High Desert State Prison Medical Inspection Report Cycle 4

Robert A. Barton Office of the Inspector General Inspector General High Desert State Prison Medical Inspection Results Cycle 4 December 2016 Medical Inspection Unit Page 1 Office of the Inspector General State of California Office of the Inspector General HIGH DESERT STATE PRISON Medical Inspection Results Cycle 4 Robert A. Barton Inspector General Roy W. Wesley Chief Deputy Inspector General Shaun R. Spillane Public Information Officer December 2016 TABLE OF CONTENTS Executive Summary ............................................................................................................................. i Overall Assessment: Adequate .............................................................................................. iii Clinical Case Review and OIG Clinician Inspection Results ............................................... iii Compliance Testing Results................................................................................................... v Population-Based Metrics ...................................................................................................... x Introduction ......................................................................................................................................... 1 About the Institution ........................................................................................................................... 1 Objectives, Scope, and Methodology.................................................................................................. 5 Case Reviews ................................................................................................................................... 6 Patient Selection for Retrospective Case Reviews .................................................................... 6 Benefits and Limitations of Targeted Subpopulation Review .................................................. 7 Case Reviews Sampled ............................................................................................................. 8 Compliance Testing ......................................................................................................................... 9 Sampling Methods for Conducting Compliance Testing .......................................................... 9 Scoring of Compliance Testing Results .................................................................................. 10 Dashboard Comparisons ......................................................................................................... 10 Overall Quality Indicator Rating for Case Reviews and Compliance Testing .............................. 11 Population-Based Metrics .............................................................................................................. 11 Medical Inspection Results ............................................................................................................... 12 Primary (Clinical) Quality Indicators of Health Care .................................................................... 12 Access to Care ......................................................................................................................... 14 Case Review Results ............................................................................................................ 14 Compliance Testing Results................................................................................................. 17 Recommendations ................................................................................................................ 18 Diagnostic Services ................................................................................................................. 19 Case Review Results ............................................................................................................ 19 Compliance Testing Results................................................................................................. 21 Recommendation for CCHCS .............................................................................................. 22 Recommendations for HDSP ............................................................................................... 22 Emergency Services................................................................................................................. 23 Case Review Results ............................................................................................................ 23 Recommendations ................................................................................................................ 25 Health Information Management (Medical Records) ............................................................. 26 Case Review Results ............................................................................................................ 26 Compliance Testing Results................................................................................................. 28 Recommendations ................................................................................................................ 29 Health Care Environment ....................................................................................................... 30 Compliance Testing Results................................................................................................. 30 Recommendations ................................................................................................................ 33 High Desert State Prison, Cycle 4 Medical Inspection Table of Contents Office of the Inspector General State of California Inter- and Intra-System Transfers ........................................................................................... 34 Case Review Results ............................................................................................................ 34 Compliance Testing Results................................................................................................. 37 Recommendations ................................................................................................................ 38 Pharmacy and Medication Management ................................................................................ 39 Case Review Results ............................................................................................................ 39 Compliance Testing Results................................................................................................. 41 Recommendations ................................................................................................................ 44 Preventive Services ................................................................................................................. 45 Compliance Testing Results................................................................................................. 45 Recommendations ................................................................................................................ 46 Quality of Nursing Performance ............................................................................................. 47 Case Review Results ............................................................................................................ 47 Recommendations ................................................................................................................ 51 Quality of Provider Performance ............................................................................................ 52 Case Review Results ............................................................................................................ 52 Recommendations ................................................................................................................ 55 Specialized Medical Housing (OHU, CTC, SNF, Hospice) .................................................... 56 Case Review Results ............................................................................................................ 56 Compliance Testing Results................................................................................................. 57 Recommendations ................................................................................................................ 58 Specialty Services .................................................................................................................... 59 Case Review Results ............................................................................................................ 59 Compliance Testing Results................................................................................................. 60 Recommendations ................................................................................................................ 61 Secondary (Administrative) Quality Indicators of Health Care..................................................... 62 Internal Monitoring, Quality Improvement, and Administrative Operations ......................... 63 Compliance Testing Results................................................................................................. 63 Recommendations ................................................................................................................ 66 Job Performance, Training, Licensing, and Certifications ..................................................... 67 Compliance Testing Results................................................................................................. 67 Recommendations ................................................................................................................ 68 Population-Based Metrics .............................................................................................................. 69 Appendix A — Compliance Test Results ......................................................................................... 73 Appendix B — Clinical Data ............................................................................................................ 87 Appendix C — Compliance Sampling Methodology ....................................................................... 90 California Correctional Health Care Services’ Response ................................................................. 91 High Desert State Prison, Cycle 4 Medical Inspection Table of Contents Office of the Inspector General State of California LIST OF TABLES AND FIGURES Health Care Quality Indicators ........................................................................................................... ii HDSP Executive Summary Table ...................................................................................................... ix HDSP Health Care Staffing Resources as of April 2016 ..................................................................... 2 HDSP Master Registry Data as of April 11, 2016 ............................................................................... 3 Commonly Used Abbreviations .......................................................................................................... 4 HDSP Results Compared to State and National HEDIS Scores ........................................................ 72 High Desert State Prison, Cycle 4 Medical Inspection List of Tables and Figures Office of the Inspector General State of California EXECUTIVE SUMMARY Pursuant to California Penal Code Section 6126, which assigns the Office of the Inspector General (OIG) responsibility for oversight of the California Department of Corrections and Rehabilitation (CDCR), the OIG conducts a comprehensive inspection program to evaluate the delivery of medical care at each of CDCR’s 35 adult prisons. The OIG explicitly makes no determination regarding the constitutionality of care in the prison setting. That determination is left to the Receiver and the federal court. The assessment of care by the OIG is just one factor in the court’s determination whether care in the prisons meets constitutional standards. The court may find that an institution the OIG found to be providing adequate care still did not meet constitutional standards, depending on the analysis of the underlying data provided by the OIG. Likewise, an institution that has been rated inadequate by the OIG could still be found to pass constitutional muster with the implementation of remedial measures if the underlying data were to reveal easily mitigated deficiencies. The OIG’s inspections are mandated by the Penal Code and not aimed at specifically resolving the court’s questions on constitutional care. To the degree that they provide another factor for the court to consider, the OIG is pleased to provide added value to the taxpayers of California. For this fourth cycle of inspections, the OIG added a clinical case review component and significantly enhanced the compliance portion of the inspection process from that used in prior cycles. In addition, the OIG added a population-based metric comparison of selected Healthcare Effectiveness Data Information Set (HEDIS) measures from other State and national health care organizations and compared that data to similar results for High Desert State Prison (HDSP). The OIG performed its Cycle 4 medical inspection at HDSP from May to July 2016. The inspection included in-depth reviews of 92 inmate-patient files conducted by clinicians, as well as reviews of documents from 390 inmate-patient files, covering 92 objectively scored tests of compliance with policies and procedures applicable to the delivery of medical care. The OIG assessed the case review and compliance results at HDSP using 14 health care quality indicators applicable to the institution, made up of 12 primary clinical indicators and 2 secondary administrative indicators. To conduct clinical case reviews, the OIG employs a clinician team consisting of a physician and a registered nurse consultant, while compliance testing is done by a team of deputy inspectors general and registered nurses trained in monitoring medical policy compliance. Of the 14 primary indicators, 7 were rated by both case review clinicians and compliance inspectors, 3 were rated by case review clinicians only, and 2 were rated by compliance inspectors only; both secondary indicators were rated by compliance inspectors only. See the Health Care Quality Indicators table on page ii. Based on that analysis, OIG experts made a considered and measured overall opinion that the quality of health care at HDSP was adequate. High Desert State Prison, Cycle 4 Medical Inspection Page i Office of the Inspector General State of California Health Care Quality Indicators All Institutions– HDSP Fourteen Primary Indicators (Clinical) Applicability Applicability Both case review 1–Access to Care All institutions and compliance Both case review 2–Diagnostic Services All institutions and compliance 3–Emergency Services All institutions Case review only 4–Health Information Management Both case review All institutions (Medical Records) and compliance 5–Health Care Environment All institutions Compliance only Both case review 6–Inter- and Intra-System Transfers All institutions and compliance Both case review 7–Pharmacy and Medication Management All institutions and compliance Female institutions 8–Prenatal and Post-Delivery Services Not Applicable only 9–Preventive Services All institutions Compliance only 10–Quality of Nursing Performance All institutions Case review only 11–Quality of Provider Performance All institutions Case review only Institutions with 12–Reception Center Arrivals Not Applicable reception centers All institutions with 13–Specialized Medical Housing Both case review an OHU, CTC, SNF, (OHU, CTC, SNF, Hospice) and compliance or Hospice Both case review 14–Specialty Services All institutions and compliance Two Secondary Indicators All Institutions– HDSP (Administrative) Applicability Applicability 15–Internal Monitoring, Quality Improvement, and Administrative All institutions Compliance only Operations 16–Job Performance, Training, Licensing, All institutions Compliance only and Certifications High Desert State Prison, Cycle 4 Medical Inspection Page ii Office of the Inspector General State of California Overall Assessment: Adequate Based on the clinical case reviews and compliance testing, the OIG’s overall assessment rating for HDSP was adequate. Of the Overall Assessment 12 primary (clinical) quality indicators applicable to HDSP, the Rating: OIG found one proficient, six adequate, and five inadequate. Of the two secondary (administrative) quality indicators, the OIG Adequate found both inadequate. To determine the overall assessment for HDSP, the OIG considered individual clinical ratings and individual compliance question scores within each of the indicator categories, putting emphasis on the primary indicators. Based on that analysis, OIG experts made a considered and measured overall opinion about the quality of health care observed at HDSP. Clinical Case Review and OIG Clinician Inspection Results The clinicians’ case reviews sampled patients with high medical needs and included a review of 1,046 patient care events.1 Of the 12 primary indicators applicable to HDSP, 10 were evaluated by clinician case review; one was proficient, six were adequate, and three were inadequate. When determining the overall adequacy of care, the OIG paid particular attention to the clinical nursing and provider quality indicators, as adequate health care staff can sometimes overcome suboptimal processes and programs. However, the opposite is not true; inadequate health care staff cannot provide adequate care, even though the established processes and programs onsite may be adequate. The OIG clinicians identify inadequate medical care based on the risk of significant harm to the patient, not the actual outcome. HDSP provided adequate care during the review period. Strong nurse leadership ensured continued health care delivery despite the vacuum in physician leadership. Conscientious nurses quickly identified patients who needed extra medical attention. TTA nurses and physicians rapidly identified and stabilized those patients whose conditions were deteriorating. Good performance in these areas markedly decreased the risk of harm and mitigated many of HDSP’s deficient areas. HDSP executives were enthusiastic about their institution’s prospects for improvement in many areas in the near future. The HDSP chief executive officer (CEO) had implemented a new systemwide tracking system that allowed the HDSP management team to quickly identify and correct various process problems. HDSP claimed some early successes during the onsite inspection. For example, HDSP explained that they had already corrected the diagnostic report review delays that OIG clinicians previously identified. 1 Each OIG clinician team includes a board-certified physician and registered nurse consultant with experience in correctional and community medical settings. High Desert State Prison, Cycle 4 Medical Inspection Page iii Office of the Inspector General State of California Though HDSP provided adequate care during the review period, the OIG clinicians identified serious problems from the case reviews and the onsite inspection. By the time of the onsite inspection in June 2016, these problems were already challenging HDSP’s continued ability to provide adequate care to its patients. For example, the Access to Care indicator was rated adequate based on the circumstances at the institution during the period of review. However, in the spring of 2016, one telemedicine physician stopped providing primary care services. This only exacerbated HDSP’s existing chronic provider shortage. By the time of the onsite inspection, backlogs in the A and B yard clinics had grown to approximately 100 appointments each and continued to worsen. Equally concerning was HDSP’s inadequate performance in the Pharmacy and Medication Management indicator. The OIG clinicians found that HDSP provided poor chronic medication continuity and unreliable nurse-administered medications. These problems resulted in several lapses in care. However, these lapses were generally well tolerated by HDSP’s healthy population, and did not significantly increase the risk of harm for patients. Program Strengths — Clinical  The institution’s emergency services were efficient and well run. HDSP nurses and providers excelled at providing high-quality care. Proficient emergency services helped to stabilize many patients who required urgent medical attention, which gave those patients the best chance at recovery.  Nurses performed well in both the outpatient and inpatient settings, which allowed effective delivery of good health care to their patients. The strong nursing performance helped mitigate some deficiencies in other areas.  Nursing leadership was actively engaged in continuously improving overall nursing care and services. HDSP nursing staff felt strongly supported by their supervisors and nursing leadership. Program Weaknesses — Clinical  HDSP suffered from a chronic inability to recruit medical providers. Chronic provider understaffing was reflected in the institution’s marginal Access to Care performance and poor provider morale. During the review period, prolonged vacancies were present at all provider levels, from the chief medical executive down to the clinic provider positions. Possible explanations for this shortage included a compensation package that was not competitive for newly hired State medical providers, as well as HDSP’s remote location.  Diagnostic services were poor. Case reviews identified strong patterns where diagnostic imaging and laboratory reports were never retrieved or reviewed by providers. Even when the reports were retrieved, they were often not reviewed timely. High Desert State Prison, Cycle 4 Medical Inspection Page iv Office of the Inspector General State of California  Health information management was poor. There were numerous documents missing from the eUHR. Scanning accuracy was also poor. Many documents were mislabeled or misfiled.  Medication management was poor. There were many examples of breaks in chronic care medication continuity. There were also many examples of nurses failing to administer medications as prescribed. Compliance Testing Results Of the 14 health care indicators applicable to HDSP, 11 were evaluated by compliance inspectors.2 There were 92 individual compliance questions within those 11 indicators, generating 1,146 data points, that tested HDSP’s compliance with California Correctional Health Care Services (CCHCS) policies and procedures.3 Those 92 questions are detailed in Appendix A — Compliance Test Results. The institution’s inspection scores in the 11 applicable indicators ranged from 40.6 percent to 87.0 percent, with the secondary (administrative) indicator Internal Monitoring, Quality Improvement, and Administrative Operations receiving the lowest score, and the primary indicator Inter- and Intra-System Transfers receiving the highest. Of the nine primary indicators applicable to compliance testing, the OIG rated one proficient, two adequate, and six inadequate. Of the two secondary indicators, which involve administrative health care functions, both were rated inadequate. Program Strengths — Compliance As the HDSP Executive Summary Table on page ix indicates, the institution’s compliance rating was proficient, scoring above 85 percent, in the primary indicator Inter- and Intra-System Transfers. The following are some of HDSP’s strengths based on its compliance scores on individual questions in all the primary health care indicators:  Patients had a standardized process to obtain and submit request forms for health care services, and nursing staff timely reviewed patients’ requests.  HDSP provided patients with timely radiology services and timely obtained final pathology results.  Specialty reports were timely scanned into patients’ medical records.  Clinical areas were appropriately disinfected, cleaned, and sanitized. 2 The OIG’s compliance inspectors are trained deputy inspectors general and registered nurses with expertise in CDCR policies regarding medical staff and processes. 3 The OIG used its own clinicians to provide clinical expert guidance for testing compliance in certain areas where CCHCS policies and procedures did not specifically address an issue. High Desert State Prison, Cycle 4 Medical Inspection Page v Office of the Inspector General State of California  For patients newly arriving at HDSP from other CDCR institutions, nursing staff properly documented an assessment and disposition on the Initial Health Screening form (CDCR Form 7277) and signed and dated the form on the same day the patient arrived at the institution.  Nursing staff ensured patients transferred from HDSP to other institutions with complete transfer packets and all applicable medications.  Nursing staff timely administered or delivered patients’ newly ordered medications and ensured that patients transferring from one housing unit to another received their medications without interruption.  Nurses employed appropriate administrative controls and followed proper protocols while preparing patients’ medications.  In its main pharmacy, HDSP properly accounted for narcotic medication.  The institution offered or provided patients with timely preventive influenza vaccinations during the most recently completed influenza season, as well as colorectal cancer screenings to older patients.  The institution timely offered or provided required immunizations to patients who suffered from chronic care conditions.  Nursing staff completed an initial assessment on all patients upon admittance to the correctional treatment center.  The institution’s specialized medical housing unit had properly working call buttons, and medical staff had timely access to enter patient cells during emergent events.  Patients timely received routine specialty services. In addition, when the institution denied provider requests for specialty services, the provider timely met with the patient to discuss alternate treatment strategies. The following are some of the strengths identified within the two secondary administrative indicators:  When patients appealed health-care-related issues, HDSP’s appeals staff addressed all of the patients’ issues.  All providers, nursing staff, and the pharmacist in charge were current with their professional licenses and certifications; the pharmacy and authorized providers who prescribe controlled substances maintained current Drug Enforcement Agency registrations. High Desert State Prison, Cycle 4 Medical Inspection Page vi Office of the Inspector General State of California  All nursing staff who administered medications possessed current clinical competency validations. Program Weaknesses — Compliance The institution received ratings of inadequate in the following primary indicators: Diagnostic Services, Health Information Management, Health Care Environment, Pharmacy and Medication Management, Preventive Services, and Specialty Services. The institution also received inadequate scores in both secondary indicators, Internal Monitoring, Quality Improvement, and Administrative Operations and Job Performance, Training, Licensing, and Certifications. The following are some of the weaknesses identified by HDSP’s compliance scores on individual questions in all the primary health care indicators:  The institution’s providers did not properly evidence their review of pathology reports or always communicate the corresponding results to patients.  