Kern Valley State Prison Medical Inspection Report Cycle 4

Robert A. Barton Office of the Inspector General Inspector General Kern Valley State Prison Medical Inspection Results Cycle 4 December 2015 Medical Inspection Unit Page 1 Office of the Inspector General State of California Office of the Inspector General KERN VALLEY STATE PRISON Medical Inspection Results Cycle 4 Robert A. Barton Inspector General Roy W. Wesley Chief Deputy Inspector General Shaun R. Spillane Public Information Officer December 2015 TABLE OF CONTENTS Executive Summary .......................................................................................................................... i Overall Assessment: Adequate .......................................................................................... iii Clinical Case Review and OIG Clinician Inspection Results............................................ iii Compliance Testing Results ............................................................................................... iv Population-Based Metrics ................................................................................................... x Introduction ...................................................................................................................................... 1 About the Institution ......................................................................................................................... 1 Objectives, Scope, and Methodology ............................................................................................... 4 Case Reviews ................................................................................................................................... 6 Patient Selection for Retrospective Case Reviews .................................................................... 6 Benefits and Limitations of Targeted Subpopulation Review ................................................... 7 Case Reviews Sampled .............................................................................................................. 7 Compliance Testing .......................................................................................................................... 9 Sampling Methods for Conducting Compliance Testing ........................................................... 9 Scoring of Compliance Testing Results ..................................................................................... 9 Dashboard Comparisons .......................................................................................................... 10 Overall Quality Indicator Rating for Case Reviews and Compliance Testing ............................... 10 Population-Based Metrics .............................................................................................................. 10 Medical Inspection Results............................................................................................................. 11 Primary (Clinical) Quality Indicators of Health Care .................................................................... 11 Access to Care ......................................................................................................................... 12 Case Review Results ......................................................................................................... 12 Compliance Testing Results .............................................................................................. 14 CCHCS Dashboard Comparative Data ............................................................................. 16 Recommendations ............................................................................................................. 16 Diagnostic Services .................................................................................................................. 17 Case Review Results ......................................................................................................... 17 Compliance Testing Results .............................................................................................. 18 Recommendations ............................................................................................................. 19 Emergency Services ................................................................................................................. 20 Case Review Results ......................................................................................................... 20 Recommendations ............................................................................................................. 22 Health Information Management (Medical Records) .............................................................. 23 Case Review Results ......................................................................................................... 23 Compliance Testing Results .............................................................................................. 24 CCHCS Dashboard Comparative Data ............................................................................. 25 Recommendation ............................................................................................................... 26 Health Care Environment ........................................................................................................ 27 Compliance Testing Results .............................................................................................. 27 Recommendations ............................................................................................................. 31 Kern Valley State Prison, Cycle 4 Medical Inspection Table of Contents Office of the Inspector General State of California Inter- and Intra-System Transfers ............................................................................................ 32 Case Review Results ......................................................................................................... 32 Compliance Testing Results .............................................................................................. 34 Recommendation ............................................................................................................... 35 Pharmacy and Medication Management ................................................................................. 36 Case Review Results ......................................................................................................... 36 Compliance Testing Results .............................................................................................. 38 CCHCS Dashboard Comparative Data ............................................................................. 41 Recommendations ............................................................................................................. 42 Preventive Services .................................................................................................................. 43 Compliance Testing Results .............................................................................................. 43 CCHCS Dashboard Comparative Data ............................................................................. 44 Recommendations ............................................................................................................. 44 Quality of Nursing Performance .............................................................................................. 45 Case Review Results ......................................................................................................... 45 Recommendations ............................................................................................................. 49 Quality of Provider Performance ............................................................................................ 50 Case Review Results ......................................................................................................... 50 Case Review Conclusion ................................................................................................... 54 Recommendations ............................................................................................................. 54 Specialized Medical Housing ................................................................................................... 55 Case Review Results ......................................................................................................... 55 Compliance Testing Results .............................................................................................. 58 Recommendations ............................................................................................................. 58 Specialty Services..................................................................................................................... 59 Case Review Results ......................................................................................................... 59 Compliance Testing Results .............................................................................................. 60 Recommendations ............................................................................................................. 61 Secondary (Administrative) Quality Indicators of Health Care ..................................................... 62 Internal Monitoring, Quality Improvement, and Administrative Operations .......................... 63 Compliance Testing Results .............................................................................................. 63 CCHCS Dashboard Comparative Data ............................................................................. 66 Recommendations ............................................................................................................. 66 Job Performance, Training, Licensing, and Certifications...................................................... 67 Compliance Testing Results .............................................................................................. 67 Recommendations ............................................................................................................. 68 Population-Based Metrics .............................................................................................................. 69 Appendix A — Compliance Test Results....................................................................................... 73 Appendix B — Clinical Data ......................................................................................................... 86 Appendix C — Compliance Sampling Methodology ..................................................................... 89 California Correctional Health Care Services’ Response ............................................................... 94 Kern Valley State Prison, Cycle 4 Medical Inspection Table of Contents Office of the Inspector General State of California LIST OF TABLES AND FIGURES Health Care Quality Indicators ........................................................................................................ ii KVSP Executive Summary Table ................................................................................................... ix KVSP Health Care Staffing Resources — June 2015 ...................................................................... 2 KVSP Master Registry Data as of June 8, 2015 ............................................................................... 2 Commonly Used Abbreviations ....................................................................................................... 3 Access to Care — KVSP Dashboard and OIG Compliance Results .............................................. 16 Health Information Management — KVSP Dashboard and OIG Compliance Results ................. 26 Pharmacy and Medication Management — KVSP Dashboard and OIG Compliance Results ..... 41 Preventive Services — KVSP Dashboard and OIG Compliance Results ...................................... 44 Internal Monitoring, Quality Improvement, and Administrative Operations — KVSP Dashboard and OIG Compliance Results ..................................................................... 66 KVSP Results Compared to State and National HEDIS Scores..................................................... 