High Desert State Prison Medical Inspection Report Cycle 5

Roy W. Wesley Office of the Inspector General Inspector General High Desert State Prison Medical Inspection Results Cycle 5 April 2018 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 5 Roy W. Wesley Inspector General Bryan B. Beyer Chief Deputy Inspector General Shaun R. Spillane Public Information Officer April 2018 T C ABLE OF ONTENTS Foreword ........................................................................................................................................ i Overall Rating: Adequate ........................................................................................................... iii Executive Summary ...................................................................................................................... iii Clinical Case Review and OIG Clinician Inspection Results .............................................. v Compliance Testing Results ............................................................................................. vi Recommendations ........................................................................................................... vii Population-Based Metrics ................................................................................................ vii Introduction ................................................................................................................................... 1 About the Institution ................................................................................................................... 1 Objectives, Scope, and Methodology.............................................................................................. 4 Case Reviews ............................................................................................................................. 5 Patient Selection for Retrospective Case Reviews .............................................................. 6 Benefits and Limitations of Targeted Subpopulation Review ............................................. 7 Case Review Sampling Methodology ................................................................................ 7 Breadth of Case Reviews ................................................................................................... 8 Case Review Testing Methodology.................................................................................... 9 Compliance Testing .................................................................................................................. 12 Sampling Methods for Conducting Compliance Testing................................................... 12 Scoring of Compliance Testing Results............................................................................ 12 Overall Quality Indicator Rating for Case Reviews and Compliance Testing ............................. 12 Population-Based Metrics ......................................................................................................... 13 Medical Inspection Results .......................................................................................................... 14 Access to Care ............................................................................................................ 16 Case Review Results ....................................................................................................... 16 Compliance Testing Results ............................................................................................ 19 Diagnostic Services .................................................................................................... 22 Case Review Results ....................................................................................................... 22 Compliance Testing Results ............................................................................................ 23 Emergency Services .................................................................................................... 25 Case Review Results ....................................................................................................... 25 Health Information Management ................................................................................ 27 Case Review Results ....................................................................................................... 27 Compliance Testing Results ............................................................................................ 29 Health Care Environment ........................................................................................... 30 Compliance Testing Results ............................................................................................ 30 Inter- and Intra-System Transfers ............................................................................... 33 Case Review Results ....................................................................................................... 33 Compliance Testing Results ............................................................................................ 35 Pharmacy and Medication Management ..................................................................... 36 Case Review Results ....................................................................................................... 36 Compliance Testing Results ............................................................................................ 38 High Desert State Prison, Cycle 5 Medical Inspection Table of Contents Office of the Inspector General State of California Prenatal and Post-Delivery Services ........................................................................... 41 Preventive Services ..................................................................................................... 42 Compliance Testing Results ............................................................................................ 42 Quality of Nursing Performance................................................................................ 44 Case Review Results ....................................................................................................... 44 Quality of Provider Performance .............................................................................. 48 Case Review Results ....................................................................................................... 48 Reception Center Arrivals ......................................................................................... 52 Specialized Medical Housing .................................................................................... 53 Case Review Results ....................................................................................................... 53 Compliance Testing Results ............................................................................................ 54 Specialty Services ..................................................................................................... 55 Case Review Results ....................................................................................................... 55 Compliance Testing Results ............................................................................................ 57 Administrative Operations (Secondary) ..................................................................... 59 Compliance Testing Results ............................................................................................ 59 Recommendations ........................................................................................................................ 62 Population-Based Metrics ............................................................................................................ 63 Appendix A — Compliance Test Results ..................................................................................... 66 Appendix B — Clinical Data ....................................................................................................... 79 Appendix C — Compliance Sampling Methodology .................................................................... 83 California Correctional Health Care Services’ Response .............................................................. 90 High Desert State Prison, Cycle 5 Medical Inspection Table of Contents Office of the Inspector General State of California L T F IST OF ABLES AND IGURES HDSP Executive Summary Table .................................................................................................. iv HDSP Health Care Staffing Resources as of August 2017 ............................................................... 2 HDSP Master Registry Data as of August 7, 2017 .......................................................................... 3 Exhibit 1. Case Review Definitions ................................................................................................ 5 Chart 1. Case Review Sample Selection .......................................................................................... 8 Chart 2. Case Review Testing and Deficiencies ............................................................................ 10 Chart 3. Inspection Indicator Review Distribution ......................................................................... 14 Table B-1: HDSP Sample Sets ...................................................................................................... 79 Table B-2: HDSP Chronic Care Diagnoses ................................................................................... 80 Table B-3: HDSP Event – Program............................................................................................... 81 Table B-4: HDSP Review Sample Summary................................................................................. 82 High Desert State Prison, Cycle 5 Medical Inspection List of Tables and Figures Office of the Inspector General State of California This page intentionally left blank. High Desert State Prison, Cycle 5 Medical Inspection Office of the Inspector General State of California F OREWORD Pursuant to California Penal Code Section 6126 et seq., which assigns the Office of the Inspector General (OIG) responsibility for oversight of the California Department of Corrections and Rehabilitation (CDCR), the OIG conducts a comprehensive inspection program to evaluate the delivery of medical care at each of CDCR’s 35 adult prisons. The OIG explicitly makes no determination regarding the constitutionality of care in the prison setting. That determination is left to the Receiver and the federal court. The assessment of care by the OIG is just one factor in the court’s determination whether care in the prisons meets constitutional standards. The OIG’s inspections are mandated by the Penal Code and not aimed at specifically resolving the court’s questions on constitutional care. To the degree that they provide another factor for the court to consider, the OIG is pleased to provide added value to the taxpayers of California. In Cycle 5, for the first time, the OIG will be inspecting institutions delegated back to CDCR from the Receivership. There is no difference in the standards used for assessment of a delegated institution versus an institution not yet delegated. At the time of the Cycle 5 inspection of High Desert State Prison, the Receiver had not delegated this institution back to CDCR. This fifth cycle of inspections will continue evaluating the areas addressed in Cycle 4, which included clinical case review, compliance testing, and a population-based metric comparison of selected Healthcare Effectiveness Data Information Set (HEDIS) measures. In agreement with stakeholders, the OIG made changes to both the case review and compliance components. The OIG found that in every inspection in Cycle 4, larger samples were taken than were needed to assess the adequacy of medical care provided. As a result, the OIG reduced the number of case reviews and sample sizes for compliance testing. Also, in Cycle 4, compliance testing included two secondary (administrative) indicators (Internal Monitoring, Quality Improvement, and Administrative Operations; and Job Performance, Training, Licensing, and Certifications). For Cycle 5, these have been combined into one secondary indicator, Administrative Operations. High Desert State Prison, Cycle 5 Medical Inspection Page i Office of the Inspector General State of California This page intentionally left blank. High Desert State Prison, Cycle 5 Medical Inspection Page ii Office of the Inspector General State of California E S XECUTIVE UMMARY The OIG performed its Cycle 5 medical inspection at High Desert State Prison (HDSP) from August to October of 2017. The inspection included in-depth reviews of 47 patient files conducted OVERALL RATING: by clinicians, as well as reviews of documents from 376 patient files, covering 87 objectively scored tests of compliance with Adequate policies and procedures applicable to the delivery of medical care. The OIG assessed the case review and compliance results at HDSP using 13 health care quality indicators applicable to the institution. To conduct clinical case reviews, the OIG employs a clinician team consisting of a physician and a registered nurse consultant, while compliance testing is done by a team of registered nurses trained in monitoring medical policy compliance. Of the applicable indicators, seven were rated by both case review clinicians and compliance inspectors, three were rated by case review clinicians only, and three were rated by compliance inspectors only. The HDSP Executive Summary Table on the following page identifies the applicable individual indicators and scores for this institution. The OIG experts made a considered and measured overall opinion that the quality of health care at HDSP was adequate. High Desert State Prison, Cycle 5 Medical Inspection Page iii Office of the Inspector General State of California HDSP Executive Summary Table Cycle 5 Cycle 4 Case Review Compliance Inspection Indicators Overall Overall Rating Rating Rating Rating 1—Access to Care Inadequate Adequate Inadequate Adequate 2—Diagnostic Services Adequate Inadequate Adequate Inadequate 3—Emergency Services Adequate Not Applicable Adequate Proficient 4—Health Information Adequate Inadequate Adequate Inadequate Management 5—Health Care Environment Not Applicable Adequate Adequate Inadequate 6—Inter- and Intra-System Adequate Inadequate Adequate Adequate Transfers 7—Pharmacy and Medication I Inadequate Inadequate Inadequate n Inadequate Management a 8—Prenatal and Post-Delivery Not Applicable Not Applicable Not Applicable Not Applicable Services 9—Preventive Services Not Applicable Adequate Adequate Inadequate 10—Quality of Nursing Adequate Not Applicable Adequate Adequate Performance 11—Quality of Provider Adequate Not Applicable Adequate Adequate Performance 12—Reception Center Arrivals Not Applicable Not Applicable Not Applicable Not Applicable 13—Specialized Medical Housing Adequate Adequate Adequate Adequate 14—Specialty Services Adequate Inadequate Adequate Adequate 15—Administrative Operations Not Applicable Inadequate Inadequate Inadequate* (Secondary) *In Cycle 4, there were two secondary (administrative) indicators. This score reflects the average of those two scores. High Desert State Prison, Cycle 5 Medical Inspection Page iv Office of the Inspector General State of California Clinical Case Review and OIG Clinician Inspection Results The clinicians’ case reviews sampled patients with high medical needs and included a review of 746 patient care events.1 As depicted on the summary table on page iv, of the 13 indicators applicable to HDSP, 10 were evaluated by clinician case review; 8 were adequate, and 2 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 compliance or performance with processes and programs. However, the opposite is not true; inadequate health care staff cannot provide adequate care, even though the established processes and programs onsite may be adequate. The OIG clinicians identify inadequate medical care based on the risk of significant harm to the patient, not the actual outcome. Program Strengths — Clinical • Nursing leadership at HDSP remained supportive and actively engaged in quality improvement projects and training for the institution’s nurses. • Provider performance in emergency settings was good. Providers made appropriate decisions when deciding whether to send patients to an outside hospital or to treat them in the TTA. Program Weaknesses — Clinical • In the area of Access to Care, service was poor due to chronic provider understaffing as well as reduced productivity resulting from transitioning to the new electronic health record system (EHRS). HDSP’s geographically remote location and its relatively lower compensation rate, compared with other CDCR institutions, contributed to the institution’s inability to recruit and retain providers. • Medication management was poor with breaks occurring in chronic care medication continuity. Providers documented patient health records inconsistently, making it unclear whether patients had received their medications. Frequently, nurses put in refill requests for medications without checking storage areas, resulting in stockrooms full of excess medications. • Providers often did not communicate diagnostic results to patients, as they did not consistently generate the required patient notifications. When providers did notify patients of their results, that communication was frequently ambiguous. 1 Each OIG clinician team consists of a board-certified physician and a registered nurse consultant with experience in correctional and community medical settings. High Desert State Prison, Cycle 5 Medical Inspection Page v Office of the Inspector General State of California Compliance Testing Results Of the 13 health care indicators applicable to HDSP, 10 were evaluated by compliance inspectors.2 Of these, four were adequate, and six were inadequate. There were 87 individual compliance questions within those ten indicators, generating 1,068 data points that tested HDSP’s compliance with California Correctional Health Care Services (CCHCS) policies and procedures.3 Those 87 questions are detailed in Appendix A — Compliance Test Results. Program Strengths — Compliance The following are some of HDSP’s strengths based on its compliance scores on individual questions in all the health care indicators: • HDSP nursing staff received and reviewed Health Care Services Request forms that patients submitted within required time frames, and nursing staff completed timely face-to-face encounters with patients. HDSP nursing staff ensured that initial health assessments were timely performed for patients admitted to the CTC, and providers timely completed their history and physical examinations for those same patients. Clinics at HDSP were appropriately clean, disinfected, and sanitary; clinic restrooms had operating sinks and sufficient hygiene supplies available; and clinic staff followed proper protocols to mitigate exposure to blood-borne pathogens and contaminated waste. • The institution properly monitored patients for tuberculosis annually; HDSP staff offered patients their influenza immunizations during the previous 12-month period; and patients who met the criteria for colorectal cancer screening received the service timely. Program Weaknesses — Compliance The following are some of the weaknesses identified by HDSP’s compliance scores on individual questions in all the health care indicators: • HDSP providers did not communicate diagnostic services’ results to patients within required time frames. • The institution did not timely scan non-dictated documents and specialty services’ reports into patients’ electronic medical records. In addition, OIG inspectors found missing initials and dates on some reports, indicating providers had not always reviewed hospital discharge reports. 2 The OIG’s compliance team consists of inspectors who are 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 for which CCHCS policies and procedures did not specifically address an issue. High Desert State Prison, Cycle 5 Medical Inspection Page vi Office of the Inspector General State of California • At HDSP, providers did not always review high priority specialty service reports within required time frames. Recommendations The OIG recommends the following: • The HDSP chief physician and surgeon (CP&S) or chief medical executive (CME) should periodically check the electronic health record system (EHRS) message center to ensure providers promptly review all pertinent results and reports. • HDSP should designate an onsite physician supervisor who can support mid-level providers, review their work, and provide appropriate supervision. • At the time of the OIG’s onsite inspection, HDSP unnecessarily delayed transmitting telemedicine specialty recommendations. The institution should send telemedicine specialty recommendations to the provider immediately, as it already does for offsite specialty recommendations. By using similar rapid processes for transmitting both types of specialty recommendations, HDSP can reduce the risk of lapses in care. Population-Based Metrics In general, HDSP performed well as measured by population-based metrics. In comprehensive diabetes care, HDSP outperformed most state and national health care plans in the five diabetic measures. However, HDSP scored lower than two health care plans for diabetic eye exams and blood pressure control. With regard to immunization measures, HDSP scored higher than all other health care plans for influenza immunizations for both younger and older adults. However, the institution’s score for pneumococcal immunizations was mixed, matching the score for one health care plan, but scoring significantly lower than one other health care plan. Colorectal cancer screening scores were mixed, with the institution scoring higher than two health plans, matching the score of one health plan, and scoring lower than two other health plans. HDSP performed well as measured by population-based metrics compared to the other health care plans reviewed. The institution may improve its scores for colorectal cancer screenings by reducing patient refusals through educating patients on the benefits of these preventive services. High Desert State Prison, Cycle 5 Medical Inspection Page vii Office of the Inspector General State of California This page intentionally left blank. High Desert State Prison, Cycle 5 Medical Inspection Page viii Office of the Inspector General State of California I NTRODUCTION Pursuant to California Penal Code Section 6126 et seq., which assigns the Office of the Inspector General (OIG) responsibility for oversight of the California Department of Corrections and Rehabilitation (CDCR), and at the request of the federal Receiver, the OIG developed a comprehensive medical inspection program to evaluate the delivery of medical care at each of CDCR’s 35 adult prisons. The OIG conducted a clinical case review and a compliance inspection, ensuring a thorough, end-to-end assessment of medical care within CDCR. High Desert State Prison (HDSP) was the 23rd medical inspection of Cycle 5. During the inspection process, the OIG assessed the delivery of medical care to patients using the primary clinical health care indicators applicable to the institution. The Administrative Operations indicator is secondary because it does not reflect the actual clinical care provided. ABOUT THE INSTITUTION Opened in 1995, High Desert State Prison (HDSP) is located approximately eight miles east of the town of Susanville, in Lassen County. The institution’s primary mission is to provide housing and programming of general population and sensitive needs high-security (Level IV) and sensitive needs medium-security (Level III) patients. The institution operates several medical clinics where health care staff members handle routine requests for medical services. In addition, HDSP operates a triage and treatment area (TTA) for urgent and emergent patient care, a receiving and release (R&R) clinic for assessment of arriving and departing patients, and