Medical records staff often failed to correctly label health care records scanned into the patients’ electronic unit health records.  Many of the institution’s inmate restrooms lacked adequate hand hygiene supplies.  Clinical staff did not always follow universal hand hygiene precautions before or after patient encounters.  Several clinics did not always have an environment conducive to providing adequate medical services.  The institution’s emergency medical response bags routinely were missing required equipment or lacked evidence that the bags had been regularly inspected.  Many chronic care patients sampled missed one or more of their keep-on-person (KOP) medication refills, which were often not delivered timely to patients.  Clinical staff did not employ strong security controls over narcotic medications assigned to clinical areas and did not follow proper protocols for storing non-narcotic medications.  Nursing staff did not always follow appropriate administrative controls and protocols during the medication distribution process.  Nursing staff did not routinely follow required protocols for administering and reading patients’ annual tuberculosis (TB) skin tests. In addition, for those patients who tested positive for TB, nurses did not administer timely TB medications or always perform required monitoring. High Desert State Prison, Cycle 4 Medical Inspection Page vii Office of the Inspector General State of California  Providers did not timely review patients’ routine specialty services reports. The following are some of the weaknesses identified within the two secondary administrative indicators:  The institution’s emergency medical response drill packages did not always include required documentation.  Health care supervisors did not complete structured performance appraisals of providers. The HDSP Executive Summary Table on the following page lists the quality indicators the OIG inspected and assessed during the clinical case reviews and objective compliance tests, and provides the institution’s rating in each area. The overall indicator ratings were based on a consensus decision by the OIG’s clinicians and non-clinical inspectors. High Desert State Prison, Cycle 4 Medical Inspection Page viii Office of the Inspector General State of California HDSP Executive Summary Table Case Compliance Overall Indicator Primary Indicators (Clinical) Review Rating Rating Rating Access to Care Adequate Adequate Adequate Diagnostic Services Inadequate Inadequate Inadequate Emergency Services Proficient Not Applicable Proficient Health Information Management Inadequate Inadequate Inadequate (Medical Records) Health Care Environment Not Applicable Inadequate Inadequate Inter- and Intra-System Transfers Adequate Proficient Adequate Pharmacy and Medication Management Inadequate Inadequate Inadequate Preventive Services Not Applicable Inadequate Inadequate Quality of Nursing Performance Adequate Not Applicable Adequate Quality of Provider Performance Adequate Not Applicable Adequate Specialized Medical Housing Adequate Adequate Adequate (OHU, CTC, SNF, Hospice) Specialty Services Adequate Inadequate Adequate The Prenatal and Post-Delivery Services and Reception Center Arrivals indicators did not apply to this institution. Case Compliance Overall Indicator Secondary Indicators (Administrative) Review Rating Rating Rating Internal Monitoring, Quality Improvement, Not Applicable Inadequate Inadequate and Administrative Operations Job Performance, Training, Licensing, and Not Applicable Inadequate Inadequate Certifications Compliance results for quality indicators are proficient (greater than 85.0 percent), adequate (75.0 percent to 85.0 percent), or inadequate (below 75.0 percent). High Desert State Prison, Cycle 4 Medical Inspection Page ix Office of the Inspector General State of California Population-Based Metrics Overall, population-based metrics showed that HDSP’s performance was generally adequate for diabetic and pneumococcal immunization measures when compared statewide and nationally, but has room for improvement regarding influenza immunizations and colorectal cancer screenings. Statewide, the institution scored better than Medi-Cal and Kaiser in all diabetic measures except blood pressure control, in which Kaiser, South region, scored higher than HDSP. Nationally, HDSP scored higher than Medicaid, Medicare, and commercial plans. However, when compared to the United States Department of Veterans Affairs (VA), the institution scored higher in two measures but lower in two others. With regard to influenza immunization measures, HDSP’s scores were generally low. For influenza immunization of younger adults, the institution scored lower than Kaiser and the VA, but slightly outperformed commercial plans. The institution performed poorly for influenza immunizations for older adults, scoring lower than both Medicare and the VA. HDSP’s scores for influenza immunizations for both younger and older adults were negatively affected by a high patient refusal rate. In contrast, HDSP outperformed both Medicare and the VA for the administration of pneumococcal immunizations. The institution outperformed commercial plans and Medicare for colorectal cancer screenings, but performed less well in comparison to Kaiser and the VA. Again, a high patient refusal rate affected the colorectal cancer screening score for HDSP. Overall, population-based metrics indicated that HDSP’s performances in comprehensive diabetes care and pneumococcal immunizations were average in comparison to statewide and national health care organizations. The institution may improve its scores in influenza immunizations and colorectal cancer screenings by making interventions to reduce patient refusals. High Desert State Prison, Cycle 4 Medical Inspection Page x Office of the Inspector General State of California INTRODUCTION Under the authority of California Penal Code Section 6126, which assigns the Office of the Inspector General (OIG) responsibility for oversight of the California Department of Corrections and Rehabilitation (CDCR), and at the request of the federal Receiver, the OIG developed a comprehensive medical inspection program to evaluate the delivery of medical care at each of CDCR’s 35 adult prisons. For this fourth cycle of inspections, the OIG augmented the breadth and quality of its inspection program used in prior cycles, adding a clinical case review component and significantly enhancing the compliance component of the program. High Desert State Prison (HDSP) was the 28th medical inspection of Cycle 4. During the inspection process, the OIG assessed the delivery of medical care to patients for 12 primary clinical health care indicators and two secondary administrative health care indicators applicable to the institution. It is important to note that while the primary quality indicators represent the clinical care being provided by the institution at the time of the inspection, the secondary quality indicators are purely administrative and are not reflective of the actual clinical care provided. The OIG is committed to reporting on each institution’s delivery of medical care to assist in identifying areas for improvement, but the federal court will ultimately determine whether any institution’s medical care meets constitutional standards. ABOUT THE INSTITUTION HDSP is located in Susanville and primarily houses medium- and high-security inmates. The institution offers offenders educational opportunities, re-entry services, recreational activities, and leisure time activity group programs to reduce recidivism. HDSP is designated a “basic” health care institution; basic facilities are typically located in rural areas, far away from tertiary care centers and specialty care providers whose services would likely be used frequently by patients with higher medical risk. Because of HDSP’s remote location and its basic health care status, CDCR generally places healthier patients in this institution. The institution operates seven regular medical clinics where health care staff provide non-urgent requests for medical services. In addition, HDSP operates a triage and treatment area (TTA) for urgent and emergency care, a receiving and release (R&R) clinic for arriving and departing inmates, and a specialty clinic. HDSP also provides health care in its correctional treatment center (CTC) for those patients who need a higher level of care. High Desert State Prison first received national accreditation from the Commission on Accreditation for Corrections in August 2013. This accreditation program is a professional peer High Desert State Prison, Cycle 4 Medical Inspection Page 1 Office of the Inspector General State of California review process based on national standards set by the American Correctional Association. HDSP received re-accreditation in August 2016. As detailed in the health care staffing resources table below, HDSP’s vacancy rate among medical managers, primary care providers, supervisors, and nurses averaged 23.3 percent in April 2016. The highest percentage of vacancies was in the managerial category at 40 percent. This was attributable to vacancies in two of five health care managerial positions: the chief medical executive (CME) and the chief support executive (CSE). As of October 2016, these positions are still vacant. The highest total number of vacancies was in nursing staff. In April 2016, HDSP had a vacancy rate of 25 percent for nursing positions, and an additional three nursing staff positions (4 percent) were on long-term medical leave. HDSP Health Care Staffing Resources as of April 2016 Primary Care Nursing Nursing Management Totals Providers Supervisors Staff Description Number % Number % Number % Number % Number % Authorized 5 4% 7.5 6% 10.5 9% 99 81% 122 100% Positions Filled Positions 3 60% 6.5 86.5% 10 95% 74 75% 93.5 76.7% Vacancies 2 40% 1 13.5% .5 5% 25 25% 28.5 23.3% Recent Hires (within 12 3 100% 3 46% 0 0% 18 24% 24 25.7% months) Staff Utilized 0 0% 0 0% 0 0% 0 0% 0 0% from Registry Redirected Staff (to Non-Patient 0 0% 0 0% 0 0% 0 0% 0 0% Care Areas) Staff on Long-term 0 0% 0 0% 0 0% 3 4% 3 3% Medical Leave Note 1: HDSP Health Care Staffing Resources data was not validated by the OIG. High Desert State Prison, Cycle 4 Medical Inspection Page 2 Office of the Inspector General State of California As of April 11, 2016, the Master Registry for HDSP showed that the institution had a total population of 3,642. Within that total population, only 0.44 percent were designated as high medical risk, Priority 1 (High 1), and 1.32 percent were designated as high medical risk, Priority 2 (High 2). Patients’ assigned risk levels are based on the complexity of their required medical care related to their specific diagnoses, frequency of higher levels of care, age, and abnormal laboratory tests 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. HDSP Master Registry Data as of April 11, 2016 Medical Risk Level # of Inmate-Patients Percentage High 1 16 0.44% High 2 48 1.32% Medium 1,503 41.27% Low 2,075 56.97% Total 3,642 100% High Desert State Prison, Cycle 4 Medical Inspection Page 3 Office of the Inspector General State of California Commonly Used Abbreviations ACLS Advanced Cardiovascular Life Support HIV Human Immunodeficiency Virus AHA American Heart Association HTN Hypertension ASU Administrative Segregation Unit INH Isoniazid (anti-tuberculosis medication) BLS Basic Life Support IV Intravenous CBC Complete Blood Count KOP Keep-on-Person (in taking medications) CC Chief Complaint LPT Licensed Psychiatric Technician CCHCS California Correctional Health Care Services LVN Licensed Vocational Nurse CCP Chronic Care Program MAR Medication Administration Record California Department of Corrections and CDCR MRI Magnetic Resonance Imaging Rehabilitation CEO Chief Executive Officer MD Medical Doctor CHF Congestive Heart Failure NA Nurse Administered (in taking medications) CME Chief Medical Executive N/A Not Applicable CMP Comprehensive Metabolic (Chemistry) Panel NP Nurse Practitioner CNA Certified Nursing Assistant OB Obstetrician CNE Chief Nurse Executive OHU Outpatient Housing Unit C/O Complains of OIG Office of the Inspector General COPD Chronic Obstructive Pulmonary Disease P&P Policies and Procedures (CCHCS) CP&S Chief Physician and Surgeon PA Physician Assistant CPR Cardio-Pulmonary Resuscitation PCP Primary Care Provider CSE Chief Support Executive POC Point of Contact CT Computerized Tomography PPD Purified Protein Derivative CTC Correctional Treatment Center PRN As Needed (in taking medications) DM Diabetes Mellitus RN Registered Nurse Directly Observed Therapy (in taking DOT Rx Prescription medications) Dx Diagnosis SNF Skilled Nursing Facility Subjective, Objective, Assessment, Plan, EKG Electrocardiogram SOAPE Education ENT Ear, Nose and Throat SOMS Strategic Offender Management System ER Emergency Room S/P Status Post eUHR electronic Unit Health Record TB Tuberculosis FTF Face-to-Face TTA Triage and Treatment Area History and Physical (reception center H&P UA Urinalysis examination) HIM Health Information Management UM Utilization Management High Desert State Prison, Cycle 4 Medical Inspection Page 4 Office of the Inspector General State of California OBJECTIVES, SCOPE, AND METHODOLOGY In designing the medical inspection program, the OIG reviewed CCHCS policies and procedures, relevant court orders, and guidance developed by the American Correctional Association. The OIG also reviewed professional literature on correctional medical care; reviewed standardized performance measures used by the health care industry; consulted with clinical experts; and met with stakeholders from the court, the Receiver’s office, CDCR, the Office of the Attorney General, and the Prison Law Office to discuss the nature and scope of the OIG’s inspection program. With input from these stakeholders, the OIG developed a medical inspection program that evaluates medical care delivery by combining clinical case reviews of patient files, objective tests of compliance with policies and procedures, and an analysis of outcomes for certain population-based metrics. To maintain a metric-oriented inspection program that evaluates medical care delivery consistently at each State prison, the OIG identified 14 primary (clinical) and 2 secondary (administrative) quality indicators of health care to measure. The primary quality indicators cover clinical categories directly relating to the health care provided to patients, whereas the secondary quality indicators address the administrative functions that support a health care delivery system. The 14 primary quality indicators are Access to Care, Diagnostic Services, Emergency Services, Health Information Management (Medical Records), Health Care Environment, Inter- and Intra-System Transfers, Pharmacy and Medication Management, Prenatal and Post-Delivery Services, Preventive Services, Quality of Nursing Performance, Quality of Provider Performance, Reception Center Arrivals, Specialized Medical Housing (OHU, CTC, SNF, Hospice), and Specialty Services. The two secondary quality indicators are Internal Monitoring, Quality Improvement, and Administrative Operations; and Job Performance, Training, Licensing, and Certifications. The OIG rates each of the quality indicators applicable to the institution under inspection based on case reviews conducted by OIG clinicians and compliance tests conducted by OIG deputy inspectors general and registered nurses. The ratings may be derived from the case review results alone, the compliance test results alone, or a combination of both these information sources. For example, the ratings for the primary quality indicators Quality of Nursing Performance and Quality of Provider Performance are derived entirely from the case review results, while the ratings for the primary quality indicators Health Care Environment and Preventive Services are derived entirely from compliance test results. As another example, primary quality indicators such as Diagnostic Services and Specialty Services receive ratings derived from both sources. At HDSP, 14 of the quality indicators were applicable, consisting of 12 primary clinical indicators and 2 secondary administrative indicators. Of the 12 primary indicators, 7 were rated by both case review clinicians and compliance inspectors, 3 were rated by case review clinicians only, and 2 were rated by compliance inspectors only; both secondary indicators were rated by compliance inspectors only. High Desert State Prison, Cycle 4 Medical Inspection Page 5 Office of the Inspector General State of California 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 an inmate-patient needing immediate care, the OIG notifies the chief executive officer of health care services and requests a status report. Additionally, if the OIG learns of significant departures from community standards, it may report such departures to the institution’s chief executive officer or to CCHCS. Because these matters involve confidential medical information protected by State and federal privacy laws, specific identifying details related to any such cases are not included in the OIG’s public report. In all areas, the OIG is alert for opportunities to make appropriate recommendations for improvement. Such opportunities may be present regardless of the score awarded to any particular quality indicator; therefore, recommendations for improvement should not necessarily be interpreted as indicative of deficient medical care delivery. CASE REVIEWS The OIG has added case reviews to the Cycle 4 medical inspections at the recommendation of its stakeholders. At the conclusion of Cycle 3, the federal Receiver and the Inspector General determined that the health care provided at the institutions was not fully evaluated by the compliance tool alone, and that the compliance tool was not designed to provide comprehensive qualitative assessments. Accordingly, the OIG added case reviews in which OIG physicians and nurses evaluate selected cases in detail to determine the overall quality of health care provided to the inmate-patients. The OIG’s clinicians perform a retrospective chart review of selected patient files to evaluate the care given by an institution’s primary care providers and nurses. Retrospective chart review is a well-established review process used by health care organizations that perform peer reviews and patient death reviews. Currently, CCHCS uses retrospective chart review as part of its death review process and in its pattern-of-practice reviews. CCHCS also uses a more limited form of retrospective chart review when performing appraisals of individual primary care providers. PATIENT SELECTION FOR RETROSPECTIVE CASE REVIEWS Because retrospective chart review is time consuming and requires qualified health care professionals to perform it, OIG clinicians must carefully sample patient records. Accordingly, the group of patients the OIG targeted for chart review carried the highest clinical risk and utilized the majority of medical services. A majority of the patients selected for retrospective chart review were classified by CCHCS as high-risk patients. The reason the OIG targeted these patients for review is twofold: High Desert State Prison, Cycle 4 Medical Inspection Page 6 Office of the Inspector General State of California 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 are considered high-risk and account for more than half of the institution’s pharmaceutical, specialty, community hospital, and emergency costs. 2. Selecting this target group for chart review provides a significantly greater opportunity to evaluate all the various aspects of the health care delivery system at an institution. Underlying the choice of high-risk patients for detailed case review, 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 will be providing adequate care to patients with less complicated health care issues. Because clinical expertise is required to determine whether the institution has provided adequate clinical care, the OIG utilizes experienced correctional physicians and registered nurses to perform this analysis. 2. The health of less complex patients is more likely to be affected by processes such as timely appointment scheduling, medication management, routine health screening, and immunizations. To review these processes, the OIG simultaneously performs a broad compliance review. 3. Patient charts generated during death reviews, sentinel events (unexpected occurrences involving death or serious injury, or risk thereof), and hospitalizations are mostly of high-risk patients. BENEFITS AND LIMITATIONS OF TARGETED SUBPOPULATION REVIEW Because the selected patients utilize the broadest range of services offered by the health care system, the OIG’s retrospective chart review provides adequate data for a qualitative assessment of the most vital system processes (referred to as “primary quality indicators”). Retrospective chart review provides an accurate qualitative assessment of the relevant primary quality indicators as applied to the targeted subpopulation of high-risk and high-utilization patients. While this targeted subpopulation does not represent the prison population as a whole, the ability of the institution to provide adequate care to this subpopulation is a crucial and vital indicator of how the institution provides health care to its whole patient population. Simply put, if the institution’s medical system does not adequately care for those patients needing the most care, then it is not fulfilling its obligations, even if it takes good care of patients with less complex medical needs. High Desert State Prison, Cycle 4 Medical Inspection Page 7 Office of the Inspector General State of California 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 can be reasonably inferred that the health care system is also providing appropriate diabetic services to the entire diabetic subpopulation. However, if these same high-risk patients needing monitoring, medications, and referrals are generally not getting those services, it is likely that the health care system is not providing appropriate diabetic services to the greater diabetic subpopulation. CASE REVIEWS SAMPLED As indicated in Appendix B, Table B–1: HDSP Sample Sets, the OIG clinicians evaluated medical charts for 72 unique inmate-patients. Appendix B, Table B–4: HDSP Case Review Sample Summary, clarifies that both nurses and physicians reviewed charts for 20 of those patients, for 92 reviews in total. Physicians performed detailed reviews of 30 charts, and nurses performed detailed reviews of 20 charts, totaling 50 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 41 inmate-patients. These generated 1,046 clinical events for review (Appendix B, Table B–3: HDSP 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 5 chronic care patient records, i.e., 4 diabetes patients and 1 anticoagulation patient (Appendix B, Table B–1: HDSP Sample Sets), the 72 unique inmate-patients sampled included patients with 243 chronic care diagnoses, including 15 additional patients with diabetes (for a total of 19) and 2 additional anticoagulation patients (for a total of 3) (Appendix B, Table B–2: HDSP Chronic Care Diagnoses). The OIG’s sample selection tool evaluated many chronic care programs because the complex and high-risk patients selected from the different categories often had multiple medical problems. While the OIG did not evaluate every chronic disease or health care staff member, the overall operation of the institution’s system and staff were assessed for adequacy. The OIG’s case review methodology and sample size matched High Desert State Prison, Cycle 4 Medical Inspection Page 8 Office of the Inspector General State of California other qualitative research. The empirical findings, supported by expert statistical consultants, showed adequate conclusions after 10 to 15 charts had undergone full clinician review. In qualitative statistics, this phenomenon is known as “saturation.” The OIG asserts that the physician sample size of 30 detailed reviews certainly far exceeds the saturation point necessary for an adequate qualitative review. With regard to reviewing charts from different providers, the case review is not intended to be a focused search for poorly performing providers; rather, it is focused on how the system cares for those patients who need 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 as either proficient (excellent), adequate (passing), inadequate (failing), or not applicable. A separate confidential HDSP Supplemental Medical Inspection Results: Individual Case Review Summaries report details the case reviews OIG clinicians conducted and is available to specific stakeholders. For further details regarding the sampling methodologies and counts, see Appendix B — Clinical Data, Table B–1; Table B–2; Table B–3; and Table B–4. COMPLIANCE TESTING SAMPLING METHODS FOR CONDUCTING COMPLIANCE TESTING From May to July 2016, deputy inspectors general and registered nurses attained answers to 92 objective medical inspection test (MIT) questions designed to assess the institution’s compliance with critical policies and procedures applicable to the delivery of medical care. To conduct most tests, inspectors randomly selected samples of inmate-patients for whom the testing objectives were applicable and reviewed their electronic unit health records. In some cases, inspectors used the same samples to conduct more than one test. In total, inspectors reviewed health records for 390 individual inmate-patients and analyzed specific transactions within their records for evidence that critical events occurred. Inspectors also reviewed management reports and meeting minutes to assess certain administrative operations. In addition, during the week of May 2, 2016, field inspectors conducted a detailed onsite inspection of HDSP’s medical facilities and clinics; interviewed key institutional employees; and reviewed employee records, logs, medical appeals, death reports, and other documents. This generated 1,146 scored data points to assess care. High Desert State Prison, Cycle 4 Medical Inspection Page 9 Office of the Inspector General State of California In addition to the scored questions, the OIG obtained information from the institution that it did not score. This included, for example, information about HDSP’s plant infrastructure, protocols for tracking medical appeals and local operating procedures, and staffing resources. For details of the compliance results, see Appendix A — Compliance Test Results. For details of the OIG’s compliance sampling methodology, see Appendix C — Compliance Sampling Methodology. SCORING OF COMPLIANCE TESTING RESULTS The OIG rated the institution in the following nine primary (clinical) and two secondary (administrative) quality indicators applicable to the institution for compliance testing:  Primary indicators: Access to Care, Diagnostic Services, Health Information Management (Medical Records), Health Care Environment, Inter- and Intra-System Transfers, Pharmacy and Medication Management, Preventive Services, Specialized Medical Housing (OHU, CTC, SNF, Hospice), and Specialty Services.  