72 Kern Valley State Prison, Cycle 4 Medical Inspection List of Tables and Figures Office of the Inspector General State of California EXECUTIVE SUMMARY Under the authority of California Penal Code Section 6126, which assigns the Office of the Inspector General (OIG) responsibility for oversight of the California Department of Corrections and Rehabilitation (CDCR), the OIG conducts a comprehensive inspection program to evaluate the delivery of medical care at each of CDCR’s 35 adult prisons. The OIG explicitly makes no determination regarding the constitutionality of care in the prison setting. That determination is left to the Receiver and the federal court. The assessment of care by the OIG is just one factor in the court’s determination whether care in the prisons meets constitutional standards. The court may find that an institution that the OIG found to be providing adequate care still does not meet constitutional standards, depending on the analysis of the underlying data provided by the OIG. Likewise, an institution that has been rated inadequate by the OIG could still be found to pass constitutional muster with the implementation of remedial measures if the underlying data were to reveal easily mitigated deficiencies. The OIG’s inspections are mandated by the Penal Code and not aimed at specifically resolving the court’s questions on constitutional care. To the degree that they provide another factor for the court to consider, the OIG is pleased to provide added value to the taxpayers of California. For this fourth cycle of inspections, the OIG added a clinical case review component and significantly enhanced the compliance portion of the inspection process from that used in prior cycles. In addition, the OIG added a population-based metric comparison of selected Healthcare Effectiveness Data Information Set (HEDIS) measures from other State and national health care organizations and compared that data to similar results for Kern Valley State Prison (KVSP). The OIG performed its Cycle 4 medical inspection at KVSP from June to August 2015. The inspection included in-depth reviews of 73 inmate-patient files conducted by clinicians, as well as reviews of documents from 439 inmate-patient files, covering 92 objectively scored tests of compliance with policies and procedures applicable to the delivery of medical care. The OIG assessed the case review and compliance results at KVSP using 14 health care quality indicators applicable to the institution, made up of 12 primary clinical indicators and two secondary administrative indicators. To conduct clinical case reviews, the OIG employs a clinician team consisting of a physician and a registered nurse consultant, while compliance testing is done by a team of deputy inspectors general trained in monitoring medical compliance. Of the 12 primary indicators, seven were rated by both case review clinicians and compliance inspectors, three were rated by case review clinicians only, and two were rated by compliance inspectors only; both secondary indicators were rated by compliance inspectors only. See the Health Care Quality Indicators table on page ii. Based on that analysis, OIG experts made a considered and measured overall opinion that the quality of health care was adequate. Kern Valley State Prison, Cycle 4 Medical Inspection Page i Office of the Inspector General State of California Health Care Quality Indicators All Institutions– KVSP Fourteen Primary Indicators (Clinical) Applicability Applicability Both case review 1–Access to Care All institutions and compliance Both case review 2–Diagnostic Services All institutions and compliance 3–Emergency Services All institutions Case review only 4–Health Information Management Both case review All institutions (Medical Records) and compliance 5–Health Care Environment All institutions Compliance only Both case review 6–Inter- and Intra-System Transfers All institutions and compliance Both case review 7–Pharmacy and Medication Management All institutions and compliance Female institutions 8–Prenatal and Post-Delivery Services Not Applicable only 9–Preventive Services All institutions Compliance only 10–Quality of Nursing Performance All institutions Case review only 11–Quality of Provider Performance All institutions Case review only Institutions with 12–Reception Center Arrivals Not Applicable reception centers All institutions with 13–Specialized Medical Housing Both case review an OHU, CTC, SNF, (OHU, CTC, SNF, Hospice) and compliance or Hospice Both case review 14–Specialty Services All institutions and compliance Two Secondary Indicators All Institutions– KVSP (Administrative) Applicability Applicability 15–Internal Monitoring, Quality Improvement, and Administrative All institutions Compliance only Operations 16–Job Performance, Training, Licensing, All institutions Compliance only and Certifications Kern Valley State Prison, Cycle 4 Medical Inspection Page ii Office of the Inspector General State of California Overall Assessment: Adequate Based on the clinical case reviews and compliance testing, the OIG’s overall assessment rating for KVSP was adequate. For the Overall Assessment 12 primary (clinical) quality indicators applicable to KVSP, the Rating: OIG found three proficient, seven adequate, and two inadequate. For the two secondary (administrative) quality indicators, the OIG Adequate found one proficient and one inadequate. To determine the overall assessment for KVSP, the OIG considered individual clinical ratings and individual compliance question scores within each of the indicator categories, putting emphasis on the primary indicators. Based on that analysis, OIG experts made a considered and measured overall opinion about the quality of health care observed at KVSP. Clinical Case Review and OIG Clinician Inspection Results The clinicians’ case reviews sampled patients with high medical needs and included a review of 1,173 patient care events.1 For the 12 primary indicators applicable to KVSP, clinicians evaluated ten by case review, with one proficient, eight adequate, and one inadequate. When determining the overall adequacy of care, the OIG paid particular attention to the clinical nursing and provider quality indicators, as adequate health care staff can sometimes overcome suboptimal processes and programs. However, the opposite is not true; inadequate health care staff cannot provide adequate care, even though the established processes and programs on site 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 — Case Review  KVSP had strong medical management committed to patient care. Medical staff greatly appreciated this leadership.  KVSP had efficient specialty and diagnostic services. Staff assigned to these services were knowledgeable about their roles and responsibilities. Staff timely retrieved and completed diagnostic tests and specialty appointments.  The providers were effective in providing medical care with diligence and a good work ethic. To assure continuity of medical care, each clinic had one assigned provider.  The spacious medical clinics provided adequate patient auditory and visual privacy. 1 Each OIG clinician team includes a board-certified physician and registered nurse consultant with experience in correctional and community medical settings. Kern Valley State Prison, Cycle 4 Medical Inspection Page iii Office of the Inspector General State of California Program Weaknesses — Case Review OIG clinicians found some major inadequacies during the inspection period, including the following:  Health Information Management was inadequate. Frequently, records were misfiled, missing, or not available when needed. These deficiencies can significantly impact patient care when medical information is shared with other health care staff.  Nursing documentation needed improvement. Some nursing documents found in both outpatient and inpatient settings had incomplete or illegible assessments. These deficiencies can significantly affect patient care since nurses are the first responders and are on site 24 hours a day. Providers depend on accurate and complete nursing assessment and documentation.  There was one unsafe condition. In case 13, a provider inappropriately increased weekly warfarin (blood-thinning medication) by 45 percent. While no harm came to the patient, this placed the patient at risk of over-anticoagulation and bleeding. Because of the anecdotal nature of this event, the OIG cautions against drawing inappropriate conclusions regarding the institution based solely on this one adverse event. Compliance Testing Results Of the 14 total indicators of health care applicable to KVSP, 11 were evaluated by compliance inspectors.2 There were 92 individual compliance questions addressing those 11 indicators, generating 1,254 data points, testing KVSP’s compliance with California Correctional Health Care Services (CCHCS) policies and procedures.3 Those 92 questions are detailed in Appendix A— Compliance Test Results. The institution’s inspection scores for the 11 applicable indicators ranged from 61.1 percent to 97.5 percent, with the primary (clinical) indicator Diagnostic Services receiving the lowest score, and the secondary (administrative) indicator Job Performance, Training, Licensing, and Certifications receiving the highest. For the nine primary indicators applicable to compliance testing, the OIG rated four proficient and five inadequate. For the two secondary indicators, which involve administrative health care functions, one was rated proficient and the other inadequate. 2 The OIG’s compliance inspectors are trained deputy inspectors general with expertise in CDCR policies regarding medical staff and processes. 3 The OIG used its own clinicians to provide clinical expert guidance for testing compliance in certain areas where CCHCS policies and procedures did not specifically address an issue. Kern Valley State Prison, Cycle 4 Medical Inspection Page iv Office of the Inspector General State of California Program Strengths — Compliance Testing As the KVSP Executive Summary Table on page ix indicates, the institution’s compliance scores were in the proficient range for the following four primary indicators: Access to Care (93.3 percent), Health Care Environment (86.8 percent), Preventive Services (90.1 percent), and Specialized Medical Housing (96.0 percent). The institution also received a proficient rating in the secondary indicator Job Performance, Training, Licensing, and Certifications (97.5 percent). The following are some of KVSP’s strengths based on its compliance scores for individual questions within all primary health care indicators:  Nursing staff timely reviewed patients’ health care service requests and timely completed face-to-face encounters with patients.  For patients who transferred into KVSP from other CDCR institutions, nursing staff completed the assessment and disposition section of the initial health screening assessment, and for those patients referred by nursing staff to a primary care provider, the provider saw the patients timely.  Providers conducted timely follow-up appointments with their sick call patients. In addition, providers also timely followed up on patients who were released from a community hospital (and returned to the institution) and patients who returned from specialty service appointments.  Inmate-patients had a standardized process to obtain and submit health care service request forms.  The institution ensured that inmate-patients timely received their radiology diagnostic services. In addition, providers communicated radiology and laboratory services test results to inmate-patients within the required time frames. Also, the institution ensured that providers timely received final pathology reports.  Institutional staff timely scanned non-dictated progress notes, initial health screening forms, and health care service request forms into patients’ health record files. Staff also timely scanned community hospital discharge reports.  KVSP ensured that clinical health care areas and their related medical equipment were appropriately disinfected, cleaned, and sanitary; clinics contained operable sinks and had sufficient quantities of hygiene supplies.  Clinical staff followed proper hand hygiene practices during patient encounters.  Clinical and non-clinic medical storage areas demonstrated adequate medical supply storage and management protocols. Kern Valley State Prison, Cycle 4 Medical Inspection Page v Office of the Inspector General State of California  KVSP’s staff ensured that the institution’s emergency response bags were inspected daily and inventoried monthly, and that they contained all essential items.  For inmate-patients who transferred into KVSP from another CDCR institution, RNs properly documented an assessment and disposition of the patient on the Initial Health Screening form (CDCR Form 7277) the same day nursing staff completed an initial screening of the patient.  The institution properly stored non-narcotic medications at all applicable clinics and all sampled medication line storage locations.  Nursing staff followed appropriate administrative controls and protocols during medication preparation and while distributing medications to inmate-patients.  In its main pharmacy, the institution followed general security, organization, and cleanliness management protocols; properly stored non-refrigerated medications; and maintained adequate controls over and properly accounted for narcotic medications.  KVSP followed adequate preventive services protocols. The institution timely administered anti-tuberculosis medication and monitored tuberculosis patient treatments. It also promptly offered patients required preventive services, which included influenza vaccinations and screenings for colorectal cancer.  For patients housed in the correctional treatment center (CTC), nurses timely completed initial patient assessments. Also, providers timely evaluated patients upon admission and completed each patient’s written history and physical examination.  Providers conducted specialty service appointments timely. In addition, the institution completed denials of providers’ requests for specialty services timely. The following are some of the strengths identified within the two secondary administrative indicators:  The institution processed inmate medical appeals timely.  The institution’s medical staff reviewed and submitted initial inmate death reports to the CCHCS Death Review Unit in a timely manner.  Providers, the pharmacist-in-charge, and the pharmacy had current licenses and registrations, and nursing staff were current on required training requirements, licenses, and certifications.  The institution’s providers, nurses, and custody officers were current with their required medical emergency response certifications. Kern Valley State Prison, Cycle 4 Medical Inspection Page vi Office of the Inspector General State of California  Structured clinical performance appraisals were completed timely for all of KVSP’s providers, and all nursing staff hired in the most recent 12 months completed the required new employee orientation class. Program Weaknesses — Compliance Testing The institution received ratings in the inadequate range for the following five primary indicators: Diagnostic Services (61.1 percent), Health Information Management (Medical Records) (65.7 percent), Inter-and Intra-System Transfers (74.7 percent), Pharmacy and Medication Management (71.9 percent), and Specialty Services (74.5 percent). The institution also received an inadequate rating in the secondary indicator Internal Monitoring, Quality Improvement, and Administrative Operations (73.7 percent). The following are some of the weaknesses identified by KVSP’s compliance scores for individual questions within all primary health care indicators:  Providers did not always document adequate evidence of their radiology, laboratory, or pathology report reviews. Further, they did not timely communicate pathology results to patients.  