a specialty clinic. The institution also provides inpatient health care in its correctional treatment center (CTC) for those patients who require a higher level of service. CCHCS has designated HDSP as a “basic” health care institution, an institution located in a rural area away from tertiary care centers and specialty care providers whose services would likely be used frequently by higher-risk patients. Because of HDSP’s remote location and its basic health care status, CDCR houses healthier patients at this institution. The institution first received national accreditation from the Commission on Accreditation for Corrections in August 2013. This accreditation program is a professional peer review process based on national standards set by the American Correctional Association. HDSP was re-accredited on August 7, 2016. Based on staffing data the OIG obtained from the institution as identified in the HDSP Health Care Staffing Resources as of August 2017 table below, HDSP’s vacancy rate among medical managers, primary care providers, supervisors, and rank-and-file nurses was 25 percent in August 2017, with the highest vacancy percentage among management at 54 percent. At the time of the OIG’s inspection, HDSP had been experiencing challenges in the area of medical leadership. In April 2017, HDSP’s chief medical executive (CME) passed away. From April 2017 until July 2017, a chief physician and surgeon (CP&S) from a different facility High Desert State Prison, Cycle 5 Medical Inspection Page 1 Office of the Inspector General State of California provided temporary, out-of-classification CME coverage. Since July 2017, the CME position at HDSP remained vacant. The HDSP CP&S position was completely vacant during the OIG’s inspection period. As of this report, the institution was in the process of filling that position. HDSP Health Care Staffing Resources as of August 2017 Primary Care Nursing Management Nursing Staff Totals Providers Supervisors Description Number % Number % Number % Number % Number % Authorized 13 8% 42.5 25% 9.7 6% 104.2 62% 169.4 100% Positions Filled 6 46% 30 71% 8 82% 83 80% 127 75% Positions Vacancies 7 54% 12.5 29% 1.7 18% 21.2 20% 42.4 25% Recent Hires (within 12 2 33% 6 20% 0 0% 26 31% 34 27% months) Staff Utilized 0 0% 0 0% 0 0% 8 10% 8 6% from Registry Redirected Staff 0 0% 0 0% 0 0% 0 0% 0 0% (to NStoanff- Pona tient CLoanrge -Aterremas ) 0 0% 0 0% 0 0% 2 2% 2 2% Medical L eave Note: HDSP Health Care Staffing Resources data was not validated by the OIG. As of August 7, 2017, the Master Registry for HDSP showed that the institution had a total population of 3,573. Within that total population, 0.6 percent was designated as high medical risk, Priority 1 (High 1), and 2.0 percent was designated as high medical risk, Priority 2 (High 2). Patients’ assigned risk levels are based on the complexity of their required medical care related to their specific diagnoses, frequency of higher levels of care, age, and abnormal laboratory results and procedures. High 1 has at least two high-risk conditions; High 2 has only one. Patients at high medical risk are more susceptible to poor health outcomes than those at medium or low medical risk. Patients at high medical risk also typically require more health care services than do patients with lower assigned risk levels. The chart below illustrates the breakdown of the institution’s medical risk levels at the start of the OIG medical inspection. High Desert State Prison, Cycle 5 Medical Inspection Page 2 Office of the Inspector General State of California HDSP Master Registry Data as of August 7, 2017 Medical Risk Level Number of Patients Percentage High 1 20 0.6% High 2 73 2.0% Medium 1,498 41.9% Low 1,982 55.5% Total 3,573 100% High Desert State Prison, Cycle 5 Medical Inspection Page 3 Office of the Inspector General State of California O , S , M BJECTIVES COPE AND ETHODOLOGY In designing the medical inspection program, the OIG reviewed CCHCS policies and procedures, relevant court orders, and guidance developed by the American Correctional Association. The OIG also reviewed professional literature on correctional medical care; reviewed standardized performance measures used by the health care industry; consulted with clinical experts; and met with stakeholders from the court, the Receiver’s office, CDCR, the Office of the Attorney General, and the Prison Law Office to discuss the nature and scope of the OIG’s inspection program. With input from these stakeholders, the OIG developed a medical inspection program that evaluates medical care delivery by combining clinical case reviews of patient files, objective tests of compliance with policies and procedures, and an analysis of outcomes for certain population-based metrics. To maintain a metric-oriented inspection program that evaluates medical care delivery consistently at each state prison, the OIG identified 15 indicators (14 primary (clinical) indicators and one secondary (administrative) indicator) of health care to measure. The primary quality indicators cover clinical categories directly relating to the health care provided to patients, whereas the secondary quality indicator addresses the administrative functions that support a health care delivery system. The HDSP Executive Summary Table on page iv of this report identifies these 15 indicators. The OIG rates each of the quality indicators applicable to the institution under inspection based on case reviews conducted by OIG clinicians and compliance tests conducted by OIG registered nurses. The case review results alone, the compliance test results alone, or a combination of both these information sources may influence an indicator’s overall rating. For example, the OIG derives the ratings for the primary quality indicators Quality of Nursing Performance and Quality of Provider Performance entirely from the case review done by clinicians, while the ratings for the primary quality indicators Health Care Environment and Preventive Services are derived entirely from compliance testing done by registered nurse inspectors. As another example, primary quality indicators such as Diagnostic Services and Specialty Services receive ratings derived from both sources. The OIG does not inspect for efficiency or cost-effectiveness of medical operations. Consistent with the OIG’s agreement with the Receiver, this report only addresses the quality of CDCR’s medical operations and its compliance with quality-related policies. Moreover, if the OIG learns of a patient needing immediate care, the OIG notifies the chief executive officer of health care services and requests a status report. Additionally, if the OIG learns of significant departures from community standards, it may report such departures to the institution’s chief executive officer or to CCHCS. Because these matters involve confidential medical information protected by state and federal privacy laws, the OIG does not include specific identifying details related to any such cases in the public report. High Desert State Prison, Cycle 5 Medical Inspection Page 4 Office of the Inspector General State of California In all areas, the OIG is alert for opportunities to make appropriate recommendations for improvement. Such opportunities may be present regardless of the score awarded to any particular quality indicator; therefore, recommendations for improvement are not necessarily indicative of deficient medical care delivery. CASE REVIEWS The OIG added case reviews to the Cycle 4 medical inspections at the recommendation of its stakeholders, which continues in the Cycle 5 medical inspections. The following exhibit provides definitions that describe this process. Exhibit 1. Case Review Definitions Case = Sample = Patient An appraisal of the medical care provided to one patient over a specific period, which can comprise detailed or focused case reviews. Detailed Case Review A review that includes all aspects of one patient’s medical care assessed over a six-month period. This review allows the OIG clinicians to examine many areas of health care delivery, such as access to care, diagnostic services, health information management, and specialty services. Focused Case Review A review that focuses on one specific aspect of medical care. This review tends to concentrate on a singular facet of patient care, such as the sick call process or the institution’s emergency medical response. Case Review Event A direct or indirect interaction between the patient and the health care system. Examples of direct interactions include provider encounters and nurse encounters. An example of an indirect interaction includes a provider reviewing a diagnostic test and placing additional orders. Case Review Deficiency A medical error in procedure or in clinical judgment. Both procedural and clinical judgment errors can result in policy non-compliance, elevated risk of patient harm, or both. Adverse Deficiency A medical error that increases the risk of, or results in, serious patient harm. Most health care organizations refer to these errors as adverse events. High Desert State Prison, Cycle 5 Medical Inspection Page 5 Office of the Inspector General State of California The OIG’s clinicians perform a retrospective case review of selected patient files to evaluate the care given by an institution’s primary care providers and nurses. Retrospective case review is a well-established review process used by health care organizations that perform peer reviews and patient death reviews. Currently, CCHCS uses retrospective case review as part of its death review process and in its pattern-of-practice reviews. CCHCS also uses a more limited form of retrospective case review when performing appraisals of individual primary care providers. Patient Selection for Retrospective Case Reviews Because retrospective case review is time consuming and requires qualified health care professionals to perform it, the OIG must carefully select a sample of patient records for clinician review. Accordingly, the group of patients the OIG targeted for case review carried the highest clinical risk and utilized the majority of medical services. The majority of patients selected for retrospective case review were high-utilizing patients with chronic care illnesses who were classified as high or medium risk. The reason the OIG targeted these patients for review is twofold: 1. The goal of retrospective case review is to evaluate all aspects of the health care system. Statewide, high-risk and high-utilization patients consume medical services at a disproportionate rate; 11 percent of the total patient population is high-risk and accounts for more than half of the institution’s pharmaceutical, specialty, community hospital, and emergency costs. 2. Selecting this target group for case review provides a significantly greater opportunity to evaluate all the various aspects of the health care delivery system at an institution. Underlying the choice of high-risk patients for detailed case review, the OIG clinical experts made the following three assumptions: 1. If the institution is able to provide adequate clinical care to the most challenging patients with multiple complex and interdependent medical problems, it is more likely to provide adequate care to patients with less complicated health care issues. Because clinical expertise is required to determine whether the institution has provided adequate clinical care, the OIG utilizes experienced correctional physicians and registered nurses to perform this analysis. 2. The health of less complex patients is more likely to be affected by processes such as timely appointment scheduling, medication management, routine health screening, and immunizations. To review these processes, the OIG simultaneously performs a broad compliance review. 3. Patient cases generated during death reviews, sentinel events (unexpected occurrences involving death or serious injury, or risk thereof), and hospitalizations are more likely to comprise high-risk patients. High Desert State Prison, Cycle 5 Medical Inspection Page 6 Office of the Inspector General State of California Benefits and Limitations of Targeted Subpopulation Review Because the patients selected utilize the broadest range of services offered by the health care system, the OIG’s retrospective case review provides adequate data for a qualitative assessment of the most vital system processes (referred to as “primary quality indicators”). Retrospective case review provides an accurate qualitative assessment of the relevant primary quality indicators as applied to the targeted subpopulation of high-risk and high-utilization patients. While this targeted subpopulation does not represent the prison population as a whole, the institution’s ability to respond with adequate medical care to this subpopulation is a crucial and vital indicator of how the institution provides health care to its whole patient population. Simply put, if the institution’s medical system does not respond adequately for those patients needing the most care, then it is not fulfilling its obligations, even if it takes good care of patients with less complex medical needs. Since the targeted subpopulation does not represent the institution’s general prison population, the OIG cautions against inappropriate extrapolation of medical conditions or outcomes from the retrospective case reviews to the general population. For example, if the high-risk diabetic patients reviewed have poorly controlled diabetes, one cannot conclude that all the diabetics’ conditions are poorly controlled. Similarly, if the high-risk diabetic patients under review have poor outcomes, one cannot conclude that the entire diabetic population is having similarly poor outcomes. The OIG does not extrapolate conditions or outcomes, but instead extrapolates the institution’s response for those patients needing the most care because the response yields valuable system information. In the above example, if the institution responds by providing appropriate diabetic monitoring, medication therapy, and specialty referrals for the high-risk patients reviewed, then it is reasonable to infer that the institution is also responding appropriately to all the diabetics in the prison. However, if these same high-risk patients needing monitoring, medications, and referrals are not getting those needed services, it is likely that the institution is not providing appropriate diabetic services. Case Review Sampling Methodology Using a pre-defined case review sampling algorithm, OIG analysts apply various filters to each institution’s patient population. The various filters include medical risk status, number of prescriptions, number of specialty appointments, number of clinic appointments, and other health-related data. The OIG uses these filters to narrow down the population to those patients with the highest utilization of medical resources (see Chart 1, next page). To prevent selection bias, the OIG ensures that the same clinicians who perform the case reviews do not participate in the sample selection process. High Desert State Prison, Cycle 5 Medical Inspection Page 7 Office of the Inspector General State of California Chart 1. Case Review Sample Selection Sample Selection Analysts apply filters to the population to obtain samples (S) with high utilization. Six permutations, Population or arrangements, of case review types are possible for each sample. S S MD RN MD RN MD RN S S S S D F D D F D Case = Sample = Patient MD RN RN D D F MD = Provider RN = Registered Nurse D = Detailed F = Focused The OIG’s case sample size matched those of other qualitative research. The empirical findings, supported by expert statistical consultants, showed adequate conclusions after 10 to 15 cases had undergone comprehensive, or detailed, clinician review. In qualitative statistics, this phenomenon is known as “saturation.” The OIG found the Cycle 4 medical inspection sample size of 30 for detailed physician reviews far exceeded the saturation point necessary for an adequate qualitative review. At the end of Cycle 4 inspections, the OIG re-analyzed the case review results using half the number of cases; there were no significant differences in the ratings. To improve inspection efficiency while preserving the quality of the inspection, the OIG reduced the number of the samples for Cycle 5 medical inspections to the current levels. For most basic institutions, the OIG samples 20 cases for detailed physician review. For intermediate institutions and several basic institutions with larger high-risk populations, the OIG samples 25 cases. For California Health Care Facility, the OIG samples 30 cases for detailed physician review. Breadth of Case Reviews As indicated in Appendix B, Table B-1: HDSP Sample Sets, the OIG clinicians evaluated medical records for 47 unique cases. Appendix B, Table B-4: HDSP Case Review Sample Summary clarifies that both nurses and physicians reviewed medical records for 13 of those cases, for 60 reviews in total. Physicians performed detailed reviews of 20 cases, and nurses performed High Desert State Prison, Cycle 5 Medical Inspection Page 8 Office of the Inspector General State of California detailed reviews of 12 cases, totaling 32 detailed reviews. Nurses also performed a focused review for an additional 27 cases, while physicians performed a focused review for one additional case. These reviews generated 746 case review events (Appendix B, Table B-3: HDSP Event – Program). While the sample method specifically pulled only 6 chronic care patient records, i.e., 5 diabetes patients and one anticoagulation patient (Appendix B, Table B-1: HDSP Sample Sets), the 47 unique patients sampled included patients with 131 chronic care diagnoses, including 8 additional patients with diabetes (for a total of 13) and zero additional anticoagulation patients (for a total of one) (Appendix B, Table B-2: HDSP Chronic Care Diagnoses). The OIG’s sample selection tool allowed evaluation of many chronic care programs because the complex and high-risk patients selected from the different categories often had multiple medical problems. While the OIG did not evaluate every chronic disease or health care staff member, the OIG did assess for adequacy the overall operation of the institution’s system and staff. Case Review Testing Methodology A physician, a nurse consultant, or both clinician inspectors review each case. The OIG clinician inspector can perform one of two different types of case review: detailed or focused (see Exhibit 1, p. 5, and Chart 1, p. 8). As the OIG clinician inspector reviews the medical record for each sample, the inspector records pertinent interactions between the patient and the health care system. These interactions are also known as case review events. When an OIG clinician inspector identifies a medical error, the inspector also records these errors as case review deficiencies. If a deficiency is of such magnitude that it caused, or had the potential to cause, serious patient harm, then the OIG clinician records it as an adverse deficiency (see Chart 2, next page). High Desert State Prison, Cycle 5 Medical Inspection Page 9 Office of the Inspector General State of California Chart 2. Case Review Testing and Deficiencies Case Review Testing The OIG clinicians examine the chosen samples, performing a detailed case review or a focused case review, to determine the events that occurred. Sample = Patient = Case No Deficiency Sample Events Deficiency A sample leading to events Deficiencies Not all events lead to deficiencies (medical errors); however, if there are errors, then the OIG clinicians determine whether any are adverse. Sample Events Deficiency* A sample leading to events with deficiencies observed Adverse * If a deficiency is serious Deficiency enough, the OIG clinician labels it adverse. When the OIG clinician inspectors have reviewed all cases, they analyze the deficiencies. OIG inspectors search for similar types of deficiencies to determine if a repeating pattern of errors existed. When the same type of error occurs multiple times, the OIG inspectors identify those errors as findings. When the error is frequent, the likelihood is high that the error is regularly recurring at the institution. The OIG categorizes and summarizes these deficiencies in one or more health care quality indicators in this report to help the institution focus on areas for improvement. High Desert State Prison, Cycle 5 Medical Inspection Page 10 Office of the Inspector General State of California Additionally, the OIG physicians also rate each of the detailed physician cases for adequacy based on whether the institution met the patient’s medical needs and if it placed the patient at significant risk of harm. The cumulative analysis of these cases gives the OIG clinicians additional perspective to help determine whether the institution is providing adequate medical services or not.4 Based on the collective results of clinicians’ case reviews, the OIG clinicians rated each quality indicator proficient (excellent), adequate (passing), or inadequate (failing). A separate confidential HDSP Supplemental Medical Inspection Results: Individual Case Review Summaries report details the case reviews the 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. 