Secondary indicators: Internal Monitoring, Quality Improvement, and Administrative Operations; and Job Performance, Training, Licensing, and Certifications. After compiling the answers to the 92 questions, the OIG derived a score for each primary and secondary quality indicator identified above by calculating the percentage score of all Yes answers for each of the questions applicable to a particular indicator, then averaging those scores. Based on 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). DASHBOARD COMPARISONS In the first ten medical inspection reports of Cycle 4, the OIG identified where similar metrics for some of the individual compliance questions were available within the CCHCS Dashboard, which is a monthly report that consolidates key health care performance measures statewide and by institution. However, there was not complete parity between the metrics due to differing time frames for data collecting and differences in sampling methods, rendering the metrics non-comparable. The OIG has removed the Dashboard comparisons to eliminate confusion. Dashboard data is available on CCHCS’s website, www.cphcs.ca.gov. High Desert State Prison, Cycle 4 Medical Inspection Page 10 Office of the Inspector General State of California OVERALL QUALITY INDICATOR RATING FOR CASE REVIEWS AND COMPLIANCE TESTING The OIG derived the final rating for each quality indicator by combining the ratings from the case reviews and from the compliance testing, as applicable. When combining these ratings, the case review evaluations and the compliance testing results usually agreed, but there were instances when the rating differed for a particular quality indicator. In those instances, the inspection team assessed the quality indicator based on the collective ratings from both components. Specifically, the OIG clinicians and deputy inspectors general discussed the nature of individual exceptions found within that indicator category and considered the overall effect on the ability of patients to receive adequate medical care. To derive an overall assessment rating 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 inmate-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 inmate-patient population. To identify outcomes for HDSP, the OIG reviewed some of the compliance testing results, randomly sampled additional patients’ records, and obtained HDSP data from the CCHCS Master Registry. The OIG compared those results to HEDIS metrics reported by other statewide and national health care organizations. High Desert State Prison, Cycle 4 Medical Inspection Page 11 Office of the Inspector General State of California MEDICAL INSPECTION RESULTS PRIMARY (CLINICAL) QUALITY INDICATORS OF HEALTH CARE The primary quality indicators assess the clinical aspects of health care. As shown on the Health Care Quality Indicators table on page ii of this report, 12 of the OIG’s primary indicators were applicable to HDSP. Of those 12 indicators, 7 were rated by both the case review and compliance components of the inspection, 3 were rated by the case review component alone, and 2 were rated by the compliance component alone. The HDSP Executive Summary Table on page ix shows the case review compliance ratings for each applicable indicator. Summary of Case Review Results: The clinical case review component assessed 10 of the 12 primary (clinical) indicators applicable to HDSP. Of these ten indicators, OIG clinicians rated one proficient, six adequate, and three inadequate. The OIG physicians rated the overall adequacy of care for each of the 30 detailed case reviews they conducted. Of these 30 cases, one was proficient, 24 were adequate, and 5 were inadequate. In the 1,046 events reviewed, there were 371 deficiencies, of which 106 were considered to be of such magnitude that, if left unaddressed, they would likely contribute to patient harm. Adverse Events Identified During Case Review: Medical care is a complex dynamic process with many moving parts, subject to human error even within the best health care organizations. Adverse events are typically identified and tracked by all major health care organizations for the purpose of quality improvement. They are not generally representative of medical care delivered by the organization. The OIG identified adverse events for the dual purposes of quality improvement and the illustration of problematic patterns of practice found during the inspection. Because of the anecdotal description of these events, the OIG cautions against drawing inappropriate conclusions regarding the institution based solely on adverse events. For HDSP, these events were not representative of overall care delivery in the institution, as several of the providers involved in these cases no longer work for HDSP or CCHCS. There were two sentinel events and one “near miss” identified in the case reviews at HDSP:  In case 30, the patient saw the ophthalmologist for intermittent vision loss. When the ophthalmologist examined the patient, there was papilledema, or swelling of the optic disc, that suggested markedly increased pressure in the brain. This was a potentially life-threatening condition, so the eye doctor referred the patient to the TTA physician with recommendations for an immediate MRI of the brain and admission to a higher level of care for emergent assessment. While the TTA physician did order an emergent MRI, the provider High Desert State Prison, Cycle 4 Medical Inspection Page 12 Office of the Inspector General State of California failed to refer the patient to a higher level of care. When the MRI returned normal, the patient was inappropriately sent back to housing. Three days later, the patient saw a different provider, who then arranged an appropriate evaluation. The patient spent the next three weeks in the hospital, where he was diagnosed with an extensive blood clot in the brain. The patient was fortunate that the three-day delay caused by the first TTA provider did not result in permanent harm. The OIG clinicians classified this provider error as a near miss.  In case 63, the patient returned from the hospital and was admitted to the correctional treatment center (CTC). The CTC nurse did not perform a complete medication reconciliation and did not obtain orders for the patient’s chronic seizure medications. The CTC provider failed to perform an admission evaluation or a history and physical. The CTC provider also neglected to reconcile the patient’s medications and failed to order the patient’s chronic seizure medications. The patient developed a seizure 12 days later and was sent to an outside emergency room. The OIG clinicians classified this as a sentinel event.  In case 3, good CTC care was provided until the patient’s clinical status deteriorated two days before he was hospitalized in an outside community hospital. The patient began to have seizures, evidenced by intermittent confusion, bruising of the arms, incontinence, and inability to follow commands. CTC nurses notified the provider multiple times due to the change in clinical condition compared to his baseline. The patient spent the majority of the second day of seizures on the floor of the CTC. Unfortunately, the provider repeatedly ignored the nurses’ concerns and did not believe that the patient was having true seizures, despite the patient having had a documented seizure disorder with associated EEG and MRI abnormalities on two separate occasions. It was not until the third day of progressive deterioration that the provider sent the patient out to the hospital. By the time the patient arrived at the hospital, he was in full-blown status epilepticus, which was a dangerous condition where epileptic seizures followed one after another without recovery of consciousness between them. He continued to seize despite aggressive interventions by the hospital. The patient died in the hospital. Earlier recognition of the patient’s seizure condition likely could have prevented his death. The OIG clinicians classified this potentially preventable death as a sentinel event. Summary of Compliance Results: The compliance component assessed 9 of the 12 primary (clinical) indicators applicable to HDSP. Of these nine indicators, OIG inspectors rated one proficient, two adequate, and six inadequate. The results of those assessments are summarized within this section of the report. The test questions used to assess compliance for each indicator are detailed in Appendix A. High Desert State Prison, Cycle 4 Medical Inspection Page 13 Office of the Inspector General State of California ACCESS TO CARE This indicator evaluates the institution’s ability to provide Case Review Rating: inmate-patients with timely clinical appointments. Areas specific to Adequate inmate-patients’ access to care are reviewed, such as initial Compliance Score: assessments of newly arriving inmates, acute and chronic care Adequate follow-ups, face-to-face nurse appointments when an inmate-patient (79.0%) requests to be seen, provider referrals from nursing lines, and Overall Rating: follow-ups after hospitalization or specialty care. Compliance testing Adequate for this indicator also evaluates whether inmate-patients have Health Care Services Request forms (CDCR Form 7362) available in their housing units. Case Review Results The OIG clinicians reviewed 280 provider, nursing, specialty, and outside hospital encounters for which a follow-up needed to be scheduled, and found 38 deficiencies relating to Access to Care. Fifteen of the 38 deficiencies were likely to cause patient harm if allowed to persist. Though scheduling and appointment problems were frequent, the deficiencies exposed patients to only moderate medical risk. HDSP Access to Care was rated adequate. Provider-to-Provider Follow-up Appointments HDSP performed marginally with provider-ordered follow-up appointments. These are among the most important aspects of the Access to Care indicator. Failure to accommodate provider-ordered appointments can often result in lapses in care or in patients being lost to follow-up. Deficiencies in this area were common, identified in cases 8, 10, 12, 14, 16, 17, 20, 23, and 26. Fortunately, most of HDSP’s deficiencies in this area did not result in patients being lost to follow-up, but instead caused delayed care. The generally healthy HDSP population was able to tolerate delays in care without excessive risk of harm.  In case 10, the provider ordered a 90-to-120-day chronic care follow-up for hyperlipidemia (high cholesterol). The patient was seen about a month later than ordered. This caused no significant risk of harm. Most deficiencies were similar in risk to case 10. However, similar delays did expose the occasional patient to elevated medical risk if the patient was not medically stable, or was somewhat complex.  In case 23, the patient had poorly controlled diabetes. The provider appropriately assessed the patient’s condition, prescribed appropriate medications, and ordered a follow-up in five to ten weeks. There was a severe lapse in care when the patient’s medications expired and he High Desert State Prison, Cycle 4 Medical Inspection Page 14 Office of the Inspector General State of California was almost lost to follow-up. The patient was not scheduled until nearly two months later than ordered. RN Sick Call Access HDSP demonstrated good ability to provide patients with prompt sick call nurse access. RN-to-Provider Referrals Any properly functioning health care system must allow nurses to refer a patient for a provider evaluation if the patient’s medical needs are beyond the nurse’s scope of practice. HDSP performed adequately, with a majority of nurse to provider referrals resulting in a timely provider appointment. Of the 37 reviewed sick call encounters where a nurse generated a provider appointment, deficiencies where the appointment did not occur timely were identified in cases 5, 9, 38, 42, and 47. RN-to-RN Follow-up Appointments Nurses often referred patients for nursing follow-up appointments to ensure clinical progress with the plan of care. HDSP kept those appointments proficiently, with only one deficiency identified in case 5. Provider Follow-up After Specialty Service The institution usually provided patients with a provider follow-up after specialty services. The OIG clinicians reviewed 68 diagnostic and consultative specialty services. The provider follow-up appointment did not occur timely in cases 8, 9, 13, 18, 20, and 30. This finding was consistent with HDSP’s inconsistency in providing timely provider appointments. Intra-System Transfers HDSP had difficulty in providing access to new patients who were transferred from another CDCR institution. The OIG clinicians reviewed seven transfer-in patients and found three deficient cases (cases 14, 22, and 34). While most HDSP patients generally tolerated delays in care, there was one notable exception in this area:  In case 14, the patient had numerous medical problems, including heart and lung problems, and internal blood clots that were hard to manage with traditional anticoagulation medications. The patient was not seen for a comprehensive intake evaluation until nearly two months after his arrival at HDSP. This delay contributed to several lapses in care, such as breaks in medication continuity and inadequate evaluation of his new-onset renal insufficiency. High Desert State Prison, Cycle 4 Medical Inspection Page 15 Office of the Inspector General State of California Follow-up After Hospitalization HDSP did well at ensuring that providers followed up with their patients after the patients returned from an outside hospital or emergency department. Among 25 hospitalization and outside emergency events reviewed, there was only one delay in provider follow-up (case 7). Follow-up After Onsite Urgent/Emergent Care HDSP did well at ensuring a provider follow-up appointment for patients who were seen in the TTA or for whom the on-call provider ordered a follow-up appointment. Such appointments were of particular importance because most of these patients had a change in medical status and were at higher risk for medical complications. The OIG clinicians reviewed 32 TTA events, 14 of which required a close provider follow-up. In only one case (case 14) was there a delay in provider follow-up. Specialized Medical Housing HDSP performed adequately with provider access during and after patients’ admission to the CTC. A provider usually saw CTC patients at appropriate intervals. The OIG clinicians reviewed ten CTC admissions with 88 encounters. In four instances, providers did not perform CTC rounds timely. There were also two instances in which the provider did not timely complete an admission note or history and physical for the CTC admission (cases 15 and 63). Specialty Access Access to specialty services is discussed in the Specialty Services indicator. HDSP generally performed well in this area. Diagnostic Results Follow-up HDSP provided adequate follow-up after abnormal results of diagnostic tests. After reviewing diagnostic results, providers indicated whether the patients required follow-up appointments on the Notification of Diagnostic Test Results (CDCR Form 7393). HDSP performed adequately in this area, only missing follow-up appointments in two cases (cases 22 and 23). Clinician Onsite Inspection The OIG clinicians tried to determine if any process problems could explain why HDSP had intermittent difficulty with ensuring timely provider appointments. The institution’s schedulers explained that the most common problem was the lack of provider availability. The recent loss of one telemedicine primary care physician in the spring of 2016 exacerbated the problem. HDSP had been chronically short of providers. Backlogs continued to grow, especially on the A and B yards where demand for medical services was highest. At the time of the clinician onsite inspection, there High Desert State Prison, Cycle 4 Medical Inspection Page 16 Office of the Inspector General State of California were backlogs of approximately 100 appointments on both yards. Frequently, HDSP providers were unable to see all the patients scheduled each day. Schedulers predicted worsening of the backlogs in the near future given the current provider shortage. The CEO noted that the institution had two vacant provider positions as well as a vacant chief physician and surgeon position. The chief medical executive position had been vacant until just one week prior to the clinician onsite inspection. The CEO explained that provider hiring was centralized at the CCHCS headquarters level. HDSP’s remote locale posed additional unique challenges for the recruitment of qualified provider staff. Clinician Summary During the review period, HDSP demonstrated an adequate ability to provide patients with Access to Care. Chronic provider understaffing was responsible for most of the identified delays. Fortunately, most of the patients at HDSP were healthy and could tolerate minor delays in care. The scheduling processes appeared to be functional, but the lack of provider availability was evident in the cases reviewed, and scheduling problems appeared to be worsening by the time of the clinician onsite inspection. Nevertheless, the OIG clinicians rated this indicator adequate. Compliance Testing Results The institution performed in the adequate range in the Access to Care indicator, with a compliance score of 79.0 percent. HDSP scored in the proficient range in the following test areas:  Patients had access to Health Care Services Request forms (CDCR Form 7362) at all six housing units inspected (MIT 1.101).  Inspectors sampled 30 health care services request forms submitted by patients throughout the institution. For 29 of the sampled patients (97 percent), nursing staff reviewed the request forms on the same day they received them. For one patient, the nurse reviewed the request one day late (MIT 1.003).  Among 29 sampled patients who submitted sick call request forms and required a face-to-face triage nurse encounter, 26 (90 percent) received timely encounters with well-documented nursing notes. For three patients, the nurse did not document any nursing notes (MIT 1.004). HDSP performed in the adequate range in the following two tests:  Of 24 sampled patients who received a high-priority or routine specialty service, 20 (83 percent) received a timely follow-up appointment with a provider. Two patients’ high-priority specialty service follow-up appointments were one and 11 days late. Two other High Desert State Prison, Cycle 4 Medical Inspection Page 17 Office of the Inspector General State of California patients’ routine specialty service follow-up appointments were 4 and 32 days late (MIT 1.008).  Among six sampled patients whom nursing staff referred to a provider and for whom the provider subsequently ordered a follow-up appointment, five (83 percent) timely received their follow-up appointments. For one patient, there was no evidence found that the follow-up visit occurred (MIT 1.006). The institution has room for improvement in the following areas:  Only 14 of 24 patients sampled who transferred into HDSP from other institutions and were referred to a provider based on nursing staff’s initial health care screening (58 percent) were seen timely. Nine patients were seen from one to 28 days late; one other patient never received his provider appointment (MIT 1.002).  Only three of five sampled patients who were discharged from a community hospital (60 percent) received a timely provider follow-up appointment upon their return to HDSP. Two patients received their follow-up appointments 7 and 11 days late (MIT 1.007).  Among 13 health care service requests sampled on which nursing staff referred the patient for a provider appointment, nine patients (69 percent) received a timely appointment. Four patients received their appointments from 2 to 44 days late (MIT 1.005).  Among 30 sampled patients who suffered from one or more chronic care conditions, only 21 (70 percent) timely received provider follow-up appointments. Nine other patients received late appointments or never received their appointments at all. More specifically, five patients received their appointments from three to 45 days late, one patient’s appointment was almost six months late, and three other patients never received their chronic care appointments (MIT 1.001). Recommendations No specific recommendations. High Desert State Prison, Cycle 4 Medical Inspection Page 18 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 Inadequate were timely provided to inmate-patients, whether the primary care Compliance Score: provider timely reviewed the results, and whether the results were Inadequate communicated to the inmate-patient within the required time (65.6%) frames. In addition, for pathology services, the OIG determines Overall Rating: whether the institution received a final pathology report and Inadequate whether the provider timely reviewed and communicated the pathology results to the patient. The case reviews also factor in the appropriateness, accuracy, and quality of the diagnostic test(s) ordered and the clinical response to the results. Case Review Results The OIG clinicians reviewed 134 diagnostic events and found 54 deficiencies, 47 of which were related to health information management, often with several deficiencies occurring within the same case. HDSP performed the majority of diagnostic services in a timely manner. However, diagnostic tests not completed in the following four cases constituted serious system deficiencies that could have led to significant delays, or even lapses in care:  In case 5, the prostate-specific antigen (PSA) test for prostate cancer was not performed.  In case 18, the provider ordered laboratory tests required for monitoring the patient’s chronic coccidioidomycosis (valley fever) infection. The laboratory tests were not performed, which contributed to a lapse in care.  In case 22, the provider ordered laboratory tests for the patient’s poorly controlled diabetes. The laboratory tests were not performed, which also contributed to a lapse in care.  In case 25, the patient was being monitored for his warfarin (anticoagulant) levels every two weeks. Inexplicably, HDSP stopped performing the laboratory tests. Fortunately, the patient’s anticoagulation levels were stable during the several months it took for the provider to reorder the laboratory tests. High Desert State Prison, Cycle 4 Medical Inspection Page 19 Office of the Inspector General State of California HDSP performed poorly retrieving radiology reports from the radiology information system and scanning them into the eUHR. Failure to retrieve radiology reports increases the risk of patient harm caused by a lapse in care when a provider is unaware of diagnostic reports. Even if the ordering provider was initially notified of the report and reviewed it, the report would still not be readily available to any subsequent medical staff. Any nurse or provider caring for the patient in the future would face a tremendous barrier in attempting to review radiology reports that had not been scanned into the eUHR. At the onsite inspection, HDSP leadership explained that they had stopped scanning radiology reports into the eUHR based on a directive from CCHCS headquarters. Failure to retrieve and scan radiology reports into the eUHR was identified in cases 5, 6, 11, 15, 18, and 26. In addition to the issues with radiology reports, HDSP often failed to retrieve laboratory reports or scan them into the eUHR. This problem was common (cases 5, 7, 9, 13, 15, 16, 20, 21, and 25). HDSP providers often failed to review diagnostic test results in a timely manner, with delays found in cases 5, 10, 13, 14, 15, 17, 18, 21, 22, 25, and 30. HDSP providers did not consistently date or initial the diagnostic test reports when they reviewed them. This deficiency was identified in cases 7, 20, 25, and 30. Clinician Onsite Inspection HDSP staff demonstrated a new tracking system that had been implemented with the CEO who worked at HDSP from January to August 2016. HDSP acknowledged that there were significant delays in the review of laboratory reports, but the new internal tracking methods had led to marked improvement in this area. Clinician Summary Radiology and laboratory tests were completed in a timely manner, with occasional episodes of diagnostic tests that were not completed. Retrieval of diagnostic test results was highly problematic, both for laboratory and radiology reports. Failure to place radiology reports into the main medical record presented a significant and ongoing risk of harm. HDSP providers often did not review diagnostic test results in a timely manner and did not always date or initial their test reports. The OIG clinicians rated this indicator inadequate. High Desert State Prison, Cycle 4 Medical Inspection Page 20 Office of the Inspector General State of California Compliance Testing Results The institution received a compliance score of 65.6 percent in the Diagnostic Services indicator, which encompasses radiology, laboratory, and pathology services. For clarity, each type of diagnostic service type is discussed separately below: Radiology Services  All ten sampled radiology services provided to patients’ were timely performed (MIT 2.001). However, providers only properly evidenced their review for eight of the ten (80 percent) sampled radiology reports by documenting their initials and date on the report within required time frames. Providers reviewed two reports 8 and 19 days late (MIT 2.002). Providers timely communicated patients’ radiology results for only seven of the ten patients (70 percent). For three patients, providers communicated the results from one to eight days late (MIT 2.003). Laboratory Services  Eight of ten sampled patients (80 percent) received their provider ordered laboratory services timely. Two of the ten patients’ services were provided two and five days late (MIT 2.004). Also, providers timely reviewed and initialed the laboratory reports for only six of the ten (60 percent) sampled patients. Providers reviewed four reports one to four days late (MIT 2.005). Finally, providers timely communicated the laboratory report results to only six of the ten patients (60 percent). Providers communicated the results to four patients from one to four days late (MIT 2.006). Pathology Services  The institution timely received the final pathology report for nine of ten patients sampled (90 percent). For one patient, the institution received the final report 41 days late (MIT 2.007). For all ten pathology services samples reviewed, there was no evidence found in the eUHR that the provider reviewed and initialed the report. As a result, the institution scored zero on this test (MIT 2.008). Lastly, providers timely communicated the final pathology results to only five of the ten patients (50 percent). For three patients, the provider communicated the pathology results from one to 48 days late; for two patients, there was no evidence found in the eUHR that the provider communicated the test results to the patients (MIT 2.009). High Desert State Prison, Cycle 4 Medical Inspection Page 21 Office of the Inspector General State of California Recommendation for CCHCS  The OIG recommends CCHCS revisit issuing directives that instruct institutions to stop scanning radiology reports into the eUHR. Any such directive presents a serious risk of patient harm. Recommendations for HDSP  The OIG recommends the institution retrieve all radiology reports that have not been scanned since late 2015 and scan them into the eUHR, and ensure that all future radiology reports are timely scanned.  