Medical records staff did not always properly label patient documents scanned into the eUHRs and did not always timely scan specialty service consultant reports and medication administration records (MARs) into patients’ eUHRs.  Several clinic exam rooms did not have sharps containers to mitigate exposure to blood-borne pathogens and contaminated waste.  Some clinics and exam rooms lacked essential core medical equipment for comprehensive examinations such as a calibrated scale, nebulization unit, oto-ophthalmoscope, or an established line marker for a Snellen vision chart.  The space or configuration of furniture in some exam rooms was not optimal for conducting clinical exams or other health screenings.  One half of the inmate-patients sampled who transferred out of KVSP with approved pending specialty service appointments did not have the approved services identified on their Health Care Transfer Information forms (CDCR Form 7371).  Nursing staff did not always timely administer medications to patients who suffered from chronic illnesses. Also, nursing staff did not ensure that patients who were temporarily housed at KVSP while en route to another institution, or those who returned from a community hospital, received their prescribed medications without interruption. Kern Valley State Prison, Cycle 4 Medical Inspection Page vii Office of the Inspector General State of California  Nursing maintained poor security controls over narcotic medications; key controls were inadequate. Also, pharmacy staff did not properly store non-narcotic refrigerated medications in the pharmacy.  The institution’s pharmacist-in-charge (PIC) did not properly process and follow up on all reported medication errors.  Inmate-patients’ tuberculosis skin test results were not always read by a registered nurse, public health nurse, or primary care provider.  The institution did not always provide timely specialty service appointments to inmate-patients who transferred into KVSP with previously approved or scheduled specialty appointments at the sending institution. Also, PCPs did not always review high-priority or routine specialty service consultant reports within policy-dictated time frames. Further, when the institution denied specialty service requests, providers did not always timely communicate the denial status to the patients. The following are some of the weaknesses identified within the two secondary administrative indicators:  KVSP failed to improve performance, reach performance objectives, or identify the status of performance objectives for some of the quality improvement initiatives identified in its 2014 Performance Improvement Work Plan.  Management did not always hold required monthly Emergency Medical Response Review Committee (EMRRC) meetings and conduct incident reviews of all unscheduled transfers out of the institution. During the months when the EMRRC convened, meeting minutes were not always approved by the warden and CEO and incident review packages did not include required documentation. The KVSP Executive Summary Table on the following page lists the quality indicators the OIG inspected and assessed during the clinical case reviews and objective compliance tests, and provides the institution’s rating in each area. The overall indicator ratings were based on a consensus decision by the OIG’s clinicians and non-clinical inspectors. Kern Valley State Prison, Cycle 4 Medical Inspection Page viii Office of the Inspector General State of California KVSP Executive Summary Table Case Compliance Overall Indicator Primary Indicators (Clinical) Review Score Rating Rating Access to Care Adequate 93.3% Proficient Diagnostic Services Adequate 61.1% Adequate Emergency Services Adequate Not Applicable Adequate Health Information Management Inadequate 65.7% Inadequate (Medical Records) Health Care Environment Not Applicable 86.8% Proficient Inter- and Intra-System Transfers Adequate 74.7% Adequate Pharmacy and Medication Management Adequate 71.9% Inadequate Preventive Services Not Applicable 90.1% Proficient Quality of Nursing Performance Adequate Not Applicable Adequate Quality of Provider Performance Adequate Not Applicable Adequate Specialized Medical Housing Adequate 96.0% Adequate Specialty Services Proficient 74.5% Adequate Note: Prenatal and Post-Delivery Services and Reception Center Arrivals indicators did not apply to this institution. Case Compliance Overall Indicator Secondary Indicators (Administrative) Review Score Rating Rating Internal Monitoring, Quality Improvement, Not Applicable 73.7 % Inadequate and Administrative Operations Job Performance, Training, Licensing, and Not Applicable 97.5% Proficient Certifications Compliance ratings for quality indicators are proficient (greater than 85.0 percent), adequate (75.0 percent to 85.0 percent), or inadequate (below 75.0 percent). Kern Valley State Prison, Cycle 4 Medical Inspection Page ix Office of the Inspector General State of California Population-Based Metrics Kern Valley State Prison performed well for population-based metrics. In four of the five comprehensive diabetes care measures, KVSP outperformed or matched other State and national organizations, including Kaiser Permanente, typically one of the highest-scoring health organizations in California. Especially notable was KVSP’s low percentage of diabetics considered to be under poor control and high percentage of diabetics considered to be under good control. In the fifth measure, eye exam rates in diabetic patients, KVSP scored lower than the other health plans; however, the institution’s lower performance was partially attributable to its high number of patient refusals for eye exams. With regard to influenza immunizations for patients under the age of 65, KVSP’s rates were higher than those reported by Kaiser Permanente and national commercial health plans (based on data obtained from health maintenance organizations). However, for older age groups, KVSP’s rates for influenza shots were lower than the U.S. Department of Veterans Affairs (VA) and Medicare. Also, KVSP’s rate for pneumococcal immunizations was lower than both Medicare and the VA. With regard to colorectal cancer screening, KVSP’s rates were lower than both Kaiser and the VA, but higher than rates reported by commercial plans and Medicare. For the immunization and cancer screening measures, KVSP’s low percentages were primarily due to patients who were offered immunizations or screenings but refused them. Overall, KVSP’s performance demonstrated by the population-based metrics indicated that the chronic care program was well run and operating as intended. Kern Valley State Prison, Cycle 4 Medical Inspection Page x Office of the Inspector General State of California INTRODUCTION Under the authority of California Penal Code Section 6126, which assigns the Office of the Inspector General (OIG) responsibility for oversight of the California Department of Corrections and Rehabilitation (CDCR), and at the request of the federal Receiver, the OIG developed a comprehensive medical inspection program to evaluate the delivery of medical care at each of CDCR’s 35 adult prisons. For this fourth cycle of inspections, the OIG augmented the breadth and quality of its inspection program used in prior cycles, adding a clinical case review component and significantly enhancing the compliance component of the program. Kern Valley State Prison (KVSP) was the eighth medical inspection of Cycle 4. During the inspection process, the OIG assessed the delivery of medical care to patients using 12 primary clinical health care indicators and two secondary administrative health care indicators applicable to the institution. It is important to note that while the primary quality indicators represent the clinical care being provided by the institution at the time of the inspection, the secondary quality indicators are purely administrative and are not reflective of the actual clinical care provided. The OIG is committed to reporting on each institution’s delivery of medical care to assist in identifying areas for improvement, but the federal court will ultimately determine whether any institution’s medical care meets constitutional standards. ABOUT THE INSTITUTION KVSP is a Level IV (maximum-security) facility consisting of four semiautonomous 180-bed facilities and two stand-alone administrative segregation units. The primary mission of KVSP is to protect the public by providing safe custody, quality health care, and appropriate supervision of sentenced offenders. The secondary mission is to provide meaningful work, training, and education programs for inmates who do not meet the criteria for assignment to a conservation camp. KVSP operates seven medical clinics where staff handle non-urgent requests for medical services. KVSP also treats inmate-patients who need urgent or emergency care in its triage and treatment area, and treats inmate-patients who require inpatient care in the correctional treatment center. The institution screens patients in its receiving and release clinic and provides clinical services in its specialty service/telemedicine clinic. In addition, on August 18, 2014, Kern Valley State Prison received national accreditation from the Commission on Accreditation for Corrections. This accreditation program is a professional peer review process based on national standards set by the American Correctional Association. Based on staffing data the OIG obtained from the institution, KVSP’s vacancy rate among licensed medical managers, primary care providers, supervisors, and rank-and-file nurses was 13 percent in June 2015, with the highest vacancy percentages among management (40 percent) and nursing staff (13 percent). Nursing supervisors and primary care providers had a low vacancy rate of just 10 percent and zero, respectively. At the time of the OIG’s inspection, the acting chief executive officer for Health Care Services (CEO) at KVSP was also the CEO at North Kern State Prison. Kern Valley State Prison, Cycle 4 Medical Inspection Page 1 Office of the Inspector General State of California KVSP Health Care Staffing Resources — June 2015 Primary Care Nursing Management Nursing Staff Totals Providers Supervisors Description Number % Number % Number % Number % Number % Authorized 5 4% 9 6% 10.5 7% 126.5 84% 151 100% Positions Filled Positions 3 60% 9 100% 9.5 90% 109.5 87% 131 87% Vacancies 2 40% 0 0% 1 10% 16.7 13% 19.7 13% Recent Hires (within 12 0 0% 3 33% 0 0% 19 17% 22 17% months) Staff Utilized 0 0% 0 0% 0 0% 4 4% 4 3% from Registry Redirected Staff (to Non-Patient 0 0% 1 11% 0 0% 0 0% 1 1% Care Areas) Staff under Disciplinary 0 0% 2 22% 0 0% 3 3% 5 4% Review Staff on Long-term 0 0% 0 0% 0 0% 3 3% 3 2% Medical Leave Note: KVSP Health Care Staffing Resources data was not validated by the OIG. As of June 8, 2015, CCHCS showed that KVSP had 3,696 inmate-patients. Within that total population, less than 1.0 percent were designated High-Risk, Priority 1 (High 1), and 3.4 percent were designated High-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 labs and procedures. High 1 has at least two high-risk conditions; High 2 has only one. High-risk patients are more susceptible to poor health outcomes than medium- or low-risk patients. High-risk patients 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. KVSP Master Registry Data as of June 8, 2015 Medical Risk Level # of Inmate-Patients Percentage High 1 21 0.57% High 2 124 3.35% Medium 1,725 46.67% Low 1,826 49.41% Total 3,696 100% Kern Valley State Prison, Cycle 4 Medical Inspection Page 2 Office of the Inspector General State of California Commonly Used Abbreviations ACLS Advanced Cardiovascular Life Support HIV Human Immunodeficiency Virus AHA American Heart Association HTN Hypertension ASU Administrative Segregation Unit INH Isoniazid (anti-tuberculosis medication) BLS Basic Life Support IV Intravenous CBC Complete Blood Count KOP Keep-on-Person (in taking medications) CC Chief Complaint LPT Licensed Psychiatric Technician CCHCS California Correctional Health Care Services LVN Licensed Vocational Nurse CCP Chronic Care Program MAR Medication Administration Record California Department of Corrections and CDCR MRI Magnetic Resonance Imaging Rehabilitation CEO Chief Executive Officer MD Medical Doctor CHF Congestive Heart Failure NA Nurse Administered (in taking medications) CME Chief Medical Executive N/A Not Applicable CMP Comprehensive Metabolic (Chemistry) Panel NP Nurse Practitioner CNA Certified Nursing Assistant OB Obstetrician CNE Chief Nurse Executive OHU Outpatient Housing Unit C/O Complains of OIG Office of the Inspector General COPD Chronic Obstructive Pulmonary Disease P&P Policies and Procedures (CCHCS) CP&S Chief Physician and Surgeon PA Physician Assistant CPR Cardio-Pulmonary Resuscitation PCP Primary Care Provider CSE Chief Support Executive POC Point of Contact CT Computerized Tomography PPD Purified Protein Derivative CTC Correctional Treatment Center PRN As Needed (in taking medications) DM Diabetes Mellitus RN Registered Nurse Directly Observed Therapy (in taking DOT Rx Prescription medications) Dx Diagnosis SNF Skilled Nursing Facility Subjective, Objective, Assessment, Plan, EKG Electrocardiogram SOAPE Education ENT Ear, Nose and Throat SOMS Strategic Offender Management System ER Emergency Room S/P Status post eUHR electronic Unit Health Record TB Tuberculosis FTF Face-to-Face TTA Triage and Treatment Area History and Physical (reception center H&P UA Urinalysis examination) HIM Health Information Management UM Utilization Management Kern Valley State Prison, Cycle 4 Medical Inspection Page 3 Office of the Inspector General State of California OBJECTIVES, SCOPE, AND METHODOLOGY In designing the medical inspection program, the OIG reviewed CCHCS policies and procedures, relevant court orders, and guidance developed by the American Correctional Association. The OIG also reviewed professional literature on correctional medical care; reviewed standardized performance measures used by the health