not appear to affect the quality of care, the OIG ultimately rated this indicator adequate. By the end of the testing period, CVSP had converted from the electronic unit health record (eUHR) to the new electronic health record system (EHRS) in January 2017; therefore, most testing occurred in the EHRS, with a minor portion of the testing done in the eUHR. Case Review Results The OIG clinicians reviewed 600 events and found three deficiencies related to health information management, two of which were significant. Inter-Departmental Transmission CVSP performed capably regarding the inter-departmental transmission of information. With the implementation of EHRS, CVSP no longer had problems with lost documentation. Hospital Records The institution performed well in retrieving hospital and emergency room records. In most cases, the institution retrieved the documentation properly, providers reviewed the information promptly, and the medical records staff scanned the records into the EHRS. Chuckawalla Valley State Prison, Cycle 5 Medical Inspection Page 22 Office of the Inspector General State of California Specialty Services The institution performed satisfactorily in retrieving specialty reports. The institution retrieved the reports timely, providers reviewed the reports appropriately, and the medical records staff scanned them into the medical record. Diagnostic Reports Diagnostic results were readily available in the electronic medical record for review by the medical staff. The OIG clinicians found this to be an improvement compared to Cycle 4. Legibility Legibility of progress notes and signatures was good. CVSP staff typed nearly all institutional documentation, and staff scanned transfer documentation into the electronic medical record in time for scheduled provider appointments. Clinician Onsite Inspection Since the implementation of the EHRS, providers reported an improvement in their ability to access important medical records. CVSP staff scanned documents appropriately, and their availability allowed providers to make well-informed, rapid medical decisions for their patients. In addition, automatic notification for new imaging studies and laboratory reports allowed providers to spend more time with patient care and less time tracking down medical information. Unavailability of pertinent documentation was rare. Case Review Conclusion The institution displayed excellent performance in retrieving the outside hospital and emergency reports, as well as the specialty reports. CVSP staff timely scanned transfer information from other institutions into the electronic medical record. Diagnostic reports were readily available, and legibility was no longer a concern. CVSP performed exceptionally well regarding health information management, and this indicator rating was proficient. Compliance Testing Results The institution scored in the inadequate range for the Health Information Management indicator, with a 71.0 percent, and showed room for improvement in the following tests: • Among 25 sampled patients who were admitted to a community hospital and then returned to the institution, only 10 of them (40 percent) had hospital discharge reports that included all key elements, were received timely by the institution, and were reviewed timely by a provider. Six of the reports did not contain all key required elements; providers failed to review eight reports timely; and one final report lacked key elements and was not timely reviewed (MIT 4.007). Chuckawalla Valley State Prison, Cycle 5 Medical Inspection Page 23 Office of the Inspector General State of California • The institution scored 46 percent in its labeling and filing of documents scanned into patients’ electronic medical records. The errors consisted of mislabeled documents. For this test, if the OIG identifies 24 mislabeled or misfiled documents, all possible points are lost, and the resulting score is zero. For the CVSP medical inspection, inspectors identified a total of 13 mislabeled documents (MIT 4.006). • For 14 of 20 specialty service consultant reports sampled (70 percent), CVSP staff scanned the reports into the patient’s health record file within five calendar days. However, CVSP staff scanned six documents between one and 14 days late (MIT 4.003). The institution scored in the adequate range in the following test: • CVSP’s records management staff timely scanned community hospital discharge reports or treatment records into 16 of the 20 sampled patients’ health records (80 percent). CVSP staff scanned four reports one to seven days late (MIT 4.004). The institution received a proficient score in the following tests: • Inspectors found only one applicable dictated document during the CVSP inspection, and staff timely scanned the document into the patient’s electronic medical record by Health Information Management staff (MIT 4.002). • The institution timely scanned nine of ten sampled non-dictated progress notes, patients’ initial health screening forms, and requests for health care services into the eUHR (90 percent). CVSP staff scanned one initial health screening form one day late (MIT 4.001). Chuckawalla Valley State Prison, Cycle 5 Medical Inspection Page 24 Office of the Inspector General State of California HEALTH CARE ENVIRONMENT This indicator addresses the general operational aspects of the Case Review Rating: institution’s clinics, including certain elements of infection control Not Applicable and sanitation, medical supplies and equipment management, the Compliance Score: availability of both auditory and visual privacy for patient visits, and Inadequate (59.7%) the sufficiency of facility infrastructure to conduct comprehensive medical examinations. The OIG rates this indicator entirely on the Overall Rating: compliance testing results from the visual observations inspectors Inadequate make at the institution during their onsite visit. The case review clinicians do not inspect for this indicator. Compliance Testing Results The institution received an inadequate compliance score of 59.7 percent in the Health Care Environment indicator, showing room for improvement in 6 of 11 test areas, as described below: • The non-clinic bulk medical supply storage areas did not meet the supply management process and support needs of the medical health care program. CVSP stored several medical supplies beyond manufacturers’ guidelines. As a result, the institution received a score of zero on this test (MIT 5.106). • The institution scored zero when inspectors examined emergency response medical bags in six applicable clinics to determine whether clinical staff inspected the bags daily and inventoried them monthly, and whether the bags contained all essential items. None of the clinics had monthly inventory logs for the emergency response bags (MIT 5.111). • The institution had configured only three of eight clinic exam rooms suitably, with appropriate space, supplies, and equipment to allow clinicians to perform proper clinical examinations (38 percent). Five clinics had one or more of the following deficiencies: no portable privacy screen was available in several patient examination areas; confidential records were clearly visible to and easily accessible by porters; examination table configurations restricted patients from fully reclining without their feet being obstructed; clinicians reported sharing examination rooms and computer access with other clinicians; and one examination room chair had a torn vinyl cover (Figure 1) (MIT 5.110). Figure 1: Examination room chair with torn vinyl cover Chuckawalla Valley State Prison, Cycle 5 Medical Inspection Page 25 Office of the Inspector General State of California • Only four of the eight clinics inspected followed appropriate medical supply storage and management protocols (50 percent). In four locations, the following deficiencies were identified: medical supplies were not orderly or clearly identifiable (Figure 2); some supplies were stored directly on the floor; personal items were stored in the same area as medical supplies; and medical supplies were found stored beyond Figure 2: Cabinet contents not manufacturers’ guidelines (MIT 5.107). clearly and easily identifiable • OIG inspectors observed clinician encounters with patients in seven clinics. Clinicians followed good hand hygiene practices in four clinics (57 percent). At three clinic locations, however, clinicians failed to wash their hands before or after patient contact, or before applying gloves (MIT 5.104). • Five of eight clinic locations (63 percent) met compliance requirements for essential core medical equipment and supplies. The remaining three clinics were missing one or more functional pieces of medical equipment necessary to conduct a comprehensive exam. The missing items included an oto-ophthalmoscope, and tips for an otoscope device. In addition, one clinic had an oto-ophthalmoscope that was non-operational at the time of inspection (MIT 5.108). The institution scored in the adequate range in the following test: • Clinic common areas at six of the eight clinics (75 percent) had environments conducive to providing medical services. OIG inspectors identified the following deficiencies at two clinics: clinicians were sharing one examination room for patient encounters, and nursing staff were conducting checks of vital signs in the hallway, in close proximity to the patient waiting area, prohibiting auditory privacy (MIT 5.109). CVSP scored in the proficient range in the following four tests: • All eight clinics were appropriately disinfected, cleaned, and sanitized. More specifically, in all clinics, inspectors observed areas that were clean, with no visible dust or dirt. In addition, cleaning logs were present and completed, attesting to crews regularly cleaning the clinics (MIT 5.101). • Health care staff at all eight clinics followed proper protocols to mitigate exposure to blood-borne pathogens and contaminated waste (MIT 5.105). • Clinical health care staff at seven of eight applicable clinics (88 percent) ensured that reusable invasive and non-invasive medical equipment was properly sterilized or Chuckawalla Valley State Prison, Cycle 5 Medical Inspection Page 26 Office of the Inspector General State of California disinfected. In one clinic, however, staff did not routinely log medical equipment during the sterilization process (MIT 5.102). • Seven of the eight clinic locations inspected (88 percent) had operable sinks and sufficient quantities of hand hygiene supplies in the examination areas. In one clinic, a patient restroom was missing antiseptic soap and disposable hand towels (MIT 5.103). Non-Scored Results The OIG gathered information to determine whether the institution maintained its physical infrastructure in a manner that supported health care management’s ability to provide timely or adequate health care. The OIG does not score this question. • When OIG inspectors interviewed health care managers, they did not identify any significant concerns. At the time of the OIG’s medical inspection, CVSP had several significant infrastructure projects underway, which included increasing clinic space at four yards, and renovation of the central health services building. These projects began in fall 2017, and the institution estimated they would complete the projects by summer 2020 (MIT 5.999). Chuckawalla Valley State Prison, Cycle 5 Medical Inspection Page 27 Office of the Inspector General State of California INTER- AND INTRA-SYSTEM TRANSFERS This indicator focuses on the management of patients’ medical needs Case Review Rating: and continuity of patient care during the inter- and intra-system Inadequate transfer process. The patients reviewed for this indicator include Compliance Score: those received from, as well as those transferring out to, other CDCR Inadequate (72.4%) institutions. The OIG review includes evaluation of the institution’s ability to provide and document health screening assessments, Overall Rating: initiation of relevant referrals based on patient needs, and the Inadequate continuity of medication delivery to patients arriving from another institution. For those patients, the OIG clinicians also review the timely completion of pending health appointments, tests, and requests for specialty services. For patients who transfer out of the institution, the OIG evaluates the ability of the institution to document transfer information that includes pre-existing health conditions, pending appointments, tests and requests for specialty services, medication transfer packages, and medication administration prior to transfer. The OIG clinicians also evaluate the care provided to patients returning to the institution from an outside hospital and check to ensure appropriate implementation of the hospital assessment and treatment plans. Case Review Results The OIG clinicians reviewed 39 inter- and intra-system transfer events, including information from both the sending and receiving institutions. These included 16 hospitalization and outside emergency room events, each of which resulted in a transfer back to the institution. There were 16 deficiencies, 5 of which were significant. Transfers In CVSP performed poorly with patients transferring into the institution. The OIG clinicians reviewed eight patients who transferred into CVSP and identified nine deficiencies, five of which were significant. Most deficiencies involved poor nursing assessment and interventions, and the R&R nurse’s failure to initiate timely provider appointments. • In case 1, the patient arrived at CVSP with high blood pressure and a need for further evaluation. Nevertheless, the R&R RN conducted an initial health screening and initiated a six-month provider appointment. The RN ignored the blood pressure and did not initiate a plan for future blood pressure monitoring. • In case 2, the asthmatic patient arrived at CVSP. The R&R RN noted the patient was past due for a chronic care appointment. Nevertheless, the nurse inappropriately initiated a prolonged, six-month provider appointment. Chuckawalla Valley State Prison, Cycle 5 Medical Inspection Page 28 Office of the Inspector General State of California • In case 4, the diabetic, high-risk patient arrived at CVSP and informed the nurse of a pending urinary test because he had blood clots in his urine. The RN did not obtain any additional information about the patient’s urinary complaints or his pending test. In addition, the