The OIG recommends HDSP track laboratory reports upon receipt of the orders to ensure that all aspects of the laboratory system are working as intended. High Desert State Prison, Cycle 4 Medical Inspection Page 22 Office of the Inspector General State of California EMERGENCY SERVICES An emergency medical response system is essential to providing Case Review Rating: effective and timely emergency medical response, assessment, Proficient treatment, and transportation 24 hours per day. Provision of Compliance Score: urgent/emergent care is based on a patient’s emergency situation, Not Applicable clinical condition, and need for a higher level of care. The OIG reviews emergency response services including first aid, basic life Overall Rating: support (BLS), and advanced cardiac life support (ACLS) Proficient 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 33 emergent events and found 27 deficiencies, of which only six were significant. HDSP performed well with emergency response times, BLS care, and 9-1-1 call activation times. Triage decisions and level-of-care determinations were also good. The OIG clinicians rated the Emergency Services indicator proficient. Provider Performance HDSP providers performed very well in this area. The main triage and treatment area (TTA) provider demonstrated good review of records and careful consideration of important differential diagnoses. The provider made timely and accurate assessments and decisions. Of the 33 emergency events reviewed, there were only two provider deficiencies. Providers who were no longer working for CCHCS or HDSP were responsible for both of those deficiencies. In the majority of cases, HDSP providers demonstrated proficient emergency performance.  In case 4, the inmate-patient was stabbed multiple times by another inmate during an altercation. The emergency response was immediate and appropriate. The patient was treated quickly, efficiently, and appropriately during the short time prior to outside emergency medical services (EMS) arrival. He received CPR, an injection catheter into the bone marrow, an injection catheter (IV) into the arm, fluid resuscitation, a chest x-ray, wound packing, and close monitoring and intervention prior to EMS arrival. The care HDSP provided gave the patient the best chance of survival prior to transfer to the trauma center. High Desert State Prison, Cycle 4 Medical Inspection Page 23 Office of the Inspector General State of California Despite proficient emergency medical care, the patient ultimately did not survive due to his significant injuries. Nursing Performance Nurses in the TTA at HDSP performed well during emergency responses. They responded quickly, made good assessments, and provided appropriate care. While the majority of the deficiencies found were due to inadequate documentation by nursing staff, these did not significantly affect patient care. In some instances, the first medical responder forms were not completed, so there was no documentation of care provided before the RN rover arrived on scene. When health care staff performed CPR, they did not complete the Cardiopulmonary Resuscitation Record (CDCR Form 7462) as required by CCHCS policy. Emergency Response  In case 2, the patient was having difficulty breathing and was unresponsive. There was a delay in calling 9-1-1. It was also unclear why a non-rebreather mask was used instead of a bag valve mask to provide oxygen during the resuscitation process.  In case 4, the patient had agonal (gasping) breathing and initially did not have a pulse. It was unclear why the nurse used a non-rebreather mask instead of a bag valve mask during CPR. The patient was successfully revived, but it was unclear why chest compressions were started (in route to the TTA) when the nurse documented that the patient had regained a pulse. Nursing Documentation In cases 2 and 31, the nurse did not document the CPR and ACLS care on the cardiopulmonary resuscitation record as required by CCHCS policy. In case 7, the nurse did not document the chief complaint, mechanism of injury, Glasgow Coma Scale (mental status measuring tool), complete vital signs, or interventions provided. The nurse did not document the date and time that the nursing progress note was completed. In case 8, the nurse documented that the patient’s chief complaint was “swollen lower extremities, and rash.” The actual complaint was chest pain. In cases 7 and 29, the First Medical Responder form (CDCR Form 7463) was incomplete. In cases 13, 14, and 27, the nurses did not document the care provided from the time of the incident to the time when the RN rover arrived at the scene. First medical responder forms were not completed. High Desert State Prison, Cycle 4 Medical Inspection Page 24 Office of the Inspector General State of California Emergency Medical Response Review Committee The OIG clinicians reviewed the committee minutes for the emergency responses addressed by the committee. The OIG found that the committee reviewed cases timely and identified training issues correctly. Clinician Summary HDSP nurses and providers repeatedly demonstrated proficient emergency response care during the review period. The OIG clinicians mostly minor deficiencies, which did not affect the quality of care. The Emergency Services indicator was rated proficient. Recommendations No specific recommendations. High Desert State Prison, Cycle 4 Medical Inspection Page 25 Office of the Inspector General State of California HEALTH INFORMATION MANAGEMENT (MEDICAL RECORDS) Health information management is a crucial link in the delivery of Case Review Rating: medical care. Medical personnel require accurate information in Inadequate 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 (70.3%) correctly labeled and organized and available in the electronic unit Overall Rating: health record (eUHR); whether the various medical records (internal Inadequate and external, e.g., hospital and specialty reports and progress notes) are obtained and scanned timely into the inmate-patient’s eUHR; whether records routed to clinicians include legible signatures or stamps; and whether hospital discharge reports include key elements and are timely reviewed by providers. Case Review Results Hospital Records The institution did well with the retrieval of emergency department (ED) physician reports and hospital discharge summaries. The OIG clinicians reviewed 12 outside ED events and 13 community hospital events. ED reports and hospital discharge summaries were retrieved and scanned in a timely manner, except in cases 27 and 63. HDSP’s providers did not consistently evidence their reviews of ED physician reports or hospital discharge summaries. The providers’ initials or dates were missing on the outside hospital reports in cases 1, 5, 7, 8, 11, 12, 13, 14, 15, 26, 28, and 63. Specialty Services The OIG clinicians found problems in the review of specialty reports. These findings, mostly in the way the medical reports were handled, are discussed in detail in the Specialty Services indicator. Diagnostic Reports HDSP demonstrated poor performance in retrieval of diagnostic reports, specifically radiological and laboratory reports. HDSP also performed poorly in the timely review of diagnostic reports. These findings are discussed in detail in the Diagnostic Services indicator. Urgent/Emergent Records HDSP nurses and providers documented their emergency encounters clearly and completely. Emergency services were a major strength of the HDSP medical program. High Desert State Prison, Cycle 4 Medical Inspection Page 26 Office of the Inspector General State of California Scanning Performance HDSP had severe problems with documents across all areas of the institution missing from the eUHR. Missing documents included clinic, TTA, and CTC provider and nurse progress notes. In addition, CTC flow sheets were missing. OIG clinicians identified missing documents in cases 7, 11, 13, 15, 21, 22, 30, 31, 33, 39, 52, 64, 69, and 70. The OIG clinicians identified many mistakes in the eUHR document scanning process, which resulted in documents being either mislabeled or misfiled. Erroneously scanned documents can create delays or lapses in care by hindering providers’ ability to find relevant clinical information. Mislabeled documents (those scanned under the wrong eUHR date or document type name) were common and widespread. The OIG clinicians found mislabeled documents in the eUHR in cases 6, 7, 8, 12, 13, 14, 15, 17, 20, 21, 24, 30, 62, and 68. Documents were misfiled into the wrong patient’s chart rarely, but the OIG identified these errors in cases 1, 3, 5, 21, and 59. Scanning times for all documents were generally good. Legibility Legibility was not a significant problem in most cases reviewed. Clinician Onsite Inspection The OIG clinicians observed clinical information transmission during the daily morning huddles. They interviewed various health care staff regarding how the information was handled, especially if clinical care occurred outside of the clinic and after regular hours. HDSP demonstrated a process by which important after-hours clinical information was made available to the respective care teams. More specifically, patients who required after-hours or weekend care were often evaluated in the TTA and managed by the TTA RN and the on-call provider. TTA staff would scan the documents into a shared network folder. Primary care teams could review the documents during the huddle the following morning. While each clinic utilized a standardized huddle report agenda every morning, substantive discussion regarding those patients was unreliable. During one of the huddles, superficial review of available documents led the primary care nurse to communicate incorrect information to the provider. Clinician Summary HDSP did well with the retrieval of outside ED reports and hospital discharge summaries. Scanning time frames were acceptable, but scanning accuracy was poor. Missing, misfiled, or mislabeled documents were common throughout the case reviews. HDSP had significant difficulty having outside ED and hospital discharge summaries reviewed and initialed or signed by a provider. There were also significant problems with handling of laboratory, radiology, and specialty reports. High Desert State Prison, Cycle 4 Medical Inspection Page 27 Office of the Inspector General State of California Information transmittal to the primary care team was inconsistent during the morning huddles. The OIG clinicians rated this indicator inadequate. Compliance Testing Results The institution received an inadequate compliance score of 70.3 percent in the Health Information Management (Medical Records) indicator and has room for improvement in the following areas:  The institution scored zero in its labeling and filing of documents scanned into patients’ electronic unit health records (eUHR). The low score was attributable to patient health care documents that were mislabeled in the eUHR. For example, a Progress Note (CDCR Form 7230) was labeled as a Refusal of Examination (CDCR Form 7225), and a nursing progress note was labeled as a provider progress note. For this test, once the OIG identifies 12 mislabeled or misfiled documents, the maximum points are lost and the resulting score is zero. During the HDSP medical inspection, inspectors identified a total of 19 documents with labeling errors, seven more than the maximum allowable errors (MIT 4.006).  HDSP’s medical records staff timely scanned medication administration records (MARs) into the eUHR files for only 14 of 20 sampled (70 percent). For six patients, MARs were scanned one to four days late (MIT 4.005). The institution performed in the adequate range in the following test areas:  When the OIG reviewed various medical documents (hospital discharge reports, initial health screening forms, certain medication administration records, and specialty service reports) to ensure that clinical staff legibly documented their names on the forms, 24 of 29 samples (83 percent) showed compliance (MIT 4.007).  The OIG reviewed the eUHR files for five patients sent or admitted to an outside hospital to determine if HDSP providers reviewed the patients’ hospital discharge reports or treatment records within three calendar days of discharge. Based on eUHR documentation, the providers timely reviewed the records for four of those patients (80 percent). The provider reviewed one patient’s discharge report one day late (MIT 4.008). In a related area, four of those five patients’ hospital discharge reports (80 percent) were also timely scanned into the eUHR. One report was scanned one day late (MIT 4.004).  Medical records staff timely scanned 16 of 20 sampled non-dictated documents into patient’s eUHR within three calendar days of the patient’s encounter (80 percent). These documents included providers’ progress notes, patients’ Initial Health Screening forms High Desert State Prison, Cycle 4 Medical Inspection Page 28 Office of the Inspector General State of California (CDCR Form 7277), and health care services request forms. Medical records staff scanned four documents between one to two days late (MIT 4.001).  Inspectors tested four provider-dictated progress notes to determine if the institution’s medical records staff scanned the documents within five calendar days of the patient encounter date. Three of the progress notes were scanned timely (75 percent) while one progress note was scanned one day late (MIT 4.002). The institution performed in the proficient range in the following test:  The institution’s medical records staff scanned specialty service consultant reports into the patient’s eUHR file within five calendar days for 19 of 20 reports reviewed (95 percent). One consultant’s report was scanned 42 days late (MIT 4.003). Recommendations No specific recommendations. High Desert State Prison, Cycle 4 Medical Inspection Page 29 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: Inadequate availability of both auditory and visual privacy for inmate-patient (44.4%) visits, and the sufficiency of facility infrastructure to conduct comprehensive medical examinations. Rating of this component is Overall Rating: based entirely on the compliance testing results from the visual Inadequate observations inspectors make at the institution during their onsite visit. Compliance Testing Results The institution received an inadequate compliance score of 44.4 percent in the Health Care Environment indicator; 9 of the 11 test areas scored in the inadequate range:  Based on the OIG’s inspection of the institution’s non-clinic medical storage areas for bulk medical supplies, the medical supply management process did not support the needs of the medical health care program. More specifically, inspectors observed medical supplies stored directly on the floor of a Conex storage container. As a result, the institution scored zero on this test (MIT 5.106).  OIG inspectors observed clinicians’ encounters with patients in nine of the institution’s clinics. Clinicians followed good hand hygiene practices in only one clinic (11 percent). In eight clinics, providers or nurses did not sanitize or wash their hands before or after patient contact, before putting on gloves, or prior to administering a blood draw procedure (MIT 5.104).  Inspectors selected eight of the institution’s emergency response bags to determine if staff inspected them daily and inventoried the contents monthly, and whether the bags contained all essential items. Only two bags (25 percent) were in compliance. Six bags were not compliant for various reasons: one was missing a CPR micro-mask; for three bags, there was no evidence demonstrating that staff on each watch conducted the required daily inspection; two inspected bags had low oxygen tanks; and two other tanks did not have the valve attached to the portable oxygen tank at the time of inspection (MIT 5.111). High Desert State Prison, Cycle 4 Medical Inspection Page 30 Office of the Inspector General State of California  Inspectors examined 11 clinics to determine if they had appropriate space, configuration, supplies, and equipment to allow clinicians to perform a proper exam. Inspectors concluded that only two of the clinics (18 percent) were adequate and that nine other clinics had one or more deficiencies, including eight clinics with torn vinyl exam table covers, seven clinics lacking access to patient privacy screens, two clinics with unsecured medical records easily Figure 1: Torn exam table vinyl patched with accessible to inmate-porters, and one exam tape which could harbor infectious agents room table providing only hindered access and a weight scale that was not usable due to its location (Figures 1 and 2) (MIT 5.110).  Only 3 of 11 clinics (27 percent) had all essential core equipment and supplies necessary to conduct a comprehensive exam. Two clinics were missing a nebulization unit, and a third clinic was missing a calibration sticker on its nebulization unit. Two clinics (including the Figure 2: Poorly positioned exam table crowded with unusable weight scale TTA) had non-functional oto-ophthalmoscopes, and another clinic did not have a scope at all. One clinic was missing a glucometer, strips, medication refrigerator, Snellen eye exam chart, and a biohazard waste receptacle. Two clinics had a Snellen eye chart but no established distance line marker. Two clinics were missing biohazard waste receptacles. In one clinic, exam rooms were missing hemoccult cards and developer, lubricating jelly, and tongue depressors (MIT 5.108).  Only 5 of 11 clinics (46 percent) followed proper protocols to mitigate exposure to blood-borne pathogens and contaminated waste. More specifically, five clinics lacked a sharps container in one or more exam rooms, and one clinic’s exam room had a sharps container that was not affixed to a permanent object and was stored in an unsecured place under a sink (MIT 5.105).  Only 6 of 11 clinics (55 percent) had operable sinks and sufficient quantities of hand hygiene supplies. The inmate restrooms in five clinics lacked disposable paper towels (MIT 5.103). High Desert State Prison, Cycle 4 Medical Inspection Page 31 Office of the Inspector General State of California  Seven of 11 clinics (64 percent) followed adequate medical supply storage and management protocols. Three clinics had medical supply areas that were not sufficiently labeled to assist unfamiliar staff who may work in the clinic. Further, one of the three clinics also had medical supplies stored in a cabinet under a sink. In addition, one clinic had personal food items and remnants of coffee grounds that inspectors found in a cabinet close to a bulk medical supply storage area (Figure 3) (MIT 5.107). Figure 3: Unsanitary personal food items stored in clinical areas  Clinic common areas at 7 of 11 clinics (64 percent) had an adequate environment conducive to providing medical services. Four clinics did not provide adequate auditory privacy surrounding the vital sign and blood-draw stations. More specifically, the station was too close to other areas where patients waited for their health care services, compromising auditory privacy (MIT 5.109). The institution performed within the adequate range in one test, as described below:  Clinical health care staff at eight of ten applicable clinics (80 percent) ensured that reusable invasive and non-invasive medical equipment was properly sterilized or disinfected. In two clinics, staff did not replace the exam table paper between patient encounters (MIT 5.102). The institution performed within the proficient range in one test:  All 11 clinics were appropriately disinfected, cleaned, and sanitized. In addition, cleaning logs were present and completed, indicating cleaning crews regularly cleaned the clinic (MIT 5.101). Other Information Obtained from Non-Scored Results The OIG gathered information to determine if the institution’s physical infrastructure was maintained in a manner that supported health care management’s ability to provide adequate health care services. The OIG did not score this question. When OIG inspectors interviewed health care management, they did not have concerns about the facility’s infrastructure or its effect on staff’s ability to provide adequate health care. At the time of inspection, the institution had several noteworthy infrastructure projects underway. Specifically, primary care clinics on four yards were being renovated, and the institution began building a new administrative segregation unit clinic and remodeling the central health facility building and pharmacy. These projects began in June 2016 with an expected completion date of April 2017 (MIT 5.999). High Desert State Prison, Cycle 4 Medical Inspection Page 32 Office of the Inspector General State of California Recommendations No specific recommendations. High Desert State Prison, Cycle 4 Medical Inspection Page 33 Office of the Inspector General State of California INTER- AND INTRA-SYSTEM TRANSFERS This indicator focuses on the management of inmate-patients’ Case Review Rating: medical needs and continuity of patient care during the inter- and Adequate intra-facility transfer process. The patients reviewed for Inter- and Compliance Score: Intra-System Transfers include inmates received from other CDCR Proficient facilities and inmates transferring out of HDSP to another CDCR (87.0%) facility. The OIG review includes evaluation of the institution’s Overall Rating: ability to provide and document health screening assessments, Adequate initiation of relevant referrals based on patient needs, and the 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 inmate-patients who transfer out of the facility, the OIG evaluates the ability of the institution to document transfer information that includes pre-existing health conditions, pending appointments, tests and requests for specialty services, medication transfer packages, and medication administration prior to transfer. The OIG clinicians also evaluate the care provided to patients returning to the institution from an outside hospital and check to ensure appropriate implementation of the hospital assessment and treatment plans. In this indicator, the OIG’s case review and compliance review processes yielded different results, with the case review giving an adequate rating and the compliance testing resulting in a proficient score. While each area’s results are discussed in detail below, the result variance is readily explained by the different testing approaches. For example, transfer documents may have been present in the medical record as required by policy, and the finding was positively reflected in the compliance rating. However, the clinical quality of those same documents may have been poor and negatively reflected in the case review rating. After considering both case review and compliance testing results, the OIG inspection team determined the final overall rating was adequate. The decision was primarily based on case review’s concerns related to hospital discharge returns, as discussed below. Case Review Results The OIG clinicians reviewed 44 events relating to inter- and intra-system transfers, including information from both the sending and receiving institutions. These included 25 hospitalization and outside emergency room events, each of which resulted in a transfer back to the institution. The inter- and intra-system transfer processes at HDSP were adequate. High Desert State Prison, Cycle 4 Medical Inspection Page 34 Office of the Inspector General State of California Transfers In The OIG clinicians reviewed eight cases in which the patient transferred into HDSP from another CDCR institution. Six of the transfer-in cases displayed only minor deficiencies: the RN did not review and sign the Health Care Transfer Information form (CDCR Form 7371) in cases 33 and 70; there were delays in provider follow-ups for newly arrived patients’ in cases 14, 22, and 34, and encounter dates were mislabeled in the eUHR on patient transfer documents in case 14. Only two of the eight reviewed transfer cases were inadequate:  In case 14, the patient transferred to HDSP. The receiving nurse did not adequately review the patient’s medical record and failed to recognize several critical medication conditions. The nurse also failed to review a recent cardiology consult from the previous month with recommendations to follow up in three months. In addition, an optometry appointment did not occur until more than two months later. Further, the patient’s chronic care visit due in October 2015 did not occur until December 2015. Finally, the patient’s cardiology follow-up due in December 2015 was not scheduled until late January 2016.  In case 33, the Initial Health Screening form (CDCR Form 7277) for transfer patients was not found in the eUHR. Transfers Out The OIG clinicians reviewed seven cases in which the patient transferred from HDSP to another CDCR institution. All seven transfer-out processes were adequate. The only deficiencies identified were minor and related to incomplete documentation of medical information on the health care transfer information form:  In case 15, the patient had a recent stomach biopsy, but the nurse did not document the procedure on the health care transfer form, and did not note on the form that the patient had a pending provider appointment to discuss the biopsy results.  In case 27, the nurse did not document that the patient was diagnosed with gastroesophageal reflux disease.  In case 71, the nurse did not document the patient’s allergies on the health care transfer information form. High Desert State Prison, Cycle 4 Medical Inspection Page 35 Office of the Inspector General State of California Hospitalizations Patients returning from hospitalizations are some of the highest-risk encounters due to two factors. First, these patients are generally hospitalized for a severe illness or injury. Second, they are at risk due to potential lapses in care that can occur during any transfer. The OIG clinicians reviewed 25 cases of patients who returned to HDSP from an offsite hospital or emergency department. Most patients returning from the hospital were processed back into the institution through the TTA. The TTA nurse appropriately reviewed the discharge medications and recommendations. The nurse also routinely obtained the correct physician orders to implement the recommended plan of care. Most hospital or emergency room summaries were appropriately received from community hospitals and were scanned into the eUHR within acceptable time frames. However, HDSP usually scanned these summaries into the eUHR without the provider initialing or dating them (also discussed in the Health Information Management indicator). The OIG clinicians’ identified other positive aspects of the hospital return process. The HDSP health care team quickly and accurately implemented medication recommendations, and providers followed up with their patients within appropriate time frames. Overall, the hospital transfer process worked well. Although the hospital transfer process was sound, HDSP nurses occasionally failed to perform adequate assessments upon patients’ return from the hospital:  In case 7, the patient was sent out to the hospital for acute hypoglycemia (low blood sugar). Upon the patient’s return to HDSP, the nurse did not check his blood sugar or address his complaint of headache.  