care industry; consulted with clinical experts; and met with stakeholders from the court, the Receiver’s office, CDCR, the Office of the Attorney General, and the Prison Law Office to discuss the nature and scope of the OIG’s inspection program. With input from these stakeholders, the OIG developed a medical inspection program that evaluates medical care delivery by combining clinical case reviews of patient files, objective tests of compliance with policies and procedures, and an analysis of outcomes for certain population-based metrics. To maintain a metric-oriented inspection program that evaluates medical care delivery consistently at each State prison, the OIG identified 14 primary (clinical) and two secondary (administrative) quality indicators of health care to measure. The primary quality indicators cover clinical categories directly relating to the health care provided to patients, whereas the secondary quality indicators address the administrative functions that support a health care delivery system. The 14 primary quality indicators are Access to Care, Diagnostic Services, Emergency Services, Health Information Management (Medical Records), Health Care Environment, Inter- and Intra-System Transfers, Pharmacy and Medication Management, Prenatal and Post-Delivery Services, Preventive Services, Quality of Nursing Performance, Quality of Provider Performance, Reception Center Arrivals, Specialized Medical Housing (OHU, CTC, SNF, Hospice), and Specialty Services. The two secondary quality indicators are Internal Monitoring, Quality Improvement, and Administrative Operations; and Job Performance, Training, Licensing, and Certifications. The OIG rates each of the quality indicators applicable to the institution under inspection based on case reviews conducted by OIG clinicians and compliance tests conducted by OIG deputy inspectors general. The ratings may be derived from the case review results alone, the compliance test results alone, or a combination of both these information sources. For example, the ratings for the primary quality indicators Quality of Nursing Performance and Quality of Provider Performance are derived entirely from the case review results, while the ratings for the primary quality indicators Health Care Environment and Preventive Services are derived entirely from compliance test results. As another example, primary quality indicators such as Diagnostic Services and Specialty Services receive ratings derived from both sources. At KVSP, 14 of the quality indicators were applicable, consisting of 12 primary clinical indicators and two secondary administrative indicators. Of the 12 primary indicators, seven were rated by both case review clinicians and compliance inspectors, three were rated by case review clinicians only, and two were rated by compliance inspectors only; both secondary indicators were rated by compliance inspectors only. Kern Valley State Prison, Cycle 4 Medical Inspection Page 4 Office of the Inspector General State of California Consistent with the OIG’s agreement with the Receiver, this report only addresses the conditions found related to medical care criteria. The OIG does not review for efficiency and economy of operations. Moreover, if the OIG learns of an inmate-patient needing immediate care, the OIG notifies the chief executive officer of health care services and requests a status report. Additionally, if the OIG learns of significant departures from community standards, it may report such departures to the institution’s chief executive officer or to CCHCS. Because these matters involve confidential medical information protected by State and federal privacy laws, specific identifying details related to any such cases are not included in the OIG’s public report. In all areas, the OIG is alert for opportunities to make appropriate recommendations for improvement. Such opportunities may be present regardless of the score awarded to any particular quality indicator; therefore, recommendations for improvement should not necessarily be interpreted as indicative of deficient medical care delivery. Kern Valley State Prison, Cycle 4 Medical Inspection Page 5 Office of the Inspector General State of California CASE REVIEWS The OIG has added case reviews to the Cycle 4 medical inspections at the recommendation of its stakeholders. At the conclusion of Cycle 3, the federal Receiver and the Inspector General determined that the health care provided at the institutions was not fully evaluated by the compliance tool alone, and that the compliance tool was not designed to provide comprehensive qualitative assessments. Accordingly, the OIG added case reviews in which OIG physicians and nurses evaluate selected cases in detail to determine the overall quality of health care provided to the inmate-patients. The OIG’s clinicians perform a retrospective chart review of selected patient files to evaluate the care given by an institution’s primary care providers and nurses. Retrospective chart review is a well-established review process used by health care organizations that perform peer reviews and patient death reviews. Currently, CCHCS uses retrospective chart review as part of its death review process and in its pattern-of-practice reviews. CCHCS also uses a more limited form of retrospective chart review when performing appraisals of individual primary care providers. PATIENT SELECTION FOR RETROSPECTIVE CASE REVIEWS Because retrospective chart review is time consuming and requires qualified health care professionals to perform it, OIG clinicians must carefully sample patient records. Accordingly, the group of patients the OIG targeted for chart review carried the highest clinical risk and utilized the majority of medical services. A majority of the patients selected for retrospective chart review were classified by CCHCS as high-risk patients. The reason the OIG targeted these patients for review is twofold: 1. The goal of retrospective chart review is to evaluate all aspects of the health care system. Statewide, high-risk and high-utilization patients consume medical services at a disproportionate rate; 9 percent of the total patient population are considered high-risk and account for more than half of the institution’s pharmaceutical, specialty, community hospital, and emergency costs. 2. Selecting this target group for chart review provides a significantly greater opportunity to evaluate all the various aspects of the health care delivery system at an institution. Underlying the choice of high-risk patients for detailed case review are three assumptions: 1. If the institution is able to provide adequate clinical care to the most challenging patients with multiple complex and interdependent medical problems, it will be providing adequate care to patients with less complicated health care issues. Because clinical expertise is required to determine whether the institution has provided adequate clinical care, the OIG utilizes experienced correctional physicians and registered nurses to perform this analysis. 2. The health of less complex patients is more likely to be affected by processes such as timely appointment scheduling, medication management, routine health screening, and Kern Valley State Prison, Cycle 4 Medical Inspection Page 6 Office of the Inspector General State of California immunizations. To review these processes, the OIG simultaneously performs a broad compliance review. 3. Patient charts generated during death reviews, sentinel events (an unexpected occurrence involving death or serious injury, or risk thereof), and hospitalizations are mostly of high-risk patients. BENEFITS AND LIMITATIONS OF TARGETED SUBPOPULATION REVIEW Because the selected patients utilize the broadest range of services offered by the health care system, the OIG’s retrospective chart review provides adequate data for a qualitative assessment of the most vital system processes (referred to as “primary quality indicators”). Retrospective chart review provides an accurate qualitative assessment of the relevant primary quality indicators as applied to the targeted subpopulation of high-risk and high-utilization patients. While this targeted subpopulation does not represent the prison population as a whole, the ability of the institution to provide adequate care to this subpopulation is a crucial and vital indicator of how the institution provides health care to its whole patient population. Simply put, if the institution’s medical system does not adequately care for those patients needing the most care, then it is not fulfilling its obligations, even if it takes good care of patients with less complex medical needs. Since the targeted subpopulation does not represent the institution’s general prison population, the OIG cautions against inappropriate extrapolation of conclusions from the retrospective chart reviews to the general population. For example, if the high-risk diabetic patients reviewed have poorly-controlled diabetes, one cannot conclude that the entire diabetic population is inadequately controlled. Similarly, if the high-risk diabetic patients under review have poor outcomes and require significant specialty interventions, one cannot conclude that the entire diabetic population is having similarly poor outcomes. Nonetheless, the health care system’s response to this subpopulation can be accurately evaluated and yields valuable systems information. In the above example, if the health care system is providing appropriate diabetic monitoring, medication therapy, and specialty referrals for the high-risk patients reviewed, then it can be reasonably inferred that the health care system is also providing appropriate diabetic services to the entire diabetic subpopulation. However, if these same high-risk patients needing monitoring, medications, and referrals are generally not getting those services, it is likely that the health care system is not providing appropriate diabetic services to the greater diabetic subpopulation. CASE REVIEWS SAMPLED As indicated in Appendix B, Table B-4, KVSP Case Review Sample Summary, the OIG clinicians evaluated medical charts for 73 unique inmate-patients. Charts for 19 of those patients were reviewed by both nurses and physicians, for 92 reviews. Physicians performed detailed reviews of 30 charts, and nurses performed detailed reviews for 19 charts, totaling 49 detailed reviews. For Kern Valley State Prison, Cycle 4 Medical Inspection Page 7 Office of the Inspector General State of California detailed case reviews, the clinicians looked at all encounters occurring in approximately six months of medical care. Nurses also performed a limited or focused review of medical records for an additional 43 inmate-patients. These generated 1,173 clinical events for review (Appendix B, Table B-3: KVSP Event — Program). For 73 sampled patients reviewed (Appendix B, Table B-1: KVSP Sample Sets) and only six specific chronic care patient records sampled (three diabetes patients and three anticoagulation patients), the final samples included patients with 157 chronic care diagnoses (Appendix B, Table B-2: KVSP Chronic Care Diagnoses). In addition, even though the process selected only three patients with diabetes, the case reviews included a total of ten patients with diabetes; seven additional patients with diabetes were pulled from other sample requests. Many chronic care programs were evaluated with the OIG’s sample selection tool because the complex and high-risk patients selected from the different categories often had multiple medical problems. While not every chronic disease or health care staff member was evaluated, the overall operation of the institution’s system and staff were assessed for adequacy. The OIG’s case review methodology and sample size matched other qualitative research. The empirical findings, supported by expert statistical consultants, showed adequate conclusions after 10 to 15 charts had undergone full clinician review. In qualitative statistics, this phenomenon is known as “saturation.” The OIG asserts that the sample size of over 30 detailed reviews certainly far exceeds the saturation point necessary for an adequate qualitative review. With regard to reviewing charts from different providers, the case review is not intended to be a focused search for poorly performing providers; rather, it is focused on how the system cares for those patients who need the most care. Nonetheless, while not sampling cases by each provider at the institution, the OIG’s pilot inspections adequately reviewed most providers. Providers would only escape OIG case review if institutional management successfully mitigated patient risk by having the more poorly performing primary care providers care for the less complicated, low-utilizing, and lower-risk patients. The OIG’s clinicians concluded the sample size was adequate to assess the quality of services provided. Based on the collective results of clinicians’ case reviews, the OIG rated each quality indicator as either proficient (excellent), adequate (passing), inadequate (failing), or not applicable. A separate confidential KVSP Supplemental Medical Inspection Results: Individual Case Review Summaries report details the case reviews OIG clinicians conducted and is available to specific stakeholders. For further details regarding the sampling methodologies and counts, see Appendix B – Clinical Data, Table B-1; Table B-2; Table B-3; and Table B-4. Kern Valley State Prison, Cycle 4 Medical Inspection Page 8 Office of the Inspector General State of California COMPLIANCE TESTING SAMPLING METHODS FOR CONDUCTING COMPLIANCE TESTING From June to August 2015, deputy inspectors general attained answers to 92 objective medical inspection test (MIT) questions designed to assess the institution’s compliance with critical policies and procedures applicable to the delivery of medical care. To conduct most tests, inspectors randomly selected samples of inmate-patients for whom the testing objectives were applicable and reviewed their electronic unit health records. In some cases, inspectors used the same samples to conduct more than one test. In total, inspectors reviewed health records for 439 individual inmate-patients and analyzed specific transactions within their records for evidence that critical events occurred. Inspectors also reviewed management reports and meeting minutes to assess certain administrative operations. In addition, during the week of June 22, 2015, field inspectors conducted a detailed onsite inspection of KVSP’s medical facilities and clinics; interviewed key institutional employees; and reviewed employee records, logs, medical appeals, death reports, and other documents. This generated 1,254 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 KVSP’s plant infrastructure, protocols for tracking medical appeals and local operating procedures, and staffing resources. For details of the compliance results, see Appendix A — Compliance Test Results. For details of the OIG’s compliance sampling methodology, see Appendix C — Compliance Sampling Methodology. SCORING OF COMPLIANCE TESTING RESULTS The OIG rated the institution in the following nine primary (clinical) and two secondary (administrative) quality indicators applicable to the institution for compliance testing:  Primary indicators: Access to Care, Diagnostic Services, Health Information Management (medical records), Health Care Environment, Inter- and Intra-System Transfers, Pharmacy and Medication Management, Preventive Services, Specialized Medical Housing, and Specialty Services.  