nurse did not check the patient’s blood sugar. The nurse did not refer the patient to a provider, but instead referred him to another primary care RN. Fortunately, the next nurse made the appropriate provider referral. • In case 9, the patient transferred to CVSP from another CDCR institution, and had a chronic care appointment due in six days. The R&R RN did not make the provider referral, and the RN did not ensure that the patient’s blood pressure medications were renewed. Fortunately, the patient submitted a medication refill request, and another RN facilitated the refill and made the provider referral. • In case 20, the patient arrived at CVSP with a diagnosis of high blood pressure. The R&R RN did not check the patient’s vital signs, which should have included a blood pressure measurement. • In case 22, the high-risk patient arrived at CVSP. The R&R RN appropriately initiated a 14-day provider referral, but the appointment did not occur for six weeks. Furthermore, the patient’s blood pressure medication expired soon after arrival, and a provider did not renew the medication. This patient went without blood pressure medication for nearly a month. Transfers Out The OIG clinicians reviewed four patients who transferred out of CVSP to other CDCR institutions. CVSP nurses always sent health care transfer information, medications, and health care equipment with the patient to the receiving institution. The CVSP nurses performed satisfactory evaluations before the patients transferred. The OIG identified only two minor deficiencies. Hospitalizations Patients returning from hospitalizations are some of the highest-risk encounters due to two factors. First, these patients are usually admitted to the hospital for a severe illness or injury. Second, they are at risk due to potential lapses in care that can occur during any transfer. CVSP performed acceptably with ensuring continuity of care and that staff addressed medications at the time of hospital discharge. The OIG clinicians reviewed 16 events in which patients returned to CVSP from an offsite hospital or emergency department. There were five minor deficiencies but no patterns of problems. During Cycle 4, the OIG identified a pattern of deficiencies whereby upon patients’ return from the hospital, institution staff automatically resumed their chronic care medications without reviewing updated medication lists from the hospital. In Cycle 5, the OIG did not encounter this problem. Chuckawalla Valley State Prison, Cycle 5 Medical Inspection Page 29 Office of the Inspector General State of California Clinician Onsite Inspection The R&R nurses received notifications of inmate transfers weekly, and properly prepared the health care transfer information packets prior to the inmate’s transfer to another institution. TTA nursing staff appropriately assessed patients who returned from an outside hospital, ED, or offsite specialist appointment, and implemented the patient’s health care needs. Case Review Conclusion CVSP’s R&R performed poorly with patients arriving from other CDCR facilities. The nurses did not always initiate provider appointments, ensure medication continuity, or perform thorough assessments. Although other aspects of the transfer process were sufficient, the institution’s inability to satisfactorily process newly arrived patients resulted in an inadequate rating for the Inter- and Intra-System Transfers indicator. Compliance Testing Results The institution obtained an inadequate score of 72.4 percent in the Inter- and Intra-System Transfers indicator, and showed room for improvement in the following two tests: • The OIG tested 25 patients who transferred into CVSP from other CDCR institutions to determine whether nurses performed complete initial health screening assessments on their day of arrival. CVSP received a score of 36 percent for this test because nursing staff correctly completed the assessment for only nine of the sampled patients. For 14 patients, nurses did not obtain a full set of vital signs. For two other patients, nurses neglected to answer one or more screening form questions (MIT 6.001). • The OIG tested ten patients who transferred out of CVSP during the onsite inspection to determine whether their transfer packages included required medications and related documentation; CVSP scored 50 percent on this test. Five packages were compliant, but for the remainder, OIG inspectors identified the following deficiencies: transfer packages were missing medications and medication reconciliation documentation; the transfer nurse did not document missing medications on the Health Care Transfer Information form (CDCR Form 7371); and a patient who had a keep-on-person (KOP) rescue medication prescription did not have it with him at the time of transfer (MIT 6.101). CVSP scored in the adequate range in the following test: • OIG inspectors sampled 20 patients who transferred out of CVSP to other CDCR institutions to determine whether CVSP identified scheduled specialty service appointments on the patients’ health care transfer forms. Nursing staff correctly listed the pending specialty service appointments for 16 of 20 patients (80 percent). For the remaining four patients, staff failed to list their pending specialty services (MIT 6.004). Chuckawalla Valley State Prison, Cycle 5 Medical Inspection Page 30 Office of the Inspector General State of California The institution received a proficient score in the following tests: • OIG inspectors examined health records for 25 patients who transferred into CVSP; five of these patients had medications requiring administration or delivery at the next dosing interval after arrival. All five sampled patients received their ordered medications timely (MIT 6.003). • The OIG reviewed the Initial Health Screening forms (CDCR Form 7277) for 25 patients who transferred into CVSP from another CDCR institution to determine whether nursing staff completed the assessment and disposition sections of the form on the same day staff completed an initial screening of the patient. Nursing staff properly completed the documents for 24 of the 25 patients sampled (96 percent). For one patient, however, nursing staff failed to refer a patient with unexplained signs or symptoms of tuberculosis (TB) to the TTA for further assessment (MIT 6.002). Chuckawalla Valley State Prison, Cycle 5 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 Case Review Rating: appropriate pharmaceutical administration and security management, Adequate encompassing the process from the written prescription to the Compliance Score: administration of the medication. By combining both a quantitative Inadequate (70.4%) compliance test with case review analysis, this assessment identifies issues in various stages of the medication management process, Overall Rating: including ordering and prescribing, transcribing and verifying, Adequate dispensing and delivering, administering, and documenting and reporting. Because numerous entities across various departments affect medication management, this assessment considers internal review and approval processes, pharmacy, nursing, health information systems, custody processes, and actions taken by the prescriber, staff, and patient. For this indicator, the case review and compliance review processes yielded different results, with the case review giving an adequate rating and the compliance review resulting in an inadequate score. While the case reviews found problems only with medication continuity, the majority of the compliance testing identified concerns related to medication storage and administrative processes. The OIG’s internal review process considered those factors that led to both scores, and determined that the storage and administrative process problems did not significantly detract from patient care. The OIG ultimately rated this indicator adequate. Case Review Results The OIG clinicians reviewed 21 events related to medications and found eight deficiencies, three of which were significant. Medication Continuity Medication continuity was satisfactory. Of the 21 medication events reviewed, three significant lapses in medication continuity occurred, as follows: • In case 6, on two separate occasions, the patient requested nitroglycerin refills (medication for cardiac chest pains) and a rescue inhaler (used for asthma). These essential medications were not refilled for more than one month. Failure to promptly dispense these critical medications could have resulted in worsening disease, unnecessary hospitalization, or even death. • In case 22, the patient was on a blood pressure medication. This chronic care medication expired, and the institution did not renew it for 26 days. The Inter- and Intra-System Transfers indicator also addresses this case. Chuckawalla Valley State Prison, Cycle 5 Medical Inspection Page 32 Office of the Inspector General State of California Medication Administration CVSP nurses administered medications timely and accurately. The OIG found no pattern of deficiencies in this area. Clinician Onsite Inspection During morning huddles, primary care teams discussed medication issues. Medication nurses reported any concerns, such as expiring medications or patients refusing their medications. Although the OIG discovered three occasions where expired medications were not renewed timely, the CVSP nurses reported that they informed providers when medications were about to expire and the medication renewals were processed timely. The OIG clinicians interviewed CVSP’s pharmacist in charge (PIC). The PIC reported an improved medication delivery process since the implementation of the EHRS. He stated the institution had experienced fewer medication errors during this cycle, which he attributed to improved medication tracking and accountability. Case Review Conclusion CVSP performed satisfactorily regarding pharmacy and medication management, and the OIG case review clinicians rated this indicator adequate. Compliance Testing Results The institution received an adequate compliance score of 70.4 percent in the Pharmacy and Medication Management indicator. For discussion purposes below, this indicator is divided into three sub-indicators: medication administration, observed medication practices and storage controls, and pharmacy protocols. Medication Administration In this sub-indicator, the institution received an average score of 80.7 percent, scoring in the proficient range in the following test: • CVSP provided ordered medications without interruption to all 16 sampled patients who had transferred from one housing unit to another (MIT 7.005). The institution scored in the adequate range in the following tests: • Staff timely provided ordered chronic care medications for 16 of 19 applicable sampled patients (84 percent). One patient did not receive the required counseling for refusing his medication; another patient did not receive required critical medication replenishments; and one final patient received multiple supplies of his medication within a replenishment time frame that was shorter than normal (MIT 7.001). Chuckawalla Valley State Prison, Cycle 5 Medical Inspection Page 33 Office of the Inspector General State of California • Inspectors sampled six patients in transit to other institutions who were temporarily laid over at CVSP. The institution provided five patients their medication without interruption (83 percent). For one patient, however, staff did not show evidence that they provided all of his ordered medications on the day after he arrived at the facility (MIT 7.006). CVSP scored in the inadequate range in the following two tests: • Clinical staff timely provided new and previously prescribed medications to 16 of 25 sampled patients who were discharged from a community hospital and then returned to the institution (64 percent). Nine patients received their ordered medications one to two days late (MIT 7.003). • CVSP timely administered or delivered new medication orders to 18 of 25 sampled patients (72 percent). Two patients received their medications one day late; one patient missed two doses of a medication; one patient received an extra, unordered dose of a medication; and for two patients, OIG inspectors found no evidence that they had received one of their medications. One final patient received one medication three days late and never received another medication at all (MIT 7.002). Observed Medication Practices and Storage Controls In this sub-indicator, the institution received a score of 70.3 percent, scoring in the inadequate range in the following tests: • The OIG inspectors observed the medication preparation and administration processes at eight applicable medication line locations. Nursing staff were compliant regarding proper hand hygiene and contamination control protocols at three locations (50 percent). At three other locations, not all nursing staff washed or sanitized their hands when required, such as before putting on gloves or before each subsequent re-gloving (MIT 7.104). • CVSP properly stored non-narcotic medications not requiring refrigeration in five of the eight applicable clinic and medication line storage locations (63 percent). In three locations, OIG inspectors observed one or more of the following deficiencies: the medication area lacked a designated area for return-to-pharmacy medications; staff did not properly separate external and internal medications when stored; medication rooms and cabinets were unlocked; multi-use medication was not labeled with the date it was opened; and medications were stored in the same area with disinfectant agents (MIT 7.102). • Staff at four of the six inspected medication preparation and administration areas demonstrated appropriate administrative controls and protocols (67 percent). At two different locations, the institution failed to provide sufficient outdoor cover for patients waiting to receive their medications to protect them from heat or inclement weather (MIT 7.106). Chuckawalla Valley State Prison, Cycle 5 Medical Inspection Page 34 Office of the Inspector General State of California • The institution employed appropriate security controls over narcotic medications in five of the seven applicable clinic and medication line locations in which narcotics were stored (71 percent). At one clinic, the narcotics logbook showed no evidence, for multiple dates, that two licensed nursing staff had performed a controlled substance