4 Regarding individual provider performance, the OIG did not design the medical inspection to be a focused search for poorly performing providers; rather, the inspection assesses each institution’s systemic health care processes. Nonetheless, while the OIG does not purposefully sample cases to review each provider at the institution, the cases usually involve most of the institutions’ providers. Providers should only escape OIG case review if institutional managers assigned poorly performing providers the care of low-utilizing and low-risk patients, or if the institution had a relatively high number of providers. High Desert State Prison, Cycle 5 Medical Inspection Page 11 Office of the Inspector General State of California COMPLIANCE TESTING Sampling Methods for Conducting Compliance Testing From August to October 2017, registered nurse inspectors obtained answers to 87 objective medical inspection test (MIT) questions designed to assess the institution’s compliance with critical policies and procedures applicable to the delivery of medical care. To conduct most tests, inspectors randomly selected samples of patients for whom the testing objectives were applicable and reviewed their electronic medical records. In some cases, inspectors used the same samples to conduct more than one test. In total, inspectors reviewed health records for 376 individual patients and analyzed specific transactions within their records for evidence that critical events occurred. Inspectors also reviewed management reports and meeting minutes to assess certain administrative operations. In addition, during the week of August 21, 2017, registered nurse 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 1,057 scored data points to assess care. In addition to the scored questions, the OIG obtained information from the institution that it did not score. This included, for example, information about 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 After compiling the answers to the 87 questions for the ten indicators for which compliance testing was applicable, the OIG compliance team derived a score for each quality indicator by calculating the percentage score of all Yes answers for each of the questions applicable to a particular indicator, then averaging those scores. Based on those results, the OIG assigned a rating to each quality indicator of proficient (greater than 85 percent), adequate (between 75 percent and 85 percent), or inadequate (less than 75 percent). OVERALL QUALITY INDICATOR RATING FOR CASE REVIEWS AND COMPLIANCE TESTING The OIG derived the final rating for each quality indicator by combining the ratings from the case reviews and from the compliance testing, as applicable. When combining these ratings, the case review evaluations and the compliance testing results usually agreed, but there were instances for this inspection when the rating differed for a particular quality indicator. In those High Desert State Prison, Cycle 5 Medical Inspection Page 12 Office of the Inspector General State of California instances, the inspection team assessed the quality indicator based on the collective ratings from both components. Specifically, the OIG clinicians and registered nurse inspectors discussed the nature of individual exceptions found within that indicator category and considered the overall effect on the ability of patients to receive adequate medical care. To derive an overall assessment rating of the institution’s medical inspection, the OIG evaluated the various rating categories assigned to each of the quality indicators applicable to the institution, giving more weight to the rating results of the primary quality indicators, which directly relate to the health care provided to patients. Based on that analysis, OIG experts made a considered and measured overall opinion about the quality of health care observed. POPULATION-BASED METRICS The OIG identified a subset of Healthcare Effectiveness Data Information Set (HEDIS) measures applicable to the CDCR patient population. To identify outcomes for 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 5 Medical Inspection Page 13 Office of the Inspector General State of California M I R EDICAL NSPECTION ESULTS The OIG’s case review and clinician teams use quality indicators to assess the clinical aspects of health care. The HDSP Executive Summary Table on page iv of this report identifies the 13 indicators applicable to this institution. The following chart depicts their union and intersection: Chart 3. Inspection Indicator Review Distribution Case Review Compliance 1 — Access to Care 2 — Diagnostic Services 3 — Emergency 5 — Health Care Services 4 — Health Information Environment Management 10 — Quality of Nursing 6 — Inter- and Intra-System 9 — Preventive Performance Transfers Services 11 — Quality of 7 — Pharmacy and Medication 15 — Administrative Provider Management Operations Performance 13 — Specialized Medical Housing 14 — Specialty Services The Administrative Operations indicator is a secondary indicator; therefore, the OIG did not rely upon this indicator when determining the institution’s overall score. Based on the analysis and results in all the primary indicators, the OIG experts made a considered and measured opinion that the quality of health care at HDSP was adequate. Summary of Case Review Results: The clinical case review component assessed ten primary (clinical) indicators applicable to HDSP. Of these ten indicators, OIG clinicians rated eight adequate and two inadequate. The OIG physicians rated the overall adequacy of care for each of the 20 detailed case reviews they conducted. Of these 20 cases, one was proficient, 15 were adequate, and 4 were inadequate. In the 746 events reviewed, there were 204 deficiencies, 76 of which were considered to be of such magnitude that, if left unaddressed, they would likely contribute to patient harm. High Desert State Prison, Cycle 5 Medical Inspection Page 14 Office of the Inspector General State of California Adverse Deficiencies Identified During Case Review: Adverse deficiencies are medical errors that markedly increased the risk of, or resulted in, serious patient harm. Medical care is a complex and dynamic process with many moving parts, subject to human error even within the best health care organizations. All major health care organizations typically identify and track adverse deficiencies for the purpose of quality improvement. Adverse deficiencies are not typically representative of medical care delivered by the organization. The OIG normally identifies adverse deficiencies for the dual purposes of quality improvement and the illustration of problematic patterns of practice found during the inspection. Because of the anecdotal nature of these deficiencies, the OIG cautions against drawing inappropriate conclusions regarding the institution based solely on adverse deficiencies. The OIG identified no adverse deficiencies in the case reviews at HDSP. Summary of Compliance Results: The compliance component assessed 10 of the 13 indicators applicable to HDSP. Of these ten indicators, OIG inspectors rated four adequate and six inadequate. The test questions used to assess compliance for each indicator are detailed in Appendix A. High Desert State Prison, Cycle 5 Medical Inspection Page 15 Office of the Inspector General State of California ACCESS TO CARE This indicator evaluates the institution’s ability to provide Case Review Rating: patients with timely clinical appointments. Compliance and Inadequate case review teams review areas specific to patients’ access to Compliance Score: care, such as initial assessments of newly arriving patients, Adequate (75.5%) acute and chronic care follow-ups, face-to-face nurse appointments when patients request to be seen, provider Overall Rating: referrals from nursing lines, and follow-ups after Inadequate hospitalization or specialty care. Compliance testing for this indicator also evaluates whether patients have Health Care Services Request forms (CDCR Form 7362) available in their housing units. In this indicator, the OIG case review and compliance review processes yielded different results, with the case reviewers assigning an inadequate rating and the compliance review resulting in an adequate score. The poor performance in provider-ordered follow-ups, nurse-requested follow-ups, provider appointments for patients newly admitted to the institution, and diagnostic results’ follow-ups all significantly affected the quality of care provided. Compliance testing also yielded poor performance in nurse-initiated follow-ups, specialty follow-ups, and hospitalization follow-ups. The OIG’s internal review process considered those factors that led to both scores. Given the clinical importance of the deficiencies identified, the OIG determined the overall rating of inadequate was appropriate for this indicator. Case Review Results The OIG clinicians reviewed 270 provider, nurse, specialty, and hospital events that required a follow-up appointment and identified 63 deficiencies relating to Access to Care¸ 35 of which were significant. These deficiencies represented problems with health care access, which will be discussed below. Provider-to-Provider Follow-up Appointments HDSP performed poorly with provider-ordered follow-up appointments. There were 19 deficiencies in this area, 11 of which were significant. The OIG clinicians identified deficiencies in cases 1, 7, 8, 9, 10, 11, 13, 17, 26, 27, and 29. There were two patterns of severe deficiencies: significant appointment delays and appointments prematurely canceled before a provider could address issues. The following are examples of these concerns: • In case 1, HDSP staff erroneously marked appointments “completed,” even though the provider did not address the reason for the appointment. Those appointments were not rescheduled. The provider also ordered a chronic care appointment for 90 days, but less than one month later, HDSP staff again erroneously canceled the appointment and dropped the patient’s chronic care program. High Desert State Prison, Cycle 5 Medical Inspection Page 16 Office of the Inspector General State of California • In case 8, the provider requested an appointment within nine days to discuss the patient’s diabetes and his apparent reluctance to manage it. Instead, the appointment occurred 18 days late, a significant delay. • Also in case 8, the provider intended to follow the patient closely by ordering a three-day follow-up appointment after adjusting diabetes medication. The provider also ordered a 30-day follow-up appointment. Both appointments were canceled inappropriately during an attempt to bundle them to provide more efficient patient care. HDSP staff thus lost the patient to follow up for more than four months and dropped his diabetes care. • In case 11, HDSP bundled three appointments to address the patient’s chronic care concerns, to discuss his cardiology consultation, and to review his medical accommodations. The provider addressed neither the cardiology consultation nor the chronic care issues, which meant the patient’s diabetes, heart disease, and high blood pressure concerns were all dropped. Ultimately, this meant the institution lost track of the patient’s medical care. RN Sick Call Access Patients who submitted sick call requests did not always see the nurse within the required time frame. Nurses received and reviewed sick call requests each morning. Of the 98 sick call requests reviewed, HDSP did not provide patients with prompt access to sick call nursing appointments in cases 10, 13, 33, and 38. Furthermore, the OIG clinicians reviewed two cases in which the nurse did not assess a patient with urgent medical symptoms on the same day. These cases are discussed in the Quality of Nursing Performance indicator. RN-to-Provider Referrals Nurses referred patients to a provider when the patient needed a higher level of care for diagnosis and treatment. HDSP performed poorly with half of these nurse-to-provider referrals that did not occur timely. The OIG clinicians reviewed 30 nursing encounters that generated a provider follow-up referral and found provider appointments were delayed in cases 1, 2, 10, 13, 15, 29, 31, 32, 33, 34, and 44. In case 2, the HDSP staff did not schedule the provider appointment at all. RN Follow-up Appointments HDSP also had difficulty with scheduling and completing registered nurse (RN) follow-up appointments that providers or nurses generated. The OIG clinicians reviewed 11 RN follow-up referrals and noted RN appointments were delayed 11 days in case 9, and 4 days in case 37. Two RN appointments did not occur at all in case 11. Provider Follow-up After Specialty Services HDSP performed well with ensuring provider follow-up appointments occurred after specialty services. The OIG clinicians reviewed 61 specialty services requiring follow-up and found minor High Desert State Prison, Cycle 5 Medical Inspection Page 17 Office of the Inspector General State of California delays in cases 2 and 19, which did not affect the quality of the care provided. Performance in this area is further discussed in the Specialty Services indicator. Intra-System Transfers As in Cycle 4, HDSP had trouble with providing timely access to provider appointments for new patients who transferred from other CDCR institutions. Of the ten transfer-in patients reviewed, the OIG clinicians identified delays in provider appointments ranging from two days up to three weeks in cases 21, 22, 31, and 41. Follow-up After Hospitalization HDSP performed well in ensuring providers followed up with their patients after an outside hospitalization or emergency department visit. CCHCS policy requires institutions to provide a follow-up appointment within five days of these visits. The OIG clinicians reviewed 19 occurrences of hospitalizations and outside emergency department visits, and observed only one significant deficiency. Follow-up After Urgent/Emergent Care HDSP performance was acceptable with ensuring provider follow-up for patients seen in the TTA and who were sent back to housing. As noted above for the preceding area, CCHCS policy requires institutions to provide a follow-up appointment within five days of such visits. The OIG clinicians reviewed 29 TTA events and found 11 of them required a five-day follow-up appointment. Two deficiencies were noted in this area. Specialized Medical Housing Provider access was good for patients admitted to the CTC. The OIG reviewed 36 CTC admissions and encounter events. Only five instances occurred in which the providers did not perform timely CTC rounds; all were minor deficiencies. Specialty Access and Follow-up The institution performed well with requesting specialist consultations and follow-up appointments. Performance in this area is discussed further in the Specialty Services indicator. Diagnostic Results Follow-up HDSP provided poor follow-up care to patients after diagnostic tests returned abnormal results. After reviewing results, providers are required to review diagnostic tests, and to request appointments and notify the patient whether further follow-up is necessary. The OIG clinicians noted several other minor delays, along with two significant delays as described in the following: • In case 8, the provider reviewed an abnormal test result showing poorly controlled diabetes, but did not request an appointment to follow up with the patient. By chance, the nurse High Desert State Prison, Cycle 5 Medical Inspection Page 18 Office of the Inspector General State of California reviewed the result 25 days later and ordered a 7-day provider follow-up. Unfortunately, the appointment occurred with a 17-day delay. Ultimately, the provider saw the patient 50 days after the abnormal blood test. • In case 9, the patient received an abnormal test result showing poorly controlled diabetes. The provider did not review the result. Fortunately, the nurse reviewed the result 45 days later and requested the follow-up. Clinician Onsite Inspection The OIG clinicians discussed the Access to Care deficiencies with HDSP schedulers, who explained the problem was a lack of available provider appointments. HDSP had lost one provider to retirement, and another to medical leave with an indeterminate return date. In addition, transitioning to the new EHRS had resulted in a severe decline in provider productivity. To ameliorate the delays, HDSP had begun closely monitoring both scheduled and completed appointments to improve current providers’ productivity levels. HDSP staff had bundled appointments to increase efficiency. Case Review Conclusion HDSP performance was poor with regard to Access to Care. The vast majority of deficiencies resulted from delayed provider follow-ups, with the most significant deficiencies leading to dropped care in several cases. The chronic situation of provider understaffing and the decrease in staff productivity experienced with the EHRS transition were obstacles that proved too difficult for the institution to overcome. While HDSP attempted to address the backlog of appointments by aggressively bundling them, unfortunately, this strategy failed when the provider did not address all the bundled issues. This bundling resulted in dropped care for patients as observed in cases 8 and 11. In both instances, HDSP lost track of these patients and failed to schedule any follow-up appointments. The case review rating for this indicator was inadequate. Compliance Testing Results The institution performed in the adequate range, with a score of 75.5 percent in the Access to Care indicator. The following tests earned scores in the proficient range: • OIG inspectors sampled 30 health care services request forms that patients submitted across all facility clinics. Nursing staff completed timely face-to-face triage encounters for all 30 patients (MIT 1.004). • Patients could access health care services request forms at all six housing units the OIG inspected (MIT 1.101). High Desert State Prison, Cycle 5 Medical Inspection Page 19 Office of the Inspector General State of California • OIG inspectors sampled 30 health care services request forms and found that nursing staff reviewed the forms on the same day received for 29 of them (97 percent). For one sample, nursing staff reviewed the services request form one day late (MIT 1.003). Two tests received scores in the adequate range: • When the OIG reviewed recent appointments for 25 sampled patients with chronic care conditions, 20 patients (80 percent) received timely provider follow-up appointments. Four patients received chronic care appointments from 11 to 93 days late. For one patient, the appointment did not occur (MIT 1.001). • Of the nine applicable patients sampled whom nursing staff referred to a provider and for whom the provider subsequently ordered a follow-up appointment, seven (78 percent) received their follow-up appointments timely. Of the remaining two patients, one received his follow-up appointment four days late, and for the other patient, OIG inspectors found no medical record evidence a follow-up appointment occurred (MIT 1.006). The OIG inspectors found room for improvement in the following four tests: • Only 17 of 26 sampled patients (65 percent) who received a high-priority or routine specialty service also received a timely follow-up appointment with a provider. Of the nine patients who did not receive timely follow-up appointments, six patients’ high-priority specialty service follow-up appointments were 2 to 31 days late, and one patient did not receive his follow-up appointment. One patient’s routine specialty service follow-up appointment was 17 days late, and one other patient did not receive his appointment (MIT 1.008). • OIG inspectors tested eight patients discharged from an outside hospital to determine whether they received a provider follow-up appointment at HDSP within five calendar days of their return to the institution. Five patients (62 percent) received a timely provider follow-up appointment. Two patients received their appointments one and three days late. For the remaining patient, OIG inspectors found no medical record evidence that his follow-up occurred (MIT 1.007). • Among 23 health care services request forms (CDCR Form 7362) sampled on which nursing staff referred the patient for a provider appointment, only 14 patients (61 percent) received timely appointments. Six patients received their appointments from 4 to 38 days late. For three other patients, OIG inspectors found no medical record evidence that the primary care visit occurred (MIT 1.005). High Desert State Prison, Cycle 5 Medical Inspection Page 20 Office of the Inspector General State of California • Among 25 patients sampled who transferred into HDSP from other institutions and whom nurses referred to a provider based on their initial health care screening, only 9 of them (36 percent) were seen timely. Eleven patients received their provider appointments from 10 to 134 days late, but for the five remaining patients, they did not receive their appointments (MIT 1.002). High Desert State Prison, Cycle 5 Medical Inspection Page 21 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 Adequate services were timely provided to patients, whether primary Compliance Score: care providers timely reviewed results, and whether providers Inadequate (58.9 %) communicated results to the patient within required time frames. In addition, for pathology services, the OIG Overall Rating: determines whether the institution received a final pathology Adequate report and 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. For this indicator, the case review and compliance review processes yielded different results, with the case reviewers assigning an adequate rating and the compliance testing resulting in an inadequate score. The main reason for the inadequate score: providers did not timely review radiology and laboratory reports; in addition, they did not communicate the results to the patient. The OIG considered results obtained from both case review and compliance testing, and concluded that the majority of the deficiencies resulted from the inattention of one provider who did not review diagnostic reports promptly and often did not forward the results to the patients. Nonetheless, the majority of HDSP providers demonstrated their awareness of the results and treated their patients appropriately. Despite the one provider’s poor documentation habits, HDSP patients continued to receive satisfactory diagnostic services. OIG clinicians determined that the overall rating for this indicator was adequate. Case Review Results The OIG clinicians reviewed 63 diagnostic events and found 10 deficiencies, 8 of which were significant. Of these ten deficiencies, seven were related to health information management and three were related to the completion of ordered tests. Test Completion HDSP completed most diagnostic services promptly. The OIG clinicians observed three significant deficiencies as explained in the following cases: • In case 1, the provider requested urgent laboratory tests be performed the next morning. Instead, HDSP staff performed the tests nine days later. • In case 5, the provider ordered blood tests, but HDSP staff never completed them. • In case 9, the provider ordered blood tests and an electrocardiogram (EKG), but HDSP staff did not perform the EKG and most of the laboratory tests. High Desert State Prison, Cycle 5 Medical Inspection Page 22 Office of the Inspector General State of California Health Information Management HDSP experienced some challenges with its health information management of diagnostic results. The OIG clinicians observed a pattern of one provider not reviewing laboratory test results and not notifying the patients of these test results as detailed in the following: • In case 7, the provider did not notify the patient of his test result showing poorly controlled diabetes. • In case 9, a patient’s laboratory result was reviewed by a nurse more than a month late, and his provider did not review it until more than four months later. • In case 16, the provider did not review the chest X-ray result and, consequently, did not notify the patient of the results. Clinician Onsite Inspection HDSP diagnostic supervisors stated that when results were ready, the EHRS sent the provider a notification to review the results in the providers’ message center. Whether the provider reviewed the results timely or at all was beyond diagnostic supervisors’ control. The majority of the deficiencies noted in this area occurred when providers did not appropriately review their messages in the EHRS. Case Review Conclusion HDSP usually performed well in completing and retrieving diagnostic studies. HDSP did not perform or delayed only a small fraction of laboratory tests. One provider reviewed diagnostic results late and did not notify the patient of the results, but this poor practice did not result in a noticeable effect on the quality of care provided to patients at the institution. The OIG clinicians rated the Diagnostic Services indicator adequate. Compliance Testing Results The institution received an inadequate compliance score of 56.7 percent in the Diagnostic Services indicator, which encompasses radiology, laboratory, and pathology services. For clarity, each type of diagnostic service is discussed separately below: Radiology Services • While HDSP providers timely performed radiology services for all ten sampled patients (100 percent) (MIT 2.001), only three of the ten patients (30 percent) received timely reviews of their corresponding diagnostic services reports. For five patients, HDSP providers reviewed their reports from one to 21 days late. For the remaining two patients, OIG inspectors found no medical record evidence that providers reviewed those reports (MIT 2.002). Providers timely communicated test results to only three of the ten sampled High Desert State Prison, Cycle 5 Medical Inspection Page 23 Office of the Inspector General State of California patients (30 percent). Providers communicated three patients’ results one to two days late, and two other patients’ results 26 and 66 days late. For two final patients, OIG inspectors found no medical record evidence that the results were communicated to them (MIT 2.003). Laboratory Services • HDSP providers timely obtained ordered diagnostic services for ten sampled patients (MIT 2.004). However, providers then signed and dated those laboratory reports for only six of those ten patients (60 percent); furthermore, providers reviewed four reports from 3 to 21 days late (MIT 2.005). Finally, providers timely communicated laboratory reports’ results to only three of the ten sampled patients (30 percent); for three patients, communication was late from 4 to 8 days, and for the remaining four patients, from 20 to 56 days (MIT 2.006). Pathology Services • The institution timely received final pathology reports for nine of ten sampled patients (90 percent), but one patient’s pathology report was received 26 days late (MIT 2.007). For five of the ten patients (50 percent), HDSP providers timely reviewed the final