Secondary indicators: Internal Monitoring, Quality Improvement, and Administrative Operations; and Job Performance, Training, Licensing, and Certifications. After compiling the answers to the 92 questions, the OIG derived a score for each primary and secondary quality indicator identified above by calculating the percentage score of all Yes answers for each of the questions applicable to a particular indicator, then averaging those scores. Based on those results, the OIG assigned a rating to each quality indicator of proficient, adequate, or inadequate. Kern Valley State Prison, Cycle 4 Medical Inspection Page 9 Office of the Inspector General State of California DASHBOARD COMPARISONS For some of the individual compliance questions, the OIG identified where similar metrics were available within the CCHCS Dashboard. There is not complete parity between the metrics due to time frames when data was collected. As a result, there is some difference between the OIG’s findings and the Dashboard metrics. The OIG compared its compliance test results with the institution’s Dashboard results and reported on that comparative data under various applicable quality indicators within the Medical Inspection Results section of this report. OVERALL QUALITY INDICATOR RATING FOR CASE REVIEWS AND COMPLIANCE TESTING The OIG derived the final rating for each quality indicator by combining the ratings from the case reviews and from the compliance testing, as applicable. When combining these ratings, the case review evaluations and the compliance testing results usually agreed, but there were instances when the rating differed for a particular quality indicator. In those instances, the inspection team assessed the quality indicator based on the collective ratings from both components. Specifically, the OIG clinicians and deputy inspectors general discussed the nature of individual exceptions found within that indicator category and considered the overall effect on the ability of patients to receive adequate medical care. To derive an overall assessment rating for the institution’s medical inspection, the OIG evaluated the various rating categories assigned to each of the quality indicators applicable to the institution, giving more weight to the rating results for the primary quality indicators, which directly relate to the health care provided to inmate-patients. Based on that analysis, OIG experts made a considered and measured overall opinion about the quality of health care observed. POPULATION-BASED METRICS The OIG identified a subset of HEDIS measures applicable to the CDCR inmate-patient population. To identify outcomes for KVSP, the OIG reviewed some of the compliance testing results, randomly sampled additional inmate-patients’ records, and obtained KVSP data from the CCHCS Master Registry. The OIG compared those results to metrics reported by other State and federal agencies. Kern Valley State Prison, Cycle 4 Medical Inspection Page 10 Office of the Inspector General State of California MEDICAL INSPECTION RESULTS PRIMARY (CLINICAL) QUALITY INDICATORS OF HEALTH CARE The primary quality indicators assess the clinical aspects of health care. As shown on the Health Care Quality Indicators table on page ii of this report, 12 of the OIG’s primary indicators were applicable to KVSP. Of those 12 indicators, seven were rated by both the case review and compliance components of the inspection, three were rated by the case review component alone, and two were rated by the compliance component alone. Summary of Case Review Results: The clinical case review component assessed 10 of the 12 primary (clinical) indicators applicable to KVSP. Among these ten indicators, one was proficient, eight were adequate, and one was inadequate. Clinicians reviewed 30 cases, rating the adequacy of care for each case. Among these 30 cases, one was proficient, 24 were adequate, and five were inadequate. For the 1,173 events reviewed, there were 381 deficiencies, of which the reviewers determined 22 to be of such magnitude that, if left unaddressed, they would likely contribute to patient harm. Adverse Events Identified During Case Review: Medical care is a complex dynamic process, and subject to human error even within the best health care organizations. Adverse events are typically identified and tracked by all major health care organizations for the purpose of quality improvement. They are not generally representative of medical care delivered by the organization. The OIG identified adverse events for the dual purposes of quality improvement and the illustration of problematic patterns of practice found during the inspection. Because of the anecdotal description of these events, the OIG cautions against drawing inappropriate conclusions regarding the institution based solely on adverse events. There was one adverse event identified in the case reviews, but it was not reflective of the overall medical care provided at KVSP. In case 13, the provider treated a patient with anticoagulation for a deep vein thrombosis (blood clot). The laboratory coagulation test (INR) was slightly low at 1.8. The provider inappropriately increased the anticoagulation medication (warfarin) by 45 percent, instead of the 10 percent guideline-recommended increase. Though not causing harm in this case, there was a significant risk for serious bleeding complications. Compliance Results: The compliance component assessed 9 of the 12 primary (clinical) indicators applicable to KVSP. The results of those assessments are summarized within this section of the report. The test questions used to assess compliance for each indicator are detailed in Appendix A. Kern Valley State Prison, Cycle 4 Medical Inspection Page 11 Office of the Inspector General State of California ACCESS TO CARE This indicator evaluates the institution’s ability to provide Case Review Rating: inmate-patients with timely clinical appointments. Areas specific to Adequate inmate-patients’ access to care are reviewed, such as initial Compliance Score: assessments of newly arriving inmates, acute and chronic care 93.3% follow-ups, face-to-face nurse appointments when an inmate-patient Overall Rating: requests to be seen, provider referrals from nursing lines, and Proficient follow-ups after hospitalization or specialty care. Compliance testing for this indicator also evaluates whether inmate-patients have Health Care Services Request forms (CDCR Form 7362) available in their housing units. For this indicator, the OIG case review and compliance review processes yielded different results, with the case review giving an adequate rating and the compliance review resulting in a proficient score. The OIG’s internal review process considered the factors leading to both scores and ultimately rated this indicator proficient. First, the institution scored high in the compliance test area; second, the identified case review deficiencies were minor in nature and unlikely to contribute to patient harm. As a result, the compliance testing results were deemed a more accurate reflection of the appropriate overall rating. Case Review Results The Office of the Inspector General clinicians reviewed 1,167 provider and nursing encounters and found 28 deficiencies related to Access to Care. All the deficiencies were minor. There were deficiency patterns identified in timeliness of nurse-to-provider sick call referrals, delays in urgent or emergent responses, and delays in patient transporting. The case review rating for Access to Care was adequate. Provider Follow-up Appointments The providers generally saw patients timely, as requested. Chronic care visits were timely scheduled. There were no deficiencies in provider follow-up appointments. RN-to-Provider Referrals Nurses performing sick call assessments are required to refer the patient to a provider when a situation arises that requires a higher level of evaluation and care. There were 248 outpatient nursing encounters reviewed, and only ten were identified where the provider appointment did not occur timely. Several referrals to the provider were not completed in a timely manner.  In case 4, the nurse assessed the patient for a sick call request for painful sores in his mouth. The nurse noted white lesions in the patient’s mouth on his cheeks and tongue. The nurse Kern Valley State Prison, Cycle 4 Medical Inspection Page 12 Office of the Inspector General State of California noted possible thrush and made a referral for a provider visit within one week. The follow-up visit occurred beyond the requested time frame.  In case 51, the patient was seen in the clinic for a complaint of a rash on his inner thigh. The nurse assessed the patient, consulted the provider, and obtained medication orders to treat the patient’s skin condition. The 14-day provider follow-up did not occur.  In case 53, the patient was seen in the clinic for a complaint of right leg pain and difficulty sleeping. The nurse assessed the patient using the sick call protocol. The nurse also documented that a referral to the provider was required. The follow-up appointment did not occur.  In case 57, the patient was seen in the clinic for a complaint of a “bump that hurts” on his upper back that was growing in size. The nurse assessed the patient, provided education, and discussed the upcoming appointment with the PCP scheduled for four days later. The appointment did not occur until nine days later.  In case 62, the patient was seen in the clinic for the complaint of multiple dark spots on his skin that “might be melanoma,” and the patient requested to see a specialist. The nurse assessed the patient, provided patient education, and made a routine referral for a physician’s further evaluation. The 14-day follow-up visit did not occur.  In case 40, the nurse referred to the provider a patient with severe abdominal pain and foot fungus. The 14-day follow-up appointment did not occur.  In case 58, the patient was seen for stomach bloating. The 14-day provider follow-up did not occur until one month later. Provider Follow-up After Specialty Service Providers generally saw their patients to follow up on specialty services. There were no significant delays. Intra-System Transfer All 14 patients who transferred into KVSP and who were referred by the nurse to the provider were seen timely. Follow-up After Hospitalization Fifty-three hospital or outside emergency department events were reviewed. The provider timely saw all patients after they returned from the higher level of care. Kern Valley State Prison, Cycle 4 Medical Inspection Page 13 Office of the Inspector General State of California Urgent and Emergent Care A provider generally saw patients timely after they were evaluated in the triage and treatment area (TTA). Among 64 urgent and emergent encounters reviewed, there were two deficiencies:  In case 28, the emergency medical service ambulance waited 22 minutes for the custody transportation team to arrive before transporting the “Code 3” patient with abdominal pain and possible drug intoxication to the outside emergency department.  In case 29, the patient was seen in the TTA for chest pain. There was a 41-minute delay from the time the patient was brought to the TTA until notification of the on-call provider. Specialized Medical Housing The provider saw patients in the correctional treatment center (CTC) appropriately and within the appropriate number of days per policy. No deficiencies were identified. Clinician Onsite Inspection The OIG clinicians interviewed KVSP staff regarding issues with access to care for patients. KVSP staff reported that patients who constantly refused to see the doctor for a follow-up visit ended up in the RN line to receive counseling. This added additional workload to an already fully scheduled RN line. Compliance Testing Results The institution received a compliance score of 93.3 percent in the Access to Care indicator, scoring proficient in seven of the nine areas tested, including three scores of 100 percent, as described below:  Inmates had access to Health Care Services Request forms (CDCR Form 7362) at all six housing units inspected, receiving a score of 100 percent for this test (MIT 1.101).  Inspectors sampled 35 service requests submitted by inmate-patients across all facility clinics. As documented on the CDCR Form 7362, in all cases, nursing staff reviewed the request form on the same day it was received (MIT 1.003). Also, nursing staff completed a face-to-face encounter with each inmate-patient within one business day of reviewing (or receiving) the request for 33 patients (94 percent). For the remaining two samples, the face-to-face encounters were insufficiently documented because the CDCR Form 7362 instructed the reader to “See Nursing Encounter Form,” which inspectors were not able to locate in the eUHR (MIT 1.004). Kern Valley State Prison, Cycle 4 Medical Inspection Page 14 Office of the Inspector General State of California  All five of the inmate-patients sampled who were referred to and seen by a PCP and for whom the PCP determined a follow-up appointment was necessary received a timely follow-up visit within the PCP’s ordered time frame (MIT 1.006).  