inventory. In another clinic, the transport procedure for narcotics was insecure. In addition, the OIG inspector found the narcotics lockbox in an unlocked state when staff used it to transport narcotics to a clinical area (MIT 7.101). • The institution properly stored non-narcotic refrigerated medications at five of the seven clinics and medication line storage locations (71 percent). At one location, exceptions consisted of refrigerator temperatures not kept within the acceptable range. At another location, the medication refrigerator was unlocked when not in use (MIT 7.103). The institution received a proficient score in the following test: • Nursing staff at all six inspected medication line locations employed appropriate administrative controls and followed appropriate protocols during medication preparation (MIT 7.105). Pharmacy Protocols In this sub-indicator, the institution received an average score of 60.0 percent, composed of scores received at the institution’s main pharmacy, with opportunities for improvement in the following areas: • The main pharmacy did not properly store refrigerated or frozen medications. The refrigerator log was missing several entries to indicate that staff had inspected the temperature of the medication refrigerator during the month of July 2017 (MIT 7.109). • The institution’s PIC properly accounted for narcotic medications stored in CVSP’s main and satellite pharmacies. OIG inspectors also reviewed monthly inventories of controlled substances in the institution’s clinical and medication line storage locations. However, OIG inspectors found several Medication Area Inspection Checklist forms (CDCR Form 7477) were missing the name, signature, and date of staff responsible for completing each inventory record. As a result, the institution scored zero on this test (MIT 7.110). In the following three tests, the institution received proficient scores: • In its main pharmacy, the institution followed general security, organization, and cleanliness management protocols (7.107). • In CVSP’s main pharmacy, the institution properly stored non-refrigerated medication (7.108). Chuckawalla Valley State Prison, Cycle 5 Medical Inspection Page 35 Office of the Inspector General State of California • CVSP’s PIC timely processed all 25 sampled medication error reports (MIT 7.111). Non-Scored Tests • In addition to the OIG’s testing of reported medication errors, OIG inspectors follow up on any significant medication errors found during the compliance testing to determine whether staff properly identified and reported the errors. The OIG provides those results for information purposes only. At CVSP, the OIG did not find any applicable medication errors (MIT 7.998). • The OIG interviewed patients in isolation units to determine whether they had immediate access to their prescribed KOP rescue medications. All ten sampled patients had access to their rescue medications (MIT 7.999). Chuckawalla Valley State Prison, Cycle 5 Medical Inspection Page 36 Office of the Inspector General State of California PRENATAL AND POST-DELIVERY SERVICES This indicator evaluates the institution’s capacity to provide timely Case Review Rating: and appropriate prenatal, delivery, and postnatal services to pregnant Not Applicable patients. This includes the ordering and monitoring of indicated Compliance Score: screening tests, follow-up visits, referrals to higher levels of care, Not Applicable e.g., high-risk obstetrics clinic, when necessary, and postnatal Overall Rating: follow-up. Not Applicable As CVSP does not have female patients, this indicator did not apply. Chuckawalla Valley State Prison, Cycle 5 Medical Inspection Page 37 Office of the Inspector General State of California PREVENTIVE SERVICES This indicator assesses whether the institution offered or provided Case Review Rating: various preventive medical services to patients. These include Not Applicable cancer screenings, tuberculosis screenings, and influenza and Compliance Score: chronic care immunizations. This indicator also assesses whether Adequate certain institutions take preventive actions to relocate patients (80.8%) identified as being at higher risk for contracting Overall Rating: coccidioidomycosis (valley fever). Adequate The OIG rates this indicator entirely through the compliance testing component; the case review process does not include a separate qualitative analysis for this indicator. Compliance Testing Results The institution performed in the adequate range in the Preventive Services indicator, with a compliance score of 80.8 percent. Three tests received scores in the proficient range: • All 25 sampled patients timely received or the institution timely offered influenza vaccinations during the most recent influenza season (MIT 9.004). • OIG inspectors found 24 of 25 patients sampled (96 percent) had either received results of a normal colonoscopy within the past ten years or the institution offered a colorectal cancer screening in the past year. For one patient, however, his medical record showed no evidence he had received results of a normal colonoscopy within the past ten years or that the institution offered a colorectal cancer screening within the past 12-month period (MIT 9.005). • CVSP scored 86 percent for the timely administration of TB medications to its patients. Of 14 sampled patients, 12 of them received their medication timely, while 2 patients missed one required medication dosage (MIT 9.001). The institution received an adequate score in the following test: • OIG inspectors tested whether CVSP offered required influenza, pneumonia, and hepatitis vaccinations to patients who suffered from a chronic condition; 15 of the 18 applicable sampled patients (83 percent) received all recommended vaccinations at required intervals. For three patients, OIG inspectors found no evidence that the patients had been offered, or evidence of the patient receiving one or more of the required vaccinations (MIT 9.008). Chuckawalla Valley State Prison, Cycle 5 Medical Inspection Page 38 Office of the Inspector General State of California CVSP scored in the inadequate range in the following tests: • The institution scored poorly in monitoring patients on TB medications. CVSP staff did not properly monitor seven of 14 sampled patients (50 percent). For three patients, staff failed to timely scan monitoring forms into the patient’s medical record; for two other patients, monthly monitoring did not occur at required intervals; and for two final patients, the OIG found no evidence of required weekly monitoring (MIT 9.002). • CVSP scored 70 percent for the required annual TB screening of patients. Of the 30 sampled patients, staff properly screened 21 of them. For six patients, the patient’s TB screening did not occur in the patient’s birth month as required per policy; and for the final three patients, OIG inspectors found no evidence of TB screening in the electronic medical record (MIT 9.003). Chuckawalla Valley State Prison, Cycle 5 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 evaluation of the institution’s nursing services. The evaluation is Case Review Rating: Adequate completed entirely by OIG nursing clinicians within the case review Compliance Score: process and does not have a score under the OIG compliance testing Not Applicable component. Case reviews include face-to-face encounters and indirect activities performed by nursing staff on behalf of the Overall Rating: Adequate patient. Review of nursing performance includes all nursing services performed onsite, such as outpatient, inpatient, urgent/emergent, patient transfers, care coordination, and medication management. The key focus areas for evaluation of nursing care include appropriateness and timeliness of patient triage and assessment, identification and prioritization of health care needs, use of the nursing process to implement interventions, and accurate, thorough, and legible documentation. Although the OIG reports nursing services provided in specialized medical housing units in the Specialized Medical Housing indicator, and those provided in the TTA or related to emergency medical responses in the Emergency Services indicator, this Quality of Nursing Performance indicator summarizes all areas of nursing services. Case Review Results The OIG nursing clinicians reviewed 156 nursing events, 96 of which were in the outpatient setting. Most outpatient nursing encounters were for sick call requests, walk-in visits, LVN care coordination appointments, or RN follow-up visits. In all, there were 54 deficiencies identified related to nursing care performance, 10 of which were significant. Nursing Assessment, Interventions, and Documentation Complete and accurate nursing assessment, timely intervention, and documentation are essential components of patient care. In general, at CVSP, outpatient nurses provided timely assessment. However, when a patient had critical symptoms such as chest pain, the nurses did not always provide a thorough assessment of symptoms and appropriate interventions. Additionally, documentation of the timeline of assessments and interventions was inconsistent and, at times, missing. Fortunately, CVSP staff did not frequently encounter patients with potentially urgent or emergent medical concerns, and most assessment and intervention deficiencies were minor. Urgent/Emergent The OIG clinicians reviewed 20 urgent/emergent events. Most deficiencies were minor and unlikely to cause harm. However, three significant deficiencies occurred regarding nursing assessment, intervention, and documentation; the Emergency Services indicator addresses these. Chuckawalla Valley State Prison, Cycle 5 Medical Inspection Page 40 Office of the Inspector General State of California Post-Hospital Returns The OIG clinicians reviewed 12 nursing encounters for patients returning from a community hospital, in which they identified three minor deficiencies. These deficiencies were for incomplete, inaccurate nursing documentation, and appointment follow-up errors. Otherwise, CVSP nursing performed well in assessing patients returning from a hospital. Inter-and Intra-System Transfers The OIG clinicians reviewed documentation from 15 patients arriving via inter-system transfers and eight who were departing. OIG clinicians identified eight nursing deficiencies, of which six were related to arrivals and two, to departures. The OIG identified three significant nursing deficiencies for patients arriving at CVSP. The Inter-and Intra-System Transfers indicator offers descriptions of care review findings. Offsite Specialty Returns The OIG clinicians reviewed 20 nursing encounters for patients returning from their offsite specialty appointments, who were assessed by a TTA nurse upon return to CVSP. The nurses reviewed specialists’ follow-up recommendations and appropriately contacted providers. The Specialty Services indicator addresses the one significant deficiency the OIG identified in this area. Outpatient Nursing Services Sick Call The OIG clinicians reviewed 41 nursing sick call encounters. Nursing performance for sick call was good. Nurses reviewed sick call requests timely, evaluating patients the same day or the next business day. Nurses generally performed accurate assessments, and made appropriate interventions and dispositions. Care Management At CVSP, an LVN served as the clinic care coordinator. The LVNs’ primary role was providing chronic care education to patients, but had no detailed nursing care guidelines or nursing expectations for their position. The OIG clinicians found that CVSP care management was good, but there were areas for improvement. The LVN care coordinator position at CVSP was limited in function because space for providing face-to-face education was minimal, which negatively affected the nurses’ ability to schedule visits in the medical clinics. The LVNs conducted patient education in the medication room, dental areas, mental health offices, or other temporarily vacant locations in the medical clinics. Although the CVSP nursing leadership team was searching for a space solution, nursing managers for the LVN care coordinators should develop guidelines, implement ongoing training, and establish job performance monitoring strategies for these nurses. Chuckawalla Valley State Prison, Cycle 5 Medical Inspection Page 41 Office of the Inspector General State of California Clinician Onsite Inspection The OIG clinicians attended a morning huddle in two medical clinics. The clinic RN facilitated the huddle, attended by a dental assistant, a mental health representative, the LVNs, the primary provider, and a scheduler. The staff participated in the discussion and provided information as outlined in the huddle script. Each of the institution’s four medical clinics had a primary care provider, a primary care RN, an LVN clinic coordinator, and a medication LVN. The OIG clinicians also visited several clinical areas and interviewed the acting chief nurse executive (CNE), supervising RNs, and various nursing staff in specialty services, the TTA, and outpatient medical clinics. The nursing staff identified no communication barriers with providers or custody officers regarding patient care. The acting CNE was working in an out-of-class assignment. However, she had worked at CVSP as a supervising RN (SRN) for several years. The nursing leadership team was well prepared and readily discussed the OIG case review findings. During the onsite staff interviews, the OIG clinicians learned that TTA staff felt their ability to provide quality medical care was good and believed the current health care leadership supported their efforts to provide quality urgent/emergent care. The SRNs planned to implement skills and competency training soon and to develop a similar training for the R&R nursing area. Case Review Conclusion Outpatient nurses demonstrated timely and appropriate nurse triage. The OIG noted opportunities for improvement in emergent services and the inter-intra system transfer process. However, most significant deficiencies in these areas were isolated and did not represent the overall nursing care offered at the institution. The Quality of Nursing Performance indicator rating was adequate. Chuckawalla Valley State Prison, Cycle 5 Medical Inspection Page 42 Office of the Inspector General State of California QUALITY OF PROVIDER PERFORMANCE In this indicator, the OIG physicians provide a qualitative