In case 12, the patient returned from the hospital after treatment of partial small bowel obstruction. The nurse did not assess the patient’s abdomen or pain level.  In case 27, the patient was sent out to the hospital for multiple stab wounds. Upon the patient’s return to HDSP, the nurse did not perform an assessment.  In case 29, the patient returned from the hospital after being evaluated for chest pain. The nurse did not assess the patient’s pain level. Similarly, there were occasional breaks in medication continuity upon patients’ transfer back to HDSP:  In case 27, the patient’s pain medication order was not processed upon his return from the hospital. This prompted a sick call nursing visit two days later. The sick call nurse processed the order, and the first dose was administered the following day. High Desert State Prison, Cycle 4 Medical Inspection Page 36 Office of the Inspector General State of California  In case 63, the nurse did not reconcile the patient’s medication orders upon his return from the hospital. Two of his seizure medications, carbamazepine and phenytoin, were overlooked and inadvertently stopped. Less than two weeks later, the patient had a seizure and was sent to an outside hospital. Clinician Onsite Inspection The receiving and release (R&R) health care area had adequate space to conduct initial health screenings. There was one RN assigned to each watch on business days. Clerical staff were assigned four days a week to process intakes and transfers. Transfer notifications were generally received on Thursdays, and the first-watch RN completed the health care transfer information forms. During the OIG’s interview, the R&R nurse demonstrated sufficient knowledge of the transfer process. Clinician Summary HDSP successfully implemented transfer processes that ensured that most patients transferring into or out of HDSP were given appropriate medical care. The majority of the cases reviewed demonstrated working processes in this area despite occasional nursing and medication deficiencies. The OIG clinicians rated this indicator adequate. Compliance Testing Results The institution obtained a proficient compliance score of 87.0 percent in the Inter- and Intra-System Transfers indicator. HDSP performed in the proficient range in the following test areas:  For all 30 sampled patients who transferred into HDSP from other CDCR facilities, nursing staff completed the Initial Health Screening form (CDCR Form 7277) on the same day the patient arrived. In addition, in all 30 instances, nursing staff timely completed the assessment and disposition section of the health screening form on the same day they performed the patient’s screening (MIT 6.001, 6.002).  The transfer packages for nine of ten sampled patients who transferred out of HDSP during the onsite inspection (90 percent) included all required medications and related documentation. Health care staff failed to ensure that one transfer patient had his rescue asthma inhaler on his person prior to clearing him for transfer (MIT 6.101). The institution scored within the adequate range in the following test:  Of 30 sampled patients who transferred into HDSP, 20 had an existing medication order upon arrival; 16 of the 20 patients (80 percent) received their medications without interruption. Four patients each received their medications one day late (MIT 6.003). High Desert State Prison, Cycle 4 Medical Inspection Page 37 Office of the Inspector General State of California The institution has an opportunity to improve in the following area:  Inspectors sampled 20 patients who transferred out of HDSP to another CDCR institution to determine whether HDSP identified the patients’ scheduled specialty service appointments on the corresponding health care transfer information form. HDSP’s nursing staff correctly listed the previously approved and still pending specialty service appointments for only 13 of the patients (65 percent). The institution’s health care staff failed to list seven of the patients’ pending specialty services (MIT 6.004). Recommendations No specific recommendations. High Desert State Prison, Cycle 4 Medical Inspection Page 38 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, Inadequate encompassing the process from the written prescription to the Compliance Score: administration of the medication. By combining both a quantitative Inadequate (57.0%) 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, Inadequate dispensing and delivering, administering, and documenting and reporting. Because effective medication management is affected by numerous entities across various departments, this assessment considers internal review and approval processes, pharmacy, nursing, health information systems, custody processes, and actions taken by the prescribing provider, staff, and patient. Case Review Results The OIG clinicians evaluate pharmacy and medication management as secondary processes as they relate to the quality of clinical care provided. Compliance testing is a more targeted approach and is heavily relied on for the overall rating for this indicator. The OIG clinicians identified 39 deficiencies in this area, 19 of which were significant. Medication Continuity HDSP could not ensure that chronic care medications were administered reliably and continuously. The OIG clinicians reviewed 84 medication administration samples (each sample with one month’s medication) for medication continuity. There were 19 months where at least one chronic care medication had lapsed, indicating a break in medication continuity. These deficiencies were identified in cases 8, 9, 11, 14, 25, and the following:  In case 22, there was a break the patient’s chronic care medication continuity for three months during the case review. This lapse occurred despite the patient on two separate occasions informing the institution that his medications were expiring.  In case 23, the patient’s chronic care medications expired and were not renewed until more than four months later when the patient transferred to a different institution. This occurred despite two visits with the HDSP diabetic care coordinator. High Desert State Prison, Cycle 4 Medical Inspection Page 39 Office of the Inspector General State of California Medication Administration HDSP could not ensure that patients were reliably administered prescribed medications. These deficiencies were identified in cases 7, 11, 14, 22, 30, 71, and the following:  In case 6, the patient had rheumatoid arthritis and was prescribed several medications to help control inflammation. Nurses failed to administer medications to the patient on several instances in October 2015 and January, February, and March 2016. In April 2016, the patient received an extra injection of methotrexate (immunosuppressant).  In case 13, the patient was administered a medication that had not been prescribed.  In case 15, the medication nurse failed to check the patient’s blood sugar and administer insulin as prescribed.  In case 19, the provider ordered antibiotics while the patient was in the CTC, but the first administration was delayed until two days later.  In case 25, the patient was taking warfarin (a blood thinner), but nurses missed doses on one day in each of two months. Pharmacy Errors HDSP had some problems with pharmacy processes during the review period. As there was extremely limited pharmacy documentation in the eUHR, the OIG clinicians had difficulty discerning if any of the various medication errors were due to pharmacy services. However, the HDSP pharmacy was likely partially responsible for the following errors:  In case 6, the provider ordered a change in the frequency of the patient’s injectable medication. The order was not changed until nearly a month after the order had been placed. Staff explained that this specific medication was non-formulary (requiring higher-level approval) and that due to the vacancy in provider leadership, there were delays in obtaining non-formulary approvals.  In case 16, the pharmacy prematurely discontinued the patient’s post-operative pain medication, morphine. At the clinician onsite inspection, HDSP explained that the patient never received morphine after his return to the institution. However, the medical record showed that the medication order was processed and administered by nurses correctly until the pharmacy suddenly and inexplicably discontinued the medication. High Desert State Prison, Cycle 4 Medical Inspection Page 40 Office of the Inspector General State of California  In case 27, upon the patient’s return from the emergency room, his prescription was not processed. Five days later, a second prescription was also not processed. Clinician Summary During the review period, HDSP had major problems ensuring chronic care medication continuity as well as ensuring accurate and consistent administration of prescribed medications. Pharmacy-related delays and errors were also present. The OIG clinicians rated this indicator inadequate. Compliance Testing Results The institution received an inadequate compliance score of 57.0 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 For this sub-indicator, the institution received an inadequate average score of 68.8 percent, showing room for improvement in the following two areas:  Clinical staff timely provided new and previously prescribed medications to only two of five patients who returned to the institution after being discharged from a community hospital (40 percent). Three other patients did not receive their medications within one day of return, including two patients who received their medications one and four days late. A third patient, who was taking 18 different medications, received eight of the medications timely, eight of medications four days late, and two of the medications not at all (MIT 7.003).  The institution timely dispensed chronic care medications to only 9 of 20 patients sampled, scoring 45 percent on this test. Ten patients missed one or more of their KOP medication refills, which were issued from six days to five months late. One other patient did not receive a Medication Counseling Referral form (CDCR Form 128C) until after his 14th day of medication refusals, then he never received the required medication counseling (MIT 7.001). The institution performed in the proficient range in the following tests:  All 30 patients sampled received their new medication orders within the required time frame. As a result, HDSP scored 100 percent on this test (MIT 7.002). High Desert State Prison, Cycle 4 Medical Inspection Page 41 Office of the Inspector General State of California  Among the 30 sampled HDSP patients who transferred from one housing unit to another, 27 of them (90 percent) received their prescribed medications without interruption. Three patients did not receive their nurse-administered medications by the next dosing interval after the transfer occurred (MIT 7.005). Observed Medication Practices and Storage Controls For this sub-indicator, the institution received a score of 49.0 percent, scoring within the inadequate range in the following four tests:  Nursing staff did not follow appropriate administrative controls and protocols during the medication distribution process at any of the six medication lines inspectors observed, scoring zero on this test. All six medication lines had one or more of the following deficiencies (MIT 7.106): o Five medication lines required patients to wait outdoors in areas that did not have adequate overhang protection from extreme heat or inclement weather. o Four medication lines had nurses who did not ensure that patients swallowed direct-observation medications. o Two lines had nurses who did not verify each patient’s identity against a picture identification. o One line did not adequately secure a portable sharps container after staff completed administering medications.  Non-narcotic refrigerated medications were properly stored at only two of nine inspected clinics and medication line storage locations (22 percent). Seven inspected locations had one or more of the following problem areas (MIT 7.103): o Six locations had no designated area for temporarily stored refrigerated medications awaiting return to the pharmacy. o Two locations had medication refrigerator temperature logs that were missing required daily entries. o One location had a medication refrigerator that was not kept locked. o One location had a medication refrigerator with an expired vaccine. High Desert State Prison, Cycle 4 Medical Inspection Page 42 Office of the Inspector General State of California  The institution properly stored non-narcotic, non-refrigerated medications at only 5 of 16 applicable clinics and medication line storage locations (31 percent). Eleven storage locations had one or more of the following identified issues (MIT 7.102): o Five locations had internal and external medications stored together. o Four locations had one or more previously opened liquid medication containers that were not labeled with the date they were first opened. o Three locations had medications that were stored beyond their expiration date. o Three locations had no designated area for temporarily stored non-refrigerated medications awaiting return to the pharmacy. o One location had a medication storage location that was not locked. o One location stored its medication cart in an unsecured location.  The OIG interviewed nursing staff and inspected narcotics storage areas at seven applicable clinic and pill line locations to assess whether strong narcotics security controls existed. Four locations (57 percent) were adequately controlled. At three other locations, required security control activities were not always performed. In one clinic, a required narcotics shift count was not performed. In two other medication line locations, the narcotics log book was missing a co-signer signature to support an end-of-shift count or the destruction of a narcotic medication (MIT 7.101). The institution performed in the adequate range in the following test:  Nursing staff followed proper hand hygiene contamination control protocols at five of six inspected medication preparation and administration locations (83 percent). At one location, nursing staff did not re-sanitize their hands after changing gloves (MIT 7.104). HDSP scored in the proficient range in the following test:  HDSP nursing staff at all six sampled locations employed appropriate administrative controls and protocols when preparing patients’ medications (MIT 7.105). Pharmacy Protocols For this sub-indicator, the institution received an average score of just 57.3 percent, and scored zero in the following test areas: High Desert State Prison, Cycle 4 Medical Inspection Page 43 Office of the Inspector General State of California  In its main pharmacy, HDSP did not properly store medications. Specifically, pharmacy staff could not produce a refrigeration log for the month of April 2016, and the month of March 2016 had three daily entries that were outside the allowable temperature range. In addition, medications designated for return to pharmacy were stored in boxes on the ground (MIT 7.108, 7.109). The institution scored in the proficient range in the following test areas:  In its main pharmacy, HDSP followed general security, organization, and cleanliness management protocols (MIT 7.107).  The HDSP pharmacist in charge maintained adequate controls and properly accounted for narcotic medications. As a result, HDSP scored a 100 percent on this test (MIT 7.110).  OIG inspectors examined 25 Medication Error Follow-up Reports and five monthly Medication Error Statistics Reports generated by the institution’s PIC and found that 26 of the 30 reports were timely or correctly processed (87 percent). Out of the 25 Medication Error Follow-up Reports reviewed, the institution’s PIC completed four of those reports between 13 to 29 days late (MIT 7.111). Non-Scored Tests In addition to the OIG’s testing reported medication errors, inspectors follow up on any significant medication errors found during the case reviews or compliance testing to determine whether the errors were properly identified and reported. The OIG provides these results for information purposes only; however at HDSP, the OIG did not find any applicable medication errors that were subject to this test (MIT 7.998). In another non-scored area, the OIG tested patients in isolation units to determine if they had immediate access to their prescribed KOP rescue inhalers and nitroglycerin medication. At HDSP, all sampled patients had access to their rescue medications (MIT 7.999). Recommendations No specific recommendations. High Desert State Prison, Cycle 4 Medical Inspection Page 44 Office of the Inspector General State of California PREVENTIVE SERVICES This indicator assesses whether various preventive medical services Case Review Rating: are offered or provided to inmate-patients. These include cancer Not Applicable screenings, tuberculosis screenings, and influenza and chronic care Compliance Score: Inadequate immunizations. This indicator also assesses whether certain (67.1%) institutions take preventive actions to relocate inmate-patients identified as being at higher risk for contracting coccidioidomycosis Overall Rating: (valley fever). Inadequate 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 inadequate range in the Preventive Services indicator, with a compliance score of 67.1 percent, showing room for improvement in the following test areas:  OIG inspectors sampled 30 patients to determine if they received annual tuberculosis (TB) screenings within the last year. Fifteen of the sampled patients were classified as Code 34 (subject only to an annual signs and symptoms check), and 15 were classified as Code 22 (requiring a TB skin test in addition to the signs and symptoms check). In total, only seven patients (23 percent) received a proper and timely completed annual TB screening. For the other 23 sampled patients, proper or timely annual screening did not occur due to one or more of the following deficiencies (MIT 9.003): o For all 15 Code 22 patients, an LVN (rather than an RN, public health nurse, or provider) read the TB test results, which was out of compliance with the CCHCS policy in effect at the time of the OIG’s review. For three Code 22 patients, nursing staff did not document when they administered the test, which prohibited inspectors from determining if the nurse timely read the test results. Further, for one other Code 22 patient sampled, the LVN read the test results more than three hours outside the maximum allowable time period of 72 hours after the initial test administration. o For eight Code 34 patients and four Code 22 patients, nursing staff failed to fully complete the history section of the Tuberculin Testing/Evaluation Report (CDCR Form 7331). High Desert State Prison, Cycle 4 Medical Inspection Page 45 Office of the Inspector General State of California  Only 5 of 14 sampled patients who received TB medications received required weekly or monthly monitoring (36 percent). In the other nine samples, either the patient missed one of his weekly or monthly TB monitoring events, staff failed to scan the monitoring results into the eUHR after each clinical encounter, or both occurred (MIT 9.002).  Seven of 15 sampled patients received all required doses of their TB medications during the most recent three-month period (47 percent). Eight patients did not receive their TB medications at the correct interval. More specifically, five patients missed one or more TB medication doses, and only one of these patients received counseling, which occurred 35 days late. Two patients had MARs indicating that they received one or more extra medication doses. Finally, one sampled patient experienced both types of deficiencies; the patient received two extra doses of his TB medication, and he also missed a required dosing interval later the same month (MIT 9.001). The institution scored in the proficient range in the following tests:  The institution timely offered all 30 sampled patients an influenza vaccination for the most recent influenza season (MIT 9.004).  The OIG initially selected 30 patients who suffered from various chronic medical conditions, 17 of whom required one or more routine vaccinations based on their particular conditions. All 17 sampled patients were timely offered vaccinations for influenza, pneumonia, or hepatitis, as applicable (MIT 9.008).  HDSP offered colorectal cancer screenings to 29 of 30 sampled patients subject to the annual screening requirement (97 percent). One patient had no eUHR evidence either that health care staff offered a fecal occult blood test within the previous 12 months or that the patient had a normal colonoscopy within the last ten years (MIT 9.005). Recommendations No specific recommendations. High Desert State Prison, Cycle 4 Medical Inspection Page 46 Office of the Inspector General State of California QUALITY OF NURSING PERFORMANCE The Quality of Nursing Performance indicator is a qualitative Case Review Rating: evaluation of the institution’s nursing services. The evaluation is Adequate completed entirely by OIG nursing clinicians within the case Compliance Score: review process, and, therefore, does not have a score under the Not Applicable compliance testing component. The OIG nurses conduct case reviews that include reviewing face-to-face encounters related to Overall Rating: nursing sick call requests identified on the Health Care Services Adequate Request form (CDCR Form 7362), urgent walk-in visits, referrals for medical services by custody staff, RN case management, RN utilization management, clinical encounters by licensed vocational nurses (LVNs) and licensed psychiatric technicians (LPTs), and any other nursing service performed on an outpatient basis. The OIG case review also includes activities and processes performed by nursing staff that are not considered direct patient encounters, such as the initial receipt and review of CDCR Form 7362 service requests and follow-up with primary care providers and other staff on behalf of the patient. Key focus areas for evaluation of outpatient nursing care include appropriateness and timeliness of patient triage and assessment, identification and prioritization of health care needs, use of the nursing process to implement interventions including patient education and referrals, and documentation that is accurate, thorough, and legible. Nursing services provided in the outpatient housing unit (OHU), correctional treatment center (CTC), or other inpatient units are reported under the Specialized Medical Housing indicator. Nursing services provided in the triage and treatment area (TTA) or related to emergency medical responses are reported under Emergency Services. Case Review Results The OIG clinicians reviewed 195 outpatient nursing encounters; 146 were for sick call requests or RN follow-up visits, and 14 were LVN encounters for chronic care coordination. There were 47 nursing deficiencies, primarily related to inadequate assessment, intervention, and documentation. There was one care coordination visit with deficiencies identified that, if left unaddressed, would have significantly affected patient care (case 23). However, the care coordinator role was fairly new to the institution, and nursing management was actively focusing on this program to develop a training tool for the nurses. The OIG clinicians rated the Quality of Nursing Performance at HDSP adequate. Nursing Sick Call Case review showed that outpatient RNs performed adequate assessments and provided appropriate dispositions for their patients’ sick call requests. The majority of the deficiencies were minor and High Desert State Prison, Cycle 4 Medical Inspection Page 47 Office of the Inspector General State of California unlikely to cause patient harm. Nevertheless, inadequate assessments or unnecessary delays in the provision of health care services increased the chance of adverse outcomes. Nursing Triage  In case 11, the nurse did not see a diabetic patient with a swollen finger on the day the nurse received the request for services.  In case 13, the nurse did not see a patient with severe headache and weakness on the day his request was received.  In case 66, the nurse did not review the sick call request on the same day it was received. Nursing Assessment and Intervention In cases 26, 29, 42, 48, 50, and the following, nurses did not perform adequate assessments based on the patients’ complaints:  In case 5, the patient reported that his medication for benign prostatic hyperplasia (enlarged prostate) was not working. The nurse failed to obtain more information and adequately assess the patient. Although the nurse noted that the patient already had a scheduled visit with the provider, the patient’s complaint was not added to the appointment and thus was not addressed.  In case 7, the patient submitted multiple sick call requests. Each time, the nurse performed inadequate assessments based on the complaints. The patient had a history of depression and suicide attempts. The nurse failed to address the patient’s report of depression to determine if a mental health referral was needed.  In case 8, the patient saw the sick call nurse for severe back pain and spasms. The nurse did not perform a physical assessment and did not obtain vital signs. Almost a month later, the patient submitted another sick call request for back pain. The nurse attempted to bring the patient in for evaluation, but the patient had been sent to the TTA for chest pain. The nurse inappropriately closed out the sick call request and never addressed the back pain.  In case 22, the patient submitted a sick call request to renew his medications. The nurses did not ensure that the medications were renewed, which caused a break in medication continuity.  In case 48, the patient submitted a sick call request indicating that he had had a seizure four days earlier. The nurse noted that the patient had seen the provider the day of the seizure and High Desert State Prison, Cycle 4 Medical Inspection Page 48 Office of the Inspector General State of California that the issue was resolved. The nurse did not see the patient face to face and failed to recognize that, in fact, the patient had not seen the provider. Nursing Documentation Overall, nursing documentation deficiencies were rare and unlikely to cause serious patient harm. However, the following cases demonstrated failures to meet requirements clearly established by CCHCS nursing policy and protocols, and that are part of the institutional nursing education and training orientation.  