Of the 30 sampled inmate-patients who had been discharged from a community hospital, 29 (97 percent) either received a timely follow-up appointment with a PCP or refused the follow-up visit. The remaining patient received a PCP follow-up appointment, but the related progress notes were unclear as to whether the provider was aware of the patient’s recent hospital stay (MIT 1.007).  Inspectors sampled 30 inmate-patients who had received a specialty service; 28 of them (93 percent) either received a timely follow-up appointment with a PCP or refused the follow-up visit, and health care staff timely documented the patient’s refusal. For two remaining patients, both of whom had received high-priority specialty services, their follow-up visits were 22 and 30 days late (MIT 1.008).  Twenty of the 22 inmate-patients sampled who transferred into KVSP from another institution and were referred to a PCP for a routine appointment based on nursing staff’s initial health care screening (91 percent) were seen timely. For one patient, the appointment was held 22 days late, and for another, 34 days late (MIT 1.002). The institution scored within the adequate range for the following two tests:  The OIG sampled 13 Health Care Service Request forms (CDCR Form 7362) where nursing staff referred the inmate-patient for a PCP appointment. Eleven of the patients (85 percent) received a timely appointment. For one patient, the nurse indicated an urgent appointment was needed and scheduled the appointment for the next day; however, due to a yard transfer, the patient was not seen until eight days later after having completed a third Form 7362. For a second patient, the nurse indicated contradictory information on the form, both checking the emergency appointment box and indicating the patient should return to the clinic as needed (MIT 1.005).  When the OIG reviewed recent appointments for 30 inmate-patients with chronic care conditions, 24 of the patients (80 percent) received timely appointments. For five patients, the appointments occurred between five days late and over four months late; for the sixth exception, inspectors could not find evidence of a chronic care appointment in the eUHR (MIT 1.001). Kern Valley State Prison, Cycle 4 Medical Inspection Page 15 Office of the Inspector General State of California CCHCS Dashboard Comparative Data The Dashboard uses the average of various medical access measure indicators to calculate the score for Scheduling & Access to Care: Medical Services. The OIG compared similar KVSP compliance scores with that Dashboard average score. As indicated in the table below, the OIG test results were based on a review of current documents as well as documents from the preceding 11 months; KVSP’s July Dashboard data reflected only the institution’s June 2015 results. Nevertheless, the OIG and Dashboard results were consistent and within the proficient range. Access to Care — KVSP Dashboard and OIG Compliance Results KVSP DASHBOARD RESULTS OIG COMPLIANCE RESULTS Access to Care (1.001, 1.004, 1.005, 1.007) Scheduling & Access to Care: Diagnostic Services (2.001, 2.004) Medical Services Specialty Services (14.001, 14.003) July 2015 July 2014 – June 2015 95% 92% Note: The CCHCS Dashboard data includes access to care for inmate-patients returning from CDCR inpatient housing units and emergency departments. The OIG does not specifically test follow-up appointments for these patients. Recommendations No specific recommendations. Kern Valley State Prison, Cycle 4 Medical Inspection Page 16 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 inmate-patients, whether the Compliance Score: primary care provider (PCP) timely reviewed the results, and 61.1% whether the results were communicated to the inmate-patient within the required time frames. In addition, for pathology Overall Rating: Adequate services, the OIG determines whether the institution received a final pathology report and whether the PCP timely reviewed and communicated the pathology results to the patient. The case reviews also factor in the appropriateness, accuracy, and quality of the diagnostic test(s) ordered and the clinical response to the results. For this indicator, the OIG’s case review and compliance review processes yielded different results, with the case review giving an adequate rating and the compliance review resulting in an inadequate score. The OIG’s internal review process considered those factors that led to both scores and ultimately rated this indicator adequate. The key factors were that the OIG’s case review showed that improperly processed laboratory orders and failures to retrieve diagnostic reports were infrequent and did not significantly affect patient care. As a result, the case review testing results were deemed a more accurate reflection of the appropriate overall rating. Case Review Results The OIG clinicians reviewed 146 diagnostic related events and found 35 deficiencies. Of those 35 deficiencies, 27 were related to health information management. Most other reviewed tests were performed as ordered, reviewed timely by providers, and relayed quickly to patients. Most laboratory tests, x-rays, and electrocardiograms (EKGs) were performed timely when ordered by a provider; however, diagnostic tests were not done as requested in the following cases:  Staff failed to perform urinalyses in cases 1 and 5.  Staff failed to perform blood tests in cases 14, 15, and 16. There was a delay in the following case:  In case 13, two ordered blood coagulation tests (INRs) were drawn two and three days late. Health information management also contributed to deficiencies in this indicator. In case 13, diagnostic reports were not retrieved or scanned into eUHR.  In cases 1, 4, 16, 17, 18, 21, 22, 26, 29, 68, 70, and 72, diagnostic reports were not appropriately signed or dated by a provider before scanning. Kern Valley State Prison, Cycle 4 Medical Inspection Page 17 Office of the Inspector General State of California  In case 21, there was delay in the provider review of diagnostic reports. The OIG’s case review resulted in an adequate rating for Diagnostic Services at KVSP since the improperly processed laboratory orders and failures to retrieve diagnostic reports were infrequent and did not significantly affect patient care. Compliance Testing Results The institution received an inadequate compliance score of 61.1 percent in the Diagnostic Services indicator, which encompasses radiology, laboratory, and pathology services. For clarity, each type of diagnostic service is discussed separately below: Radiology Services  For all ten of the radiology services sampled, the services were timely performed and the diagnostic report results were timely communicated to the inmate-patients (MIT 2.001, 2.003). However, providers only properly evidenced their review of the radiology results for two of the ten patients reviewed (20 percent) (MIT 2.002). Laboratory Services  Laboratory services were completed within the time frame specified in the provider’s order for eight of ten patients sampled (80 percent). Two patients’ laboratory services were received 22 and 55 days late (MIT 2.004). However, providers properly evidenced their review of the laboratory test results for only five of those ten patients (50 percent) (MIT 2.005).  Providers timely communicated the test results to nine of the ten sampled patients (90 percent). For one patient, inspectors did not find evidence in the eUHR that the patient received any notification of the test results (MIT 2.006). Pathology Services  With regard to providers’ review and communication of pathology results, the institution scored poorly. Some providers did not document evidence of their review on the final report. As a result, KVSP scored zero on this test (MIT 2.008). Further, providers communicated pathology results timely to only two of the ten inmate-patients who received the service (20 percent). For eight patients, the provider did not discuss the final pathology results with the patient within two business days of receipt of the final diagnostic test results. The providers communicated the results between 5 and 58 days late (MIT 2.009). However, for nine of ten pathology services sampled (90 percent), the institution did receive the final diagnostic reports timely. Only one pathology report was received late, which was late by 15 days (MIT 2.007). Kern Valley State Prison, Cycle 4 Medical Inspection Page 18 Office of the Inspector General State of California Recommendations To improve the diagnostic management process, the OIG recommends that KVSP implement a tracking system to monitor diagnostic services from the time they are ordered to the time they are completed. Kern Valley State Prison, Cycle 4 Medical Inspection Page 19 Office of the Inspector General State of California EMERGENCY SERVICES An emergency medical response system is essential to providing Case Review Rating: effective and timely emergency medical response, assessment, Adequate treatment, and transportation 24 hours per day. Provision of Compliance Score: urgent/emergent care is based on a patient’s emergency situation, Not Applicable clinical condition, and need for a higher level of care. The OIG reviews emergency response services including first aid, basic life Overall Rating: Adequate support (BLS), and advanced cardiac life support (ACLS) consistent with the American Heart Association guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiovascular care, and the provision of services by knowledgeable staff appropriate to each individual’s training, certification, and authorized scope of practice. The OIG evaluates this quality indicator entirely through clinicians’ reviews of case files and conducts no separate compliance testing element. Case Review Results The OIG clinicians reviewed 64 triage and treatment area (TTA) urgent and emergent events and found 31 deficiencies, mainly in nursing care. These minor deficiencies did not significantly affect patient care. In general, KVSP performed well with emergency response times, BLS care (one BLS event occurred during the review), and 9-1-1 activation times. Even with the deficiencies noted, the case reviews showed that patients requiring urgent or emergent services received timely and adequate care in the majority of cases. Provider Performance The TTA providers generally evaluated patients timely and made adequate assessments. Triage decisions were sound, and patients were transferred to the appropriate levels of care. The quality of provider care in emergency services was adequate. The OIG identified only two deficiencies:  In case 30, the patient was unconscious with a presumptive diagnosis of grand mal seizure. The provider failed to order a blood glucose test to check for hypoglycemia. There was no documentation of the type of intravenous fluid given. There was no documentation of the phone call with the provider for this emergency event.  In case 32, the provider failed to obtain an EKG and a finger-stick glucose level to evaluate a patient with loss of consciousness possibly due to arrhythmia and hypoglycemia. Kern Valley State Prison, Cycle 4 Medical Inspection Page 20 Office of the Inspector General State of California Nursing Performance Emergency Services nursing deficiencies often related to inadequate documentation. Nursing documentation entries must be accurate, valid, complete, truthful, dated, timed, and legible, and they must contain standardized terminology. One of the essential principles of basic nursing practice is that anything not documented is considered not done. Based on these important standards, some TTA nursing documentation was incomplete, disorganized, and illegible. The OIG nurse reviewers identified 23 emergency nursing encounters with 14 minor nursing deficiencies. The following cases demonstrated areas for improvement, primarily related to incomplete or inaccurate documentation:  In case 1, the patient complained of pain in his kidneys. The LVN checked the patient’s vital signs and called the TTA nurse to report the pain and an elevated blood pressure of 171/100. The TTA nurse declined to assess the patient, stating that the patient was seen that morning in the nursing line. The clinic nurse advised the LVN to add the patient to the list for the following day’s nursing line.  In case 2, a nurse saw a patient in the clinic for coughing, red throat, labored breathing, and wheezing. The clinic nurse called the provider, who ordered the patient be sent to the TTA for further evaluation and treatment by the TTA provider. While the patient was in the TTA, the TTA nurse failed to document the assessment or treatment plan for the patient, and only recorded a set of vital signs.  In case 69, a patient with chest pain was in the TTA for almost two hours. An EKG was not done. The pain assessment and documentation was incomplete (did not include the severity of pain, quality of pain, radiation of pain, what made it better or worse, accompanying symptoms, past history, etc.). Vital signs were not taken, and the nurse did not listen to the lungs nor document the patient’s skin color or the presence or absence of sweating.  