evaluation of the adequacy of provider care at the institution. The case review Case Review Rating: clinicians review the provider care regarding appropriate evaluation, Adequate diagnosis, and management plans for programs including, but not Compliance Score: Not Applicable limited to, nursing sick call, chronic care programs, TTA, specialized medical housing, and specialty services. OIG physicians Overall Rating: alone assess provider care. There is no compliance testing Adequate component associated with this quality indicator. Case Review Results The OIG clinicians reviewed 154 medical provider encounters and identified 65 deficiencies related to provider performance, 29 of which were significant. Assessment and Decision-Making CVSP providers often made excellent medical decisions. The providers communicated well with the other medical staff. They were familiar with their patients and could provide medical care tailored to patient needs. The providers frequently monitored their high-risk patients for health changes. Medical assessments and decisions had become simplified and routine, as the medical providers knew and understood their patients’ medical concerns. Although five significant deficiencies occurred during the assessment and decision-making process, such occurrences were rare. The following are two examples: • In case 10, the patient had recurrent episodes of chest pain. The cardiologist recommended a cardiac catheterization procedure to evaluate the coronary arteries. One provider waited nine days to order the test, but then inexplicably cancelled it three days later. Additionally, the supervising physician also inappropriately denied the procedure. Two months later, the patient required outside emergency room services due to continued chest pain. After he returned, another provider re-ordered the procedure, which was finally completed three months after the cardiologist’s recommendation. This delay could have resulted in a significant cardiac event, such as a heart attack. Fortunately, the test showed no disease. • In case 41, the patient was having difficulty swallowing and had lost a significant amount of weight. An imaging test showed a possible mass; the radiologist recommended further testing with a computerized tomography (CT) scan of the neck, and a consultation with an ear, nose, and throat specialist (ENT). The provider delayed diagnoses and treatment of possible cancer by not promptly ordering the neck CT and inappropriately ordering a “routine” ENT consultation. Fortunately, the CT scan showed no mass. Chuckawalla Valley State Prison, Cycle 5 Medical Inspection Page 43 Office of the Inspector General State of California Review of Records CVSP providers occasionally failed to sufficiently review emergency room and specialty reports. Providers sometimes inexplicably neglected to follow through with outside specialists’ recommendations. While such deficiencies were uncommon occurrences, they offer opportunities for practice improvement. Of the 29 significant deficiencies in this indicator, 9 occurred in this area, as illustrated in the following four examples: • In case 3, the patient, who had experienced two prior heart attacks, and the institution transferred him to the emergency room for chest pain. The emergency room physician recommended a cardiac stress test and a cardiology consultation, but the CVSP provider did not order them. The provider also did not review the laboratory results, which showed high blood-sugar levels that should have raised concern for the onset of diabetes. • In case 5, the patient had cancer. The oncologist needed a biopsy to identify the patient’s type of metastatic cancer and to formulate the most appropriate treatment plan. On four occasions, the CVSP provider overlooked the oncologist’s urgent recommendations to perform the biopsy. This error contributed 16 days to the nearly 2-month delay in obtaining the vital test. • In case 17, the provider evaluated a high-risk cardiac patient after the patient had been evaluated in an emergency room for chest pain. The CVSP provider ignored the emergency room physician’s recommendations for a cardiology consultation. • In case 30, the patient had melanoma (aggressive skin cancer) and a right chest mass. The surgeon recommended an ultrasound, a mammogram, and a chest mass excision to check for a melanoma recurrence. By the end of the review period, the CVSP provider ordered the mammogram and ultrasound, but did not order the excision. The provider also inappropriately ordered a six-month follow-up appointment. Emergency Care Providers made appropriate triage decisions when patients arrived emergently to the TTA. Emergency provider care was satisfactory. The Emergency Services indicator summary provides additional details about this area. Chronic Care CVSP providers’ chronic care performance was sufficient. Providers regularly monitored, assessed, and treated properly patients’ chronic medical conditions. Half the chronic care deficiencies occurred in case 14; the OIG discussed these with medical leadership during the onsite inspection. The other chronic care deficiencies did not reveal any discernible pattern of deficiencies. Details of case 14 follow: Chuckawalla Valley State Prison, Cycle 5 Medical Inspection Page 44 Office of the Inspector General State of California • In case 14, providers infrequently saw the patient, who had poorly controlled diabetes. Despite abnormal laboratory tests, providers did not make timely appointments, and provider follow-ups were inappropriately prolonged. These deficiencies led to long periods of poor blood sugar control for the patient without the appropriate management and treatment. Specialty Services CVSP providers usually requested specialty consultations appropriately. Although providers correctly ordered the specialty referrals, the quality of the follow-up was sometimes lacking, as outlined in the following example: • In case 4, the urologist recommended an electrocardiogram, a chest X-ray, and pertinent laboratory tests before a surgical intervention. The provider, however, did not address these recommendations. Health Information Management CVSP providers were successful in documenting their findings and the thought processes supporting their treatment plans. Provider legibility was good since all provider notes were either typed or dictated into the electronic medical record. Clinician Onsite Inspection The OIG clinicians found that CVSP providers were content with their work, leadership, and ancillary services. CVSP employed several physician assistants, a telemedicine provider, and two onsite physicians. The chief physician and surgeon reviewed medical care weekly. In one clinic, the telemedicine provider was highly esteemed by the clinic’s medical staff. Daily morning huddles served institutional staff exceptionally well with medical information from the preceding night communicated at those meetings. The staff also discussed same-day scheduled patients, high-risk patients, and other important medical information. The medical huddle was fluid and efficient. The OIG clinicians discussed the deficiencies identified in the case reviews. CVSP providers and leaders fostered an open forum for this discussion and viewed the conversation as an improvement opportunity for staff. The medical leadership agreed that the institution’s providers needed to improve their record review process and planned to allocate extra time to allow providers to review the medical records thoroughly. CVSP also agreed that providers needed to address specialty recommendations by either implementing them or explaining why they would not do so. The institution’s medical leaders also explained that in case 14, medical staffing levels had been poor and that their providers had been able to address only emergent conditions until CVSP had hired additional providers. By the time of the OIG’s onsite inspection, CVSP employed a nearly full Chuckawalla Valley State Prison, Cycle 5 Medical Inspection Page 45 Office of the Inspector General State of California complement of medical providers. The institution’s medical leaders reported that they felt medical care would continue to improve with the majority of their staffing shortage issues resolved. Case Review Conclusion In general, the care provided by CVSP medical providers was appropriate. The OIG clinicians found some evidence of poor assessments and improper records’ review, but those instances were infrequent. After considering all factors, the OIG rated the Quality of Provider Care indicator adequate. Chuckawalla Valley State Prison, Cycle 5 Medical Inspection Page 46 Office of the Inspector General State of California RECEPTION CENTER ARRIVALS This indicator focuses on the management of medical needs and Case Review Rating: continuity of care for patients arriving from outside the CDCR Not Applicable system. The OIG review includes evaluation of the ability of the Compliance Score: institution to provide and document initial health screenings, initial Not Applicable health assessments, continuity of medications, and completion of Overall Rating: required screening tests; address and provide significant Not Applicable accommodations for disabilities and health care appliance needs; and identify health care conditions needing treatment and monitoring. The patients reviewed for reception center cases are those received from non-CDCR facilities, such as county jails. CVSP does not have a reception center; therefore, this indicator did not apply. Chuckawalla Valley State Prison, Cycle 5 Medical Inspection Page 47 Office of the Inspector General State of California SPECIALIZED MEDICAL HOUSING This indicator addresses whether the institution follows appropriate policies and procedures when admitting patients to onsite inpatient Case Review Rating: Not Applicable facilities, including completion of timely nursing and provider Compliance Score: assessments. The chart review assesses all aspects of medical care Not Applicable related to these housing units, including quality of provider and nursing care. Overall Rating: Not Applicable Because CVSP has neither a correctional treatment center (CTC) nor an outpatient housing unit (OHU), this indicator did not apply. Chuckawalla Valley State Prison, Cycle 5 Medical Inspection Page 48 Office of the Inspector General State of California SPECIALTY SERVICES This indicator focuses on specialist care from the time a physician Case Review Rating: completes a request for services or physician’s order for specialist Adequate care to the time of receipt of related recommendations from Compliance Score: specialists. This indicator also evaluates the providers’ timely Inadequate review of specialist records and documentation reflecting the (74.9%) patients’ care plans, including the course of care when specialist Overall Rating: recommendations were not ordered, and whether the results of Adequate specialists’ reports are communicated 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 patient on the plan of care. For this indicator, the case review and compliance review processes yielded different results, with the case review giving an adequate rating and the compliance review resulting in an inadequate score. Compliance testing showed that provider review of routine specialty service reports and scheduling of follow-up appointments for specialty service denials were not timely. However, case review indicated that these delays did not affect the quality of care, and that even if providers did not always properly document evidence of their review, they typically took appropriate action for patients who received a specialty service appointment or request. The OIG’s internal review process considered those factors that led to both scores, and as the identified deficiencies did not cause significant quality concerns during the case review process, the OIG ultimately rated this indicator adequate. Case Review Results The OIG clinicians reviewed 98 events related to Specialty Services, the majority of which were specialty consultations and procedures. Thirteen deficiencies occurred in this category, six of which were significant. Access to Specialty Services Access to specialty services was satisfactory. The specialty department scheduled necessary consultations promptly. Telemedicine specialists made up more than 75 percent of the specialty referrals. This manner of providing specialty services met the needs of CVSP’s patient population. While significant specialty access deficiencies were infrequent, the OIG did identify some, as follows: • In case 4, the patient had bladder cancer. The surgeon recommended additional chemotherapy and the provider ordered an oncology consultation urgently. However, the oncology consultation was delayed by two weeks. Chuckawalla Valley State Prison, Cycle 5 Medical Inspection Page 49 Office of the Inspector General State of California • In case 8, the patient was admitted to the hospital for worsening abdominal pain with ulcerative colitis (autoimmune disease that causes inflammation of the large intestine). After discharge from the hospital, the patient was supposed to receive a follow-up with the gastroenterologist in two weeks. However, this appointment was delayed an additional two weeks. • In case 10, the cardiologist recommended a heart catheterization procedure. The providers inappropriately delayed the procedure on several occasions. Even after the providers finally ordered the correct procedure, there was an additional two-week delay. Nursing Performance Nursing performed well supporting specialty services. The OIG reviewed 20 events related to specialty nursing care and identified only one significant deficiency: • In case 24, the patient with cardiovascular disease, diabetes, and high blood pressure was taking a blood pressure medication that also lowers the heart rate. The patient returned to CVSP after receiving a coronary stent placement. Despite his tachycardia (fast heart rate) and complaints of acute knee pain, the nurse did not re-assess the patient’s pulse or examine his knee for possible swelling and circulation problems, which could have indicated complications resulting from his recent surgery. Provider Performance CVSP providers performed well with specialty services. Their referrals to a specialist were appropriate. However, on several occasions, providers superficially reviewed the specialty