pathology reports, but for the other five patients, their final pathology reports were reviewed from two to ten days late (MIT 2.008). Providers timely communicated final pathology results to only four of the ten sampled patients (40 percent). For five patients, the provider communicated pathology results from 2 to 24 days late, and one final patient never received any provider communication concerning his result (MIT 2.009). High Desert State Prison, Cycle 5 Medical Inspection Page 24 Office of the Inspector General State of California EMERGENCY SERVICES An emergency medical response system is essential to Case Review Rating: providing effective and timely emergency medical response, Adequate assessment, treatment, and transportation 24 hours per day. Compliance Score: Provision of urgent/emergent care is based on a patient’s Not Applicable emergency situation, clinical condition, and need for a higher Overall Rating: level of care. The OIG reviews emergency response services Adequate including first aid, basic life support (BLS), and advanced cardiac life support (ACLS) consistent with the American Heart Association guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiovascular care, and the provision of services by knowledgeable staff appropriate to each individual’s training, certification, and authorized scope of practice. The OIG evaluates this quality indicator entirely through clinicians’ reviews of case files and conducts no separate compliance testing element. Case Review Results The OIG clinicians reviewed 29 urgent/emergent events and found 22 deficiencies related mostly to nursing documentation. Only one deficiency was considered significant. CPR Response During the review period, three cases required emergency medical CPR responses. In each case, HDSP performed well with emergency response times, CPR and other emergency interventions, and 9-1-1 activation. HDSP staff documented the CPR emergency events and medical interventions clearly, except for one case in which the provider failed to document provider interventions during the provision of CPR. Provider Performance HDSP providers performed well in the emergent setting, properly assessing and triaging their patients. Providers sent patients requiring a higher level of care to an outside hospital promptly. HDSP staff appropriately treated those patients not requiring hospitalization in the TTA. The OIG identified no patterns of deficiencies. Nursing Performance As was evident during the Cycle 4 inspection, HDSP nurses continued providing proper care during emergency responses. They responded promptly to medical emergencies and provided appropriate interventions. High Desert State Prison, Cycle 5 Medical Inspection Page 25 Office of the Inspector General State of California Nursing Documentation HDSP transitioned to the EHRS in January 2017. Nursing leadership acknowledged the institution’s staff had experienced challenges with completing documentation in the EHRS, specifically in the TTA. Nursing staff continued to receive periodic training to remedy this situation. The OIG clinicians found incomplete chronological information and missing nursing documentation during their review of emergency medical response encounters. First medical responders and TTA nurses consistently neglected to document relevant patient information, such as initial assessments of vital signs, specific times when they contacted the on-call physician or the 9-1-1 ambulance service, and status updates concerning the patient’s condition while in the TTA. Additionally, first medical responders did not complete progress notes about emergency event details, including their nursing assessments and interventions for five events reviewed in one case. These documentation deficiencies resulted in an inability to precisely and accurately assess the patient’s clinical condition and determine which interventions the nurses may have been provided before the patient arrived in the TTA. However, the OIG clinicians considered the majority of the deficiencies minor because they usually consisted of incomplete or missing nursing documentation. Although these deficiencies did not affect the patient’s care, they represent areas the institution can target for quality improvement. Emergency Medical Response Review Committee The Emergency Medical Response Review Committee (EMRRC) appropriately discussed and identified deficiencies, and documented actions taken to correct problems noted in the 13 emergent medical response cases the OIG clinicians reviewed. Clinician Onsite Inspection The TTA was appropriately equipped and well-staffed with nurses trained to handle emergency events onsite. A provider covered the TTA during business hours, and an on-call provider was readily available during after-hours. During interviews, TTA nurses reported that nurses from both the clinics and the CTC assisted during medical emergencies when needed. HDSP also reported its plan in January 2018 to provide emergency telemedicine services through a contracted community hospital. Case Review Conclusion In general, HDSP’s performance was good, with the majority of deficiencies due to nursing documentation issues. HDSP staff provided proper care and sent patients to the outside hospital when needed. For patients with less serious problems, the staff treated, and returned, them to housing appropriately. The indicator for Emergency Services was rated adequate. High Desert State Prison, Cycle 5 Medical Inspection Page 26 Office of the Inspector General State of California HEALTH INFORMATION MANAGEMENT Health information management is a crucial link in the delivery of Case Review Rating: medical care. Medical personnel require accurate information in Adequate order to make sound judgments and decisions. This indicator Compliance Score: examines whether the institution adequately manages its health Inadequate (66.0%) care information. This includes determining whether the information is correctly labeled and organized and available in the Overall Rating: electronic medical record; whether the various medical records Adequate (internal and external, e.g., hospital and specialty reports and progress notes) are obtained and scanned timely into the patient’s electronic medical record; whether records routed to clinicians include legible signatures or stamps; and whether hospital discharge reports include key elements and are timely reviewed by providers. In this indicator, the OIG’s case review and compliance review processes yielded different results, with the case reviewers assigning an adequate rating and the compliance testing resulting in an inadequate score. The compliance testing score identified problems had occurred with scanning accuracy, retrieval of specialty consultation reports, and provider review of hospital discharge reports. There were more samples in the case reviews, which provided a more accurate representation of these measures. Even though providers did not always sign the hospital discharge reports, providers demonstrated in their notes that they had properly reviewed the reports. The OIG’s internal review process considered the factors that led to both results and determined that the overall rating for this indicator was adequate. During the OIG’s testing period, HDSP had converted to the new electronic health record system (EHRS) in January 2017; therefore, most testing occurred in the EHRS, with a minor portion of the testing done in the electronic unit health record (eUHR). Case Review Results The OIG clinicians reviewed 746 events and found 24 deficiencies related to health information management, 8 of which were significant. Most of the deficiencies involved the provider not signing reports and consultations. Inter-Departmental Transmission During the review period, HDSP transitioned to the EHRS. While HDSP lost one order before the transition to the new system, after its implementation, no further transmission errors occurred among the different departments at the institution. High Desert State Prison, Cycle 5 Medical Inspection Page 27 Office of the Inspector General State of California Hospital Records HDSP demonstrated good performance with the retrieval of emergency department and hospital discharge summaries. The OIG clinicians noted one significant deficiency in which the institution failed to retrieve the discharge summary for a hospitalization in case 17. Specialty Services HDSP’s performance in handling specialty reports was satisfactory. Performance in this area is also discussed in the Specialty Services indicator. Diagnostic Reports HDSP performed poorly with the timely review of diagnostic reports. Performance in this area is discussed in greater detail in the Diagnostic Services indicator. Urgent/Emergent Records HDSP nurses did a poor job documenting their emergency encounters. Performance in this area is also discussed in the Emergency Services indicator. Scanning Performance HDSP performed adequately in this area after transitioning to the EHRS. The OIG identified minor deficiencies of mislabeled documents in three cases and misdated reports in two cases. Legibility At HDSP, legibility was not an issue after the institution transitioned to the EHRS. Clinician Onsite Inspection The OIG clinicians observed several morning huddles in the individual clinic. At those meetings, participants disseminated clinical information about overnight events, new arrivals, recent transfers, medications soon to expire, and sick call requests. Providers demonstrated familiarity with their patients. Case Review Conclusion HDSP performed well with retrieving outside specialty reports, hospital discharge summaries, and outside emergency department reports. Scanning time frames were acceptable; scanning accuracy was satisfactory. There were fewer missing, misfiled, or mislabeled documents after the EHRS transition. However, the institution experienced difficulty with ensuring providers reviewed and signed laboratory and hospital discharge summary reports. The nursing documentation from the TTA was suspect, and this aspect is detailed in the Emergency Services indicator. Nonetheless, most health information was available to providers when they needed to review it; thus, the indicator rating was adequate. High Desert State Prison, Cycle 5 Medical Inspection Page 28 Office of the Inspector General State of California Compliance Testing Results The institution scored in the inadequate range with a score of 66.0 percent in the Health Information Management indicator. The following tests showed room for improvement: • The institution scored 58 percent for correctly labeling and filing documents scanned into patients’ electronic medical records. For this test, the OIG bases its score on an allowable maximum of 24 mislabeled or misfiled documents. For the HDSP medical inspection, OIG inspectors identified 14 documents that were either mislabeled or missing from the medical record (MIT 4.006). • Among eight sampled patients admitted to an outside hospital who then returned to the institution, HDSP providers timely reviewed five patients’ corresponding hospital discharge reports within three calendar days of their discharge (62 percent). For the other three sampled patients, the provider did not sign the hospital discharge report (MIT 4.007). • For 13 of 20 specialty service consultant reports sampled (65 percent), HDSP staff scanned the reports into the patient’s health record file within five calendar days. However, HDSP staff scanned six documents from one to 8 days late and scanned one document 165 days late (MIT 4.003). • Institution staff timely scanned 9 of 13 sampled documents, such as non-dictated provider progress notes, nursing initial health screening forms, and patient health care service request forms into the patient’s electronic medical record within three calendar days of the patient encounter (69 percent); HDSP scanned four documents from one to four days late (MIT 4.001). One test received a score of adequate: • HDSP’s records management staff timely scanned outside hospital discharge reports or treatment records into six of the eight sampled patients’ health records (75 percent), but two reports were scanned four and ten days late (MIT 4.004). High Desert State Prison, Cycle 5 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 Not Applicable control and sanitation, medical supplies and equipment Compliance Score: management, the availability of both auditory and visual privacy Adequate (76.6%) for patient visits, and the sufficiency of facility infrastructure to conduct comprehensive medical examinations. The OIG rates Overall Rating: this component entirely on the compliance testing results from Adequate the visual observations inspectors make at the institution during their onsite visit. This indicator is evaluated entirely by compliance testing. There is no case review portion. Compliance Testing Results The institution received scores in the proficient range on the following four tests: • All 12 clinics were appropriately clean, disinfected, and sanitary. In addition, cleaning logs were present and completed, indicating crews regularly cleaned the clinics (MIT 5.101). • The bulk medical supply storage areas (outside of the clinics) met the supply management process and support needs of the medical health care program, earning HDSP a score of 100 percent on this test (MIT 5.106). • Of the 12 clinic locations inspected, 11 of them (92 percent) had operating sinks and sufficient quantities of hand hygiene supplies in examination areas. One clinic’s patient restroom did not have sufficient quantities of hygiene supplies such as antiseptic soap (MIT 5.103). • Health care staff at 11 of 12 clinics followed proper protocols to mitigate exposure to blood-borne pathogens and contaminated waste (92 percent). Personal protective equipment was not available within the immediate area of one clinic (MIT 5.105). Three tests received scores in the adequate range: • Clinical health care staff in 9 of the 11 applicable clinics (82 percent) properly sterilized or disinfected reusable invasive and non-invasive medical equipment. At one location, staff did not follow adequate sterilization safeguards for invasive medical equipment. At another location, clinical staff relied on the cleaning crew to disinfect the examination table before the start of the new shift. The OIG inspectors noted that the staff did not replace protective paper on the examination table in between patient encounters (MIT 5.102). High Desert State Prison, Cycle 5 Medical Inspection Page 30 Office of the Inspector General State of California • Nine of the 12 clinics (75 percent) maintained core equipment or other essential supplies necessary to conduct comprehensive examinations in their clinic common areas and examination rooms. Deficiencies in equipment and supplies included the following: one clinic lacked a demarcation line for the Snellen eye examination chart; another clinic was missing its nebulization unit; in a third clinic, the oto-ophthalmoscope was not working during the OIG’s inspection (MIT 5.108). • Nine of the 12 clinics (75 percent) maintained clinic common areas that were conducive to providing medical services. In the remaining three clinics, the location of blood draw stations compromised patients’ auditory privacy (MIT 5.109). Four tests showed areas in which the institution can improve: • In 8 of the 11 (73 percent) applicable clinic examination rooms that the OIG observed, inspectors found appropriate space, configuration, supplies, and equipment to allow clinicians to perform proper clinical examinations. In two clinic locations, the examination tables had torn vinyl covers; and in another clinic, no portable screen was available to provide visual privacy for patients (MIT 5.110). • OIG inspectors observed clinician encounters with patients in 11 applicable clinics. Clinicians followed good hand hygiene practices in six clinics (55 percent). At five clinics, however, clinicians failed to wash their hands before or after patient contact, or before applying gloves (MIT 5.104). • In 6 of the 12 clinics inspected (50 percent), the OIG found that staff followed appropriate medical supply storage and management protocols. At the remaining six clinics, the OIG found medical supplies stored beyond manufacturers’ guidelines; medical supplies were also inappropriately stored in the same area with disinfecting agents and personal items (Figure 1) (MIT 5.107). • OIG inspectors examined emergency medical response bags (EMRBs) and the crash cart to determine whether HDSP staff inspected them daily, inventoried them monthly, and if they contained all essential items. EMRBs were compliant in four of the Figure 1: Medical supplies eight applicable clinical locations where they were inappropriately stored with stored (50 percent). In four locations, the EMRB log other agents. was incomplete, as staff had not properly verified that the bag’s compartments were sealed and intact (MIT 5.111). High Desert State Prison, Cycle 5 Medical Inspection Page 31 Office of the Inspector General State of California Non-Scored Results The OIG gathered information to determine if the institution’s physical infrastructure was maintained in a manner that supported health care management’s ability to provide timely or adequate health care. The OIG does not score this question. • When OIG inspectors interviewed health care managers, they did not identify any significant concerns. At the time of the OIG’s medical inspection, HDSP had several significant infrastructure projects underway, which included increasing clinic space at five yards, expansion of the pharmacy, and expansion of the telemedicine clinic. These projects were started fall 2016, and the institution estimates they will be completed by the end of summer 2018 (MIT 5.999). High Desert State Prison, Cycle 5 Medical Inspection Page 32 Office of the Inspector General State of California INTER- AND INTRA-SYSTEM TRANSFERS This indicator focuses on the management of patients’ medical Case Review Rating: needs and continuity of patient care during the inter- and Adequate intra-system transfer process. The patients reviewed for this Compliance Score: indicator include those received from, as well as those Inadequate (70.3%) transferring out to, other CDCR institutions. The OIG review includes evaluation of the institution’s ability to provide and Overall Rating: document health screening assessments, initiation of relevant Adequate 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 patients who transfer out of the institution, the OIG evaluates the ability of the institution to document transfer information that includes pre-existing health conditions, pending appointments, tests and requests for specialty services, medication transfer packages, and medication administration prior to transfer. The OIG clinicians also evaluate the care provided to patients returning to the institution from an outside hospital and check to ensure appropriate implementation of the hospital assessment and treatment plans. In this indicator, the OIG’s case review and compliance review process yielded different results, with the case reviewers assigning an adequate rating and the compliance testing resulting in an inadequate score. HDSP scored zero on one compliance test for incomplete transfer packets, and this test adversely affected the overall compliance score. However, the incomplete transfer packets were not clinically significant in the cases reviewed by the OIG clinicians. The OIG’s internal review process considered those factors that led to both results and rated this indicator adequate. Case Review Results The OIG clinicians reviewed 37 inter- and intra-system transfer events, including information from both the sending and receiving institutions. These included 21 hospitalizations and outside emergency room events, each of which resulted in a transfer back to the institution. Transfers In HDSP performed acceptably with ensuring that patients who transferred from another CDCR institution received sufficient health care. The OIG clinicians reviewed ten such cases. Two transfer-in cases showed room for improvement: • In case 22, the high-risk patient with a history of stroke, paralysis on his right side, and hypertension arrived. The receiving nurse did not schedule a provider follow-up appointment within seven days after arrival, as required by CCHCS policy. The provider evaluated the patient more than a month later, but neither documented a progress note nor High Desert State Prison, Cycle 5 Medical Inspection Page 33 Office of the Inspector General State of California ordered a follow-up appointment. HDSP stopped the patient’s care. Four months later, HDSP still had not scheduled a provider follow-up for the patient. • In case 31, the receiving nurse scheduled a provider follow-up within 14 days, but staff inappropriately canceled the appointment. Fortunately, a provider saw the patient more than a month later due to his medication refusals. In four additional transfer-in cases, the OIG identified minor deficiencies, which included the following concerns: delays in provider appointments for newly arrived patients, a mislabeled form scanned into the electronic health record, and incomplete nursing assessment information listed on the initial health screening form. Transfers Out The OIG clinicians reviewed six cases in which patients transferred from HDSP to other CDCR institutions. The transfer-out process in all six cases was good. Hospitalizations Patients returning from hospitalizations are some of the highest-risk encounters due to two factors. First, these patients usually require hospitalization for a severe illness or injury, and second, they are at risk due to potential lapses in care that can occur during any transfer. The HDSP health care team performed well in the hospital transfer process. The OIG clinicians reviewed the records for 21 patients who had returned to HDSP from an offsite hospital admission or an emergency department visit. HDSP nurses properly processed most patients returning from the hospital through the TTA. Compared to Cycle 4, the TTA nurses have significantly improved the quality of their assessments for patients returning from the hospital. Clinician Onsite Inspection The receiving and release (R&R) health care area had sufficient space in which to conduct initial health care screenings. HDSP staff sent transfer notifications weekly, and the first-watch RN reviewed the health care transfer information. One RN covered each shift on business days, and administrative staff assisted in processing patient intakes and transfers four days per week. Case Review Conclusion HDSP performed sufficiently for patients who transferred into or out of the institution. The health care staff did well in ensuring continuity of care for those patients who transferred from an outside hospital. Overall, the OIG clinicians found the transfer processes at HDSP adequate. High Desert State Prison, Cycle 5 Medical Inspection Page 34 Office of the Inspector General State of California Compliance Testing Results The institution scored in the inadequate range for this indicator, with a score of 70.3 percent. The institution can improve in the following area: • During the onsite inspection, HDSP received a score of zero when the OIG inspectors tested nine patients transferring out of the institution to determine whether the patients’ transfer packages included required medications and related documentation. The OIG identified nine packages with one or more of the following deficiencies: transfer packages were missing the required transfer checklist forms and medications noted on patients’ active medication lists, and the OIG identified at least one medication for which there was no active medication order (MIT 6.101). Two tests received scores in the adequate range: • OIG inspectors tested 20 patients who transferred out of HDSP to other CDCR institutions to determine whether their previously scheduled specialty service appointments were listed on the health care transfer form. HDSP nursing staff identified these scheduled appointments on the transfer form for 15 of the 20 samples