In case 72, there was inconsistent documentation of the amount of oxygen given to the patient. On one section of the document, it was written as 10 liters per minute of oxygen. However, on the summary, it was written as only 5 liters per minute. In the same case, there was no record of whether the “NOW” order of 60 mg of prednisone was administered prior to discharging the patient from the TTA. Staff also failed to use a wheelchair to transport this patient with shortness of breath to the TTA and instead allowed him to walk. Staff delayed calling 9-1-1 for the following two cases:  In case 26, the nurse did not administer naloxone (antidote medication for a narcotics overdose) to an unresponsive patient per the CCHCS nursing protocol and did not call 9-1-1 until approximately 24 minutes after staff initiated BLS. Progress notes from the nurses and the provider had time discrepancies. Nursing staff did not properly document the oxygen rate. Kern Valley State Prison, Cycle 4 Medical Inspection Page 21 Office of the Inspector General State of California  In case 24, custody staff found the patient unresponsive and appropriately initiated BLS, but there was an 11-minute delay in calling 9-1-1. Onsite Clinician Inspection During the onsite visit, the TTA had ample space for patient evaluation and working areas for both nurses and providers. It also had adequate lighting and was appropriately stocked with medications and medical equipment, such as an automated external defibrillator and an emergency crash cart. KVSP maintained patients’ privacy at all times when a patient received a medical examination. Recommendations  The OIG recommends that KVSP develop TTA-specific nursing expectations and ensure all nurses are trained.  The OIG recommends that the EMRRC review all emergency responses where staff performed CPR and specifically determine whether 9-1-1 was called at the first opportunity. When the committee identifies delays in calling 9-1-1, the OIG recommends the responding staff members receive additional training. Kern Valley State Prison, Cycle 4 Medical Inspection Page 22 Office of the Inspector General State of California HEALTH INFORMATION MANAGEMENT (MEDICAL RECORDS) Health information management is a crucial link in the delivery of Case Review Rating: medical care. Medical personnel require accurate information in Inadequate order to make sound judgments and decisions. This indicator Compliance Score: examines whether the institution adequately manages its health care 65.7% information. This includes determining whether the information is correctly labeled and organized and available in the electronic unit Overall Rating: Inadequate health record (eUHR); whether the various medical records (internal and external, e.g., hospital and specialty reports and progress notes) are obtained and scanned timely into the inmate-patient’s eUHR; whether records routed to clinicians include legible signatures or stamps; and whether hospital discharge reports include key elements and are timely reviewed by providers. Case Review Results The OIG clinicians identified 100 deficiencies related to Health Information Management, and rated the indicator inadequate. Hospital Records  Most hospital records were retrieved, reviewed, and scanned into the eUHR. However, there were some significant deficiencies. The most severe deficiency occurred when OIG clinicians could not find the hospital records (specifically a discharge summary) in the eUHR for case 20. These types of records contain the most vital information for the continuity of care between the inpatient and outpatient settings.  Providers did not properly initial many hospital discharge summaries to indicate that they reviewed the information. This deficiency occurred in cases 24, 25, 26, 28, 29, 31, and 32. Missing Documents (Progress Notes and Forms)  Most nursing and provider progress notes were scanned into the eUHR; however, in cases 2, 3, 4, 29, 30, 31, and 68, progress notes were missing. In case 30, there was no corresponding note on the phone call with the provider documenting decision-making for an emergency event.  Missing documents were identified in cases 40, 42, 53, 56, 57, 66, 69, and 72. In case 72, a nurse documented the patient refused nebulizer treatment; however, there was no refusal form on file. Kern Valley State Prison, Cycle 4 Medical Inspection Page 23 Office of the Inspector General State of California Scanning Performance Mislabeled or misfiled documents were identified in cases 1, 3, and 65. These errors can greatly hinder the ability to find relevant clinical information. In case 3, a provider progress note for a different patient was found in the eUHR. Specialty Services Reports  Most specialty reports were processed without any significant problems. However, deficiencies in the processing of specialty reports occurred frequently. In 13 cases, specialty reports were not properly signed by a provider.  The specialty report was not scanned into the eUHR in case 18. Diagnostic Reports There were significant problems in the retrieval and review of diagnostic reports. These findings are discussed in detail in the Diagnostic Services section. Legibility Illegible progress notes, signatures, or initials were found from both nurses and providers. Illegible progress notes pose a significant medical risk to patients, especially when the medical care must be reviewed by other staff, or when there is a transfer of care to another team. Compliance Testing Results The institution received an inadequate compliance score of 65.7 percent in the Health Information Management (Medical Records) indicator, and improvements could be made in the following areas:  The institution scored zero in its labeling and filing of documents scanned into inmate-patients’ electronic Unit Health Records (eUHRs). The most common errors were various health care documents labeled with an incorrect document type, and missing documents (MIT 4.006).  The OIG also tested specialty services reports and MARs to determine if the institution timely scanned the documents into the eUHR. Only 11 of the 20 sampled specialty reports (55 percent) and 12 of the 20 sampled MARs (60 percent) were timely scanned. Nine specialty reports were scanned one to three days late, and eight MARs were scanned from one to four days late (MIT 4.003, 4.005).  The OIG reviewed community hospital discharge reports and treatment records for 30 sampled inmate-patients who the institution sent to an outside hospital. For 23 of the 30 patients (77 percent), the discharge summary reports were complete and timely reviewed by Kern Valley State Prison, Cycle 4 Medical Inspection Page 24 Office of the Inspector General State of California KVSP providers. For five patients, KVSP providers reviewed the hospital discharge summary reports one to two days late. For two other patients, there was no evidence that a KVSP provider reviewed the discharge report at all. For one of those two patients, the discharge report was missing key information and there was no evidence that KVSP followed-up with the hospital to obtain it (MIT 4.008).  Only 25 of 32 samples of various medical documents (78 percent), such as hospital discharge reports, initial health screening forms, keep-on-person (KOP) MARs, and specialty service reports showed compliance with clinical staff having legibly documented their names on the forms. Six of the seven noted exceptions related to nurses who did not legibly sign KOP MARs. There was also one instance where a provider did not legibly sign a hospital discharge report (MIT 4.007). The institution performed well in its scanning of the following health care documents:  The institution’s medical records staff timely scanned miscellaneous documents, such as non-dictated providers’ progress notes, initial health screening forms, and patients’ requests for health care services. Specifically, 19 of the 20 documents sampled (95 percent) were timely scanned into the patient’s eUHR within three calendar days of the inmate-patient’s encounter. For one patient, a provider’s progress note was scanned only one day late (MIT 4.001).  The institution also timely scanned community hospital discharge reports or treatment records into inmate-patients’ eUHRs. Nineteen of 20 documents sampled (95 percent) were timely scanned within three calendar days of the hospital discharge. For one patient, the hospital discharge summary was scanned just one day late (MIT 4.004). CCHCS Dashboard Comparative Data As indicated on the following page, for three applicable comparative measures, the OIG’s compliance results for KVSP were inconsistent with the July 2015 KVSP Dashboard results. The OIG test results were based on a review of current documents as well as documents from the preceding nine months; KVSP’s July Dashboard data reflected only the institution’s June 2015 results. Given these disparate time frames, KVSP’s Dashboard results were slightly lower than the OIG’s results for non-dictated medical documents and community hospital documents. Conversely, for specialty documents, KVSP Dashboard results were much higher than the OIG’s results. For dictated documents, the OIG did not identify any comparable documents during the sample test period from which to make a comparison. Kern Valley State Prison, Cycle 4 Medical Inspection Page 25 Office of the Inspector General State of California Health Information Management — KVSP Dashboard and OIG Compliance Results KVSP DASHBOARD RESULTS OIG COMPLIANCE RESULTS Availability of Health Information: Health Information Management (4.001) Non-Dictated Medical Documents Non-Dictated Medical Documents July 2015 September 2014–June 2015 87% 95% Note: The Dashboard results were obtained from the Non-Dictated Documents Drilldown data for “Medical Documents 3 Days.” KVSP DASHBOARD RESULTS OIG COMPLIANCE RESULTS Availability of Health Information: Health Information Management (4.003) Specialty Notes Specialty Documents July 2015 October 2014–March 2015 89% 55% Note: The Dashboard measure includes specialty notes from dental, optometry, and physical therapy appointments, which the OIG omits from its sample. KVSP DASHBOARD RESULTS OIG COMPLIANCE RESULTS Availability of Health Information: Health Information Management (4.004) Community Hospital Records Community Hospital Discharge Documents July 2015 (November 2014 – April 2015) 88% 95% Recommendation The OIG recommends that all clinical staff, particularly providers who sign reports and nurses who sign KOP MAR documents, demonstrate that they timely reviewed documents by consistently and legibly signing (or initialing) and dating medical records. The OIG also recommends that health care management consider requiring clinical staff to utilize name stamps and encouraging the use of dictation. Kern Valley State Prison, Cycle 4 Medical Inspection Page 26 Office of the Inspector General State of California HEALTH CARE ENVIRONMENT This indicator addresses the general operational aspects of the Case Review Rating: institution’s clinics, including certain elements of infection control Not Applicable and sanitation, medical supplies and equipment management, the Compliance Score: availability of both auditory and visual privacy for inmate-patient 86.8% visits, and the sufficiency of facility infrastructure to conduct comprehensive medical examinations. Rating of this component is Overall Rating: Proficient based entirely on the compliance testing results from the visual observations inspectors make at the institution during their onsite visit. Clinician Comments Although OIG clinicians did not rate the Health Care Environment at KVSP, they obtained the following information during their onsite visit:  KVSP medical clinics generally had adequate space to provide patient care with auditory and visual privacy. The clinics also had ample lighting and were well stocked with medications and medical equipment. However, visual privacy was lacking in the administrative segregation housing unit exam room because two glass windows were not covered.  The TTA had adequate space for patient evaluation with working areas for both nurses and providers. The TTA had ample lighting and was well stocked with medications and medical equipment, such as an automated external defibrillator and an emergency crash cart.  Providers led morning huddles, attendance of which included clinic and medication nurses, custody staff, and office technicians. These meetings were productive, and staff discussed pertinent matters related to nurse and provider lines as well as any custody issues related to access to care. Compliance Testing Results The institution scored well in the Health Care Environment indicator, with a compliance score of 86.8 percent. The institution performed at a proficient level in the following areas:  All 11 clinics were appropriately disinfected, cleaned, and sanitary. In addition, cleaning logs were present and properly completed, indicating that the clinic rooms were cleaned as scheduled (MIT 5.101). Kern Valley State Prison, Cycle 4 Medical Inspection Page 27 Office of the Inspector General State of California  Health care staff in all 11 clinics followed proper sanitation protocols at the start of each shift and changed the exam table paper between inmate-patient encounters, when required (MIT 5.102).  Inspectors examined KVSP’s 11 clinics to verify that adequate hygiene supplies were available and sinks were operable; all clinics were compliant (MIT 5.103).  Inspectors observed ten applicable clinics’ inmate-patient clinician encounters; clinicians followed good hand hygiene practices in all instances (MIT 5.104).  The non-clinic medical storage area, located in KVSP’s main medical storage warehouse, generally met the supply management process and support needs of the medical health care program. The institution scored 100 percent for this test (MIT 5.106).  All 11 clinics inspected followed adequate medical supply storage and management protocols in their clinical areas (MIT 5.107).  For each of nine different clinical areas, inspectors examined one emergency response bag to verify that it contained all essential items and that institutional staff were inspecting the bag daily and inventorying it monthly. KVSP’s emergency response bags were compliant in all nine clinics inspected (MIT 5. 