consultations and did not sufficiently address the specialty recommendations. The Quality of Provider Performance indicator discusses this situation in detail. Health Information Management At CVSP, providers correctly retrieved, scanned, and reviewed specialty reports. Only one significant deficiency was identified: • In case 22, the patient promptly underwent Holter monitor testing (recording the heart’s electrical activity for extended periods of time). However, CVSP did not scan the results into the electronic medical record for six weeks. Clinician Onsite Inspection During the OIG inspection, CVSP’s telemedicine specialty services provided more than 75 percent of specialty consultations. The institution’s leaders reported that this shift to telemedicine lowered transportation costs but provided a similar quality of care as that of offsite specialists. Because CVSP is an institution located in a remote locale, this shift from offsite specialty care was important to the institution’s ability to provide timely quality care. Telemedicine appointments frequently Chuckawalla Valley State Prison, Cycle 5 Medical Inspection Page 50 Office of the Inspector General State of California occurred within the appropriate time frame. All CVSP providers were satisfied with the specialty department and its responsiveness to their needs. Even so, the specialty staff admitted that, occasionally, the transition to the EHRS delayed some telemedicine appointments. By design, the EHRS routed provider orders for telemedicine follow-ups to CCHCS’ telemedicine services operation in Sacramento, instead of directly to CVSP. When this occurred, the CVSP telemedicine nurse was unaware of the order for a follow-up appointment; at times, follow-ups were missed. By the time of the onsite inspection, the institution had created an effective workaround process for this rerouting of these requests. Case Review Conclusion Specialty services functioned well within the institution, with most consultations ordered and processed timely. In general, consultants performed appropriately when evaluating patients, and providers reviewed recommendations thoroughly, ordering appropriate specialist consultations and follow-up care as necessary. The OIG rated the Specialty Services indicator adequate. Compliance Testing Results The institution received an inadequate compliance score of 74.9 percent in the Specialty Services indicator, with improvement needed in the following areas: • When patients are approved or scheduled for specialty services at one institution and then transfer to another, CCHCS policy requires that the receiving institution reschedule and provide the patient’s appointment within the required time frame. Only 12 of the 20 sampled patients (60 percent) who transferred to CVSP with approved specialty services received their appointments within the required time frame. The institution held five patients’ appointments from 3 to 51 days late and one patient’s more than four months late. For two other patients, there was no evidence they ever received their appointments (MIT 14.005). • Providers timely received and reviewed 9 of the 14 applicable routine specialists’ reports that inspectors sampled (64 percent). For three patients, providers reviewed the reports two, six, and eight days late; for two other patients, providers never reviewed the specialists’ reports (MIT 14.004). • For 19 applicable sampled patients who had a specialty service request denied by CVSP’s health care management, 13 patients (68 percent) received a timely notification of the denied service, including a provider appointment with the patient within 30 days to discuss alternate treatment strategies. For four patients, the providers’ follow-up visits occurred from 3 to 32 days late. For two other patients, no evidence showed that a provider appointment ever occurred to discuss the denial (MIT 14.007). Chuckawalla Valley State Prison, Cycle 5 Medical Inspection Page 51 Office of the Inspector General State of California • Of the 15 sampled patients, 11 of them (73 percent) received or refused their high-priority specialty services appointment or service within 14 calendar days of the provider’s order. Four patients received their specialty service from 3 to 13 days late (MIT 14.001). CVSP scored in the adequate range in the following two tests: • The institution’s administration timely denied providers’ specialty services requests for 17 of 20 sampled patients (85 percent). Three specialty services requests were denied from one to 30 days late (MIT 14.006). • Providers timely received and reviewed specialists’ reports for 12 of the 15 sampled patients (80 percent). CVSP received one patient’s specialist report five days late; there was no provider review for one other patient’s report; and for the final patient, there was no report in the electronic medical record (MIT 14.002). The institution received a proficient score in the following test: • CVSP provided routine specialty service appointments to 14 of 15 patients tested within the required time frame (93 percent). One patient received his specialty service one day late (MIT 14.003). Chuckawalla Valley State Prison, Cycle 5 Medical Inspection Page 52 Office of the Inspector General State of California ADMINISTRATIVE OPERATIONS (SECONDARY) This indicator focuses on the institution’s administrative health care Case Review Rating: oversight functions. The OIG evaluates whether the institution Not Applicable promptly processes patient medical appeals and addresses all Compliance Score: appealed issues. Inspectors also verify that the institution follows Proficient reporting requirements for adverse/sentinel events and patient (90.0%) deaths. The OIG verifies that the Emergency Medical Response Overall Rating: Review Committee (EMRRC) performs required reviews and that Proficient 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. In addition, the OIG examines whether the institution adequately manages its health care staffing resources by evaluating whether job performance reviews are completed as required; specified staff possess current, valid credentials and professional licenses or certifications; nursing staff receive new employee orientation training and annual competency testing; and clinical and custody staff have current emergency medical response certifications. The Administrative Operations indicator is a secondary indicator; therefore, it was not relied on for the institution’s overall score. Compliance Testing Results The institution performed in the proficient range in the Administrative Operations indicator, receiving a compliance score of 90.0 percent. The following 12 tests earned scores of 100 percent: • The institution promptly processed all patient medical appeals in each of the most recent 12 months (MIT 15.001). • CVSP took appropriate steps to ensure the accuracy of its Dashboard data reporting (MIT 15.004). • The OIG inspected incident package documentation for five emergency medical responses reviewed by CVSP’s EMRRC during the prior six-month period; all sampled packages complied with policy (MIT 15.005). • Based on a sample of ten second-level medical appeals, the institution’s responses addressed all of the patients’ appealed issues (MIT 15.102). • Medical staff promptly submitted the initial Inmate Death Report (CDCR Form 7229A) to CCHCS’ Death Review Unit for one applicable death that occurred at CVSP in the prior 12-month period (MIT 15.103). Chuckawalla Valley State Prison, Cycle 5 Medical Inspection Page 53 Office of the Inspector General State of California • All ten sampled nurses were current with their clinical competency validations (MIT 15.105). • The OIG reviewed performance evaluation packets for CVSP’s four providers, and CVSP met all performance review requirements for them (MIT 15.106). • All providers at the institution were current with their professional licenses. Similarly, all nursing staff and the PIC were current with their professional licenses and certification requirements (MIT 15.107, 15.109). • All active duty providers and nurses were current with their emergency response certifications (MIT 15.108). • All pharmacy staff and providers who prescribed controlled substances had current Drug Enforcement Agency registrations (MIT 15.110). • All nursing staff hired within the last year had received new employee orientation training in a timely manner (MIT 15.111). One test received an adequate score: • OIG inspectors reviewed Quality Management Committee (QMC) meeting minutes covering the most recent six months. While five months’ minutes (83 percent) demonstrated QMC evaluation of the institutional scorecard performance data and an identification of improvement opportunities, one month’s minutes did not (MIT 15.003). The institution received inadequate scores in the following tests: • The OIG inspected records from June 2017 for five nurses to determine whether their nursing supervisors properly completed monthly performance reviews. Inspectors identified the following deficiencies for the five nurses’ monthly nursing reviews (MIT 15.104): o The supervisor did not complete the required number of reviews for four nurses; o The supervisor’s review did not summarize aspects that were well done or that needed improvement for three nurses; o The documentation did not confirm that the supervising nurse discussed the findings with all five nurses. • OIG inspectors reviewed drill packages for three emergency medical response drills conducted during the prior quarter. Only two of the three drill packages were properly completed (67 percent). One drill package did not evidence required custody participation in emergency response drill testing (MIT 15.101). Chuckawalla Valley State Prison, Cycle 5 Medical Inspection Page 54 Office of the Inspector General State of California Non-Scored Results The OIG gathered non-scored data regarding the completion of death review reports by CCHCS’ Death Review Committee (DRC). • One death occurred at CVSP during the OIG’s review period, an unexpected (Level 1) death. CCHCS policy requires the DRC to complete its death review summary report within 60 days from the date of death for this event; the report is then to be submitted to the institution’s CEO within seven calendar days thereafter. For this single Level 1 death, the DRC completed its report 100 days late (160 days after death). Inspectors found no evidence that the death review summary was ever submitted to CVSP’s CEO (MIT 15.998). • The OIG discusses the institution’s health care staffing resources in the About the Institution section of this report (MIT 15.999). Chuckawalla Valley State Prison, Cycle 5 Medical Inspection Page 55 Office of the Inspector General State of California R ECOMMENDATIONS The OIG recommends the following: • CVSP nursing managers should develop guidelines, implement training, and establish job performance monitoring strategies for licensed vocational nurse (LVN) care coordinators. Chuckawalla Valley State Prison, Cycle 5 Medical Inspection Page 56 Office of the Inspector General State of California P -B M OPULATION ASED ETRICS The compliance testing and the case reviews give an accurate assessment of how the institution’s health care systems are functioning with regard to the patients with the highest risk and utilization. This information is vital to assess the capacity of the institution to provide sustainable, adequate care. However, one significant limitation of the case review methodology is that it does not give a clear assessment of how the institution performs for the entire population. For better insight into this performance, the OIG has turned to population-based metrics. For comparative purposes, the OIG has selected several Healthcare Effectiveness Data and Information Set (HEDIS) measures for disease management to gauge the institution’s effectiveness in outpatient health care, especially chronic disease management. The Healthcare Effectiveness Data and Information Set is a set of standardized performance measures developed by the National Committee for Quality Assurance with input from over 300 organizations representing every sector of the nation’s health care industry. Over 90 percent of the nation’s health plans as well as many leading employers and regulators use HEDIS. It was designed to ensure that the public (including employers, the Centers for Medicare and Medicaid Services, and researchers) has the information it needs to accurately compare the performance of health care plans. Health plans use HEDIS data to produce health plan report cards, analyze quality improvement activities, and create performance benchmarks. Methodology For population-based metrics, the OIG used a subset of HEDIS measures applicable to the CDCR patient population. Selection of the measures was based on the availability, reliability, and feasibility of the data required for performing the measurement. The OIG collected data utilizing various information sources, including the electronic medical records, the Master Registry (maintained by CCHCS), as well as a random sample of patient records analyzed and abstracted by trained personnel. The OIG did not independently validate data obtained from the CCHCS Master Registry and the Diabetic Registry, and we presume the data 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 the following CVSP Results Compared to State and National HEDIS Scores table. Multiple health plans publish their HEDIS performance measures at the state and national levels. The OIG has provided selected results for several health plans in both categories for comparative purposes. Chuckawalla Valley State Prison, Cycle 5 Medical Inspection Page 57 Office of the Inspector General State of California Results of Population-Based Metrics 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 well with its management of diabetes. When compared statewide, the institution outperformed Medi-Cal in all five diabetic measures, and Kaiser (North and South) in four of five measures. Kaiser (North and South) scored higher than CVSP in diabetic eye exams. When compared nationally, CVSP outperformed Medicaid and commercial health plans in all five diabetic measures. CVSP outperformed Medicare in four of five measures, with CVSP performing less well in diabetic eye exams. When compared to the United States Department of Veterans Affairs (VA), CVSP scored higher in three of the four applicable