tested (75 percent), but for the remaining five patients, staff did not identify pending specialty service appointments on the transfer forms (MIT 6.004). • Seventeen sampled patients transferred to HDSP from other CDCR institutions with existing medication orders that required nursing staff to issue or administer medications to them upon their arrival. Of those patients, 13 of them (77 percent) received their medications timely, but the remaining 4 patients did not receive their medications at the next dosing interval as CCHCS policy requires (MIT 6.003). One test received a score of proficient: • For 25 patients newly arriving at HDSP from other CDCR institutions, nursing staff properly documented an assessment and disposition of the Initial Health Screening form (CDCR Form 7277), signing and dating the form on the same day the patient arrived at HDSP (MIT 6.001, 6.002). High Desert State Prison, Cycle 5 Medical Inspection Page 35 Office of the Inspector General State of California PHARMACY AND MEDICATION MANAGEMENT This indicator is an evaluation of the institution’s ability to Case Review Rating: provide appropriate pharmaceutical administration and Inadequate security management, encompassing the process from the Compliance Score: written prescription to the administration of the medication. Inadequate (68.8%) By combining both a quantitative compliance test with case review analysis, this assessment identifies issues in various Overall Rating: stages of the medication management process, including Inadequate ordering and prescribing, transcribing and verifying, dispensing and delivering, administering, and documenting and reporting. Because numerous entities across various departments affect medication management, this assessment considers internal review and approval processes, pharmacy, nursing, health information systems, custody processes, and actions taken by the prescriber, staff, and patient. Case Review Results The OIG clinicians evaluated 46 events related to medications and found 18 deficiencies, 6 of which were significant. HDSP’s medication processes were problematic. Medication Continuity HDSP did not ensure that nurses administered chronic care medications continuously. The patients experienced breaks in the continuity of chronic medications in cases 9, 10, 13, 15, 16, 17, and the following two cases: • In case 11, breaks occurred in administering the patient’s keep-on-person (KOP) medications. In February, March, and May 2017, the patient did not receive some of his medications. • In case 12, breaks occurred in administering the patient’s chronic care medications. In May and June 2017, the patient did not receive some of his medications. Medication Administration At times, HDSP nurses were unable to administer prescribed medications timely or accurately. The nurses documented various reasons for not administering medications; examples included: the patient did not show up to receive his monthly KOP medications, custody did not release the patient to pick up his medications, nurses did not request medication refills, or the medications were not available. One major problem was that when the patient arrived at the next medication administration time, the nurses still did not issue the patient’s KOP medications. The OIG clinicians identified these deficiencies in cases 11, 12, 13, 16, and the following case: High Desert State Prison, Cycle 5 Medical Inspection Page 36 Office of the Inspector General State of California • In case 17, the provider ordered Tamiflu (a medication used to treat the influenza virus), but the patient did not receive the medication. The nurse documented in the EHRS that the patient did not come to pick up his medication. However, the nurse also entered contradictory documentation showing the nurse administered the patient’s other medications at the same time that the nurse should have given the Tamiflu. Pharmacy Errors HDSP had one deficiency in the pharmacy process as outlined in the following example: • In case 15, the provider ordered sumatriptan to be dispensed the next day, but the patient did not receive it until 25 days later. Clinician Onsite Inspection The OIG clinicians discussed the concerns identified during their review with the nursing and pharmacy supervisors, who explained the challenges their staff faced during the EHRS transition. The new system automatically, and erroneously, initiated medication orders without receiving requests from either the provider or the patient. The EHRS did not route the orders to the pharmacy, so the pharmacy did not dispense any medication. Because the EHRS considered the faulty orders valid, the system required the nurses to document the administration of the non-existent medications. Furthermore, the EHRS would not allow staff to proceed with their other, valid tasks without first addressing the invalid orders by entering a response into the system. Thus, nurses who needed to complete their work would select various options at random and input them into the EHRS to answer why they did not administer these incorrectly ordered medications. Some chose to enter “medication not given; medication not available,” while others chose “late; nursing judgment.” This error-laden process explained some of the deficiencies the OIG clinicians identified. HDSP supervisors explained a second problem. Nursing staff often would place medications in storage areas, but then would fail to look in these areas when it came time to administer medications to their patients. Instead of retrieving these stored medications, the nurses would erroneously document that the medications were inexplicably “missing” or could not be located. The nurses would then repeatedly request refills from the pharmacy, which resulted in an excessive supply of medications in the clinic. HDSP was developing policies and training to manage their medications more effectively. Case Review Conclusion The EHRS transition caused complications in the workflow between the pharmacy and the clinic. The faulty system-generated orders created confusion for the nurses and resulted in the erroneous documentation. HDSP was working on training its nursing staff, so they could learn how to update their patients’ records properly in the EHRS in these situations. Nonetheless, due to the unreliable nature of HDSP’s medication documentation process, sometimes, it was impossible to High Desert State Prison, Cycle 5 Medical Inspection Page 37 Office of the Inspector General State of California determine whether patients had received their medications. The case review clinicians rated the Pharmacy and Medication Management indicator inadequate. Compliance Testing Results The institution received a score of 68.8 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 score of 69.1 percent. The following test showed room for improvement: • Among 16 applicable sampled patients, 6 of them (37 percent) timely received their chronic care medications timely. Three patients did not receive their KOP medications as ordered; seven others received “nurse administered” medications one to five days late (MIT 7.001). Three tests earned scores in the adequate range: • Of the 25 sampled patients at HDSP who transferred from one housing unit to another, 21 of them (84 percent) received their prescribed “nurse administered” medications without interruption. Four patients did not receive their medications at the next dosing interval after the transfer occurred as required by CCHCS policy (MIT 7.005). • HDSP timely administered or delivered new medications as ordered to 20 of the 25 sampled patients (80 percent). Of the five patients who did not receive their medication timely, HDSP staff delayed three patients’ initial doses from one to two days; for two others, HDSP staff did not give the medications at all (MIT 7.002). • Clinical staff timely provided new and previously prescribed medications to six of eight patients sampled who had been discharged from a community hospital and returned to the institution (75 percent). For two patients, the medical record revealed no evidence that they received their ordered “nurse administered” medication (MIT 7.003). Observed Medication Practices and Storage Controls The institution scored 62.6 percent in this sub-indicator, with the following tests scoring in the inadequate range: • The institution received a score of zero when the OIG inspected medication preparation and administration areas to determine whether clinical staff demonstrated appropriate administrative controls and protocols. In six locations, one or more of the following deficiencies were identified: patients waiting to receive their medications did not have High Desert State Prison, Cycle 5 Medical Inspection Page 38 Office of the Inspector General State of California sufficient outdoor cover to protect them from heat or inclement weather; the medication nurse did not always ensure that patients swallowed direct observation therapy medication; and the medication nurse did not always verify patients’ identities by a picture form of identification (MIT 7.106). • The institution employed adequate security controls over narcotic medications in two of the seven applicable clinic and medication line locations where narcotics were stored (29 percent). At five clinics, the following deficiencies were identified: the narcotics logbook showed that on multiple occasions, controlled substance inventory counts were not performed by two nurses; nurses left narcotic medications unsecured on top of the medication cart; and nurses did not counter-sign the narcotics logbook to verify the proper destruction of controlled substances (MIT 7.101). • Inspectors observed the medication preparation and administration processes at six applicable medication administration locations. The nursing staff was compliant with proper hand hygiene and contamination control protocols at four locations (67 percent). At two locations, some nursing staff did not wash or sanitize their hands before subsequent re-gloving (MIT 7.104). Three tests received scores of proficient: • HDSP properly stored refrigerated non-narcotic medications in eight of nine clinics and medication line storage locations (89 percent). At one location, however, a medication refrigerator was not sanitary (MIT 7.103). • HDSP properly stored non-narcotic medications that did not require refrigeration in 11 of the 12 (92 percent) applicable clinics and medication line storage locations. In one location, nurses did not label a multi-use medication with the date staff opened it (MIT 7.102). • Nursing staff at all six of the inspected medication line locations employed appropriate administrative controls and followed appropriate protocols during medication preparation (MIT 7.105). Pharmacy Protocols HDSP scored 76 percent in this sub-indicator, with the following tests earning proficient scores: • HDSP’s main pharmacy followed general security, organizational, and cleanliness management protocols. In addition, the institution properly stored non-refrigerated and refrigerated medications in the main pharmacy (100 percent) (MIT 7.107, 7.108, 7.109). The following test received an adequate score: High Desert State Prison, Cycle 5 Medical Inspection Page 39 Office of the Inspector General State of California • The institution’s pharmacist in charge (PIC) followed required protocols for 20 of the 25 medication error reports and monthly statistical reports reviewed (80 percent). For four medication error reports, the PIC completed corresponding medication error follow-up review (CDCR Form 7541) reports from 3 to 37 days late, but for one, the OIG inspectors found no evidence the PIC had completed this report (MIT 7.111). The following test showed room for improvement: • OIG inspectors also reviewed monthly controlled substance inventories in the institution’s clinical and medication line storage locations, and they found several Medication Area Inspection Checklist forms (CDCR Form 7477) missing the name, signature, and date of the pharmacist in charge (PIC) responsible for completing each inventory record. As a result, the institution received a score of zero in this test (MIT 7.110). However, in HDSP’s main pharmacy, the PIC properly accounted for narcotic medications stored there. Non-Scored Tests • In addition to the OIG’s testing of reported medication errors, inspectors follow up on any significant medication errors found during compliance testing to determine whether HDSP properly identified and reported errors. The OIG provides those results for information purposes only. At HDSP, the OIG did not find any applicable medication errors (MIT 7.998). • The OIG interviewed patients housed in isolation units to determine whether they had immediate access to their prescribed KOP rescue inhalers and nitroglycerin medications. Ten applicable patients interviewed indicated they had access to their rescue medications (MIT 7.999). High Desert State Prison, Cycle 5 Medical Inspection Page 40 Office of the Inspector General State of California PRENATAL AND POST-DELIVERY SERVICES This indicator evaluates the institution’s capacity to provide Case Review Rating: timely and appropriate prenatal, delivery, and postnatal services Not Applicable to pregnant patients. This includes the ordering and monitoring of Compliance Score: indicated screening tests, follow-up visits, referrals to higher Not Applicable levels of care, e.g., high-risk obstetrics clinic, when necessary, Overall Rating: and postnatal follow-up. Not Applicable As HDSP does not have female patients, this indicator does not apply. High Desert State Prison, Cycle 5 Medical Inspection Page 41 Office of the Inspector General State of California PREVENTIVE SERVICES This indicator assesses whether the institution offered or Case Review Rating: provided various preventive medical services to patients. These Not Applicable include cancer screenings, tuberculosis screenings, and influenza Compliance Score: and chronic care immunizations. This indicator also assesses Adequate (81.3%) whether certain institutions take preventive actions to relocate patients identified as being at higher risk for contracting Overall Rating: coccidioidomycosis (valley fever). Adequate The OIG rates this indicator entirely through the compliance testing component; the case review process does not include a separate qualitative analysis for this indicator. Compliance Testing Results The institution scored in the adequate range for this indicator at 81.3 percent. The following three tests were in the proficient range: • HDSP offered annual influenza vaccinations to all 25 sampled patients subject to the annual screening requirement (MIT 9.004). • The OIG found that 28 of 30 (93 percent) sampled patients received annual tuberculosis (TB) screenings. For two patients, the annual TB screening did not occur during their birth months as required by current CCHCS policy (MIT 9.003). • The OIG found that HDSP successfully screened 24 of 25 sampled patients (96 percent) for colorectal cancer. The patients underwent a colonoscopy procedure within the past ten years or were offered colorectal cancer testing within the previous 12 months (MIT 9.005). One test received an adequate score: • The OIG reviewed HDSP’s monitoring of nine sampled patients who received TB medications and found the institution in compliance for seven patients (78 percent). For two patients, OIG inspectors found no documentation of the required monitoring (MIT 9.002). Two tests revealed the institution could improve in this area: • The OIG tested whether HDSP offered required influenza, pneumonia, and hepatitis vaccinations to patients who suffered from a chronic condition; 13 of the 20 sampled patients (65 percent) received the required vaccines. For the other seven patients, the OIG found no evidence that the patients received or refused their required vaccinations (MIT 9.008). High Desert State Prison, Cycle 5 Medical Inspection Page 42 Office of the Inspector General State of California • HDSP scored poorly in administering TB medications timely. The OIG examined health care records for nine patients who were on TB medications during the inspection period; only five patients received all their required medications (56 percent). Four patients missed scheduled doses, and none of them received the requisite provider counseling regarding missed doses (MIT 9.001). High Desert State Prison, Cycle 5 Medical Inspection Page 43 Office of the Inspector General State of California QUALITY OF NURSING PERFORMANCE The Quality of Nursing Performance indicator is a qualitative Case Review Rating: evaluation of the institution’s nursing services. The evaluation Adequate is completed entirely by OIG nursing clinicians within the case Compliance Score: review process and does not have a score under the OIG Not Applicable compliance testing component. Case reviews include Overall Rating: face-to-face encounters and indirect activities performed by Adequate nursing staff on behalf of the patient. Review of nursing performance includes all nursing services performed onsite, such as outpatient, inpatient, urgent/emergent, patient transfers, care coordination, and medication management. The key focus areas for evaluation of nursing care include appropriateness and timeliness of patient triage and assessment, identification and prioritization of health care needs, use of the nursing process to implement interventions, and accurate, thorough, and legible documentation. Although the OIG reports nursing services provided in specialized medical housing units in the Specialized Medical Housing indicator, and those provided in the TTA or related to emergency medical responses in the Emergency Services indicator, this Quality of Nursing Performance indicator summarizes all areas of nursing services. Case Review Results The OIG clinicians reviewed 287 nursing encounters, 177 of which were in the outpatient setting. Most outpatient nursing encounters were for sick call requests, care coordination, and RN follow-up visits. There were 65 deficiencies identified related to the overall performance of nursing care, 4 of which were significant. The OIG clinicians considered the majority of nursing deficiencies minor. These resulted from insufficient assessment or incomplete documentation. The OIG clinicians identified the same pattern of deficiencies in the Cycle 4 medical inspection, which persists in this cycle. The OIG clinicians rated this indicator adequate. Nursing Assessment The majority of HDSP nurses assessed patients appropriately. They asked for a history of the patient’s complaint and requests for medical care, reviewed the medical records, and provided a thorough physical examination. However, in some cases, nurses did not complete basic assessments such as checking vital signs, ascertaining pain levels, asking patients to describe their symptoms, or examining pertinent areas of the patient’s body related to the complaints. Nonetheless, the OIG clinicians considered most of these nursing assessment deficiencies minor. Nursing Intervention HDSP nurses provided appropriate and timely nursing interventions. Key factors in providing nursing interventions included addressing all of the patient’s complaints during the nursing High Desert State Prison, Cycle 5 Medical Inspection Page 44 Office of the Inspector General State of California encounter, referring the patient to the provider when needed, and providing education or instructions to the patient. The OIG clinicians identified significant deficiencies in only two of the cases reviewed in which nurses did not recognize the need to intervene appropriately: • In case 30, the patient submitted a sick call request stating his balance had worsened. He was dizzy every day, and he was afraid he would fall down in his cell. The patient had an upcoming provider appointment in three weeks. The nurse failed to recognize the need to refer the patient to the provider urgently. In addition, the nurse did not assess the patient for possible orthostatic hypotension (a drop in his blood pressure) associated with positional changes (e.g., from sitting or lying down to standing) and to evaluate whether the patient’s current housing placement was appropriate given possible concerns over his safety. • In case 35, the patient submitted a sick call request stating he had recently seen the dermatologist who noted the presence of a skin infection. The dermatologist recommended two specific medications for treatment. The patient had not received the medications and stated his skin condition was spreading across his face and head. Nonetheless, the nurse did not examine the patient’s skin. The nurse also did not review the dermatologist’s recommendations, did not determine whether the provider had ordered the medications, and did not contact the provider for further instructions. Nursing Documentation Nursing documentation at HDSP was usually appropriate and corroborated the delivery of good nursing care. The OIG clinicians found only minor documentation deficiencies that occurred mostly during emergent medical events. These deficiencies are discussed in the Emergency Services indicator. Nursing Sick Call The OIG clinicians reviewed 98 nursing sick call visits. In this area, HDSP nurses demonstrated good care and nursing competence. HDSP nurses promptly reviewed sick call requests and assessed patients with medical symptoms. However, the OIG identified two significant deficiencies in which nurses failed to recognize potentially urgent conditions while reviewing sick call requests, which should have prompted the nurses to assess the patients the same day as detailed in the following cases: • In case 15, the patient submitted a sick call request complaining of fever, coughing up blood, and the inability to keep fluids down. The nurse did not assess the patient on the same day and instead wrote on the sick call form that the patient would see the provider. The provider evaluated the patient two days later. • In case 38, the patient submitted a sick call request for influenza symptoms. These included a sore throat, an earache, and a high fever, but the nurse did not assess him until the next day. High Desert State Prison, Cycle 5 Medical Inspection Page 45 Office of the Inspector General State of California Care Management/Care Coordination The LVN care coordinators routinely conducted face-to-face assessments with an assigned group of patients for systematic monitoring and management of their health care needs. HDSP improved the care coordination process compared to Cycle 4. For example, care coordinators monitored and followed up with their patients timely. They usually performed a thorough review of their patients’ medical records, which included recent diagnostic results, blood pressure readings, and blood sugar levels. During the onsite inspection, the OIG clinicians observed the care coordinators using visual aids to teach patients about their disease processes and care management. While most care coordination was good, the following are examples of minor deficiencies in this area: • In case 2, the patient’s pulse rate was low during a care coordinator visit. The nurse informed the provider who ordered a re-check of the patient’s pulse rate in two hours. The nurse did not check the patient’s pulse rate as ordered. • In case 12, the nurse did not thoroughly review the patient’s medical record and failed to recognize that the nurses had not performed the ordered weekly blood pressure checks. Urgent/Emergent Care First medical responders and TTA nurses provided excellent care during emergent medical responses. The nurses were prompt, skilled, and well organized during these events. Although the nurses did not always document pertinent information such as emergent event timelines, initial nursing assessments, and nursing interventions, these minor deficiencies did not affect the care delivered. Nursing care in this area is further discussed in the Emergency Services indicator. Transfers and Post-Hospital Returns Nursing performance in this area was good. Compared to the Cycle 4 medical inspection, the TTA nurses had greatly improved with their provision of adequate assessments