In case 6, the nurse “cloned” (copied) progress notes for weekly chemotherapy injections over a four-month period. In addition, during annual TB testing, the LVN did not document the time the TB test was administered.  In case 7, the nurse did not document the date and time of the nursing encounter on the sick call request form.  In case 11, the nurse completed a refusal form for TB testing instead of a medication refusal.  In case 49, the nurse did not document wound care on seven dates over two months.  In case 65, the nurse’s handwriting was illegible. The sick call form was not completed properly. There was no date and time when the form was reviewed, and the nurse did not document the date of the provider appointment. Care Management LVNs were assigned as care coordinators in the primary care clinics at HDSP. They routinely conducted face-to-face assessments with chronic care patients. These nurses tracked their patients’ chronic conditions, medication compliance, diagnostic tests, and health care needs, and provided education based on each patient’s chronic conditions. There was significant room for improvement in the quality of the care coordinator performance.  In cases 8 and 11, the care coordinator did not obtain vital signs, even though part of the reason for the care coordination was the evaluation of the patient’s blood pressure.  In case 15, a patient with hypertension and diabetes saw the LVN for a chronic care visit. The LVN did not review the patient’s medication list or his recent diagnostic results, and failed to check for peripheral edema (accumulation of fluid causing swelling). The LVN also failed to review the patient’s blood sugar levels and last eye exam. High Desert State Prison, Cycle 4 Medical Inspection Page 49 Office of the Inspector General State of California  In case 23, the patient saw the LVN for diabetic care visit in January 2016. The LVN did not recognize that the patient was well overdue for his provider follow-up from October 2015 and that all of the patient’s chronic care medications had expired. Despite a markedly elevated average blood glucose level (HbA1c), the nurse did not notify the provider or ensure that the patient received adequate follow-up. At a second visit in April 2016, the care coordinator noted that the patient’s HbA1c level was still elevated but did not ensure that the patient had adequate follow-up. The nurse also failed to recognize that most of the patient’s chronic care medications had expired. Offsite Medical Return and Specialty Services At HDSP, patients returning from offsite specialty appointments were processed in the TTA. The OIG clinicians reviewed 26 nursing encounters and found only minor deficiencies, mostly related to incomplete or illegible documentation. See the Specialty Services indicator for specific findings on nursing performance. Emergency Services The OIG clinicians reviewed 33 urgent/emergent encounters and found 18 deficiencies related to nursing care. Nursing performance was good. See the Emergency Services indicator for specific findings. Specialized Medical Housing The specialized medical housing nursing care provided in the HDSP correctional treatment center was adequate. See the Specialized Medical Housing indicator for specific findings. Medication Administration The OIG clinicians found significant problems with medication administration that placed patients at risk of serious harm. See the Pharmacy and Medication Management indicator for specific findings. Inter- and Intra-System Transfers Nursing performance in this area was adequate. See the Inter- and Intra-System Transfers indicator for specific findings. Clinician Onsite Inspection The OIG clinicians attended the morning huddles in the A, B, C, and D primary care clinics. The outpatient RN facilitated the huddle and provided the reports gathered by the primary care team. Each member of the primary care team (physician, RN, LVN, and scheduler) as well as mental High Desert State Prison, Cycle 4 Medical Inspection Page 50 Office of the Inspector General State of California health, dental, and custody staff attended the huddle. It was organized and allowed sufficient time to discuss health care issues, such as TTA visits, transfers in and out, hospitalizations, significant diagnostic and laboratory results, medication issues, physician and RN lines, mental health and dental referrals, and patient encounters with both nurse and provider. Changes in custody programs affecting clinic schedules, such as lock-downs and modified programming, were also discussed. However, at one clinic huddle, the RN did not properly review the TTA events that occurred over the weekend, and reported the wrong information to the provider. There were a total of eight primary care RNs assigned in HDSP’s six outpatient clinics. An LVN care coordinator was also assigned in each of the buildings. The OIG clinicians visited the various clinic areas and interviewed the staff on the nursing sick call, care coordination, and referral processes. On an average day, each clinic received 40 sick call requests, 15 of which involved symptom complaints. The outpatient RN generally saw 15 patients daily, including walk-ins. There was no nursing sick call backlog in any clinic. The nursing staff demonstrated good knowledge of their patient population, their duties and responsibilities, and the proper communication channels for reporting issues. The medication line nurses were also observed during pill pass and asked about their medication management procedure, including medication continuity during transfers and medication error reporting. The OIG clinicians also interviewed nursing staff from other clinical areas, including specialty services, telemedicine, public health, receiving and release, and correctional treatment center. Most of the nurses interviewed were actively involved in various ongoing nursing projects, such as the Complete Care Model and Healthy Work Environment programs. HDSP nursing staff felt strongly supported by their supervisors and nursing leadership, and stated they have no major barriers in communicating with their team and supervisors to meet patient care needs. The chief nursing executive also confirmed that the nursing supervisors and managers were actively engaged in continuously improving nursing care and services. Nursing supervisor and training files were also reviewed during the visit. Recommendations No specific recommendations. High Desert State Prison, Cycle 4 Medical Inspection Page 51 Office of the Inspector General State of California QUALITY OF PROVIDER PERFORMANCE In this indicator, the OIG physicians provide a qualitative Case Review Rating: evaluation of the adequacy of provider care at the institution. Adequate Appropriate evaluation, diagnosis, and management plans are Compliance Score: reviewed for programs including, but not limited to, nursing sick Not Applicable call, chronic care programs, TTA, specialized medical housing, and specialty services. The assessment of provider care is Overall Rating: Adequate performed entirely by OIG physicians. There is no compliance testing component associated with this quality indicator. Case Review Results The OIG clinicians reviewed 250 medical provider encounters and identified 38 deficiencies related to provider performance at HDSP, 13 of which were significant. Of the 30 detailed, physician-reviewed cases, one was proficient, 24 were adequate, and 5 were inadequate. The care provided by HDSP medical providers was adequate. Assessment and Decision-Making In the majority of encounters, HDSP providers made adequate assessments and sound decisions. While several deficiencies were identified in this area, no significant pattern of poor provider performance was identified. The OIG clinicians considered those deficiencies identified to be occasional oversights that typically occur in the process of providing medical care. Review of Records Most of the errors in this area were minor and due to provider oversight. The OIG clinicians did not detect any fundamental problems with HDSP provider work habits during the review period. In most encounters, HDSP providers adequately reviewed records when caring for their patients. A mild pattern of inadequate record review was identified in cases 8, 18, 23, and the following:  In case 10, the provider neglected to review recent laboratory reports during a scheduled appointment.  In case 14, the patient had recently returned from an outside hospital for congestive heart failure. The provider did not recognize that the patient had been recently hospitalized and neglected to review the discharge summary. At the onsite inspection, it was determined that this oversight was due to the inexperience of the relatively new HDSP provider, who had difficulty navigating the eUHR system and finding documents. High Desert State Prison, Cycle 4 Medical Inspection Page 52 Office of the Inspector General State of California Emergency Care TTA providers, both on site and on call, made timely and accurate assessments and decisions for their patients requiring urgent or emergent care. This is further discussed in the Emergency Services indicator. Chronic Care HDSP’s patient population was relatively healthy. HDSP had no patients with HIV and only a handful of patients with end-stage liver disease. There was only one patient taking warfarin (case 25). The provider seemed unfamiliar with CCHCS anticoagulation protocols and did not monitor the patient’s warfarin levels as closely as CCHCS recommends. Otherwise, the patient received adequate care. Diabetic management performance was inconsistent, and suffered mostly from various system problems (see the Access to Care, Diagnostic Services, and Pharmacy and Medication Management indicators). Provider oversight and lack of familiarity with CCHCS care guides were responsible for most of the deficiencies in this area.  In case 22, the patient had poorly controlled diabetes. Inadequate access to care resulted in several delays in care. Poor laboratory services resulted in inadequate monitoring. Provider oversight also contributed to inadequate care, as the provider neglected to order a diabetic monitoring test and made minimal medication changes when the patient presented with symptoms of out-of-control diabetes. The provider also failed to order an appropriate follow-up interval for this patient.  In case 23, the patient experienced a prolonged break in medication continuity. Inadequate access to care also contributed to delays in care. The provider neglected to properly review the medical record and failed to recognize that the patient’s medications had expired, or that the patient’s diabetes was poorly controlled. The provider ordered an inappropriately long follow-up interval. Specialized Medical Housing HDSP providers performed adequately in the CTC. This is further discussed in the Specialized Medical Housing indicator. High Desert State Prison, Cycle 4 Medical Inspection Page 53 Office of the Inspector General State of California Specialty Services Reviews of specialty services referrals revealed that HDSP providers referred appropriately and diligently. When providers saw patients for follow-up after specialty services, the providers reviewed reports and took appropriate actions. Clinician Onsite Inspection HDSP had recently experienced significant instability among medical provider leadership. At the time of the OIG clinician inspection in June 2016, HDSP had just hired a chief medical executive (CME) to fill a position that had remained vacant for nearly a year. The chief physician and surgeon (CP&S) position was and had been vacant for the past half year. The chief executive officer (CEO) had been hired less than six months earlier, but that position was once again vacant by the time of the OIG inspection. HDSP providers unanimously described their own morale as poor. Providers acutely felt the problems that insufficient staffing and leadership caused. At one point, there were only two providers to take after-hours calls for the entire institution. Providers also explained that some medication problems, including many delays in the processing of non-formulary requests, were caused by the chronic vacancies in medical leadership. All HDSP providers complained that there was not enough time allotted to perform all the tasks expected of them. The CEO and the regional deputy medical executive (DME) acknowledged that HDSP had a severe provider recruitment problem, in both leadership and line-staff levels. One physician and one mid-level provider position remained vacant at the time of the OIG clinician onsite inspection. Providers attributed the difficulty in recruitment to the institution’s remote locale. However, the DME explained that other institutions were also experiencing difficulty hiring qualified provider staff, likely due to compensation packages that were not competitive. Clinician Summary Overall, HDSP providers performed adequately with their assessments and decision-making. However, sometimes providers did not carefully review patient’s medical records. Provider emergency care performance was excellent, CTC provider performance was adequate, and specialty referrals were also appropriate. However, chronic care performance was only barely adequate. HDSP management and provider staffing levels were suboptimal and chronically understaffed. At the time of the clinician onsite inspection, HDSP had already lost one provider that had been performing well during the review period. Remaining providers expressed poor morale due to the amount of extra work that had been shifted to them. HDSP has had severe difficulty in recruiting providers for both their medical leadership and regular provider positions. In addition to the High Desert State Prison, Cycle 4 Medical Inspection Page 54 Office of the Inspector General State of California problems common to all CDCR institutions, such as concerns about compensation packages, HDSP’s remote locale and rural lifestyle posed additional recruitment challenges. While the OIG clinicians rated HDSP provider performance adequate, HDSP’s lack of provider staffing challenged its ability to maintain that performance level. Recommendations No specific recommendations. High Desert State Prison, Cycle 4 Medical Inspection Page 55 Office of the Inspector General State of California SPECIALIZED MEDICAL HOUSING (OHU, CTC, SNF, HOSPICE) This indicator addresses whether the institution follows appropriate Case Review Rating: policies and procedures when admitting inmate-patients to onsite Adequate inpatient facilities, including completion of timely nursing and Compliance Score: provider assessments. The chart review assesses all aspects of Adequate medical care related to these housing units, including quality of (82.0%) provider and nursing care. HDSP’s only specialized medical Overall Rating: housing unit is a correctional treatment center (CTC). Adequate Case Review Results The institution had 20 medical beds, 10 mental health crisis beds, and 2 observation rooms in the CTC. There were 10 negative pressure rooms (designed to minimize spread of airborne infections) that were mostly used for new admissions and mental health patients. The OIG clinicians reviewed 88 provider and 130 nursing CTC encounters. There were 47 deficiencies, of which 12 were due to provider performance and 22 were due to nursing performance. The OIG clinicians rated this indicator adequate. Provider Performance The OIG clinicians reviewed nine cases in which patients were admitted to the CTC. The main provider in the CTC performed well. The provider made thorough and accurate assessments and made good decisions in the majority of cases reviewed.  In case 15, the patient was admitted to the CTC due to severe joint pain and difficulty walking. The CTC provider ordered an exhaustive battery of tests to diagnose the patient’s symptoms. When the patient developed signs and symptoms suggestive of a severe infection, the CTC nurses and provider immediately recognized the risk and sent the patient to a higher level of care. The CTC provider repeatedly demonstrated highly proficient assessment and decision-making skills in this case. Although the quality of the assessments was good, the main CTC provider occasionally failed to perform initial assessments timely, resulting in lapses in care. Additionally, other CTC providers did not consistently see their patients within the time frames required by CCHCS policy, with lapses identified in cases 3 and 5. The following two cases displayed provider deficiencies in the CTC:  In case 15, the provider did not perform an admission evaluation within 24 hours of the patient’s admission to the CTC. High Desert State Prison, Cycle 4 Medical Inspection Page 56 Office of the Inspector General State of California  In case 63, the patient returned from a prolonged outside hospitalization for surgery. The provider did not perform an admission evaluation or a history and physical examination, which led to an oversight whereby the provider did not reorder the patient’s seizure medication. The patient developed seizures 12 days later and was sent to an outside emergency department. Nursing Performance CTC nursing staff provided good care and performed accurate and timely assessments in the CTC. When there were changes in clinical conditions, HDSP nurses performed comprehensive evaluations and appropriately communicated with the CTC provider. Of the 130 CTC nursing encounters reviewed, only 22 minor deficiencies were identified, consisting of occasional inadequate assessments, failures to initiate patient care plans, and incomplete nursing documentation.  In cases 3, 5, and 69, the CTC nurses did not perform adequate assessments.  In cases 5 and 69, the CTC nurses failed to initiate or review the patients’ care plans for falls and potential for injury.  In cases 3, 5, 15, 69, and 71, the CTC nurses did not document the patients’ vital signs or weight on the appropriate document. Onsite Clinician Inspection At the time of the OIG clinicians’ visit, there were six medical and ten mental health patients admitted in the CTC. The nurses had immediate access to the medical patients, and there were adequate custody staff present to provide access to all patients. Nurse staffing levels were adequate as well. There was sufficient nurse staffing on all shifts at the CTC. Policies and procedures manuals were readily accessible to staff. The OIG clinicians interviewed nursing staff, who demonstrated their thorough knowledge of CTC procedures, and nursing staff had access to CTC policies when needed. Nursing staff communicated that they were satisfied with their jobs. Compliance Testing Results The institution received an adequate compliance score of 82.0 percent in the Specialized Medical Housing indicator, which focused on the CTC. HDSP scored within the proficient range in the following three tests:  For all ten patients sampled, nursing staff timely completed an initial assessment on the day the patient was admitted to the CTC (MIT 13.001). High Desert State Prison, Cycle 4 Medical Inspection Page 57 Office of the Inspector General State of California  The call-button system in HDSP’s CTC operated properly. In addition, according to knowledgeable staff who regularly worked in the CTC, during an emergent event, responding staff could access a patient’s room in less than one minute, which management indicated was reasonable. As a result, the institution received a score of 100 percent on this test (MIT 13.101).  Providers completed a history and physical exam within 72 hours of the patient’s admission to the CTC for nine of the ten patients sampled (90 percent). For one patient, the provider did not complete a history and physical exam at all (MIT 13.003). The institution scored in the adequate range in the following test area:  Providers timely evaluated eight of the ten patients sampled within 24 hours of admission to the HDSP’s CTC (80 percent). Two other sampled patients did not have adequate evidence to support a timely evaluation. For one patient, the provider completed the patient encounter three days late. In another instance, the provider did not document the time of the patient encounter (which was a history and physical examination), and inspectors could not determine if the encounter occurred within 24 hours of admission to the CTC (MIT 13.002). HDSP showed room for improvement in the following area:  Providers who work in the CTC completed their subjective, objective, assessment, plan, and education (SOAPE) notes at the required three-day intervals for only four of the ten patients tested (40 percent). For six patients, the provider’s SOAPE notes were completed one to three days late (MIT 13.004). Recommendations No specific recommendations. High Desert State Prison, Cycle 4 Medical Inspection Page 58 Office of the Inspector General State of California SPECIALTY SERVICES This indicator focuses on specialist care from the time a request for Case Review Rating: services or physician’s order for specialist care is completed to the Adequate time of receipt of related recommendations from specialists. This Compliance Score: indicator also evaluates the providers’ timely review of specialist Inadequate records and documentation reflecting the patients’ care plans, (73.3%) including course of care when specialist recommendations were not Overall Rating: ordered, and whether the results of specialists’ reports are Adequate communicated to the patients. For specialty services denied by the institution, the OIG determines whether the denials are timely and appropriate, and whether the inmate-patient is updated on the plan of care. In this indicator, the OIG’s 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. The OIG’s internal review process considered those factors that led to both results and ultimately rated this indicator adequate. The key factor warranting the higher overall rating was the case review finding that while patients sometimes got their services late, the providers excelled at making specialty referrals, and the patients did receive their services. In addition, the OIG case review clinicians found that late provider reviews of specialty reports did not negatively affect patient care. Case Review Results The OIG clinicians reviewed 116 events related to specialty services, which included 66 specialty consultations and procedures and 26 nursing encounters. In total, 51 deficiencies were found in this category, of which 39 were related to specialty report handling and 8 were related to nursing services. Despite the large number of deficiencies in this category, only 4 of the 51 deficiencies were significant. OIG clinicians found this indicator to be adequate. Access to Specialty Services HDSP performed well with access to specialty services. Out of 66 specialty consultations and procedures, only three deficiencies were identified in this area. HDSP performed equally well with both routine and urgent specialty referrals. Nursing Performance Patients returning from offsite specialty appointments were seen in the TTA. Patients utilizing telemedicine specialty services were assisted by a telemedicine specialty nurse. There were no patterns of deficiencies identified for nursing services. Nurses performed well in this area. High Desert State Prison, Cycle 4 Medical Inspection Page 59 Office of the Inspector General State of California Provider Performance HDSP providers performed proficiently when ordering specialty services. They made appropriate referrals for specialty services. Providers specified the proper priority on the Request for Specialty Services (CDCR Form 7243) for nearly all diagnostic and consultative requests. Health Information Management HDSP’s specialty department did well in the retrieval of specialty reports, with nearly all relevant reports retrieved, except in one instance (case 5). Though most specialty reports were eventually retrieved, there were occasional delays in the retrieval of the reports. The OIG clinicians identified these deficiencies in cases 13, 16, 24, 26, and 30. Delays in retrieval of specialty reports increased the risk of lapses in care. The HDSP specialty department displayed room for improvement in this area. Nearly all specialty reports at HDSP were scanned into the eUHR without a provider’s initials or date of the review. HDSP providers nearly always reviewed the specialty reports and documented their review in a progress note, which rendered this finding minor. HDSP providers timely reviewed specialty reports in nearly all cases. Compliance Testing Results The institution received an inadequate compliance score of 73.3 percent in the Specialty Services indicator. HDSP scored in the inadequate range in the following four tests:  Providers timely received and reviewed only 4 of the 11 sampled specialists’ reports for patients who received a routine specialty service (36 percent). For five patients, providers reviewed the routine specialty services reports from 4 to 33 days late. For the two other patients, providers did not review the specialty service reports at all. In one instance, the provider could not locate the specialty report, but it was actually present in the eUHR at the time of the provider’s search. In a second instance, the patient refused the provider visit and the provider never reviewed the specialty report. OIG inspectors concluded that that the patient’s refusal did not alleviate the provider’s responsibility to timely review the report (MIT14.004).  When patients are approved or scheduled for a specialty service at one institution and then transfer to another institution, policy requires that the receiving institution ensure that the patient’s appointment is timely rescheduled or scheduled, and provided. Eleven of 20 sampled patients (55 percent) who transferred to HDSP with an approved specialty service appointment received their previously approved services within the required time frame. However, nine of the sampled patients who transferred into HDSP did not receive their specialty service timely; six patients received their services from 7 to 85 days late; two High Desert State Prison, Cycle 4 Medical Inspection Page 60 Office of the Inspector General State of California patients refused the service, but their refusals were both 11 days late; and one patient never received his specialty service at all (MIT 14.005).  For 19 patients sampled who had a specialty service denied by HDSP’s health care management, 13 patients (68 percent) received a provider follow-up visit within 30 days of the denial so that alternate treatment strategies could be discussed. For six other patients, the provider’s follow-up visit occurred 2 to 40 days late (MIT 14.007).  