measures, with the VA scoring higher in diabetic eye exams. Immunizations Comparative data for immunizations was only fully available for the VA and partially available for Kaiser, commercial plans, Medicaid, and Medicare. CVSP outperformed all applicable health care plans for influenza immunizations for both younger and older adults. However, with regard to pneumococcal immunizations, CVSP scored lower than both Medicare and the VA. However, the 19 percent patient refusal rate negatively affected the institutions’ score for pneumococcal immunizations. Cancer Screening With respect to colorectal cancer screening, the institution had mixed results. CVSP scored higher than commercial health care plans and Medicare, but scored slightly lower than Kaiser (North and South) and the VA. If not for the 23 percent patient refusal rate, CVSP would have scored higher than all applicable health care plans. Summary CVSP’s population-based metrics performance reflected a well-functioning chronic care program, compared to the other state and national health care entities reviewed. The institution may improve its scores for pneumococcal immunizations and colorectal cancer screening by reducing patient refusals through patient education about the benefits of these preventive services. Chuckawalla Valley State Prison, Cycle 5 Medical Inspection Page 58 Office of the Inspector General State of California CVSP Results Compared to State and National HEDIS Scores California National HEDIS HEDIS CVSP HEDIS HEDIS Kaiser Kaiser HEDIS HEDIS VA Clinical Measures Com- Medi-Cal (No. (So. Medicaid Medicare Average Cycle 5 mercial 20152 CA) CA) 20164 20164 20155 Results1 20164 20163 20163 Comprehensive Diabetes Care HbA1c Testing (Monitoring) 100% 86% 94% 94% 86% 90% 93% 98% Poor HbA1c Control (>9.0%)6, 7 12% 39% 20% 23% 45% 34% 27% 19% HbA1c Control (<8.0%)6 77% 49% 70% 63% 46% 55% 63% - Blood Pressure Control 91% 63% 83% 83% 59% 60% 62% 74% (<140/90)6 Eye Exams 64% 53% 68% 81% 53% 54% 69% 89% Immunizations Influenza Shots - Adults (18–64) 81% - 56% 57% 39% 48% - 55% Influenza Shots - Adults (65+) 81% - - - - - 72% 76% Immunizations: Pneumococcal 63% - - - - - 71% 93% Cancer Screening Colorectal Cancer Screening 78% - 79% 82% - 63% 67% 82% 1. Unless otherwise stated, data was collected in July 2017 by reviewing medical records from a sample of CVSP’s population of applicable patients. These random statistical sample sizes were based on a 95 percent confidence level with a 15 percent maximum margin of error. 2. HEDIS Medi-Cal data was obtained from the California Department of Health Care Services 2015 HEDIS Aggregate Report for Medi-Cal Managed Care. 3. Data was obtained from Kaiser Permanente November 2016 reports for the Northern and Southern California regions. 4. National HEDIS data for Medicaid, commercial plans, and Medicare was obtained from the 2016 State of Health Care Quality Report, available on the NCQA website: www.ncqa.org. The results for commercial plans were based on data received from various health maintenance organizations. 5. The Department of Veterans Affairs (VA) data was obtained from the VA’s website, www.va.gov. For the Immunizations: Pneumococcal measure only, the data was obtained from the VHA Facility Quality and Safety Report - Fiscal Year 2012 Data. 6. For this indicator, the entire applicable 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. Chuckawalla Valley State Prison, Cycle 5 Medical Inspection Page 59 Office of the Inspector General State of California A A — C T R PPENDIX OMPLIANCE EST ESULTS Chuckawalla Valley State Prison Range of Summary Scores: 59.74% – 90.00% Indicator Compliance Score (Yes %) 1–Access to Care 77.60% 2–Diagnostic Services 66.54% 3–Emergency Services Not Applicable 4–Health Information Management (Medical Records) 70.97% 5–Health Care Environment 59.74% 6–Inter- and Intra-System Transfers 72.40% 7–Pharmacy and Medication Management 70.35% 8–Prenatal and Post-Delivery Services Not Applicable 9–Preventive Services 80.84% 10–Quality of Nursing Performance Not Applicable 11–Quality of Provider Performance Not Applicable 12–Reception Center Arrivals Not Applicable 13–Specialized Medical Housing (OHU, CTC, SNF, Hospice) Not Applicable 14–Specialty Services 74.91% 15–Administrative Operations 90.00% Chuckawalla Valley State Prison, Cycle 5 Medical Inspection Page 60 Office of the Inspector General State of California Scored Answers Yes Reference + 1 – Access to Care Number Yes No No Yes % N/A Chronic care follow-up appointments: Was the patient’s most recent chronic care visit within the health care guideline’s 1.001 16 9 25 64.00% 0 maximum allowable interval or within the ordered time frame, whichever is shorter? For endorsed patients received from another CDCR institution: If 1.002 the nurse referred the patient to a provider during the initial health 16 6 22 72.73% 3 screening, was the patient seen within the required time frame? Clinical appointments: Did a registered nurse review the patient’s 1.003 30 0 30 100% 0 request for service the same day it was received? Clinical appointments: Did the registered nurse complete a face- 1.004 to-face visit within one business day after the CDCR Form 7362 26 4 30 86.67% 0 was reviewed? Clinical appointments: If the registered nurse determined a referral to a primary care provider was necessary, was the patient 1.005 8 2 10 80.00% 20 seen within the maximum allowable time or the ordered time frame, whichever is the shorter? Sick call follow-up appointments: If the primary care provider 1.006 ordered a follow-up sick call appointment, did it take place within 3 1 4 75.00% 26 the time frame specified? Upon the patient’s discharge from the community hospital: Did 1.007 the patient receive a follow-up appointment within the required 18 7 25 72.00% 0 time frame? Specialty service follow-up appointments: Do specialty service 1.008 primary care physician follow-up visits occur within required time 12 13 25 48.00% 5 frames? Clinical appointments: Do patients have a standardized process to 1.101 6 0 6 100% 0 obtain and submit health care services request forms? Overall percentage: 77.60% Chuckawalla Valley State Prison, Cycle 5 Medical Inspection Page 61 Office of the Inspector General State of California Scored Answers Yes Reference + 2 – Diagnostic Services Number Yes No No Yes % N/A Radiology: Was the radiology service provided within the time 2.001 8 0 8 100% 2 frame specified in the provider’s order? Radiology: Did the primary care provider review and initial the 2.002 4 6 10 40.00% 0 diagnostic report within specified time frames? Radiology: Did the primary care provider communicate the results 2.003 6 4 10 60.00% 0 of the diagnostic study to the patient within specified time frames? Laboratory: Was the laboratory service provided within the time 2.004 10 0 10 100% 0 frame specified in the provider’s order? Laboratory: Did the primary care provider review and initial the 2.005 8 1 9 88.89% 1 diagnostic report within specified time frames? Laboratory: Did the primary care provider communicate the 2.006 results of the diagnostic study to the patient within specified time 4 6 10 40.00% 0 frames? Pathology: Did the institution receive the final diagnostic report 2.007 7 3 10 70.00% 0 within the required time frames? Pathology: Did the primary care provider review and initial the 2.008 8 2 10 80.00% 0 diagnostic report within specified time frames? Pathology: Did the primary care provider communicate the results 2.009 2 8 10 20.00% 0 of the diagnostic study to the patient within specified time frames? Overall percentage: 66.54% 3 – Emergency Services Only case review clinicians evaluate this indicator. There is no compliance testing component. Chuckawalla Valley State Prison, Cycle 5 Medical Inspection Page 62 Office of the Inspector General State of California Scored Answers Yes Reference + 4 – Health Information Management Number Yes No No Yes % N/A Are non-dictated healthcare documents (provider progress notes) 4.001 9 1 10 90.00% 0 scanned within 3 calendar days of the patient encounter date? Are dictated/transcribed documents scanned into the patient’s 4.002 electronic health record within five calendar days of the encounter 1 0 1 100% 0 date? Are High-Priority specialty notes (either a Form 7243 or other 4.003 scanned consulting report) scanned within the required time 14 6 20 70.00% 0 frame? Are community hospital discharge documents scanned into the 4.004 patient’s electronic health record within three calendar days of 16 4 20 80.00% 0 hospital discharge? Are medication administration records (MARs) scanned into the 4.005 Not Applicable patient’s electronic health record within the required time frames? During the inspection, were medical records properly scanned, 4.006 11 13 24 45.83% 0 labeled, and included in the correct patients’ files? For patients discharged from a community hospital: Did the preliminary hospital discharge report include key elements and 4.007 10 15 25 40.00% 0 did a primary care provider review the report within three calendar days of discharge? Overall percentage: 70.97% Chuckawalla Valley State Prison, Cycle 5 Medical Inspection Page 63 Office of the Inspector General State of California Scored Answers Yes Reference + 5 – Health Care Environment Number Yes No No Yes % N/A Are clinical health care areas appropriately disinfected, cleaned, 5.101 8 0 8 100% 0 and sanitary? Do clinical health care areas ensure that reusable invasive and 5.102 non-invasive medical equipment is properly sterilized or 7 1 8 87.50% 0 disinfected as warranted? Do clinical health care areas contain operable sinks and sufficient 5.103 7 1 8 87.50 0 quantities of hygiene supplies? Does clinical health care staff adhere to universal hand hygiene 5.104 4 3 7 57.14% 1 precautions? Do clinical health care areas control exposure to blood-borne 5.105 8 0 8 100% 0 pathogens and contaminated waste? Warehouse, Conex, and other non-clinic storage areas: Does the 5.106 medical supply management process adequately support the needs 0 1 1 0.00% 0 of the medical health care program? Does each clinic follow adequate protocols for managing and 5.107 4 4 8 50.00% 0 storing bulk medical supplies? Do clinic common areas and exam rooms have essential core 5.108 5 3 8 62.50% 0 medical equipment and supplies? Do clinic common areas have an adequate environment conducive 5.109 6 2 8 75.00% 0 to providing medical services? Do clinic exam rooms have an adequate environment conducive 5.110 3 5 8 37.50% 0 to providing medical services? Emergency response bags: Are TTA and clinic emergency 5.111 medical response bags inspected daily and inventoried monthly, 0 6 6 0.00% 2 and do they contain essential items? Overall percentage: 59.74% Chuckawalla Valley State Prison, Cycle 5 Medical Inspection Page 64 Office of the Inspector General State of California Scored Answers Yes Reference + 6 – Inter- and Intra-System Transfers Number Yes No No Yes % N/A For endorsed patients received from another CDCR institution or COCF: Did nursing staff complete the initial health screening and 6.001 9 16 25 36.00% 0 answer all screening questions on the same day the patient arrived at the institution? For endorsed patients received from another CDCR institution or COCF: When required, did the RN complete the assessment and disposition section of the health screening form; refer the patient 6.002 24 1 25 96.00% 0 to the TTA, if TB signs and symptoms were present; and sign and date the form on the same day staff completed the health screening? For endorsed patients received from another CDCR institution or COCF: If the patient had an existing medication order upon 6.003 5 0 5 100% 20 arrival, were medications administered or delivered without interruption? For patients transferred out of the facility: Were scheduled 6.004 specialty service appointments identified on the patient’s health 16 4 20 80.00% 0 care transfer information form? For patients transferred out of the facility: Do medication transfer 6.101 packages include required medications along with the 5 5 10 50.00% 0 corresponding transfer packet required documents? Overall percentage: 72.40% Chuckawalla Valley State Prison, Cycle 5 Medical Inspection Page 65 Office of the Inspector General State of California Scored Answers 7 – Pharmacy and Medication Yes Reference + Management Number Yes No No Yes % N/A Did the patient receive all chronic care medications within the 7.001 required time frames or did the institution follow departmental 16 3 19 84.21% 6 policy for refusals or no-shows? Did health care staff administer, make available, or deliver new 7.002 order prescription medications to the patient within the required 18 7 25 96.00% 0 time frames? Upon the patient’s discharge from a community hospital: Were all 7.003 ordered medications administered, made available, or delivered to 16 9 25 64.00% 0 the patient within required time frames? For patients received from a county jail: Were all medications ordered by the institution’s reception center provider 7.004 Not Applicable administered, made available, or delivered to the patient within the required time frames? Upon the patient’s transfer from one housing unit to another: 7.005 16 0 16 100% 0 Were medications continued without interruption? For patients en route who lay over at the institution: If the 7.006 temporarily housed patient had an existing medication order, were 5 1 6 83.33% 0 medications administered or delivered without interruption? All clinical and medication line storage areas for narcotic 7.101 medications: Does the Institution employ strong medication 5 2 7 71.43% 2 security over narcotic medications assigned to its clinical areas? All clinical and medication line storage areas for non-narcotic medications: Does the Institution properly store non-narcotic 7.102 5 3 8 62.50% 1 medications that do not require refrigeration in assigned clinical areas? All clinical and medication line storage areas for non-narcotic 7.103 medications: Does the institution properly store non-narcotic 5 2 7 71.43% 2 medications that require refrigeration in assigned clinical areas? Medication preparation and administration areas: Do nursing staff employ and follow hand hygiene contamination control protocols 7.104 3 3 6 50.00% 3 during medication preparation and medication administration processes? Medication preparation and administration areas: Does the 7.105 institution employ appropriate administrative