for patients returning from the hospital. Medication Administration HDSP nurses performed poorly when administering medications. In several cases, patients did not receive their KOP medications timely. These deficiencies are also discussed in the Pharmacy and Medication Management indicator. Specialized Medical Housing Nurses provided good care to patients in the CTC, with no significant deficiencies identified in the cases reviewed. High Desert State Prison, Cycle 5 Medical Inspection Page 46 Office of the Inspector General State of California Offsite Specialty Services Returns Nurses processed patients returning from offsite specialty appointments through the TTA. The OIG clinicians found that nurses did not usually inform the provider of the specialist’s findings and recommendations when patients were seen in the telemedicine specialty clinic. At HDSP, nursing managers were already aware of this issue and agreed such lapses could potentially delay necessary health care services, which could affect patient outcomes. Clinician Onsite Inspection During their inspection, the OIG clinicians attended morning huddles in the clinics and the CTC, visited the clinic areas, and interviewed the nurses. Huddle content was complete, and the staff held in-depth patient care discussions. Schedulers were present to facilitate appointment changes as needed. Additionally, nurse-staffing levels in the outpatient clinics, R&R, CTC, and TTA were appropriate for patient needs. Some outpatient clinics and medication rooms had higher nurse-staffing levels based on requirements for a higher security level or patient populations with special needs. The nurses were knowledgeable about their clinical assignments and had participated in different training programs for the institution’s various nursing positions. Nursing leadership remained actively involved in continuously improving nursing services, and nursing staff expressed feelings of overall job satisfaction. The OIG nurse clinician also met with the chief nurse executive (CNE) and the supervising RN III to discuss specific cases reviewed, along with other nursing issues identified during the onsite visit. HDSP’s nursing managers readily addressed the cases reviewed, acknowledged the nursing issues needing improvement, and described their plans of action. The OIG clinicians also reviewed nursing supervisor and training files, which indicated that quarterly performance discussions had occurred between supervisors and staff, as well as yearly training sessions on required nursing competency skills, such as emergency medical response and nursing protocols. Case Review Conclusion The institution’s patients generally received good nursing care. The institution should view nursing deficiencies identified in this indicator as potential areas to improve quality. The OIG case review clinicians rated the Quality of Nursing Performance indicator adequate. High Desert State Prison, Cycle 5 Medical Inspection Page 47 Office of the Inspector General State of California QUALITY OF PROVIDER PERFORMANCE In this indicator, the OIG physicians provide a qualitative Case Review Rating: evaluation of the adequacy of provider care at the institution. The Adequate case review clinicians review the provider care regarding Compliance Score: appropriate evaluation, diagnosis, and management plans for Not Applicable programs including, but not limited to, nursing sick call, chronic Overall Rating: care programs, TTA, specialized medical housing, and specialty Adequate services. OIG physicians alone assess provider care. There is no compliance testing component associated with this quality indicator. Case Review Results The OIG clinicians reviewed 130 medical provider encounters and identified 32 deficiencies related to provider performance, 20 of which were significant. Of the 20 detailed cases reviewed, one received a proficient rating, 15 received adequate ratings, and 4 received inadequate ratings. Assessment and Decision-Making In the majority of encounters, HDSP providers made sound assessments and decisions. While the majority of the assessments and decisions were good, there was room for improvement. The following cases present examples of poor assessments or decisions: • In case 8, the provider knew that the patient was about to start a religious fast, but did not adjust the patient’s diabetes medications to reduce the risk of fluctuating blood sugar levels. • In case 10, the provider started the patient on opioid medication, but this patient had a history of substance abuse. At a follow-up appointment, the provider did not thoroughly assess the patient’s ability to perform normal daily activities and continued the opioid medication without proper justification. Given the patient’s substance abuse history, the provider should have ensured that there was a good reason to continue the opioid medication. • Also in case 10, the provider did not examine the patient’s lungs during a chronic care appointment even though a chief complaint was shortness of breath. Additionally, there was also a noticeable pattern of certain providers not ordering follow-up appointments. This pattern occurred in cases 7, 8, 9, and 26. Review of Records HDSP providers promptly reviewed diagnostics, medications, outside hospital reports, and specialty reports with only a few exceptions. Some deficiencies were due to simple provider High Desert State Prison, Cycle 5 Medical Inspection Page 48 Office of the Inspector General State of California oversight and were of no great consequence, but other deficiencies were significant. The following cases offer examples: • In case 7, the provider did not review the patient’s records when he refused an appointment. This error led to a two months’ lapse in care. • In case 9, the patient’s test result showed his diabetes was severely out of control. The provider failed to review the test result, which caused a lapse in care. Eventually, the nurse saw the patient one and a half months later, and then the nurse requested a follow-up appointment. • In case 10, the provider did not thoroughly review the patient’s medications. The provider prescribed a second non-steroidal anti-inflammatory (NSAID) drug, which was contraindicated. The second medication increased the risk of gastrointestinal or kidney damage, or heart failure. • In case 16, the provider did not review the laboratory results and did not review the tests when seeing the patient a few days later. The provider missed these opportunities to evaluate the patient’s hepatitis C status. Chronic Care Patients at HDSP were mostly healthy. Only one patient was taking anticoagulation medication, and HDSP providers managed his condition well. Management of hypertension, heart disease, and pulmonary disease at the institution was acceptable. Diabetes care was inconsistent because several of the patients reviewed refused to take their medications or were intermittently refusing medications. This situation made it difficult for providers to deliver proper care. Most diabetic care deficiencies resulted from providers failing to order follow-up appointments or failing to address diabetes concerns during chronic care appointments. The following cases provide examples: • In case 7, the patient was an intermittently compliant diabetic patient with uncontrolled blood sugar levels. Although the nurses checked his blood sugar levels regularly, the provider did not adjust the medications to help improve the diabetic control. When the patient refused a chronic care visit, the provider failed to reschedule the appointment and allowed the patient’s chronic care visits to lapse. • In case 8, the patient took a test, which showed uncontrolled diabetes. The provider reviewed the result, but failed to order a follow-up appointment, resulting in a lapse in care. Fortunately, the nurse reviewed the result 25 days later and ordered a provider follow-up. High Desert State Prison, Cycle 5 Medical Inspection Page 49 Office of the Inspector General State of California • In case 9, the provider failed to address the patient’s diabetes during his chronic care visit and also failed to order a chronic care follow-up appointment, with both elements contributing to a lapse in the patient’s diabetic care. Specialty Services HDSP providers referred patients appropriately. They reviewed specialty services and made proper assessments except in the following instance: • In case 11, the provider did not adequately review the cardiology recommendations and did not order a follow-up appointment for the patient with the cardiologist. Emergency Care TTA providers at the institution performed well. They made accurate assessments and demonstrated good decision-making skills in caring for their patients. These aspects are further discussed in the Emergency Services indicator. Specialized Medical Housing HDSP providers performed well in the CTC. This performance is further discussed in the Specialized Medical Housing indicator. Clinician Onsite Inspection As in Cycle 4, HDSP providers again described their morale as poor. Since July 2016, HDSP had lost two more providers. One mid-level provider had retired, and another was on medical leave. The remaining providers lamented the lack of physician leadership, but they praised their CEO for providing administrative leadership wherever possible. They repeatedly pleaded for more providers and were distraught over the EHRS. The system severely reduced their productivity at the time of its implementation. By the time of the onsite inspection, the providers believed that they had nearly returned to their previous collective level of productivity. The providers expressed dissatisfaction with what they perceived as a focus on productivity to the exclusion of providing a high level of patient care. One mid-level provider was responsible for a disproportionately large share of the provider deficiencies. This provider did not review diagnostic results and reports either timely or thoroughly, and often did not address all relevant issues during patient evaluations; for example, often improperly marking patients’ appointments “completed” even when not addressing the reasons for the visits. The provider often exacerbated the situation when failing to order follow-up appointments. At times, the provider did not complete a progress note until months later. In Cycle 4, the OIG noted similar deficiencies for this same individual, who had offered similar explanations for personal errors made at that time. The provider attributed the errors to being overworked; in addition to staffing a regular clinic, the provider staffed evening clinics twice a week and covered weekend clinics as well. Despite CCHCS recently assigning an offsite High Desert State Prison, Cycle 5 Medical Inspection Page 50 Office of the Inspector General State of California physician to provide remote supervision, this provider expressed receiving insufficient support and supervision. Both the CME and CP&S positions were vacant at the time of the OIG’s onsite inspection. The OIG clinicians discussed provider care with the individual providers and with the regional deputy medical executive (DME). After months, if not years, of vacancy, HDSP had just hired a CP&S and a CME, both of whom started after the OIG’s onsite inspection. HDSP was also scheduled to implement emergency department services via telemedicine in the upcoming weeks in an attempt to reduce the institutional providers’ on-call workloads. The regional DME complimented the performance of his providers, who were working under difficult circumstances. He attributed the institution’s chronic state of understaffing to HDSP’s remote locale, as well as its lower compensation rate compared to that offered by other CDCR institutions. HDSP providers did not receive the additional 15 percent recruitment and retention pay differential that other CDCR providers had received in July 2017. Case Review Conclusion HDSP providers performed well in emergent situations, in the CTC, and for specialty care. As a whole, the providers exhibited good decision-making skills, with the exceptions of insufficiently reviewing patients’ medical records and overlooking certain aspects of diabetes care. The OIG clinicians considered the situation of chronic understaffing, the lack of physician leadership and supervision, the disproportionate number of errors by one overworked provider, and the difficulty of providing care to patients who sometimes refused appointments and medications. These elements likely contributed to both the insufficient record review and the poor diabetic care. Because other systematic concerns could reasonably explain the provider challenges identified in the cases reviewed, the OIG clinicians ultimately rated this indicator only just adequate. High Desert State Prison, Cycle 5 Medical Inspection Page 51 Office of the Inspector General State of California RECEPTION CENTER ARRIVALS This indicator focuses on the management of medical needs and Case Review Rating: continuity of care for patients arriving from outside the CDCR Not Applicable system. The OIG review includes evaluation of the ability of the Compliance Score: institution to provide and document initial health screenings, Not Applicable initial health assessments, continuity of medications, and Overall Rating: completion of required screening tests; address and provide Not Applicable significant accommodations for disabilities and health care appliance needs; and identify health care conditions needing treatment and monitoring. The patients reviewed for reception center cases are those received from non-CDCR facilities, such as county jails. HDSP does not have a reception center; therefore, this indicator does not apply. High Desert State Prison, Cycle 5 Medical Inspection Page 52 Office of the Inspector General State of California SPECIALIZED MEDICAL HOUSING This indicator addresses whether the institution follows Case Review Rating: appropriate policies and procedures when admitting patients to Adequate onsite inpatient facilities, including completion of timely nursing Compliance Score: and provider assessments. The case review assesses all aspects of Adequate (77.5%) medical care related to these housing units, including quality of provider and nursing care. HDSP’s only specialized medical Overall Rating: housing unit is a correctional treatment center (CTC). Adequate Case Review Results In the institution’s CTC, there were 20 medical beds, ten mental health crisis beds, and two observation rooms. HDSP used ten negative pressure rooms for new admissions and mental health patients. The OIG clinicians reviewed six CTC admissions, including 35 provider encounters and 36 nursing encounters. Most of the nursing encounters included a review of several consecutive days of nursing care. Seven minor deficiencies were identified, consisting of inadequate nursing assessment, incomplete documentation, and a provider’s lapse in visiting assigned patients within the time frames specified by CCHCS policy. Provider Performance HDSP had one provider assigned to the CTC and the TTA with cross coverage rendered by other providers when the assigned provider was unavailable. Providers performed well with offering accurate assessments and demonstrated good decision-making skills. However, they did not consistently see patients within the 72-hour time frame specified by CCHCS policy, with this lapse occurring four times in one case. Nursing Performance HDSP nurses continued providing the same level of adequate nursing care to CTC patients as they had during the Cycle 4 inspection. No significant deficiencies were identified in the cases reviewed. Clinician Onsite Inspection During the inspection, the OIG clinicians attended the CTC morning huddle that HDSP had recently implemented. In addition to the CTC health care and custody team, the TTA RN and pharmacist also attended the huddle. The CTC shift lead RN coordinated the huddle discussion similarly to the process established in the outpatient clinic huddles. The team discussed both medical and mental health patients, including those who were hospitalized at an external facility. At the time of the OIG’s onsite visit, there were two mental health patients and seven medical patients in the CTC. In addition, two medical patients were hospitalized at an external facility. High Desert State Prison, Cycle 5 Medical Inspection Page 53 Office of the Inspector General State of California The primary CTC provider was a temporary, contracted physician. HDSP assigned one shift lead RN, two RNs, and an LVN to the CTC at all times. A psychiatric technician was also available during the second and third watches to assist with patient care. The shift lead RN could describe each nurse’s responsibilities and demonstrated sufficient knowledge of CTC procedures. Case Review Conclusion Providers and nurses at HDSP provided appropriate and timely care in the CTC. The OIG clinicians rated the Specialized Medical Housing indicator adequate. Compliance Testing Results The institution received a score of 77.5 percent in this indicator. Three tests earned scores in the proficient range: • When OIG inspectors observed the condition of call buttons in the CTC patient rooms, they found those that were tested were all working properly. In addition, according to staff members interviewed, custody officers and clinicians could expeditiously access patients’ locked rooms when emergent events occurred (MIT 13.101). • For 9 of the 10 sampled patients (90 percent), nursing staff timely completed an initial health assessment on the day the patient entered the CTC. For one patient, OIG inspectors found no medical record evidence a registered nurse had completed an assessment (MIT 13.001). • HDSP providers evaluated 9 of 10 sampled patients (90 percent) within 24 hours of admission to the CTC, with only one patient evaluated a day late (MIT 13.002). One test did indicate room for improvement: • When OIG inspectors tested whether providers had completed their Subjective, Objective, Assessment, Plan, and Education (SOAPE) notes at the required three-day intervals, they found that providers timely completed SOAPE notes for only 3 of the 10 sampled patients (30 percent). In addition, provider visits for seven patients ranged from one to eight days late (MIT 13.003). High Desert State Prison, Cycle 5 Medical Inspection Page 54 Office of the Inspector General State of California SPECIALTY SERVICES This indicator focuses on specialist care from the time a Case Review Rating: physician completes a request for services or a physician’s order Adequate for specialist care to the time of receipt of related Compliance Score: recommendations from specialists. This indicator also evaluates Inadequate (72.6%) the providers’ timely review of specialist records and documentation reflecting the patients’ care plans, including the Overall Rating: course of care when specialist recommendations were not Adequate ordered, and whether the results of specialists’ reports are communicated to the patients. For specialty services denied by the institution, the OIG determines whether the denials are timely and appropriate, and whether the provider updates the patient on the plan of care. In this indicator, the OIG case review and compliance review processes yielded different results, with the case reviewers assigning an adequate rating and the compliance testing receiving an inadequate score. Compliance review testing received an inadequate score due to a delay in the provider’s review of specialty services, delays in denials of requests for specialty services, and a delay in communicating a denied request for service to the patient. Case review showed providers reviewed specialty services appropriately, and the delays did not increase the risk of harm. Likewise, neither the delays in denying referrals nor the communication delays increased the risk of harm to the patient. The OIG’s internal review process considered the factors leading to both scores and ultimately determined the overall rating for this indicator was adequate. Case Review Results The OIG clinicians reviewed 70 events related to Specialty Services, which included 53 specialty consultations and procedures, and 10 nursing encounters. In total, eight deficiencies were found in this category, with three related to access to care, two to specialty report handling, and three to nursing performance. Four of the eight deficiencies were significant and are explained in detail below. Access to Specialty Services HDSP performed well in access to specialty services, experiencing no problems with accessing specialists. Specialty services were provided within adequate time frames when the provider ordered them. One significant deficiency was noted in which the provider failed to order a specialty follow-up appointment. Two minor deficiencies were found for which HDSP delayed the provider follow-up to review specialist recommendations. Nursing Performance HDSP nursing performance was acceptable for patients returning from offsite specialty appointments. However, in contrast to the TTA nurses who processed the patients when they High Desert State Prison, Cycle 5 Medical Inspection Page 55 Office of the Inspector General State of California returned from offsite specialty visits, the nurses who processed the patients who utilized telemedicine specialty services occasionally failed to inform the provider of the specialist’s findings and recommendations. In two cases, this resulted in delays in implementing necessary recommendations such as changes in medication dosage or requests for diagnostic tests. Provider Performance HDSP providers made timely and proper referrals for specialty services with the appropriate priority. Only one significant deficiency was noted in the following case: • In case 11, the provider did not review a specialty report thoroughly enough to order a recommended laboratory test and a follow-up appointment with the specialist. Health Information Management HDSP’s specialty department performed well in retrieving most specialty reports promptly. The providers timely reviewed the specialty reports with only two significant exceptions occurring in the following case: • In case 15, the patient saw the neurologist, but HDSP did not retrieve and scan the report until four months later. The provider never did sign the report. • Also in case 15, the hematologist-oncologist saw the patient, and the report was properly retrieved. Nonetheless, the provider reviewed the report 24 days later. Clinician Onsite Inspection The OIG clinicians discussed the deficiencies with HDSP supervisors of medical records and nursing. Regarding the nursing deficiencies, HDSP implemented recommendations from offsite specialists much sooner than those from telemedicine specialists. Staff explained that the TTA nurses relayed the offsite recommendations directly to the clinic when the patients returned to the institution. Conversely, telemedicine specialty services nurses did not relay information to the clinic staff. Referring to the CCHCS policy, they instead presumed that the provider would review the recommendations when the patient followed up with the provider within 14 days. The telemedicine nurses explained that, occasionally, the verbal information the specialist provided differed from that contained in the specialist’s written report. Therefore, the nurses thought it was better to hold off relaying information until the report was available. The OIG does not agree with the institution’s intentional delay in transmitting telemedicine specialty recommendations. Some of the information was time-sensitive, for example, starting medication administration or ensuring appropriately timely follow-up specialty appointments. Expediting such instructions was critical for providers to initiate appropriate orders. High Desert State Prison, Cycle 5 Medical Inspection Page 56 Office of the Inspector General State of California Case Review Conclusion HDSP performed well with both specialty access and retrieving offsite specialty recommendations. However, HDSP sometimes introduced unnecessary delays in the communication of telemedicine specialty