Providers timely received and reviewed the specialists’ reports for 10 of 14 sampled patients who received a high-priority specialty service (71 percent). One report was received one day late and then reviewed 39 days late, and three other reports were received timely but reviewed from 6 to 13 days late (MIT 14.002). The institution scored in the proficient range in the following three test areas:  All 15 patients sampled timely received their routine specialty service appointment within 90 calendar days of the provider’s order (MIT 14.003).  When patients did not meet the minimum requirements to receive a specialty service, the institution timely denied providers’ specialty service requests for 19 of 20 sampled patients (95 percent). One patient’s specialty request was denied by the institution two days late (MIT 14.006).  For 13 of 15 patients sampled (87 percent), their high-priority specialty services appointment occurred within 14 calendar days of the provider’s order; two other patients received their specialty service appointments late by one and eight days (MIT 14.001). Recommendations No specific recommendations. High Desert State Prison, Cycle 4 Medical Inspection Page 61 Office of the Inspector General State of California SECONDARY (ADMINISTRATIVE) QUALITY INDICATORS OF HEALTH CARE The last two quality indicators (Internal Monitoring, Quality Improvement, and Administrative Operations; and Job Performance, Training, Licensing, and Certifications) involve health care administrative systems and processes. Testing in these areas applies only to the compliance component of the process. Therefore, there is no case review assessment associated with either of the two indicators. As part of the compliance component of the first of these two indicators, the OIG does not score several questions. Instead, the OIG presents the findings for informational purposes only. For example, the OIG describes certain local processes in place at HDSP. To test both the scored and non-scored areas within these two secondary quality indicators, OIG inspectors interviewed key institutional employees and reviewed documents during their onsite visit to HDSP in May 2016. They also reviewed documents obtained from the institution and from CCHCS prior to the start of the inspection. Of these two secondary indicators, OIG compliance inspectors rated both inadequate. The test questions used to assess compliance for each indicator are detailed in Appendix A. High Desert State Prison, Cycle 4 Medical Inspection Page 62 Office of the Inspector General State of California INTERNAL MONITORING, QUALITY IMPROVEMENT, AND ADMINISTRATIVE OPERATIONS This indicator focuses on the institution’s administrative health care Case Review Rating: oversight functions. The OIG evaluates whether the institution Not Applicable promptly processes inmate-patient medical appeals and addresses Compliance Score: all appealed issues. Inspectors also verify that the institution follows Inadequate reporting requirements for adverse/sentinel events and inmate (40.6%) deaths, and whether the institution is making progress toward its Overall Rating: Performance Improvement Work Plan initiatives. In addition, the Inadequate OIG verifies that the Emergency Medical Response Review Committee (EMRRC) performs required reviews and that staff perform required emergency response drills. Inspectors also assess whether the Quality Management Committee (QMC) meets regularly and adequately addresses program performance. For those institutions with licensed facilities, inspectors also verify that required committee meetings are held. 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 received an inadequate compliance score of 40.6 percent in the Internal Monitoring, Quality Improvement, and Administrative Operations indicator. The institution scored poorly in the following test areas, which significantly contributed to the inadequate score:  The institution had not taken adequate steps to ensure the accuracy of its Dashboard data. Specifically, HDSP’s Quality Management Committee did not have an established forum in which to discuss and document methodologies used to conduct periodic validation and testing of Dashboard data or the related results of data validation testing. As a result, HDSP scored zero on this test (MIT 15.004).  Emergency response drill packages for the three medical emergency response drills conducted in the prior quarter did not include required documentation. Specifically, all three sampled drill packages lacked the Triage and Treatment Services Flowsheet (CDCR Form 7464). Two of these drill packages were also missing the First Medical Responder Data Collection Tool (CDCR Form 7463). As a result, HDSP scored zero on this test (MIT 15.101).  Medical staff promptly submitted the Initial Inmate Death Report (CDCR Form 7229A) to CCHCS’s Death Review Unit for only one of five applicable deaths that occurred at HDSP High Desert State Prison, Cycle 4 Medical Inspection Page 63 Office of the Inspector General State of California in the prior 12-month period (20 percent). For four of the deaths, HDSP did not submit the death report in accordance with CCHCS policy. In two of those instances, the death report was submitted late to CCHCS by approximately one to five hours; and in two other instances, the institution’s CEO or CME failed to evidence their review of the death report prior to the document’s submission to CCHCS (MIT 15.103).  During the most recent 12-month period, HDSP’s Local Governing Body committee only held one quarterly meeting that included documented meeting minutes demonstrating management was exercising its required responsibilities (25 percent). For two other sampled quarters, such evidence was not found in the minutes. For another sampled quarter, the meeting simply was not held (MIT 15.006).  The HDSP’s 2015 Performance Improvement Work Plan included evidence that demonstrated the institution either improved or reached targeted goals for only two of its seven applicable performance objectives (29 percent). Five of the quality improvement initiatives had insufficient progress information to demonstrate the corresponding performance objectives either improved or reached the targeted level (MIT 15.005).  The OIG inspected meeting minutes for 12 emergency medical response incidents reviewed by the institution’s Emergency Medical Response Review Committee (EMRRC) during the most recent six-month period. Of the 12 sampled incidents, only 5 (42 percent) complied with CCHCS policy. Seven sampled packages were not in compliance because the required EMRRC checklist was either missing or not properly completed. For two of the seven incidents, the institution’s warden did not date the minutes to demonstrate the incidents were reviewed and approved timely (MIT 15.007).  HDSP timely processed all inmate medical appeals for only eight of the most recent 12 months (67 percent). For this test, the OIG considers appeals to be timely processed if 95 percent or more of the medical appeals are processed within the month and less than 5 percent of the appeals are classified as overdue. Based on appeals data received from the institution, more than 5 percent of medical appeals were overdue in 4 of the 12 sampled months. Those individual months’ overdue rates ranged from 6 to 14 percent (MIT 15.001). HDSP scored adequate in the following test:  The institution’s QMC met monthly, evaluated program performance, and took action when staff identified improvement opportunities in five of the six months inspectors reviewed. However, the QMC meeting minutes for January 2016 did not include evidence that the committee reviewed Dashboard data or program performance. As a result, HDSP received a score of 83 percent on this test (MIT 15.003). High Desert State Prison, Cycle 4 Medical Inspection Page 64 Office of the Inspector General State of California The institution scored in the proficient range in the following test:  Inspectors sampled ten second-level medical appeals and found that the institution’s responses addressed all of the patients’ appealed issues (MIT 15.102). Other Information Obtained from Non-Scored Areas  The OIG gathered non-scored data regarding the completion of death review reports and found that CCHCS’s Death Review Committee untimely sent the final report to the institution for all five applicable deaths that occurred during the testing period. As of November 2015, CCHCS changed its policy on the required completion dates for death reviews to be finalized. As a result, this test area is discussed in two parts below (MIT 15.996): o Prior to November 1, 2015, CCHCS’s Death Review Committee was required to complete a death review summary report within 30 business days of the death and submit it to the institution’s CEO within five additional business days. There were four deaths that occurred during the OIG’s review period but prior to November 1, 2015, at HDSP. The Death Review Committee completed the death review summary for three of those deaths from one to 132 days late. An additional death review summary for a death that occurred in late March 2015 had yet to be finalized, but it was overdue at the time of the OIG’s inspection. For those three reports that were completed late, the institution’s CEO was also notified of the reports’ completion from 3 to 134 days late. o As of November 1, 2015, the CCHCS Death Review Committee is required to complete a death review summary report within 60 calendar days from the date of the inmate death for a Level I (unexpected) death, or 30 calendar days for a Level II (expected) death. CCHCS is also required to submit the report to the institution’s chief executive officer within seven calendar days of completion. At HDSP, one Level I death occurred in early December 2015, and the death review summary report had yet to be finalized and was overdue by the time of the OIG’s inspection.  Inspectors met with the institution’s CEO to inquire about HDSP’s protocols for tracking medical appeals. The health care appeals coordinator provided monthly appeals summary reports to the institution’s managerial staff. The reports contained a breakdown of appeals completed and the number of appeals that were overdue or remained open. The reports also indicated the category of the appeal, such as medical, dental, or mental health, and a listing of appeal subject areas ranked by the total number of appeals filed. HDSP’s management staff used the reports to track potential problem areas. The total number of appeals were High Desert State Prison, Cycle 4 Medical Inspection Page 65 Office of the Inspector General State of California tracked by type of appeal to aid management in identifying problem areas. Management then reviewed the number of appeals to determine whether a trend was occurring or a systemic problem was present. The reports were augmented by monthly meetings with the institution’s Inmate Advisory Council to identify any medical problem areas that may have arisen. When problem areas were substantiated, management provided additional training as needed. For example, the institution’s CEO had recently identified pain management as a problem area to address because medication led in total volume of appeals received. HDSP arranged for a medical conference to be attended by its providers as well as headquarters staff in order to provide additional guidance on this topic (MIT 15.997).  Non-scored data regarding the institution’s practices for implementing local operating procedures (LOPs) indicated that the institution had an effective process in place for revising existing LOPs and developing new ones. When new or revised statewide policies and procedures were received from CCHCS, the institution’s Health Program Specialist (HPS) and medical staff assigned to the update developed recommendations for a new LOP or revisions to an existing LOP, as needed. When LOP changes were needed, the changes were processed or developed through a medical sub-committee and then submitted to the full QMC membership for final review and approval. Once approved, the LOPs were made available via HDSP’s intranet, to which all health care employees had access. At the time of the OIG’s inspection in May 2016, HDSP had implemented 42 of the 49 stakeholder-recommended LOPs (86 percent); however, 12 of the 42 LOPs were actually expired at the time of the OIG’s visit (MIT 15.998).  HDSP’s health care staffing resources are discussed in the About the Institution section on page 2 of this report (MIT 15.999). Recommendations No specific recommendations. High Desert State Prison, Cycle 4 Medical Inspection Page 66 Office of the Inspector General State of California JOB PERFORMANCE, TRAINING, LICENSING, AND CERTIFICATIONS In this indicator, the OIG examines whether the institution Case Review Rating: adequately manages its health care staffing resources by evaluating Not Applicable whether job performance reviews are completed as required; Compliance Score: specified staff possess current, valid credentials and professional Inadequate licenses or certifications; nursing staff receive new employee (65.8%) orientation training and annual competency testing; and clinical and Overall Rating: custody staff have current medical emergency response Inadequate certifications. 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 received an inadequate compliance score of 65.8 percent in the Job Performance, Training, Licensing, and Certifications indicator. HDSP scored in the inadequate range in the following four tests:  None of the institution’s seven providers who required a structured clinical performance appraisal appropriately received one. At the time of the OIG’s onsite visit, five of the seven providers had evaluations that were overdue by one to seven months. In addition, one provider’s most recent performance appraisal package lacked a 360-Degree evaluation, and another provider’s evaluation lacked evidence that the Unit Health Record Clinical Appraisal (UCA) results were discussed with the provider. As a result, HDSP scored zero on this test (MIT 16.103).  Five nursing staff hired by HDSP within the prior 12 months did not receive new employee orientation training within 30 days of their arrival. Therefore, the institution scored zero on this test (MIT 16.107).  The OIG examined nursing supervisors’ monthly nursing reviews for five subordinate nurses, all completed during March 2016. Only three of the five supervisors (60 percent) properly completed their required reviews. For one subordinate nurse, no reviews were completed at all, and for another, the supervising nurse did not discuss the review evaluation findings with the subordinate nurse (MIT 16.101).  The OIG examined provider, nursing, and custody staff records to determine if the institution ensured that required staff members had current emergency response High Desert State Prison, Cycle 4 Medical Inspection Page 67 Office of the Inspector General State of California certifications. The institution’s providers, nursing staff, and non-managerial custody officers were all compliant, but custody managers were not. More specifically, the institution did not require custody staff at the rank of captain or higher to maintain CPR certifications. The OIG is aware that the California Penal Code exempts custody managers who primarily perform managerial duties from medical emergency response certification training; however, CCHCS policy does not allow for such an exemption. As a result, HDSP received a score of 67 percent on this test (MIT 16.104). The institution received a proficient score of 100 percent in the following areas:  All providers, nursing staff, and the pharmacist in charge were current with their professional licenses and certification requirements (MIT 16.001, 16.105).  All ten nurses sampled were current on their clinical competency validations (MIT 16.102).  The institution’s pharmacy and providers who prescribed controlled substances were current with their Drug Enforcement Agency registrations (MIT 16.106). Recommendations No specific recommendations. High Desert State Prison, Cycle 4 Medical Inspection Page 68 Office of the Inspector General State of California POPULATION-BASED METRICS The compliance testing and the case reviews give an accurate assessment of how the institution’s health care systems are functioning with regard to the patients with the highest risk and utilization. This information is vital to assess the capacity of the institution to provide sustainable, adequate care. However, one significant limitation of the case review methodology is that it does not give a clear assessment of how the institution performs for the entire population. For better insight into this performance, the OIG has turned to population-based metrics. For comparative purposes, the OIG has selected several Healthcare Effectiveness Data and Information Set (HEDIS) measures for disease management to gauge the institution’s effectiveness in outpatient health care, especially chronic disease management. The Healthcare Effectiveness Data and Information Set is a set of standardized performance measures developed by the National Committee for Quality Assurance with input from over 300 organizations representing every sector of the nation’s health care industry. It is used by over 90 percent of the nation’s health plans as well as many leading employers and regulators. It was designed to ensure that the public (including employers, the Centers for Medicare and Medicaid Services, and researchers) has the information it needs to accurately compare the performance of health care plans. Healthcare Effectiveness Data and Information Set data is often used to produce health plan report cards, analyze quality improvement activities, and create performance benchmarks. Methodology For population-based metrics, the OIG used a subset of HEDIS measures applicable to the CDCR patient population. Selection of the measures was based on the availability, reliability, and feasibility of the data required for performing the measurement. The OIG collected data utilizing various information sources, including the eUHR, the Master Registry (maintained by CCHCS), as well as a random sample of patient records analyzed and abstracted by trained personnel. Data obtained from the CCHCS Master Registry and Diabetic Registry was not independently validated by the OIG and is presumed to be accurate. For some measures, the OIG used the entire population rather than statistically random samples. While the OIG is not a certified HEDIS compliance auditor, the OIG uses similar methods to ensure that measures are comparable to those published by other organizations. Comparison of Population-Based Metrics For High Desert State Prison (HDSP), nine HEDIS measures were applicable for comparison and are listed in the following HDSP Results Compared to State and National HEDIS Scores table. Multiple health plans publish their HEDIS performance measures at the State and national levels. High Desert State Prison, Cycle 4 Medical Inspection Page 69 Office of the Inspector General State of California The OIG has provided selected results for several health plans in both categories for comparative purposes. Results of Population-Based Metric Comparison Comprehensive Diabetes Care For chronic care management, the OIG chose measures related to the management of diabetes. Diabetes is the most complex common chronic disease requiring a high level of intervention on the part of the health care system in order to produce optimal results. HDSP performed very well with its management of diabetes. At the State level, HDSP matched or bettered Medi-Cal’s and Kaiser’s high performance levels in all five diabetic measures selected, with the exception of blood pressure control, in which HDSP scored 1 percentage point lower than Kaiser (South region). When compared nationally, HDSP scored better than Medicaid, Medicare, and commercial health plans in each of the five diabetic measures. HDSP outperformed the United States Department of Veterans Affairs (VA) in two of the four applicable measures (diabetics under poor control and diabetic blood pressure control); however, the VA scored higher in the areas of diabetic monitoring and diabetic eye examinations. Immunizations Comparative data for immunizations was only fully available for the VA, and partially available for Kaiser Permanente, Medicare, and commercial. With respect to administering influenza shots to younger adults, HDSP performed less well than Kaiser and the VA, but outperformed commercial plans by 1 percentage point. The 49 percent patient refusal rate for younger adults negatively affected the institution’s score. The institution also performed poorly for administering influenza vaccinations to older adults, scoring 22 and 26 percentage points lower than Medicare and the VA, respectively. Again, a high refusal rate of 50 percent for older adults affected the institution’s poor score. However, regarding pneumococcal vaccinations, HDSP’s score of 100 percent exceeded both Medicare’s and the VA’s scores of 70 and 93 percent, respectively. Cancer Screening With respect to colorectal cancer screening, there were mixed results. Statewide, HDSP scored lower than Kaiser, North region, by 4 percentage points, and lower than Kaiser, South region, by 6 percentage points. Nationally, HDSP outperformed commercial plans and Medicare, but failed to surpass the VA’s score of 82 percent. However, the 21 percent patient refusal rate for this measure also negatively affected the institution’s score. High Desert State Prison, Cycle 4 Medical Inspection Page 70 Office of the Inspector General State of California Summary Overall, HDSP’s comparative HEDIS results reflect an adequate chronic care program. While the institution scored comparatively well in the areas of comprehensive diabetes care and pneumococcal immunizations, it did not perform well at providing influenza vaccinations, and it performed comparatively poorly at providing colorectal cancer screenings. HDSP could improve its scores related to these underperforming areas by increasing patient education to help reduce patient refusals, a factor that significantly affected HDSP’s overall performance. High Desert State Prison, Cycle 4 Medical Inspection Page 71 Office of the Inspector General State of California HDSP Results Compared to State and National HEDIS Scores California National Kaiser Kaiser HDSP HEDIS (No.CA) (So.CA) HEDIS Clinical Measures Medi- HEDIS HEDIS HEDIS Com- HEDIS VA Cycle 4 Cal Scores Scores Medicaid mercial Medicare Average Results1 20152 20153 20153 20154 20154 20154 20145 Comprehensive Diabetes Care HbA1c Testing (Monitoring) 97% 86% 95% 94% 86% 91% 93% 99% Poor HbA1c Control (>9.0%) 6,7 13% 39% 18% 24% 44% 31% 25% 19% HbA1c Control (<8.0%) 6 70% 49% 70% 62% 47% 58% 65% - Blood Pressure Control (<140/90) 84% 63% 84% 85% 62% 65% 65% 78% Eye Exams 84% 53% 69% 81% 54% 56% 69% 90% Immunizations Influenza Shots - Adults (18–64) 51% - 54% 55% - 50% - 58% Influenza Shots - Adults (65+) 50% - - - - - 72% 76% Immunizations: Pneumococcal 100% - - - - - 70% 93% Cancer Screening Colorectal Cancer Screening 76% - 80% 82% - 64% 67% 82% 1. Unless otherwise stated, data was collected in May 2016 by reviewing medical records from a sample of HDSP’s population of applicable inmate-patients. These random statistical sample sizes were based on a 95 percent confidence level with a 15 percent maximum margin of error. 2. HEDIS Medi-Cal data was obtained from the California Department of Health Care Services 2015 HEDIS Aggregate Report for the Medi-Cal Managed Care Program. 3. Data was obtained from Kaiser Permanente November 2015 reports for the Northern and Southern California regions. 4. National HEDIS data for Medicaid, commercial, and Medicare was obtained from the 2015 State of Health Care Quality Report, available on the NCQA website: www.ncqa.org. The results for commercial were based on data received from various health maintenance organizations. 5. The Department of Veterans Affairs (VA) data was obtained from the 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. 6. For this indicator, the entire applicable HDSP 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. High Desert State Prison, Cycle 4 Medical Inspection Page 72 Office of the Inspector General State of California APPENDIX A — COMPLIANCE TEST RESULTS High Desert State Prison Range of Summary Scores: 40.58% - 87.00% Indicator Compliance Score (Yes %) Access to Care 78.95% Diagnostic Services 65.56% Emergency Services Not Applicable Health Information Management (Medical Records) 70.34% Health Care Environment 44.44% Inter- and Intra-System Transfers 87.00% Pharmacy and Medication Management 57.04% Prenatal and Post-Delivery Services Not Applicable Preventive Services 67.06% Quality of Nursing Performance Not Applicable Quality of Provider Performance Not Applicable Reception Center Arrivals Not Applicable Specialized Medical Housing (OHU, CTC, SNF, Hospice) 82.00% Specialty Services 73.27% Internal Monitoring, Quality Improvement, and Administrative Operations 40.58% Job Performance, Training, Licensing, and Certifications 65.83% High Desert State Prison, Cycle 4 Medical Inspection Page 73 Office of the Inspector General State of California Scored Answers Yes Reference + Number Access to Care Yes No No Yes % N/A 1.001 Chronic care follow-up appointments: Was the inmate-patient’s 21 9 30 70.00% 0 most recent chronic care visit within the health care guideline’s maximum allowable interval or within the ordered time frame, whichever is shorter? 1.002 For endorsed inmate-patients received from another CDCR 14 10 24 58.33% 6 institution: If the nurse referred the inmate-patient to a provider during the initial health screening, was the inmate-patient seen within the required time frame? 1.003 Clinical appointments: Did a registered nurse review the 29 1 30 96.67% 0 inmate-patient’s request for service the same day it was received? 1.004 Clinical appointments: Did the registered nurse complete a 26 3 29 89.66% 1 face-to-face visit within one business day after the CDCR Form 7362 was reviewed? 1.005 Clinical appointments: If the registered nurse determined a referral 9 4 13 69.23% 17 to a primary care provider was necessary, was the inmate-patient seen within the maximum allowable time or the ordered time frame, whichever is the shorter? 1.006 Sick call follow-up appointments: If the primary care provider 5 1 6 83.33% 24 ordered a follow-up sick call appointment, did it take place within the time frame specified? 1.007 Upon the inmate-patient’s discharge from the community 3 2 5 60.00% 0 hospital: Did the inmate-patient receive a follow-up appointment within the required time frame? 1.008 Specialty service follow-up appointments: Do specialty service 20 4 24 83.33% 6 primary care physician follow-up visits occur within required time frames? 1.101 Clinical appointments: Do inmate-patients have a standardized 6 0 6 100.00% 0 process to obtain and submit health care services request forms? Overall percentage: 78.95% High Desert State Prison, Cycle 4 Medical Inspection Page 74 Office of the Inspector General State of California Scored Answers Yes Reference + Diagnostic Services Number Yes No No Yes % N/A 2.001 Radiology: Was the radiology service provided within the time 10 0 10 100.00% 0 frame specified in the provider’s order? 