controls and 6 0 6 100% 3 protocols when preparing medications for patients? Medication preparation and administration areas: Does the 7.106 Institution employ appropriate administrative controls and 4 2 6 66.67% 3 protocols when distributing medications to patients? Pharmacy: Does the institution employ and follow general 7.107 security, organization, and cleanliness management protocols in 1 0 1 100% 0 its main and satellite pharmacies? Chuckawalla Valley State Prison, Cycle 5 Medical Inspection Page 66 Office of the Inspector General State of California Scored Answers 7 – Pharmacy and Medication Yes Reference + Management Number Yes No No Yes % N/A Pharmacy: Does the institution’s pharmacy properly store non- 7.108 1 0 1 100% 0 refrigerated medications? Pharmacy: Does the institution’s pharmacy properly store 7.109 0 1 1 0.00% 0 refrigerated or frozen medications? Pharmacy: Does the institution’s pharmacy properly account for 7.110 0 1 1 0.00% 0 narcotic medications? Does the institution follow key medication error reporting 7.111 25 0 25 100% 0 protocols? Overall percentage: 70.35% 8 – Prenatal and Post-Delivery Services The institution has no female patients, so this indicator is not applicable. Chuckawalla Valley State Prison, Cycle 5 Medical Inspection Page 67 Office of the Inspector General State of California Scored Answers Yes Reference + 9 – Preventive Services Number Yes No No Yes % N/A Patients prescribed TB medication: Did the institution administer 9.001 12 2 14 85.71% 0 the medication to the patient as prescribed? Patients prescribed TB medication: Did the institution monitor the 9.002 patient monthly for the most recent three months he or she was on 7 7 14 50.00% 0 the medication? Annual TB Screening: Was the patient screened for TB within the 9.003 21 9 30 70.00% 0 last year? Were all patients offered an influenza vaccination for the most 9.004 25 0 25 100% 0 recent influenza season? All patients from the age of 50 - 75: Was the patient offered 9.005 24 1 25 96.00% 0 colorectal cancer screening? Female patients from the age of 50 through the age of 74: Was the 9.006 Not Applicable patient offered a mammogram in compliance with policy? Female patients from the age of 21 through the age of 65: Was 9.007 Not Applicable patient offered a pap smear in compliance with policy? Are required immunizations being offered for chronic care 9.008 15 3 18 83.33% 7 patients? Are patients at the highest risk of coccidioidomycosis (valley 9.009 Not Applicable fever) infection transferred out of the facility in a timely manner? Overall percentage: 80.84% 10 – Quality of Nursing Performance Only case review clinicians evaluate this indicator. There is no compliance testing component. 11 – Quality of Provider Performance Only case review clinicians evaluate this indicator. There is no compliance testing component. Chuckawalla Valley State Prison, Cycle 5 Medical Inspection Page 68 Office of the Inspector General State of California 12 – Reception Center Arrivals The institution has no reception center, so this indicator was not applicable. 13 – Specialized Medical Housing The institution does not have a CTC or OHU, so this indicator was not applicable. Chuckawalla Valley State Prison, Cycle 5 Medical Inspection Page 69 Office of the Inspector General State of California Scored Answers Yes Reference + 14 – Specialty Services Number Yes No No Yes % N/A Did the patient receive the high priority specialty service within 14.001 14 calendar days of the primary care provider order or the 11 4 15 73.33% 0 Physician Request for Service? Did the primary care provider review the high priority specialty 14.002 12 3 15 80.00% 0 service consultant report within the required time frame? Did the patient receive the routine specialty service within 90 14.003 calendar days of the primary care provider order or Physician 14 1 15 93.33% 0 Request for Service? Did the primary care provider review the routine specialty service 14.004 9 5 14 64.29% 1 consultant report within the required time frame? For endorsed patients received from another CDCR institution: If the patient was approved for a specialty services appointment at 14.005 12 8 20 60.00% 0 the sending institution, was the appointment scheduled at the receiving institution within the required time frames? Did the institution deny the primary care provider request for 14.006 17 3 20 85.00% 0 specialty services within required time frames? Following the denial of a request for specialty services, was the 14.007 13 6 19 68.42% 1 patient informed of the denial within the required time frame? Overall percentage: 74.91% Chuckawalla Valley State Prison, Cycle 5 Medical Inspection Page 70 Office of the Inspector General State of California Scored Answers Yes Reference 15 – Administrative Operations + Number Yes No No Yes % N/A Did the institution promptly process inmate medical appeals 15.001 12 0 12 100% 0 during the most recent 12 months? Does the institution follow adverse / sentinel event reporting 15.002 Not Applicable requirements? Did the institution Quality Management Committee (QMC) meet at least monthly to evaluate program performance, and did the 15.003 5 1 6 83.33% 0 QMC take action when improvement opportunities were identified? Did the institution’s Quality Management Committee (QMC) or 15.004 other forum take steps to ensure the accuracy of its Dashboard 1 0 1 100% 0 data reporting? Does the Emergency Medical Response Review Committee 15.005 perform timely incident package reviews that include the use of 5 0 5 100% 0 required review documents? For institutions with licensed care facilities: Does the Local Governing Body (LGB), or its equivalent, meet quarterly and 15.006 Not Applicable exercise its overall responsibilities for the quality management of patient health care? Did the institution complete a medical emergency response drill 15.101 for each watch and include participation of health care and 2 1 3 66.67% 0 custody staff during the most recent full quarter? Did the institution’s second level medical appeal response address 15.102 10 0 10 100% 0 all of the patient’s appealed issues? Did the institution’s medical staff review and submit the initial 15.103 1 0 1 100% 0 inmate death report to the Death Review Unit in a timely manner? Does the institution’s Supervising Registered Nurse conduct 15.104 0 5 5 0.00% 0 periodic reviews of nursing staff? Are nursing staff who administer medications current on their 15.105 10 0 10 100% 0 clinical competency validation? 15.106 Are structured clinical performance appraisals completed timely? 4 0 4 100% 0 15.107 Do all providers maintain a current medical license? 6 0 6 100% 0 Are staff current with required medical emergency response 15.108 2 0 2 100% 1 certifications? Are nursing staff and the Pharmacist-in-Charge current with their professional licenses and certifications, and is the pharmacy 15.109 licensed as a correctional pharmacy by the California State Board 6 0 6 100% 0 of Pharmacy? Chuckawalla Valley State Prison, Cycle 5 Medical Inspection Page 71 Office of the Inspector General State of California Scored Answers Yes Reference 15 – Administrative Operations + Number Yes No No Yes % N/A Do the institution’s pharmacy and authorized providers who 15.110 prescribe controlled substances maintain current Drug 1 0 1 100% 0 Enforcement Agency (DEA) registrations? 15.111 Are nursing staff current with required new employee orientation? 1 0 1 100% 0 Overall percentage: 90.00% Chuckawalla Valley State Prison, Cycle 5 Medical Inspection Page 72 Office of the Inspector General State of California A B — C D PPENDIX LINICAL ATA Table B-1: CVSP Sample Sets Sample Set Total Death Review/Sentinel Events 1 Diabetes 6 Emergency Services – Non-CPR 2 High Risk 4 Hospitalization 4 Intra-System Transfers In 3 Intra-System Transfers Out 3 RN Sick Call 15 Specialty Services 3 41 Chuckawalla Valley State Prison, Cycle 5 Medical Inspection Page 73 Office of the Inspector General State of California Table B-2: CVSP Chronic Care Diagnoses Diagnosis Total Anemia 2 Arthritis/Degenerative Joint Disease 3 Asthma 3 Cancer 3 Cardiovascular Disease 9 Chronic Kidney Disease 2 Chronic Pain 10 Diabetes 12 Gastroesophageal Reflux Disease 5 Hepatitis C 4 Hyperlipidemia 22 Hypertension 24 Mental Health 2 Migraine Headaches 1 Seizure Disorder 2 Thyroid Disease 1 105 Chuckawalla Valley State Prison, Cycle 5 Medical Inspection Page 74 Office of the Inspector General State of California Table B-3: CVSP Event – Program Diagnosis Total Anemia 2 Arthritis/Degenerative Joint Disease 3 Asthma 3 Cancer 3 Cardiovascular Disease 9 Chronic Kidney Disease 2 Chronic Pain 10 Diabetes 12 Gastroesophageal Reflux Disease 5 Hepatitis C 4 Hyperlipidemia 22 Hypertension 24 Mental Health 2 Migraine Headaches 1 Seizure Disorder 2 Thyroid Disease 1 105 Chuckawalla Valley State Prison, Cycle 5 Medical Inspection Page 75 Office of the Inspector General State of California Table B-4: CVSP Review Sample Summary Total MD Reviews Detailed 20 MD Reviews Focused 2 RN Reviews Detailed 9 RN Reviews Focused 21 Total Reviews 52 Total Unique Cases 41 Overlapping Reviews (MD & RN) 11 Chuckawalla Valley State Prison, Cycle 5 Medical Inspection Page 76 Office of the Inspector General State of California A C — C S M PPENDIX OMPLIANCE AMPLING ETHODOLOGY Chuckawalla Valley State Prison Sample Category Quality (number of Indicator samples) Data Source Filters Access to Care MIT 1.001 Chronic Care Patients Master Registry • Chronic care conditions (at least one condition per patient—any risk level) (25) • Randomize MIT 1.002 Nursing Referrals OIG Q: 6.001 • See Intra-System Transfers (25) MITs 1.003–006 Nursing Sick Call MedSATS • Clinic (each clinic tested) (5 per clinic) • Appointment date (2–9 months) (30) • Randomize MIT 1.007 Returns from OIG Q: 4.007 • See Health Information Management (Medical Community Hospital Records) (returns from community hospital) (25) MIT 1.008 Specialty Services OIG Q: 14.001 & • See Specialty Services Follow-up 14.003 (30) MIT 1.101 Availability of Health OIG onsite • Randomly select one housing unit from each yard Care Services review Request Forms (6) Diagnostic Services MITs 2.001–003 Radiology Radiology Logs • Appointment date (90 days–9 months) • Randomize (10) • Abnormal MITs 2.004–006 Laboratory Quest • Appt. date (90 days–9 months) • Order name (CBC or CMPs only) • Randomize (10) • Abnormal MITs 2.007–009 Pathology InterQual • Appt. date (90 days–9 months) • Service (pathology related) (10) • Randomize Chuckawalla Valley State Prison, Cycle 5 Medical Inspection Page 77 Office of the Inspector General State of California Sample Category Quality (number of Indicator samples) Data Source Filters Health Information Management (Medical Records) MIT 4.001 Timely Scanning OIG Qs: 1.001, • Non-dictated documents (10) 1.002, & 1.004 • 1st 10 IPs MIT 1.001, 1st 5 IPs MITs 1.002, 1.004 MIT 4.002 OIG Q: 1.001 • Dictated documents (1) • First 20 IPs selected MIT 4.003 OIG Qs: 14.002 • Specialty documents (20) & 14.004 • First 10 IPs for each question MIT 4.004 OIG Q: 4.007 • Community hospital discharge documents (20) • First 20 IPs selected MIT 4.005 OIG Q: 7.001 • MARs (Not Applicable) • First 20 IPs selected MIT 4.006 Documents for • Any misfiled or mislabeled document identified (13) any tested inmate during OIG compliance review (24 or more = No) MIT 4.007 Returns from Inpatient claims • Date (2–8 months) Community Hospital data • Most recent 6 months provided (within date range) • Rx count • Discharge date • Randomize (each month individually) • First 5 patients from each of the 6 months (if not 5 in a month, supplement from another, as needed) (25) Health Care Environment MITs 5.101–105 Clinical Areas OIG inspector • Identify and inspect all onsite clinical areas. MITs 5.107–111 (8) onsite review Inter- and Intra-System Transfers MITs 6.001–003 Intra-System SOMS • Arrival date (3–9 months) Transfers • Arrived from (another CDCR facility) • Rx count • Randomize (25) MIT 6.004 Specialty Services MedSATS • Date of transfer (3–9 months) Send-Outs • Randomize (20) MIT 6.101 Transfers Out OIG inspector • R&R IP transfers with medication (10) onsite review Chuckawalla Valley State Prison, Cycle 5 Medical Inspection Page 78 Office of the Inspector General State of California Sample Category Quality (number of Indicator samples) Data Source Filters Pharmacy and Medication Management MIT 7.001 Chronic Care OIG Q: 1.001 See Access to Care Medication • At least one condition per patient—any risk level • Randomize (25) MIT 7.002 New Medication Master Registry • Rx count Orders • Randomize (25) • Ensure no duplication of IPs tested in MIT 7.001 MIT 7.003 Returns from OIG Q: 4.007 • See Health Information Management (Medical Community Hospital Records) (returns from community hospital) (25) MIT 7.004 RC Arrivals – OIG Q: 12.001 • See Reception Center Arrivals Medication Orders (Not Applicable) MIT 7.005 Intra-Facility Moves MAPIP transfer • Date of transfer (2–8 months) data • To location/from location (yard to yard and to/from ASU) • Remove any to/from MHCB • NA/DOT meds (and risk level) (16) • Randomize MIT 7.006 En Route SOMS • Date of transfer (2–8 months) • Sending institution (another CDCR facility) • Randomize (6) • NA/DOT meds MITs 7.101–103 Medication Storage OIG inspector • Identify and inspect clinical & med line areas that Areas onsite review store medications (varies by test) MITs 7.104–106 Medication OIG inspector • Identify and inspect onsite clinical areas that Preparation and onsite review prepare and administer medications Administration Areas (varies by test) MITs 7.107–110 Pharmacy OIG inspector • Identify & inspect all onsite pharmacies (1) onsite review MIT 7.111 Medication Error Monthly • All monthly statistical reports with Level 4 or Reporting medication error higher (25) reports • Select a total of 5 months MIT 7.999 Isolation Unit KOP Onsite active • KOP rescue inhalers & nitroglycerin medications Medications medication for IPs housed in isolation units (10) listing Prenatal and Post-Delivery Services MITs 8.001–007 Recent Deliveries OB Roster • Delivery date (2–12 months) (Not Applicable) • Most recent deliveries (within date range) Pregnant Arrivals OB Roster • Arrival date (2–12 months) (Not Applicable) • Earliest arrivals (within date range) Chuckawalla Valley State Prison, Cycle 5 Medical Inspection Page 79 Office of the Inspector General State of California Sample Category