recommendations. The overall rating for this indicator was adequate. Compliance Testing Results The institution received a score of 72.6 percent in this indicator, with the following four tests demonstrating room for improvement: • Among 20 sampled patients for whom HDSP’s health care management denied a specialty service, only 12 of them (60 percent) received timely notification of the service denial, including a provider meeting with the patient within 30 days to discuss alternate treatment strategies. For two patients, the providers’ follow-up visits occurred 3 and 16 days late. For six patients, no provider follow-up appointments occurred during which reasons for denials could be discussed (MIT 14.007). • When HDSP providers ordered high-priority specialty services for patients, the ordering provider did not always review the specialty report within the required time frame. While providers timely reviewed 9 of the 14 sampled specialty reports (64 percent), 4 other reports were reviewed from one to eight days late, and for one report, the OIG found no medical record evidence of review (MIT 14.002). • When patients are approved or scheduled for specialty services at one institution and then transfer to another, policy requires that the receiving institution schedule and provide these patients specialty appointments within required time frames. Of the 20 applicable sampled patients who transferred into HDSP with approved specialty services, 14 of them (70 percent) received their appointments within the required time frame. Two patients’ services were 12 and 19 days late, and for four remaining patients, OIG inspectors found no medical record evidence the specialty service was performed (MIT 14.005). • The institution timely denied providers’ specialty service requests for 14 of 20 patients sampled (70 percent). Six of the specialty services requests were denied between one and 13 days late (MIT 14.006). Two tests received scores in the adequate range: • Providers timely received and reviewed 10 of the 13 sampled routine specialists’ reports (77 percent). For two patients, providers reviewed the reports seven and eight days late; and for the final patient, OIG inspectors found no medical record evidence a provider reviewed the report (MIT 14.004). High Desert State Prison, Cycle 5 Medical Inspection Page 57 Office of the Inspector General State of California • HDSP provided routine specialty service appointments within required time frames to 12 of 15 patients tested (80 percent). Three patients received their specialty services from one day to 54 days late (MIT 14.003). One test earned a score of proficient: • For 13 of 15 sampled patients (87 percent), their high-priority specialty services’ appointments occurred within 14 calendar days of the provider’s order, but two patients received their specialty services 6 and 28 days late (MIT 14.001). High Desert State Prison, Cycle 5 Medical Inspection Page 58 Office of the Inspector General State of California ADMINISTRATIVE OPERATIONS (SECONDARY) This indicator focuses on the institution’s administrative health Case Review Rating: care oversight functions. The OIG evaluates whether the Not Applicable institution promptly processes patient medical appeals and Compliance Score: addresses all appealed issues. Inspectors also verify that the Inadequate (62.0%) institution follows reporting requirements for adverse/sentinel events and patient deaths. The OIG verifies that the Emergency Overall Rating: Medical Response Review Committee (EMRRC) performs Inadequate 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. In addition, the OIG examines whether the institution adequately manages its health care staffing resources by evaluating whether job performance reviews are completed as required; specified staff possess current, valid credentials and professional licenses or certifications; nursing staff receive new employee orientation training and annual competency testing; and clinical and custody staff have current emergency medical response certifications. The Administrative Operations indicator is a secondary indicator; therefore, it was not relied on for the institution’s overall score. Compliance Testing Results The institution received a score of 62.0 percent in this indicator with several tests demonstrating room for improvement: • The OIG inspected records from June 2017 for five nurses to determine whether their nursing supervisors properly completed monthly performance reviews. OIG inspectors identified that supervisors had not completed the requisite number of reviews for all five nurses, resulting in a score of zero in this test (MIT 15.104). • None of HDSP’s providers had received either timely or properly completed appraisals, including the following (MIT 15.106): o Four providers’ evaluations were overdue by 11 to 22 months, and one provider had no performance appraisals available for review; o Among the five providers tested, the most recently completed evaluations for two providers did not include 360-degree evaluations. • HDSP had hired 23 nurses over the preceding 12-month period. The OIG inspectors identified two nurses who had received their orientations four weeks late (MIT 15.111). High Desert State Prison, Cycle 5 Medical Inspection Page 59 Office of the Inspector General State of California • The OIG inspectors reviewed data received from the institution (which was not validated by the OIG) to determine whether HDSP timely processed at least 95 percent of its monthly patient medical appeals during the most recent 12-month period. HDSP was compliant with only one of the 12 months’ appeals reviewed (8 percent) (MIT 15.001). • HDSP’s local governing body met quarterly during the four-quarter period ending March 2017, but only one of the corresponding meeting minutes was sufficiently detailed and timely approved (25 percent). Three meetings’ minutes were insufficient because they lacked discussions on adopting local operating procedures as CCHCS policy requires (MIT 15.006). • The institution did not meet the emergency response drill requirements for the most recent quarter for two of its three watches, resulting in a score of 33 percent. More specifically, the institution’s first- and second-watch drill packages lacked evidence that custody staff participated in the emergency response drills (MIT 15.101). • Medical staff reviewed and timely submitted the Initial Inmate Death Report (CDCR Form 7229A) to CCHCS’ Death Review Unit for two of four cases tested, resulting in a score of 50 percent. For one death report packet, the death report form was missing the initials of either the CME or the CEO. For the other death report packet, the institution did not submit the death report within the required time frame, instead, submitting it one business day late (MIT 15.103). One test earned an adequate score: • The OIG examined 12 of the institution’s Emergency Medical Response Review Committee (EMRRC) incident packages for emergency medical responses during the prior 12-month period. Of this dozen, nine of them (75 percent) complied with policy, but the remaining three packages contained improperly completed checklists (MIT 15.005). Several tests earned scores in the proficient range: • HDSP’s QMC met monthly, evaluated program performance, and took action when management identified areas for improvement opportunities (MIT 15.003). • The institution took adequate steps to ensure the accuracy of its Dashboard data reporting (MIT 15.004). • Based on a sample of ten second-level medical appeals, the institution’s responses addressed all of the patients’ appealed issues (MIT 15.102). • All ten sampled nurses were current with their clinical competency validations (MIT 15.105). High Desert State Prison, Cycle 5 Medical Inspection Page 60 Office of the Inspector General State of California • All providers at the institution were current with their professional licenses. Similarly, all nursing staff and the PIC were current with their professional licenses and certification requirements (MIT 15.107, 15.109). • All active-duty providers and nurses were current with their emergency response certifications (MIT 15.108). • All pharmacy staff and providers who prescribed controlled substances had current Drug Enforcement Agency registrations (MIT 15.110). Non-Scored Results • The OIG gathered non-scored data regarding the CCHCS Death Review Committee (DRC) completing its death review reports. Three unexpected (Level 1) deaths occurred during the OIG’s review period. The DRC was required to complete its death review summary reports within 60 calendar days from the dates of death and submit these reports to the institution’s CEO within seven calendar days thereafter. While one death review report was completed timely, the DRC completed the other two reports 60 and 97 days late, respectively, and submitted them to HDSP’s CEO one to two days thereafter (MIT 15.998). • The OIG discusses the institution’s health care staffing resources in the About the Institution section of this report (MIT 15.999). High Desert State Prison, Cycle 5 Medical Inspection Page 61 Office of the Inspector General State of California R ECOMMENDATIONS The OIG recommends the following: • The HDSP chief physician and surgeon (CP&S) or chief medical executive (CME) should periodically check the electronic health records system (EHRS) message center to ensure providers promptly review all pertinent results and reports. • HDSP should designate an onsite physician supervisor who can support mid-level providers, review their work, and provide appropriate supervision, all of which should lead to improved mid-level provider performance. • At the time of the OIG’s onsite inspection, HDSP unnecessarily delayed transmitting telemedicine specialty recommendations. The institution should send telemedicine specialty recommendations to the provider immediately, as it already does for offsite specialty recommendations. By using similar rapid processes for transmitting both types of specialty recommendations, HDSP can reduce the risk of lapses in care. High Desert State Prison, Cycle 5 Medical Inspection Page 62 Office of the Inspector General State of California P -B M OPULATION ASED ETRICS The compliance testing and the case reviews give an accurate assessment of how the institution’s health care systems are functioning with regard to the patients with the highest risk and utilization. This information is vital to assess the capacity of the institution to provide sustainable, adequate care. However, one significant limitation of the case review methodology is that it does not give a clear assessment of how the institution performs for the entire population. For better insight into this performance, the OIG has turned to population-based metrics. For comparative purposes, the OIG has selected several Healthcare Effectiveness Data and Information Set (HEDIS) measures for disease management to gauge the institution’s effectiveness in outpatient health care, especially chronic disease management. The Healthcare Effectiveness Data and Information Set is a set of standardized performance measures developed by the National Committee for Quality Assurance with input from over 300 organizations representing every sector of the nation’s health care industry. It is used by over 90 percent of the nation’s health plans as well as many leading employers and regulators. HEDIS was designed to ensure that the public (including employers, the Centers for Medicare and Medicaid Services, and researchers) has the information it needs to accurately compare the performance of health care plans. Healthcare Effectiveness Data and Information Set data is often used to produce health plan report cards, analyze quality improvement activities, and create performance benchmarks. Methodology For population-based metrics, the OIG used a subset of HEDIS measures applicable to the CDCR patient population. Selection of the measures was based on the availability, reliability, and feasibility of the data required for performing the measurement. The OIG collected data utilizing various information sources, including the electronic medical record, the Master Registry (maintained by CCHCS), as well as a random sample of patient records analyzed and abstracted by trained personnel. Data obtained from the CCHCS Master Registry and Diabetic Registry was not independently validated by the OIG and is presumed to be accurate. For some measures, the OIG used the entire population rather than statistically random samples. While the OIG is not a certified HEDIS compliance auditor, the OIG uses similar methods to ensure that measures are comparable to those published by other organizations. Comparison of Population-Based Metrics For High Desert State Prison, nine HEDIS measures were selected 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. The OIG has provided selected results for several health plans in both categories for comparative purposes. High Desert State Prison, Cycle 5 Medical Inspection Page 63 Office of the Inspector General State of California Results of Population-Based Metric Comparison Comprehensive Diabetes Care For chronic care management, the OIG chose measures related to the management of diabetes. Diabetes is the most complex common chronic disease requiring a high level of intervention on the part of the health care system in order to produce optimal results. HDSP performed well with its management of diabetes. When compared statewide, HDSP outperformed Medi-Cal in all five diabetic measures, and the institution outperformed Kaiser in three of the five diabetic measures. HDSP scored slightly lower in blood pressure control than Kaiser (North and South), and the institution performed lower than Kaiser South in eye exams. When compared nationally, the institution outperformed Medicaid, Commercial Plans, and Medicare in all five diabetic measures. The institution also outperformed the United States Department of Veterans Affairs (VA) in three of the four applicable measures, with HDSP scoring lower in diabetic eye exams. Immunizations Comparative data for immunizations was only fully available for the VA and partially available for Kaiser, commercial plans, Medicaid, and Medicare. With respect to administering influenza vaccinations to younger adults and older adults, HDSP outperformed all healthcare plans. With regard to administering pneumococcal vaccines to older adults, HDSP matched Medicare, but scored lower than the VA. Cancer Screening With respect to colorectal cancer screening, HDSP scored higher than commercial plans and Medicare, and matched Kaiser North. However, the institution scored lower than Kaiser South and the VA. The 18 percent refusal rate for colorectal cancer screening at the institution negatively affected the score for this measure. Summary HDSP performed well with regard to population-based metrics in comparison to the other health care plans reviewed. The institution may improve its scores colorectal cancer screenings by reducing patient refusals through educating patients on the benefits of these preventive services. High Desert State Prison, Cycle 5 Medical Inspection Page 64 Office of the Inspector General State of California HDSP Results Compared to State and National HEDIS Scores California National HEDIS HEDIS HDSP HEDIS HEDIS Kaiser Kaiser HEDIS HEDIS VA Clinical Measures Com- Medi-Cal (No. (So. Medicaid Medicare Average Cycle 5 mercial 20152 CA) CA) 20164 20164 20155 Results1 20164 20163 20163 Comprehensive Diabetes Care HbA1c Testing (Monitoring) 100% 86% 94% 94% 86% 90% 93% 98% Poor HbA1c Control (>9.0%)6, 7 16% 39% 20% 23% 45% 34% 27% 19% HbA1c Control (<8.0%)6 75% 49% 70% 63% 46% 55% 63% - Blood Pressure Control 76% 63% 83% 83% 59% 60% 62% 74% (<140/90)6 Eye Exams 73% 53% 68% 81% 53% 54% 69% 89% Immunizations Influenza Shots - Adults (18–64) 67% - 56% 57% 39% 48% - 55% Influenza Shots - Adults (65+) 86% - - - - - 72% 76% Immunizations: Pneumococcal 71% - - - - - 71% 93% Cancer Screening Colorectal Cancer Screening 79% - 79% 82% - 63% 67% 82% 1. Unless otherwise stated, data was collected in August 2017 by reviewing medical records from a sample of HDSP’s population of applicable patients. These random statistical sample sizes were based on a 95 percent confidence level with a 15 percent maximum margin of error. 2. HEDIS Medi-Cal data was obtained from the California Department of Health Care Services 2015 HEDIS Aggregate Report for Medi-Cal Managed Care. 3. Data was obtained from Kaiser Permanente November 2016 reports for the Northern and Southern California regions. 4. National HEDIS data for Medicaid, commercial plans, and Medicare was obtained from the 2016 State of Health Care Quality Report, available on the NCQA website: www.ncqa.org. The results for commercial plans were based on data received from various health maintenance organizations. 5. The Department of Veterans Affairs (VA) data was obtained from the VA’s website, www.va.gov. For the Immunizations: Pneumococcal measure only, the data was obtained from the VHA Facility Quality and Safety Report - Fiscal Year 2012 Data. 6. For this indicator, the entire applicable 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 5 Medical Inspection Page 65 Office of the Inspector General State of California A A — C T R PPENDIX OMPLIANCE EST ESULTS High Desert State Prison Range of Summary Scores: 58.9% – 81.3% Indicator Compliance Score (Yes %) 1 – Access to Care 75.5% 2 – Diagnostic Services 58.9% 3 – Emergency Services Not Applicable 4 – Health Information Management (Medical Records) 66.0% 5 – Health Care Environment 76.6% 6 – Inter- and Intra-System Transfers 70.3% 7 – Pharmacy and Medication Management 68.8% 8 – Prenatal and Post-Delivery Services Not Applicable 9 – Preventive Services 81.3% 10 – Quality of Nursing Performance Not Applicable 11 – Quality of Provider Performance Not Applicable 12 – Reception Center Arrivals Not Applicable 13 – Specialized Medical Housing (OHU, CTC, SNF, Hospice) 77.5% 14 – Specialty Services 72.6% 15 – Administrative Operations 62.0% High Desert State Prison, Cycle 5 Medical Inspection Page 66 Office of the Inspector General State of California Scored Answers Yes Reference + 1 – Access to Care Number Yes No No Yes % N/A Chronic care follow-up appointments: Was the patient’s most recent chronic care visit within the health care guideline’s 1.001 20 5 25 80.0% 0 maximum allowable interval or within the ordered time frame, whichever is shorter? For endorsed patients received from another CDCR institution: If 1.002 the nurse referred the patient to a provider during the initial health 9 16 25 36.0% 0 screening, was the patient seen within the required time frame? Clinical appointments: Did a registered nurse review the patient’s 1.003 29 1 30 96.7% 0 request for service the same day it was received? Clinical appointments: Did the registered nurse complete a face- 1.004 to-face visit within one business day after the CDCR Form 7362 30 0 30 100.0% 0 was reviewed? Clinical appointments: If the registered nurse determined a referral to a primary care provider was necessary, was the patient 1.005 14 9 23 60.9% 7 seen within the maximum allowable time or the ordered time frame, whichever is the shorter? Sick call follow-up appointments: If the primary care provider 1.006 ordered a follow-up sick call appointment, did it take place within 7 2 9 77.8% 21 the time frame specified? Upon the patient’s discharge from the community hospital: Did 1.007 the patient receive a follow-up appointment within the required 5 3 8 62.5% 0 time frame? Specialty service follow-up appointments: Do specialty service 1.008 primary care physician follow-up visits occur within required time 17 9 26 65.4% 4 frames? Clinical appointments: Do patients have a standardized process to 1.101 6 0 6 100.0% 0 obtain and submit health care services request forms? Overall percentage: 75.5% High Desert State Prison, Cycle 5 Medical Inspection Page 67 Office of the Inspector General State of California Scored Answers Yes Reference + 2 – Diagnostic Services Number Yes No No Yes % N/A Radiology: Was the radiology service provided within the time 2.001 10 0 10 100.0% 0 frame specified in the provider’s order? Radiology: Did the primary care provider review and initial the 2.002 3 7 10 30.0% 0 diagnostic report within specified time frames? Radiology: Did the primary care provider communicate the results 2.003 3 7 10 30.0% 0 of the diagnostic study to the patient within specified time frames? Laboratory: Was the laboratory service provided within the time 2.004 10 0 10 100.0% 0 frame specified in the provider’s order? Laboratory: Did the primary care provider review and initial the 2.005 6 4 10 60.0% 0 diagnostic report within specified time frames? Laboratory: Did the primary care provider communicate the 2.006 results of the diagnostic study to the patient within specified time 3 7 10 30.0% 0 frames? Pathology: Did the institution receive the final diagnostic report 2.007 9 1 10 90.0% 0 within the required time frames? Pathology: Did the primary care provider review and initial the 2.008 5 5 10 50.0% 0 diagnostic report within specified time frames? Pathology: Did the primary care provider communicate the results 2.009 4 6 10 40.0% 0 of the diagnostic study to the patient within specified time frames? Overall percentage: 58.9% 3 – Emergency Services This indicator is evaluated only by case review clinicians. There is no compliance testing component. High Desert State Prison, Cycle 5 Medical Inspection Page 68 Office of the Inspector General State of California Scored Answers Yes Reference + 4 – Health Information Management Number Yes No No Yes % N/A Are non-dictated healthcare documents (provider progress notes) 4.001 9 4 13 69.2% 0 scanned within 3 calendar days of the patient encounter date? Are dictated/transcribed documents scanned into the patient’s 4.002 electronic health record within five calendar days of the encounter Not Applicable date? Are High-Priority specialty notes (either a Form 7243 or other 4.003 scanned consulting report) scanned within the required time 13 7 20 65.0% 0 frame? Are community hospital discharge documents scanned into the 4.004 patient’s electronic health record within three calendar days of 6 2 8 75.0% 0 hospital discharge? Are medication administration records (MARs) scanned into the 4.005 Not Applicable patient’s electronic health record within the required time frames? During the inspection, were medical records properly scanned, 4.006 14 10 24 58.3% 0 labeled, and included in the correct patients’ files? For patients discharged from a community hospital: Did the preliminary hospital discharge report include key elements and 4.007 5 3 8 62.5% 0 did a primary care provider review the report within three calendar days of discharge? Overall percentage: 66.0% High Desert State Prison, Cycle 5 Medical Inspection Page 69 Office of the Inspector General State of California Scored Answers Yes Reference + 5 – Health Care Environment Number Yes No No Yes % N/A Are clinical health care areas appropriately disinfected, cleaned 5.101 12 0 12 100.0% 0 and sanitary? Do clinical health care areas ensure that reusable invasive and 5.102 non-invasive medical equipment is properly sterilized or 9 2 11 81.8% 1 disinfected as warranted? Do clinical health care areas contain operable sinks and sufficient 5.103 11 1 12 91.7% 0 quantities of hygiene supplies? Does clinical health care staff adhere to universal hand hygiene 5.104 6 5 11 54.6% 1 precautions? Do clinical health care areas control exposure to blood-borne 5.105 11 1 12 91.7% 0 pathogens and contaminated waste? Warehouse, Conex and other non-clinic storage areas: Does the 5.106 medical supply management process adequately support the needs 1 0 1 100.0% 0 of the medical health care program? Does each clinic follow adequate protocols for managing and 5.107 6 6 12 50.0% 0 storing bulk medical supplies? Do clinic common areas and exam rooms have essential core 5.108 9 3 12 75.0% 0 medical equipment and supplies? Do clinic common areas have an adequate environment conducive 5.109 9 3 12 75.0% 0 to providing medical services? Do clinic exam rooms have an adequate