2.002 Radiology: Did the primary care provider review and initial the 8 2 10 80.00% 0 diagnostic report within specified time frames? 2.003 Radiology: Did the primary care provider communicate the results 7 3 10 70.00% 0 of the diagnostic study to the inmate-patient within specified time frames? 2.004 Laboratory: Was the laboratory service provided within the time 8 2 10 80.00% 0 frame specified in the provider’s order? 2.005 Laboratory: Did the primary care provider review and initial the 6 4 10 60.00% 0 diagnostic report within specified time frames? 2.006 Laboratory: Did the primary care provider communicate the results 6 4 10 60.00% 0 of the diagnostic study to the inmate-patient within specified time frames? 2.007 Pathology: Did the institution receive the final diagnostic report 9 1 10 90.00% 0 within the required time frames? 2.008 Pathology: Did the primary care provider review and initial the 0 10 10 0.00% 0 diagnostic report within specified time frames? 2.009 Pathology: Did the primary care provider communicate the results 5 5 10 50.00% 0 of the diagnostic study to the inmate-patient within specified time frames? Overall percentage: 65.56% Emergency Services Scored Answers Assesses reaction times and responses to emergency situations. The OIG RN clinicians will use detailed information obtained from the institution’s incident Not Applicable packages to perform focused case reviews. High Desert State Prison, Cycle 4 Medical Inspection Page 75 Office of the Inspector General State of California Scored Answers Yes Health Information Management Reference + Number (Medical Records) Yes No No Yes % N/A 4.001 Are non-dictated progress notes, initial health screening forms, and 16 4 20 80.00% 0 health care service request forms scanned into the eUHR within three calendar days of the inmate-patient encounter date? 4.002 Are dictated / transcribed documents scanned into the eUHR within 3 1 4 75.00% 0 five calendar days of the inmate-patient encounter date? 4.003 Are specialty documents scanned into the eUHR within the required 19 1 20 95.00% 0 time frame? 4.004 Are community hospital discharge documents scanned into the 4 1 5 80.00% 0 eUHR within three calendar days of the inmate-patient date of hospital discharge? 4.005 Are medication administration records (MARs) scanned into the 14 6 20 70.00% 0 eUHR within the required time frames? 4.006 During the eUHR review, did the OIG find that documents were 0 12 12 0.00% 0 correctly labeled and included in the correct inmate-patient’s file? 4.007 Did clinical staff legibly sign health care records, when required? 24 5 29 82.76% 0 4.008 For inmate-patients discharged from a community hospital: Did 4 1 5 80.00% 0 the preliminary hospital discharge report include key elements and did a PCP review the report within three calendar days of discharge? Overall percentage: 70.34% High Desert State Prison, Cycle 4 Medical Inspection Page 76 Office of the Inspector General State of California Scored Answers Yes Reference + Number Health Care Environment Yes No No Yes % N/A 5.101 Infection Control: Are clinical health care areas appropriately 11 0 11 100.00% 0 disinfected, cleaned and sanitary? 5.102 Infection control: Do clinical health care areas ensure that reusable 8 2 10 80.00% 1 invasive and non-invasive medical equipment is properly sterilized or disinfected as warranted? 5.103 Infection Control: Do clinical health care areas contain operable sinks 6 5 11 54.55% 0 and sufficient quantities of hygiene supplies? 5.104 Infection control: Does clinical health care staff adhere to universal hand 1 8 9 11.11% 2 hygiene precautions? 5.105 Infection control: Do clinical health care areas control exposure to 5 6 11 45.45% 0 blood-borne pathogens and contaminated waste? 5.106 Warehouse, Conex and other non-clinic storage areas: Does the 0 1 1 0.00% 0 medical supply management process adequately support the needs of the medical health care program? 5.107 Clinical areas: Does each clinic follow adequate protocols for managing 7 4 11 63.64% 0 and storing bulk medical supplies? 5.108 Clinical areas: Do clinic common areas and exam rooms have essential 3 8 11 27.27% 0 core medical equipment and supplies? 5.109 Clinical areas: Do clinic common areas have an adequate environment 7 4 11 63.64% 0 conducive to providing medical services? 5.110 Clinical areas: Do clinic exam rooms have an adequate environment 2 9 11 18.18% 0 conducive to providing medical services? 5.111 Emergency response bags: Are TTA and clinic emergency medical 2 6 8 25.00% 3 response bags inspected daily and inventoried monthly, and do they contain essential items? 5.999 For Information Purposes Only: Does the institution’s health care management believe that all clinical areas have physical plant Information Only infrastructures sufficient to provide adequate health care services? Overall percentage: 44.44% High Desert State Prison, Cycle 4 Medical Inspection Page 77 Office of the Inspector General State of California Scored Answers Yes Reference + Number Inter- and Intra-System Transfers Yes No No Yes % N/A 6.001 For endorsed inmate-patients received from another CDCR 30 0 30 100.00% 0 institution or COCF: Did nursing staff complete the initial health screening and answer all screening questions on the same day the inmate-patient arrived at the institution? 6.002 For endorsed inmate-patients received from another CDCR 30 0 30 100.00% 0 institution or COCF: When required, did the RN complete the assessment and disposition section of the health screening form; refer the inmate-patient to the TTA, if TB signs and symptoms were present; and sign and date the form on the same day staff completed the health screening? 6.003 For endorsed inmate-patients received from another CDCR 16 4 20 80.00% 10 institution or COCF: If the inmate-patient had an existing medication order upon arrival, were medications administered or delivered without interruption? 6.004 For inmate-patients transferred out of the facility: Were 13 7 20 65.00% 0 scheduled specialty service appointments identified on the Health Care Transfer Information Form 7371? 6.101 For inmate-patients transferred out of the facility: Do 9 1 10 90.00% 0 medication transfer packages include required medications along with the corresponding Medical Administration Record (MAR) and Medication Reconciliation? Overall percentage: 87.00% High Desert State Prison, Cycle 4 Medical Inspection Page 78 Office of the Inspector General State of California Scored Answers Yes Reference + Number Pharmacy and Medication Management Yes No No Yes % N/A 7.001 Did the inmate-patient receive all chronic care medications within 9 11 20 45.00% 10 the required time frames or did the institution follow departmental policy for refusals or no-shows? 7.002 Did health care staff administer or deliver new order prescription 30 0 30 100.00% 0 medications to the inmate-patient within the required time frames? 7.003 Upon the inmate-patient’s discharge from a community 2 3 5 40.00% 0 hospital: Were all medications ordered by the institution’s primary care provider administered or delivered to the inmate-patient within one calendar day of return? 7.004 For inmate-patients received from a county jail: Were all medications ordered by the institution’s reception center provider Not Applicable administered or delivered to the inmate-patient within the required time frames? 7.005 Upon the inmate-patient’s transfer from one housing unit to 27 3 30 90.00% 0 another: Were medications continued without interruption? 7.006 For en route inmate-patients who lay over at the institution: If the temporarily housed inmate-patient had an existing medication Not Applicable order, were medications administered or delivered without interruption? 7.101 All clinical and medication line storage areas for narcotic 4 3 7 57.14% 10 medications: Does the institution employ strong medication security controls over narcotic medications assigned to its clinical areas? 7.102 All clinical and medication line storage areas for non-narcotic 5 11 16 31.25% 1 medications: Does the institution properly store non-narcotic medications that do not require refrigeration in assigned clinical areas? 7.103 All clinical and medication line storage areas for non-narcotic 2 7 9 22.22% 8 medications: Does the institution properly store non-narcotic medications that require refrigeration in assigned clinical areas? 7.104 Medication preparation and administration areas: Do nursing 5 1 6 83.33% 11 staff employ and follow hand hygiene contamination control protocols during medication preparation and medication administration processes? 7.105 Medication preparation and administration areas: Does the 6 0 6 100.00% 11 institution employ appropriate administrative controls and protocols when preparing medications for inmate-patients? High Desert State Prison, Cycle 4 Medical Inspection Page 79 Office of the Inspector General State of California Scored Answers Yes Reference + Number Pharmacy and Medication Management Yes No No Yes % N/A 7.106 Medication preparation and administration areas: Does the 0 6 6 0.00% 11 institution employ appropriate administrative controls and protocols when distributing medications to inmate-patients? 7.107 Pharmacy: Does the institution employ and follow general 1 0 1 100.00% 0 security, organization, and cleanliness management protocols in its main and satellite pharmacies? 7.108 Pharmacy: Does the institution’s pharmacy properly store 0 1 1 0.00% 0 non-refrigerated medications? 7.109 Pharmacy: Does the institution’s pharmacy properly store 0 1 1 0.00% 0 refrigerated or frozen medications? 7.110 Pharmacy: Does the institution’s pharmacy properly account for 1 0 1 100.00% 0 narcotic medications? 7.111 Pharmacy: Does the institution follow key medication error 26 4 30 86.67% 0 reporting protocols? 7.998 For Information Purposes Only: During eUHR compliance testing and case reviews, did the OIG find that medication errors Information Only were properly identified and reported by the institution? 7.999 For Information Purposes Only: Do inmate-patients in isolation housing units have immediate access to their KOP prescribed Information Only rescue inhalers and nitroglycerin medications? Overall percentage: 57.04% Prenatal and Post-Delivery Services Scored Answers This indicator is not applicable to this institution. Not Applicable High Desert State Prison, Cycle 4 Medical Inspection Page 80 Office of the Inspector General State of California Scored Answers Yes Reference + Number Preventive Services Yes No No Yes % N/A 9.001 Inmate-patients prescribed TB medications: Did the institution 7 8 15 46.67% 0 administer the medication to the inmate-patient as prescribed? 9.002 Inmate-patients prescribed TB medications: Did the institution 5 9 14 35.71% 1 monitor the inmate-patient monthly for the most recent three months he or she was on the medication? 9.003 Annual TB Screening: Was the inmate-patient screened for TB 7 23 30 23.33% 0 within the last year? 9.004 Were all inmate-patients offered an influenza vaccination for the 30 0 30 100.00% 0 most recent influenza season? 9.005 All inmate-patients from the age 50 through the age of 75: Was 29 1 30 96.67% 0 the inmate-patient offered colorectal cancer screening? 9.006 Female inmate-patients from the age of 50 through the age of 74: Was the inmate-patient offered a mammogram in compliance Not Applicable with policy? 9.007 Female inmate-patients from the age of 21 through the age of 65: Was the inmate-patient offered a pap smear in compliance with Not Applicable policy? 9.008 Are required immunizations being offered for chronic care 17 0 17 100.00% 13 inmate-patients? 9.009 Are inmate-patients at the highest risk of coccidioidomycosis (valley Not Applicable fever) infection transferred out of the facility in a timely manner? Overall percentage: 67.06% High Desert State Prison, Cycle 4 Medical Inspection Page 81 Office of the Inspector General State of California Quality of Nursing Performance Scored Answers The quality of nursing performance will be assessed during case reviews, conducted by OIG clinicians, and is not applicable for the compliance portion of the medical inspection. The methodologies OIG clinicians use to evaluate the quality of nursing Not Applicable performance are presented in a separate inspection document entitled OIG MIU Retrospective Case Review Methodology. Quality of Provider Performance Scored Answers The quality of provider performance will be assessed during case reviews, conducted by OIG clinicians, and is not applicable for the compliance portion of the medical inspection. The methodologies OIG clinicians use to evaluate the quality of Not Applicable provider performance are presented in a separate inspection document entitled OIG MIU Retrospective Case Review Methodology. Reception Center Arrivals Scored Answers This indicator is not applicable to this institution. Not Applicable High Desert State Prison, Cycle 4 Medical Inspection Page 82 Office of the Inspector General State of California Scored Answers Specialized Medical Housing Yes Reference + (OHU, CTC, SNF, Hospice) Number Yes No No Yes % N/A 13.001 For all higher-level care facilities: Did the registered nurse complete an 10 0 10 100.00% 0 initial assessment of the inmate-patient on the day of admission, or within eight hours of admission to CMF’s Hospice? 13.002 For OHU, CTC, & SNF only: Did the primary care provider for OHU or 8 2 10 80.00% 0 attending physician for a CTC & SNF evaluate the inmate-patient within 24 hours of admission? 13.003 For OHU, CTC, & SNF only: Was a written history and physical 9 1 10 90.00% 0 examination completed within 72 hours of admission? 13.004 For all higher-level care facilities: Did the primary care provider 4 6 10 40.00% 0 complete the Subjective, Objective, Assessment, Plan, and Education (SOAPE) notes on the inmate-patient at the minimum intervals required for the type of facility where the inmate-patient was treated? 13.101 For OHU and CTC Only: Do inpatient areas either have properly 1 0 1 100.00% 0 working call systems in its OHU & CTC or are 30-minute patient welfare checks performed; and do medical staff have reasonably unimpeded access to enter inmate-patient’s cells? Overall percentage: 82.00% High Desert State Prison, Cycle 4 Medical Inspection Page 83 Office of the Inspector General State of California Scored Answers Yes Reference + Number Specialty Services Yes No No Yes % N/A 14.001 Did the inmate-patient receive the high priority specialty service 13 2 15 86.67% 0 within 14 calendar days of the PCP order? 14.002 Did the PCP review the high priority specialty service consultant 10 4 14 71.43% 1 report within three business days after the service was provided? 14.003 Did the inmate-patient receive the routine specialty service within 15 0 15 100.00% 0 90 calendar days of the PCP order? 14.004 Did the PCP review the routine specialty service consultant report 4 7 11 36.36% 4 within three business days after the service was provided? 14.005 For endorsed inmate-patients received from another CDCR 11 9 20 55.00% 0 institution: If the inmate-patient was approved for a specialty services appointment at the sending institution, was the appointment scheduled at the receiving institution within the required time frames? 14.006 Did the institution deny the primary care provider request for 19 1 20 95.00% 0 specialty services within required time frames? 14.007 Following the denial of a request for specialty services, was the 13 6 19 68.42% 1 inmate-patient informed of the denial within the required time frame? Overall percentage: 73.27% High Desert State Prison, Cycle 4 Medical Inspection Page 84 Office of the Inspector General State of California Scored Answers Yes Internal Monitoring, Quality Improvement, and Reference + Number Administrative Operations Yes No No Yes % N/A 15.001 Did the institution promptly process inmate medical appeals during the 8 4 12 66.67% 0 most recent 12 months? 15.002 Does the institution follow adverse/sentinel event reporting Not Applicable requirements? 15.003 Did the institution Quality Management Committee (QMC) meet at 5 1 6 83.33% 0 least monthly to evaluate program performance, and did the QMC take action when improvement opportunities were identified? 15.004 Did the institution’s Quality Management Committee (QMC) or other 0 1 1 0.00% 0 forum take steps to ensure the accuracy of its Dashboard data reporting? 15.005 For each initiative in the Performance Improvement Work Plan (PIWP), 2 5 7 28.57% 1 has the institution performance improved or reached the targeted performance objective(s)? 15.006 For institutions with licensed care facilities: Does the local governing 1 3 4 25.00% 0 body (LGB), or its equivalent, meet quarterly and exercise its overall responsibilities for the quality management of patient health care? 15.007 Does the Emergency Medical Response Review Committee perform 5 7 12 41.67% 0 timely incident package reviews that include the use of required review documents? 15.101 Did the institution complete a medical emergency response drill for each 0 3 3 0.00% 0 watch and include participation of health care and custody staff during the most recent full quarter? 15.102 Did the institution’s second level medical appeal response address all of 10 0 10 100.00% 0 the inmate-patient’s appealed issues? 15.103 Did the institution’s medical staff review and submit the initial inmate 1 4 5 20.00% 0 death report to the Death Review Unit in a timely manner? 15.996 For Information Purposes Only: Did the CCHCS Death Review Committee submit its inmate death review summary to the institution Information Only timely? 15.997 For Information Purposes Only: Identify the institution’s protocols Information Only for tracking medical appeals. 15.998 For Information `Purposes Only: Identify the institution’s protocols Information Only for implementing health care local operating procedures. 15.999 For Information Purposes Only: Identify the institution’s health care Information Only staffing resources. Overall percentage: 40.58% High Desert State Prison, Cycle 4 Medical Inspection Page 85 Office of the Inspector General State of California Scored Answers Yes Job Performance, Training, Licensing, and Reference + Number Certifications Yes No No Yes % N/A 16.001 Do all providers maintain a current medical license? 7 0 7 100.00% 0 16.101 Does the institution’s Supervising Registered Nurse conduct periodic 3 2 5 60.00% 0 reviews of nursing staff? 16.102 Are nursing staff who administer medications current on their clinical 10 0 10 100.00% 0 competency validation? 16.103 Are structured clinical performance appraisals completed timely? 0 7 7 0.00% 0 16.104 Are staff current with required medical emergency response 2 1 3 66.67% 0 certifications? 16.105 Are nursing staff and the pharmacist in charge current with their 5 0 5 100.00% 1 professional licenses and certifications? 16.106 Do the institution’s pharmacy and authorized providers who prescribe 1 0 1 100.00% 0 controlled substances maintain current Drug Enforcement Agency (DEA) registrations? 16.107 Are nursing staff current with required new employee orientation? 0 1 1 0.00% 0 Overall percentage: 65.83% High Desert State Prison, Cycle 4 Medical Inspection Page 86 Office of the Inspector General State of California APPENDIX B — CLINICAL DATA Table B-1: HDSP Sample Sets Sample Set Total Anticoagulation 1 CTC/OHU 5 Death Review/Sentinel Events 5 Diabetes 4 Emergency Services – CPR 1 Emergency Services – Non-CPR 5 High Risk 5 Hospitalization 5 Intra-System Transfers In 3 Intra-System Transfers Out 3 RN Sick Call 30 Specialty Services 5 72 High Desert State Prison, Cycle 4 Medical Inspection Page 87 Office of the Inspector General State of California Table B-2: HDSP Chronic Care Diagnoses Diagnosis Total Anticoagulation 3 Arthritis/Degenerative Joint Disease 6 Asthma 13 COPD 12 Cancer 2 Cardiovascular Disease 9 Chronic Kidney Disease 5 Chronic Pain 24 Coccidioidomycosis 1 DVT/PE 1 Deep Venous Thrombosis/Pulmonary Embolism 3 Diabetes 19 Gastroesophageal Reflux Disease 22 Hepatitis C 19 Hyperlipidemia 24 Hypertension 41 Mental Health 20 Migraine Headaches 3 Rheumatological Disease 2 Seizure Disorder 6 Sleep Apnea 4 Thyroid Disease 4 243 High Desert State Prison, Cycle 4 Medical Inspection Page 88 Office of the Inspector General State of California Table B-3: HDSP Event – Program Program Total Diagnostic Services 139 Emergency Care 53 Hospitalization 32 Intra-System Transfers In 12 Intra-System Transfers Out 7 Not Specified 2 Outpatient Care 438 Specialized Medical Housing 247 Specialty Services 116 1,046 Table B-4: HDSP Case Review Sample Summary Total MD Reviews, Detailed 30 MD Reviews, Focused 1 RN Reviews, Detailed 20 RN Reviews, Focused 41 Total Reviews 92 Total Unique Cases 72 Overlapping Reviews (MD & RN) 20 High Desert State Prison, Cycle 4 Medical Inspection Page 89 Office of the Inspector General State of California APPENDIX C — COMPLIANCE SAMPLING METHODOLOGY High Desert 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 inmate-patient—any risk level) (30)  Randomize MIT 1.002 Nursing Referrals OIG Q: 6.001  See Intra-System Transfers (30) 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: 4.008  See Health Information Management (Medical community hospital Records) (returns from community hospital) (5) 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 request review 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 High Desert State Prison, Cycle 4 Medical Inspection Page 90 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 (20) 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 (4)  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 (5)  First 20 IPs selected MIT 4.005 OIG Q: 7.001  MARs (20)  First 20 IPs selected MIT 4.006 Documents for  Any misfiled or mislabeled document identified (12) 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, (29) 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 inmate-patients from each of the 6 months (if not 5 in a month, supplement from another, as (5) needed) Health Care Environment MIT 5.101-105 Clinical areas OIG inspector  Identify and inspect all onsite clinical areas. MIT 5.107–111 (11) onsite review Inter- and Intra-System Transfers MIT 6.001-003 Intra-system transfers SOMS  Arrival date (3–9 months)  Arrived from (another CDCR facility)  Rx count (30)  Randomize 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 High Desert State Prison, Cycle 4 Medical Inspection Page 91 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 inmate-patient—any risk level (30)  Randomize MIT 7.002 New Medication Master Registry  Rx count Orders  Randomize (30)  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) (5) 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 (17) MITs 7.107-110 Pharmacy OIG inspector  Identify & inspect all onsite pharmacies (1) onsite review MIT 7.111 Medication error Monthly  All monthly statistic reports with Level 4 or higher reporting medication error  Select a total of 5 months (30) reports 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 MIT 8.001-007 Recent Deliveries OB Roster  Delivery date (2–12 months) N/A at this institution  Most recent deliveries (within date range) Pregnant Arrivals OB Roster  Arrival date (2–12 months) N/A at this institution  Earliest arrivals (within date range) High Desert State Prison, Cycle 4 Medical Inspection Page 92 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) (15)  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 three yrs prior to inspection)  Date of birth (age 24–53) N/A at this institution  Randomize MIT 9.008 Chronic care OIG Q: 1.001  Chronic care conditions (at least 1 condition per vaccinations IP—any risk level)  Randomize (30)  Condition must require vaccination(s) MIT 9.009 Valley fever Cocci transfer  Reports from past 2–8 months status report  Institution  Ineligibility date (60 days prior to inspection date) N/A at this institution  All High Desert State Prison, Cycle 4 Medical Inspection Page 93 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) (10)  Randomize MIT 13.101 Call buttons OIG inspector  Review by location CTC (all) onsite review Specialty Services Access MITs 14.001–002 High-priority MedSATS  Approval date (3–9 months) (15)  Randomize MITs 14.003–004 Routine MedSATS  Approval date (3–9 months) (15)  Remove optometry, physical therapy or podiatry  Randomize MIT 14.005 Specialty services MedSATS  Arrived from (other CDCR institution) arrivals  Date of transfer (3–9 months) (20)  Randomize MIT 14.006-007 Denials InterQual  Review date (3–9 months) (10)  Randomize IUMC/MAR  Meeting date (9 months) Meeting Minutes  Denial upheld (10)  Randomize High Desert State Prison, Cycle 4 Medical Inspection Page 94 Office of the Inspector General State of California Sample Category Quality (number of Indicator samples) Data Source Filters Internal Monitoring, Quality Improvement, & 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 Performance Institution PIWP  PIWP with updates (12 months) improvement work  Medical initiatives plans (PIWP) (8) MIT 15.006 LGB LGB meeting  Quarterly meeting minutes (12 months) (4) minutes MIT 15.007 EMRRC EMRRC meeting  Monthly meeting minutes (6 months) (12) 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  Initial death reports (5) 12 months MIT 15.996 Death Review OIG summary  Between 35 business days & 12 months prior Committee log - deaths  CCHCS death reviews (5) MIT 15.998 Local operating Institution LOPs  All LOPs procedures (LOPs) (all) High Desert State Prison, Cycle 4 Medical Inspection Page 95 Office of the Inspector General State of California Sample Category Quality (number of Indicator samples) Data Source Filters Job Performance, Training, Licensing, and Certifications MIT 16.001 Provider licenses Current provider  Review all listing (at start of (7) inspection) MIT 16.101 RN Review Onsite  RNs who worked in clinic or emergency setting Evaluations supervisor six or more days in sampled month periodic RN  Randomize (5) reviews MIT 16.102 Nursing Staff Onsite nursing  On duty one or more years Validations education files  Nurse administers medications (10)  Randomize MIT 16.103 Provider Annual OIG Q:16.001  All required performance evaluation documents Evaluation Packets (7) MIT 16.104 Medical Emergency Onsite  All staff Response certification o Providers (ACLS) Certifications tracking logs o Nursing (BLS/CPR) (all) o Custody (CPR/BLS) MIT 16.105 Nursing staff and Onsite tracking  All required licenses and certifications Pharmacist in charge system, logs, or Professional employee files Licenses and Certifications (all) MIT 16.106 Pharmacy and Onsite listing of  All DEA registrations Providers’ Drug provider DEA Enforcement Agency registration #s & (DEA) Registrations pharmacy registration (all) document MIT 16.107 Nursing Staff New Nursing staff  New employees (hired within last 12 months) Employee training logs Orientations (all) High Desert State Prison, Cycle 4 Medical Inspection Page 96 Office of the Inspector General State of California C C ALIFORNIA ORRECTIONAL H C S ’ EALTH ARE ERVICES R ESPONSE High Desert State Prison, Cycle 4 Medical Inspection Page 97 Office of the Inspector General State of California