Quality (number of Indicator samples) Data Source Filters Preventive Services MITs 9.001–002 TB Medications Maxor • Dispense date (past 9 months) • Time period on TB meds (3 months or 12 weeks) (14) • Randomize MIT 9.003 TB Evaluation, SOMS • Arrival date (at least 1 year prior to inspection) Annual Screening • Birth Month (30) • Randomize MIT 9.004 Influenza SOMS • Arrival date (at least 1 year prior to inspection) Vaccinations • Randomize (25) • Filter out IPs tested in MIT 9.008 MIT 9.005 Colorectal Cancer SOMS • Arrival date (at least 1 year prior to inspection) Screening • Date of birth (51 or older) (25) • Randomize MIT 9.006 Mammogram SOMS • Arrival date (at least 2 yrs. prior to inspection) (Not Applicable) • Date of birth (age 52–74) • Randomize MIT 9.007 Pap Smear SOMS • Arrival date (at least three yrs. prior to inspection) (Not Applicable) • Date of birth (age 24–53) • Randomize MIT 9.008 Chronic Care OIG Q: 1.001 • Chronic care conditions (at least 1 condition per Vaccinations IP—any risk level) • Randomize (25) • Condition must require vaccination(s) MIT 9.009 Valley Fever Cocci transfer • Reports from past 2–8 months (number will vary) status report • Institution (Not Applicable) • Ineligibility date (60 days prior to inspection date) • All Chuckawalla Valley State Prison, Cycle 5 Medical Inspection Page 80 Office of the Inspector General State of California Sample Category Quality (number of Indicator samples) Data Source Filters Reception Center Arrivals MITs 12.001–008 RC SOMS • Arrival date (2–8 months) (Not Applicable) • Arrived from (county jail, return from parole, etc.) • Randomize Specialized Medical Housing MITs 13.001–004 CTC CADDIS • Admit date (1–6 months) • Type of stay (no MH beds) • Length of stay (minimum of 5 days) (Not Applicable) • Randomize MIT 13.101 Call Buttons OIG inspector • Review by location CTC onsite review (Not Applicable) Specialty Services MITs 14.001–002 High-Priority MedSATS • Approval date (3–9 months) (15) • Randomize MITs 14.003–004 Routine MedSATS • Approval date (3–9 months) • Remove optometry, physical therapy, or podiatry (15) • Randomize MIT 14.005 Specialty Services MedSATS • Arrived from (other CDCR institution) Arrivals • Date of transfer (3–9 months) (20) • Randomize MITs 14.006–007 Denials InterQual • Review date (3–9 months) (20) • Randomize IUMC/MAR • Meeting date (9 months) Meeting Minutes • Denial upheld (0) • Randomize Chuckawalla Valley State Prison, Cycle 5 Medical Inspection Page 81 Office of the Inspector General State of California Sample Category Quality (number of Indicator samples) Data Source Filters Administrative Operations MIT 15.001 Medical Appeals Monthly medical • Medical appeals (12 months) (all) appeals reports MIT 15.002 Adverse/Sentinel Adverse/sentinel • Adverse/sentinel events (2–8 months) Events events report (Not Applicable) MITs 15.003–004 QMC Meetings Quality • Meeting minutes (12 months) Management Committee (6) meeting minutes MIT 15.005 EMRRC EMRRC meeting • Monthly meeting minutes (6 months) (5) minutes MIT 15.006 LGB LGB meeting • Quarterly meeting minutes (12 months) (Not Applicable) minutes MIT 15.101 Medical Emergency Onsite summary • Most recent full quarter Response Drills reports & • Each watch documentation (3) for ER drills MIT 15.102 2nd Level Medical Onsite list of • Medical appeals denied (6 months) Appeals appeals/closed (10) appeals files MIT 15.103 Death Reports Institution-list of • Most recent 10 deaths deaths in prior 12 • Initial death reports (1) months MIT 15.104 RN Review Onsite supervisor • RNs who worked in clinic or emergency setting Evaluations periodic RN six or more days in sampled month reviews • Randomize (5) MIT 15.105 Nursing Staff Onsite nursing • On duty one or more years Validations education files • Nurse administers medications (10) • Randomize MIT 15.106 Provider Annual Onsite • All required performance evaluation documents Evaluation Packets provider (4) evaluation files MIT 15.107 Provider licenses Current provider • Review all listing (at start of (6) inspection) MIT 15.108 Medical Emergency Onsite • All staff Response certification o Providers (ACLS) Certifications tracking logs o Nursing (BLS/CPR) (all) • Custody (CPR/BLS) MIT 15.109 Nursing staff and Onsite tracking • All required licenses and certifications Pharmacist in system, logs, or Charge Professional employee files Licenses and Certifications (all) Chuckawalla Valley State Prison, Cycle 5 Medical Inspection Page 82 Office of the Inspector General State of California Sample Category Quality (number of Indicator samples) Data Source Filters Administrative Operations MIT 15.110 Pharmacy and Onsite listing of • All DEA registrations Providers’ Drug provider DEA Enforcement Agency registration #s & (DEA) Registrations pharmacy registration (all) document MIT 15.111 Nursing Staff New Nursing staff • New employees (hired within last 12 months) Employee training logs • Orientations (all) MIT 15.998 Death Review OIG summary log • Between 35 business days & 12 months prior Committee - deaths • CCHCS death reviews (1) Chuckawalla Valley State Prison, Cycle 5 Medical Inspection Page 83 Office of the Inspector General State of California Sample Category Quality (number of Indicator samples) Data Source Filters Health Information Management (Medical Records) MIT 4.001 Timely Scanning OIG Qs: 1.001, • Non-dictated documents (10) 1.002, & 1.004 • 1st 10 IPs MIT 1.001, 1st 5 IPs MITs 1.002, 1.004 MIT 4.002 OIG Q: 1.001 • Dictated documents (1) • First 20 IPs selected MIT 4.003 OIG Qs: 14.002 • Specialty documents (20) & 14.004 • First 10 IPs for each question MIT 4.004 OIG Q: 4.008 • Community hospital discharge documents (20) • First 20 IPs selected MIT 4.005 OIG Q: 7.001 • MARs Not Applicable • First 20 IPs selected MIT 4.006 Documents for • Any misfiled or mislabeled document identified (13) any tested inmate during OIG compliance review (12 or more = No) MIT 4.007 Legible Signatures & OIG Qs: 4.008, • First 8 IPs sampled Review 6.001, 6.002, • One source document per IP 7.001, 12.001, (25) 12.002 & 14.002 MIT 4.008 Returns from Inpatient claims • Date (2–8 months) Community Hospital data • Most recent 6 months provided (within date range) • Rx count • Discharge date • Randomize (each month individually) • First 5 patients from each of the 6 months (if not 5 in a month, supplement from another, as needed) (30) Health Care Environment MITs 5.101–105 Clinical Areas OIG inspector • Identify and inspect all onsite clinical areas. MITs 5.107–111 (9) onsite review Inter- and Intra-System Transfers MITs 6.001–003 Intra-System SOMS • Arrival date (3–9 months) Transfers • Arrived from (another CDCR facility) • Rx count • Randomize (30) MIT 6.004 Specialty Services MedSATS • Date of transfer (3–9 months) Send-Outs • Randomize (20) MIT 6.101 Transfers Out OIG inspector • R&R IP transfers with medication (3) onsite review Chuckawalla Valley State Prison, Cycle 5 Medical Inspection Page 84 Office of the Inspector General State of California Sample Category Quality (number of Indicator samples) Data Source Filters Pharmacy and Medication Management MIT 7.001 Chronic Care OIG Q: 1.001 See Access to Care Medication • At least one condition per patient—any risk level • Randomize (40) MIT 7.002 New Medication Master Registry • Rx count Orders • Randomize (40) • Ensure no duplication of IPs tested in MIT 7.001 MIT 7.003 Returns from OIG Q: 4.008 • See Health Information Management (Medical Community Hospital Records) (returns from community hospital) (30) MIT 7.004 RC Arrivals – OIG Q: 12.001 • See Reception Center Arrivals Medication Orders N/A at this institution MIT 7.005 Intra-Facility Moves MAPIP transfer • Date of transfer (2–8 months) data • To location/from location (yard to yard and to/from ASU) • Remove any to/from MHCB • NA/DOT meds (and risk level) (30) • Randomize MIT 7.006 En Route SOMS • Date of transfer (2–8 months) • Sending institution (another CDCR facility) • Randomize (0) • NA/DOT meds MITs 7.101–103 Medication Storage OIG inspector • Identify and inspect clinical & med line areas that Areas onsite review store medications (varies by test) MITs 7.104–106 Medication OIG inspector • Identify and inspect onsite clinical areas that Preparation and onsite review prepare and administer medications Administration Areas (varies by test) MITs 7.107–110 Pharmacy OIG inspector • Identify & inspect all onsite pharmacies (1) onsite review MIT 7.111 Medication Error Monthly • All monthly statistical reports with Level 4 or Reporting medication error higher (30) reports • Select a total of 5 months MIT 7.999 Isolation Unit KOP Onsite active • KOP rescue inhalers & nitroglycerin medications Medications medication for IPs housed in isolation units (19) listing Prenatal and Post-Delivery Services MITs 8.001–007 Recent Deliveries OB Roster • Delivery date (2–12 months) N/A at this institution • Most recent deliveries (within date range) Pregnant Arrivals OB Roster • Arrival date (2–12 months) N/A at this institution • Earliest arrivals (within date range) Chuckawalla Valley State Prison, Cycle 5 Medical Inspection Page 85 Office of the Inspector General State of California Sample Category Quality (number of Indicator samples) Data Source Filters Preventive Services MITs 9.001–002 TB Medications Maxor • Dispense date (past 9 months) • Time period on TB meds (3 months or 12 weeks) (9) • Randomize MIT 9.003 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 MIT 9.004 Influenza SOMS • Arrival date (at least 1 year prior to inspection) Vaccinations • Randomize (30) • Filter out IPs tested in MIT 9.008 MIT 9.005 Colorectal Cancer SOMS • Arrival date (at least 1 year prior to inspection) Screening • Date of birth (51 or older) (30) • Randomize MIT 9.006 Mammogram SOMS • Arrival date (at least 2 yrs. prior to inspection) • Date of birth (age 52–74) N/A at this institution • Randomize MIT 9.007 Pap Smear SOMS • Arrival date (at least 3 yrs. prior to inspection) • Date of birth (age 24–53) N/A at this institution • Randomize MIT 9.008 Chronic Care OIG Q: 1.001 • Chronic care conditions (at least 1 condition per Vaccinations IP—any risk level) • Randomize (20) • Condition must require vaccination(s) MIT 9.009 Valley Fever Cocci transfer • Reports from past 2–8 months (number will vary) status report • Institution • Ineligibility date (60 days prior to inspection date) N/A at this institution • All Chuckawalla Valley State Prison, Cycle 5 Medical Inspection Page 86 Office of the Inspector General State of California Sample Category Quality (number of Indicator samples) Data Source Filters Reception Center Arrivals MITs 12.001–008 RC SOMS • Arrival date (2–8 months) • Arrived from (county jail, return from parole, etc.) N/A at this institution • Randomize Specialized Medical Housing MITs 13.001–004 CTC CADDIS • Admit date (1–6 months) • Type of stay (no MH beds) • Length of stay (minimum of 5 days) (5) • Randomize MIT 13.101 Call Buttons OIG inspector • Review by location CTC (all) onsite review Specialty Services MITs 14.001–002 High-Priority MedSATS • Approval date (3–9 months) (15) • Randomize MITs 14.003–004 Routine MedSATS • Approval date (3–9 months) (15) • Remove optometry, physical therapy, or podiatry • Randomize MIT 14.005 Specialty Services MedSATS • Arrived from (other CDCR institution) Arrivals • Date of transfer (3–9 months) (20) • Randomize MITs 14.006–007 Denials InterQual • Review date (3–9 months) (20) • Randomize IUMC/MAR • Meeting date (9 months) Meeting Minutes • Denial upheld (0) • Randomize Chuckawalla Valley State Prison, Cycle 5 Medical Inspection Page 87 Office of the Inspector General State of California Sample Category Quality (number of Indicator samples) Data Source Filters Administrative Operations MIT 15.001 Medical Appeals Monthly medical • Medical appeals (12 months) (all) appeals reports MIT 15.002 Adverse/Sentinel Adverse/sentinel • Adverse/sentinel events (2–8 months) Events events report (0) MITs 15.003–004 QMC Meetings Quality • Meeting minutes (12 months) Management Committee (6) meeting minutes MIT 15.005 EMRRC EMRRC meeting • Monthly meeting minutes (6 months) (12) minutes MIT 15.006 LGB LGB meeting • Quarterly meeting minutes (12 months) (4) minutes MIT 15.101 Medical Emergency Onsite summary • Most recent full quarter Response Drills reports & • Each watch documentation (3) for ER drills MIT 15.102 2nd Level Medical Onsite list of • Medical appeals denied (6 months) Appeals appeals/closed (10) appeals files MIT 15.103 Death Reports Institution-list of • Most recent 10 deaths deaths in prior 12 • Initial death reports (5) months MIT 15.104 RN Review Onsite supervisor • RNs who worked in clinic or emergency setting Evaluations periodic RN six or more days in sampled month reviews • Randomize (3) MIT 15.105 Nursing Staff Onsite nursing • On duty one or more years Validations education files • Nurse administers medications (10) • Randomize MIT 15.106 Provider Annual OIG Q:16.001 • All required performance evaluation documents Evaluation Packets (8) MIT 15.107 Provider licenses Current provider • Review all listing (at start of (10) inspection) MIT 15.108 Medical Emergency Onsite • All staff Response certification o Providers (ACLS) Certifications tracking logs o Nursing (BLS/CPR) (all) • Custody (CPR/BLS) MIT 15.109 Nursing staff and Onsite tracking • All required licenses and certifications Pharmacist in system, logs, or Charge Professional employee files Licenses and Certifications (all) Chuckawalla Valley State Prison, Cycle 5 Medical Inspection Page 88 Office of the Inspector General State of California Sample Category Quality (number of Indicator samples) Data Source Filters Administrative Operations MIT 15.110 Pharmacy and Onsite listing of • All DEA registrations Providers’ Drug provider DEA Enforcement Agency registration #s & (DEA) Registrations pharmacy registration (all) document MIT 15.111 Nursing Staff New Nursing staff • New employees (hired within last 12 months) Employee training logs • Orientations (all) MIT 15.998 Death Review OIG summary • Between 35 business days & 12 months prior Committee log - deaths • CCHCS death reviews (5) Chuckawalla Valley State Prison, Cycle 5 Medical Inspection Page 89 Office of the Inspector General State of California C C ALIFORNIA ORRECTIONAL H C S ’ EALTH ARE ERVICES R ESPONSE Chuckawalla Valley State Prison, Cycle 5 Medical Inspection Page 90 Office of the Inspector General State of California