environment conducive 5.110 8 3 11 72.7% 1 to providing medical services? Emergency response bags: Are TTA and clinic emergency 5.111 medical response bags inspected daily and inventoried monthly, 4 4 8 50.0% 4 and do they contain essential items? Overall percentage: 76.6% High Desert State Prison, Cycle 5 Medical Inspection Page 70 Office of the Inspector General State of California Scored Answers Yes Reference + 6 – Inter- and Intra-System Transfers Number Yes No No Yes % N/A For endorsed patients received from another CDCR institution or COCF: Did nursing staff complete the initial health screening and 6.001 25 0 25 100.0% 0 answer all screening questions on the same day the patient arrived at the institution? For endorsed patients received from another CDCR institution or COCF: When required, did the RN complete the assessment and disposition section of the health screening form; refer the patient 6.002 25 0 25 100.0% 0 to the TTA, if TB signs and symptoms were present; and sign and date the form on the same day staff completed the health screening? For endorsed patients received from another CDCR institution or COCF: If the patient had an existing medication order upon 6.003 13 4 17 76.5% 8 arrival, were medications administered or delivered without interruption? For patients transferred out of the facility: Were scheduled 6.004 specialty service appointments identified on the patient’s health 15 5 20 75.0% 0 care transfer information form? For patients transferred out of the facility: Do medication transfer 6.101 packages include required medications along with the 0 9 9 0.0% 0 corresponding transfer packet required documents? Overall percentage: 70.3% High Desert State Prison, Cycle 5 Medical Inspection Page 71 Office of the Inspector General State of California Scored Answers 7 – Pharmacy and Medication Yes Reference + Management Number Yes No No Yes % N/A Did the patient receive all chronic care medications within the 7.001 required time frames or did the institution follow departmental 6 10 16 37.5% 9 policy for refusals or no-shows? Did health care staff administer, make available, or deliver new 7.002 order prescription medications to the patient within the required 20 5 25 80.0% 0 time frames? Upon the patient’s discharge from a community hospital: Were all 7.003 ordered medications administered, made available, or delivered to 6 2 8 75.0% 0 the patient within required time frames? For patients received from a county jail: Were all medications ordered by the institution’s reception center provider 7.004 Not Applicable administered, made available, or delivered to the patient within the required time frames? Upon the patient’s transfer from one housing unit to another: 7.005 21 4 25 84.0% 0 Were medications continued without interruption? For patients en route who lay over at the institution: If the 7.006 temporarily housed patient had an existing medication order, were Not Applicable medications administered or delivered without interruption? All clinical and medication line storage areas for narcotic 7.101 medications: Does the Institution employ strong medication 2 5 7 28.6% 5 security over narcotic medications assigned to its clinical areas? All clinical and medication line storage areas for non-narcotic medications: Does the Institution properly store non-narcotic 7.102 11 1 12 91.7% 0 medications that do not require refrigeration in assigned clinical areas? All clinical and medication line storage areas for non-narcotic 7.103 medications: Does the institution properly store non-narcotic 8 1 9 88.9% 3 medications that require refrigeration in assigned clinical areas? Medication preparation and administration areas: Do nursing staff employ and follow hand hygiene contamination control protocols 7.104 4 2 6 66.7% 6 during medication preparation and medication administration processes? Medication preparation and administration areas: Does the 7.105 institution employ appropriate administrative controls and 6 0 6 100.0% 6 protocols when preparing medications for patients? Medication preparation and administration areas: Does the 7.106 Institution employ appropriate administrative controls and 0 6 6 0.0% 6 protocols when distributing medications to patients? Pharmacy: Does the institution employ and follow general 7.107 security, organization, and cleanliness management protocols in 1 0 1 100.0% 0 its main and satellite pharmacies? High Desert State Prison, Cycle 5 Medical Inspection Page 72 Office of the Inspector General State of California Scored Answers 7 – Pharmacy and Medication Yes Reference + Management Number Yes No No Yes % N/A Pharmacy: Does the institution’s pharmacy properly store non- 7.108 1 0 1 100.0% 0 refrigerated medications? Pharmacy: Does the institution’s pharmacy properly store 7.109 1 0 1 100.0% 0 refrigerated or frozen medications? Pharmacy: Does the institution’s pharmacy properly account for 7.110 0 1 1 0.0% 0 narcotic medications? Does the institution follow key medication error reporting 7.111 20 5 25 80.0% 0 protocols? Overall percentage: 68.8% 8 – Prenatal and Post-Delivery Services The institution had no female patients, so this indicator was not applicable. High Desert State Prison, Cycle 5 Medical Inspection Page 73 Office of the Inspector General State of California Scored Answers Yes Reference + 9 – Preventive Services Number Yes No No Yes % N/A Patients prescribed TB medication: Did the institution administer 9.001 5 4 9 55.6% 0 the medication to the patient as prescribed? Patients prescribed TB medication: Did the institution monitor the 9.002 patient monthly for the most recent three months he or she was on 7 2 9 77.8% 0 the medication? Annual TB Screening: Was the patient screened for TB within the 9.003 28 2 30 93.3% 0 last year? Were all patients offered an influenza vaccination for the most 9.004 25 0 25 100.0% 0 recent influenza season? All patients from the age of 50 - 75: Was the patient offered 9.005 24 1 25 96.0% 0 colorectal cancer screening? Female patients from the age of 50 through the age of 74: Was the 9.006 Not Applicable patient offered a mammogram in compliance with policy? Female patients from the age of 21 through the age of 65: Was 9.007 Not Applicable patient offered a pap smear in compliance with policy? Are required immunizations being offered for chronic care 9.008 13 7 20 65.0% 5 patients? Are patients at the highest risk of coccidioidomycosis (valley 9.009 Not Applicable fever) infection transferred out of the facility in a timely manner? Overall percentage: 81.3% 10 – Quality of Nursing Performance This indicator is evaluated only by case review clinicians. There is no compliance testing component. 11 – Quality of Provider Performance This indicator is evaluated only by case review clinicians. There is no compliance testing component. High Desert State Prison, Cycle 5 Medical Inspection Page 74 Office of the Inspector General State of California 12 – Reception Center Arrivals The institution had no reception center, so this indicator was not applicable. Scored Answers Yes Reference + 13 – Specialized Medical Housing Number Yes No No Yes % N/A For OHU, CTC, and SNF: Did the registered nurse complete an 13.001 initial assessment of the patient on the day of admission, or within 9 1 10 90.0% 0 eight hours of admission to CMF’s Hospice? For CTC and SNF only: Was a written history and physical 13.002 9 1 10 90.0% 0 examination completed within the required time frame? For OHU, CTC, SNF, and Hospice: Did the primary care provider complete the Subjective, Objective, Assessment, Plan, and 13.003 3 7 10 30.0% 0 Education (SOAPE) notes on the patient at the minimum intervals required for the type of facility where the patient was treated? For OHU and CTC only: Do inpatient areas either have properly working call systems in its OHU & CTC or are 30-minute patient 13.101 1 0 1 100.0% 0 welfare checks performed; and do medical staff have reasonably unimpeded access to enter patient’s cells? Overall percentage: 77.5% High Desert State Prison, Cycle 5 Medical Inspection Page 75 Office of the Inspector General State of California Scored Answers Yes Reference + 14 – Specialty Services Number Yes No No Yes % N/A Did the patient receive the high priority specialty service within 14.001 14 calendar days of the primary care provider order or the 13 2 15 86.7% 0 Physician Request for Service? Did the primary care provider review the high priority specialty 14.002 9 5 14 64.3% 1 service consultant report within the required time frame? Did the patient receive the routine specialty service within 90 14.003 calendar days of the primary care provider order or Physician 12 3 15 80.0% 0 Request for Service? Did the primary care provider review the routine specialty service 14.004 10 3 13 76.9% 2 consultant report within the required time frame? For endorsed patients received from another CDCR institution: If the patient was approved for a specialty services appointment at 14.005 14 6 20 70.0% 0 the sending institution, was the appointment scheduled at the receiving institution within the required time frames? Did the institution deny the primary care provider request for 14.006 14 6 20 70.0% 0 specialty services within required time frames? Following the denial of a request for specialty services, was the 14.007 12 8 20 60.0% 0 patient informed of the denial within the required time frame? Overall percentage: 72.6% High Desert State Prison, Cycle 5 Medical Inspection Page 76 Office of the Inspector General State of California Scored Answers Yes Reference 15 – Administrative Operations + Number Yes No No Yes % N/A Did the institution promptly process inmate medical appeals 15.001 1 11 12 8.3% 0 during the most recent 12 months? Does the institution follow adverse / sentinel event reporting 15.002 Not Applicable requirements? Did the institution Quality Management Committee (QMC) meet at least monthly to evaluate program performance, and did the 15.003 6 0 6 100.0% 0 QMC take action when improvement opportunities were identified? Did the institution’s Quality Management Committee (QMC) or 15.004 other forum take steps to ensure the accuracy of its Dashboard 1 0 1 100.0% 0 data reporting? Does the Emergency Medical Response Review Committee 15.005 perform timely incident package reviews that include the use of 9 3 12 75.0% 0 required review documents? For institutions with licensed care facilities: Does the Local Governing Body (LGB), or its equivalent, meet quarterly and 15.006 1 3 4 25.0% 0 exercise its overall responsibilities for the quality management of patient health care? Did the institution complete a medical emergency response drill 15.101 for each watch and include participation of health care and 1 2 3 33.3% 0 custody staff during the most recent full quarter? Did the institution’s second level medical appeal response address 15.102 10 0 10 100.0% 0 all of the patient’s appealed issues? Did the institution’s medical staff review and submit the initial 15.103 2 2 4 50.0% 0 inmate death report to the Death Review Unit in a timely manner? Does the institution’s Supervising Registered Nurse conduct 15.104 0 5 5 0.0% 0 periodic reviews of nursing staff? Are nursing staff who administer medications current on their 15.105 10 0 10 100.0% 0 clinical competency validation? 15.106 Are structured clinical performance appraisals completed timely? 0 5 5 0.0% 0 15.107 Do all providers maintain a current medical license? 5 0 5 100.0% 0 Are staff current with required medical emergency response 15.108 2 0 2 100.0% 1 certifications? Are nursing staff and the Pharmacist-in-Charge current with their professional licenses and certifications, and is the pharmacy 15.109 6 0 6 100.0% 1 licensed as a correctional pharmacy by the California State Board of Pharmacy? High Desert State Prison, Cycle 5 Medical Inspection Page 77 Office of the Inspector General State of California Scored Answers Yes Reference 15 – Administrative Operations + Number Yes No No Yes % N/A Do the institution’s pharmacy and authorized providers who 15.110 prescribe controlled substances maintain current Drug 1 0 1 100.0% 0 Enforcement Agency (DEA) registrations? 15.111 Are nursing staff current with required new employee orientation? 0 1 1 0.0% 0 Overall percentage: 62.0% High Desert State Prison, Cycle 5 Medical Inspection Page 78 Office of the Inspector General State of California A B — C D PPENDIX LINICAL ATA Table B-1: HDSP Sample Sets Sample Set Total Anticoagulation 1 CTC/OHU 2 Death Review/Sentinel Events 2 Diabetes 5 Emergency Services – CPR 1 Emergency Services – Non-CPR 2 High Risk 4 Hospitalization 4 Intra-System Transfers In 3 Intra-System Transfers Out 3 RN Sick Call 18 Specialty Services 2 47 High Desert State Prison, Cycle 5 Medical Inspection Page 79 Office of the Inspector General State of California Table B-2: HDSP Chronic Care Diagnoses Diagnosis Total Anemia 1 Anticoagulation 1 Arthritis/Degenerative Joint Disease 1 Asthma 8 COPD 6 Cardiovascular Disease 6 Chronic Kidney Disease 2 Chronic Pain 15 Cirrhosis/End-Stage Liver Disease 1 Coccidioidomycosis 1 Deep Venous Thrombosis/Pulmonary Embolism 2 Diabetes 13 Gastroesophageal Reflux Disease 5 Hepatitis C 13 Hyperlipidemia 14 Hypertension 22 Mental Health 8 Migraine Headaches 1 Seizure Disorder 5 Sleep Apnea 4 Thyroid Disease 2 131 High Desert State Prison, Cycle 5 Medical Inspection Page 80 Office of the Inspector General State of California Table B-3: HDSP Event – Program Diagnosis Total Diagnostic Services 83 Emergency Care 54 Hospitalization 28 Intra-System Transfers In 10 Intra-System Transfers Out 6 Not Specified 1 Outpatient Care 415 Specialized Medical Housing 77 Specialty Services 72 746 High Desert State Prison, Cycle 5 Medical Inspection Page 81 Office of the Inspector General State of California Table B-4: HDSP Review Sample Summary Total MD Reviews Detailed 20 MD Reviews Focused 1 RN Reviews Detailed 12 RN Reviews Focused 27 Total Reviews 60 Total Unique Cases 47 Overlapping Reviews (MD & RN) 13 High Desert State Prison, Cycle 5 Medical Inspection Page 82 Office of the Inspector General State of California A C — C S M PPENDIX OMPLIANCE AMPLING ETHODOLOGY 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 patient—any risk level) (25) • Randomize MIT 1.002 Nursing Referrals OIG Q: 6.001 • See Intra-System Transfers (25) MITs 1.003–006 Nursing Sick Call MedSATS • Clinic (each clinic tested) (5 per clinic) • Appointment date (2–9 months) (30) • Randomize MIT 1.007 Returns from OIG Q: 4.007 • See Health Information Management (Medical Community Hospital Records) (returns from community hospital) (8) MIT 1.008 Specialty Services OIG Q: 14.001 & • See Specialty Services Follow-up 14.003 (30) MIT 1.101 Availability of Health OIG onsite • Randomly select one housing unit from each yard Care Services review Request Forms (6) Diagnostic Services MITs 2.001–003 Radiology Radiology Logs • Appointment date (90 days–9 months) • Randomize (10) • Abnormal MITs 2.004–006 Laboratory Quest • Appt. date (90 days–9 months) • Order name (CBC or CMPs only) • Randomize (10) • Abnormal MITs 2.007–009 Pathology InterQual • Appt. date (90 days–9 months) • Service (pathology related) (10) • Randomize High Desert State Prison, Cycle 5 Medical Inspection Page 83 Office of the Inspector General State of California Sample Category Quality (number of Indicator samples) Data Source Filters Health Information Management (Medical Records) MIT 4.001 Timely Scanning OIG Qs: 1.001, • Non-dictated documents (13) 1.002, & 1.004 • 1st 10 IPs MIT 1.001, 1st 5 IPs MITs 1.002, 1.004 MIT 4.002 OIG Q: 1.001 • Dictated documents (0) • First 20 IPs selected MIT 4.003 OIG Qs: 14.002 • Specialty documents (20) & 14.004 • First 10 IPs for each question MIT 4.004 OIG Q: 4.007 • Community hospital discharge documents (8) • First 20 IPs selected MIT 4.005 OIG Q: 7.001 • MARs (0) • First 20 IPs selected MIT 4.006 Documents for • Any misfiled or mislabeled document identified (10) any tested inmate during OIG compliance review (24 or more = No) MIT 4.007 Returns From Inpatient claims • Date (2–8 months) Community Hospital data • Most recent 6 months provided (within date range) • Rx count • Discharge date • Randomize (each month individually) • First 5 patients from each of the 6 months (if not 5 in a month, supplement from another, as needed) (8) Health Care Environment MIT 5.101–105 Clinical Areas OIG inspector • Identify and inspect all onsite clinical areas. MIT 5.107–111 (12) onsite review Inter- and Intra-System Transfers MIT 6.001–003 Intra-System SOMS • Arrival date (3–9 months) Transfers • Arrived from (another CDCR facility) • Rx count • Randomize (25) MIT 6.004 Specialty Services MedSATS • Date of transfer (3–9 months) Send-Outs • Randomize (20) MIT 6.101 Transfers Out OIG inspector • R&R IP transfers with medication (9) onsite review High Desert State Prison, Cycle 5 Medical Inspection Page 84 Office of the Inspector General State of California Sample Category Quality (number of Indicator samples) Data Source Filters Pharmacy and Medication Management MIT 7.001 Chronic Care OIG Q: 1.001 See Access to Care Medication • At least one condition per patient—any risk level • Randomize (25) MIT 7.002 New Medication Master Registry • Rx count Orders • Randomize (25) • Ensure no duplication of IPs tested in MIT 7.001 MIT 7.003 Returns from OIG Q: 4.007 • See Health Information Management (Medical Community Hospital Records) (returns from community hospital) (8) MIT 7.004 RC Arrivals – OIG Q: 12.001 • See Reception Center Arrivals Medication Orders (N/A at this institution) MIT 7.005 Intra-Facility Moves MAPIP transfer • Date of transfer (2–8 months) data • To location/from location (yard to yard and to/from ASU) • Remove any to/from MHCB • NA/DOT meds (and risk level) (25) • Randomize MIT 7.006 En Route SOMS • Date of transfer (2–8 months) • Sending institution (another CDCR facility) • Randomize (0) • NA/DOT meds MITs 7.101–103 Medication Storage OIG inspector • Identify and inspect clinical & med line areas that Areas onsite review store medications (varies by test) MITs 7.104–106 Medication OIG inspector • Identify and inspect onsite clinical areas that Preparation and onsite review prepare and administer medications Administration Areas (varies by test) MITs 7.107–110 Pharmacy OIG inspector • Identify & inspect all onsite pharmacies (1) onsite review MIT 7.111 Medication Error Monthly • All monthly statistic reports with Level 4 or higher Reporting medication error • Select a total of 5 months (25) reports MIT 7.999 Isolation Unit KOP Onsite active • KOP rescue inhalers & nitroglycerin medications Medications medication for IPs housed in isolation units (10) listing Prenatal and Post-Delivery Services MIT 8.001–007 Recent Deliveries OB Roster • Delivery date (2–12 months) (N/A at this • Most recent deliveries (within date range) institution) Pregnant Arrivals OB Roster • Arrival date (2–12 months) (N/A at this • Earliest arrivals (within date range) institution) High Desert State Prison, Cycle 5 Medical Inspection Page 85 Office of the Inspector General State of California Sample Category Quality (number of Indicator samples) Data Source Filters Preventive Services MITs 9.001–002 TB Medications Maxor • Dispense date (past 9 months) • Time period on TB meds (3 months or 12 weeks) (9) • Randomize MIT 9.003 TB Evaluation, SOMS • Arrival date (at least 1 year prior to inspection) Annual Screening • Birth Month (30) • Randomize MIT 9.004 Influenza SOMS • Arrival date (at least 1 year prior to inspection) Vaccinations • Randomize (25) • Filter out IPs tested in MIT 9.008 MIT 9.005 Colorectal Cancer SOMS • Arrival date (at least 1 year prior to inspection) Screening • Date of birth (51 or older) (25) • Randomize MIT 9.006 Mammogram SOMS • Arrival date (at least 2 yrs prior to inspection) (N/A at this • Date of birth (age 52–74) institution) • Randomize MIT 9.007 Pap Smear SOMS • Arrival date (at least three yrs prior to inspection) (N/A at this • Date of birth (age 24–53) institution) • Randomize MIT 9.008 Chronic Care OIG Q: 1.001 • Chronic care conditions (at least 1 condition per Vaccinations IP—any risk level) • Randomize (25) • Condition must require vaccination(s) MIT 9.009 Valley Fever Cocci transfer • Reports from past 2–8 months (number will vary) status report • Institution (N/A at this • Ineligibility date (60 days prior to inspection date) institution) • All High Desert State Prison, Cycle 5 Medical Inspection Page 86 Office of the Inspector General State of California Sample Category Quality (number of Indicator samples) Data Source Filters Reception Center Arrivals MITs 12.001–008 RC SOMS • Arrival date (2–8 months) (N/A at this • Arrived from (county jail, return from parole, etc.) 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 onsite review (all) Specialty Services MITs 14.001–002 High-Priority MedSATS • Approval date (3–9 months) (15) • Randomize MITs 14.003–004 Routine MedSATS • Approval date (3–9 months) • Remove optometry, physical therapy or podiatry (15) • Randomize MIT 14.005 Specialty Services MedSATS • Arrived from (other CDCR institution) Arrivals • Date of transfer (3–9 months) (20) • Randomize MIT 14.006–007 Denials InterQual • Review date (3–9 months) (16) • Randomize IUMC/MAR • Meeting date (9 months) Meeting Minutes • Denial upheld (4) • Randomize High Desert State Prison, Cycle 5 Medical Inspection Page 87 Office of the Inspector General State of California Sample Category Quality (number of Indicator samples) Data Source Filters Administrative Operations MIT 15.001 Medical Appeals Monthly medical • Medical appeals (12 months) (all) appeals reports MIT 15.002 Adverse/Sentinel Adverse/sentinel • Adverse/sentinel events (2–8 months) Events events report (0) MITs 15.003–004 QMC Meetings Quality • Meeting minutes (12 months) Management Committee (6) meeting minutes MIT 15.005 EMRRC EMRRC meeting • Monthly meeting minutes (6 months) (12) minutes MIT 15.006 LGB LGB meeting • Quarterly meeting minutes (12 months) (4) minutes MIT 15.101 Medical Emergency Onsite summary • Most recent full quarter Response Drills reports & • Each watch documentation (3) for ER drills MIT 15.102 2nd Level Medical Onsite list of • Medical appeals denied (6 months) Appeals appeals/closed (10) appeals files MIT 15.103 Death Reports Institution-list of • Most recent 10 deaths deaths in prior 12 • Initial death reports (4) months MIT 15.104 RN Review Onsite supervisor • RNs who worked in clinic or emergency setting Evaluations periodic RN six or more days in sampled month reviews • Randomize (5) MIT 15.105 Nursing Staff Onsite nursing • On duty one or more years Validations education files • Nurse administers medications (10) • Randomize MIT 15.106 Provider Annual Onsite • All required performance evaluation documents Evaluation Packets provider (5) evaluation files MIT 15.107 Provider licenses Current provider • Review all listing (at start of (5) inspection) MIT 15.108 Medical Emergency Onsite • All staff Response certification o Providers (ACLS) Certifications tracking logs o Nursing (BLS/CPR) (all) • Custody (CPR/BLS) MIT 15.109 Nursing staff and Onsite tracking • All required licenses and certifications Pharmacist in system, logs, or Charge Professional employee files Licenses and Certifications (all) High Desert State Prison, Cycle 5 Medical Inspection Page 88 Office of the Inspector General State of California Sample Category Quality (number of Indicator samples) Data Source Filters Administrative Operations MIT 15.110 Pharmacy and Onsite listing of • All DEA registrations Providers’ Drug provider DEA Enforcement Agency registration #s & (DEA) Registrations pharmacy registration (all) document MIT 15.111 Nursing Staff New Nursing staff • New employees (hired within last 12 months) Employee training logs • Orientations (all) MIT 15.998 Death Review OIG summary log • Between 35 business days & 12 months prior Committee - deaths • CCHCS death reviews (4) High Desert State Prison, Cycle 5 Medical Inspection Page 89 Office of the Inspector General State of California C C ALIFORNIA ORRECTIONAL H C S ’ EALTH ARE ERVICES R ESPONSE High Desert State Prison, Cycle 5 Medical Inspection Page 90 Office of the Inspector General State of California