111). The institution performed at an adequate level in the following area:  The clinic common areas generally had an adequate environment conducive to providing medical services; however, opportunities for improvement were revealed. While 9 of 11 clinics received adequate scores (82 percent), two clinics (A Yard and C Yard) lacked adequate auditory privacy for inmate-patients seen in the clinics’ common hallways during the initial triage interview, blood drawing, and vital sign encounters (Figure 1) Figure 1: A Yard Clinic, Triage Area (Nurses triage patients in verbal range of other waiting (MIT 5.109). patients) Kern Valley State Prison, Cycle 4 Medical Inspection Page 28 Office of the Inspector General State of California While KVSP generally performed well in the Health Care Environment indicator, inspectors deemed some areas inadequate and needing improvement.  When inspecting for proper protocols to mitigate exposure to blood-borne pathogens and contaminated waste, only 6 of 11 clinics were acceptable. The institution received a score of only 55 percent on this test because five clinics had one or more exam rooms that lacked a sharps container (MIT 5.105).  The OIG inspected various exam rooms in each of KVSP’s 11 clinics, observing patient Figure 2: A Yard Clinic, PCP Room (Leg extender under counter top) encounters and interviewing clinical staff, to determine if appropriate space, configuration, supplies, and equipment allowed clinicians to perform a proper clinical exam. The exam rooms or treatment spaces in only 6 of the 11 clinics (55 percent) were sufficient. Five clinics had exam areas that were unacceptable for a variety of reasons. For example, five of the clinics had exam tables not properly situated in the exam room to provide unimpeded access to clinicians and inmate-patients (Figures 2 through 5). Figure 3: Administrative Segregation B1 Unit Clinic (Exam table used as storage area) Figure 4: B Yard Clinic, PCP Exam Room Figure 5: R&R Clinic, Exam Room (Leg extender blocking doorway & no exam table (Non-essential items in exam room and exam table paper) used as a storage area) Kern Valley State Prison, Cycle 4 Medical Inspection Page 29 Office of the Inspector General State of California The OIG also had concerns about inmate-patient privacy in the R&R clinic. Specifically, inspectors observed during R&R triage interviews that the inmate-patient sat in a common area hallway chair located outside of the room where the triaging nurse sat (Figure 6) (MIT 5.110).  Only seven of 11 clinics inspected (64 percent) met the OIG’s compliance requirements Figure 6: R&R Clinic, Triage conducted in hallway outside nurse’s station for essential core medical equipment and supplies. Four clinics had common areas or exam rooms that were missing equipment or supplies necessary to conduct a comprehensive exam. Deficiencies consisted of three clinics with a weight scale present but that had no evidence of current calibration; one clinic without an established distance marker on the floor for its Snellen vision chart; and the R&R clinic missing a nebulization unit, oto-ophthalmoscope, and disposable paper for its exam table (MIT 5.108). Other Information Obtained from Non-Scored Results The OIG gathered information to determine if the institution’s physical infrastructure is maintained in a manner that supports health care management’s ability to provide timely or adequate health care. The OIG does not score this question. When OIG inspectors interviewed KVSP’s health care management and asked if all clinical areas had physical plant infrastructures sufficient to provide adequate health care services, management indicated there were no issues preventing the institution from providing adequate health care. The institution had the following projects planned for construction in mid-2016 (MIT 5.999):  Project A – Health Care Facility Improvement Program (HCFIP) Phase I (Statewide Medication Distribution Project). The construction was in progress at the time of the inspection and on target with the proposed timelines.  Project B – HCFIP Phase II. Building for this phase is proposed to start in May 2016. Pre-work had started and was on schedule at the time of the OIG’s inspection. Kern Valley State Prison, Cycle 4 Medical Inspection Page 30 Office of the Inspector General State of California Recommendations  The OIG recommends clinical staff ensure that clinic common areas and exam areas maintain auditory privacy for inmate-patients being examined or triaged in those areas, and that exam tables are properly situated in the exam rooms so that clinicians have unimpeded access to patients.  The OIG recommends that all clinics have a full complement of core items that includes a nebulization unit, disposable paper for the exam table, and a Snellen chart line marker on the floor, and that all clinic exam rooms have a sharps container. Kern Valley State Prison, Cycle 4 Medical Inspection Page 31 Office of the Inspector General State of California INTER- AND INTRA-SYSTEM TRANSFERS This indicator focuses on the management of inmate-patients’ Case Review Rating: medical needs and continuity of patient care during the inter- and Adequate intra-facility transfer process. The patients reviewed for Inter- and Compliance Score: Intra-System Transfers include inmates received from other CDCR 74.7% facilities and inmates transferring out of KVSP to another CDCR Overall Rating: facility. The OIG review includes evaluation of the institution’s Adequate ability to provide and document health screening assessments, initiation of relevant referrals based on patient needs, and the continuity of medication delivery to patients arriving from another institution. For those patients, the OIG clinicians also review the timely completion of pending health appointments, tests, and requests for specialty services. For inmate-patients who transfer out of the facility, the OIG evaluates the ability of the institution to document transfer information that includes pre-existing health conditions, pending appointments, tests and requests for specialty services, medication transfer packages, and medication administration prior to transfer. The OIG clinicians also evaluate the care provided to patients returning to the institution from an outside hospital and check to ensure appropriate implementation of the hospital assessment and treatment plans. For this indicator, the OIG’s case review and compliance review processes yielded different results, with the case review giving an adequate rating and the compliance review resulting in an inadequate score. The OIG’s internal review process considered the factors leading to both scores and ultimately rated this indicator adequate. First, the OIG’s case review showed most deficiencies were minor; second, the compliance score of 74.7 percent was very close to the adequate range. Case Review Results The OIG clinicians reviewed 23 encounters related to Inter- and Intra-System Transfers, including information from both the sending and receiving institutions. Nine encounters were reviewed for inmates transferring out of KVSP to other institutions, and 14 were reviewed for inmates transferring into KVSP from other institutions. In addition, the OIG reviewed 53 hospitalization events, the majority of which resulted in transfers back to the institution. In general, the Inter- and Intra-System Transfers processes at KVSP were adequate, with the majority of transferring inmates receiving timely continuity of health care services. There were 24 minor deficiencies related to delays in appointment scheduling, missed medication doses, and incomplete nursing documentation. Specific examples of case review findings are listed below. Kern Valley State Prison, Cycle 4 Medical Inspection Page 32 Office of the Inspector General State of California Transfers in from Other CDCR Institutions or Intra-Facility (from Other KVSP Housing Yards) KVSP handled patient transfers from other CDCR institutions well. The receiving nurse properly reviewed incoming patients’ transfer forms and referred the patients for appropriate medical services. The following nursing deficiencies were found:  In cases 7 and 8, nurses did not document on the health screening form whether the patients received effective communication during the clinical encounter. In addition, they failed to include timelines for the referrals to the PCP and specialty clinics. Transfers out to Other CDCR Institutions The deficiencies for inmates transferring out of KVSP were mainly due to incomplete nursing documentation of significant medical information on the Health Care Transfer Information form (CDCR Form 7371). The following deficiencies were found:  In case 9, the RN did not include on the transfer form the patient’s recent bowel obstruction surgery. The form also lacked the most recent PCP visit to follow up on a radiology positron emission tomography (PET) scan to rule out a malignancy. However, the PCP at the receiving institution was aware of this information. The RN also failed to document the patient’s history of an attempted suicide.  In case 11, the RN failed to document on the transfer form a past-due ophthalmology follow-up visit. However, the receiving institution ordered the visit, which occurred within the requested time frame. Hospitalizations Patients returning from hospitalizations are some of the highest-risk encounters due to two factors. First, these patients are of higher acuity since they have just been hospitalized for a severe illness in most cases. Second, they are at risk due to the potential lapses in care that can occur during any transfer of care. The majority of hospital return patients were processed appropriately by the TTA RN. The following deficiencies were identified after returns from hospitalization:  The hospital discharge summaries were not properly signed by the provider in cases 24, 25, 26, 28, 29, 31, and 32.  Medication lapses occurred after return from hospitalization in cases 28, 68, 70, and 71.  In case 71, the hospital’s discharge plan was implemented incompletely. The KVSP orders failed to include keeping the wound area dry and clean and allowing activity as tolerated and diet as tolerated. Kern Valley State Prison, Cycle 4 Medical Inspection Page 33 Office of the Inspector General State of California  In case 29, nursing staff failed to follow the CCHCS refusal policy. The patient returned from the hospital and refused to be examined by the TTA nurse. The refusal form was a preprinted one, did not cover the specific information based on the patient’s condition and reasons for clinical assessment post hospitalization, and lacked the required two signatures. Onsite Clinician Inspection At the time of the OIG clinicians’ inspection, KVSP’s receiving and release (R&R) clinic provided ample space for examination and auditory privacy for the patients being interviewed during initial screening. The nursing staff assigned to the area were very knowledgeable about the procedures and processes of transferring patients in and out of the institution. Compliance Testing Results Kern Valley State Prison obtained an inadequate compliance score of 74.7 percent in the Inter- and Intra-System Transfers indicator. Although KVSP scored in the adequate to proficient range for three of the five tests, two test areas received an inadequate score. The institution has an opportunity to improve in the following two areas:  The OIG tested 20 inmate-patients who transferred out of KVSP to another CDCR institution to determine whether their scheduled specialty service appointments were listed on the Health Care Transfer Information form (CDCR Form 7371). Staff had identified the scheduled appointments on the transfer forms of only 10 of the 20 patients sampled (50 percent) (MIT 6.004).  The institution scored 67 percent when the OIG tested three inmate-patients who transferred out of the institution during the onsite inspection to determine whether the patients’ transfer packages included required medications and related documentation. Two packages were compliant, but for a third patient, who had a keep-on-person (KOP) rescue medication prescription, the medication was not on his person at the time of transfer (MIT 6.101). The institution scored within the proficient or adequate range for the following three tests:  The OIG reviewed the Initial Health Screening forms (CDCR Form 7277) for 30 inmate-patients who transferred into KVSP from another CDCR institution to determine if nursing staff completed the assessment and disposition sections of the form on the same day staff completed an initial screening of the patient. Nursing staff properly completed the documents for 29 of the patients sampled (97 percent). For one patient, nursing staff failed to sign the document (MIT 6.002).  The OIG tested 30 inmate-patients who transferred into KVSP from another CDCR institution to determine whether they received a complete initial health screening assessment from nursing staff on their day of arrival. The institution received a score of 80 percent for Kern Valley State Prison, Cycle 4 Medical Inspection Page 34 Office of the Inspector General State of California this test because nursing staff timely completed the assessment for only 24 of the sampled patients. For six patients, nurses neglected to answer one or more of the screening form questions (MIT 6.001).  Of the 30 sampled inmate-patients who transferred into KVSP, ten had an existing medication order upon arrival. Inspectors tested those patients’ records to determine if they received their medications without interruption; eight of the ten patients (80 percent) received their medications timely. Two patients did not receive a scheduled dose of one of their nurse-administered medications (MIT 6.003). Recommendation The OIG recommends that KVSP improve the hospital return process for medication continuity. The OIG suggests KVSP use a form that specifies the medication, dosage route, frequency, duration, and start date and time for each new prescription. Additionally, the OIG recommends pre-hospitalization medication administration records (MARs) be removed from the medication binder, or pre-hospital medications be clearly marked as discontinued. Kern Valley State Prison, Cycle 4 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 security Adequate management, encompassing the process from the written Compliance Score: prescription to the administration of the medication. By combining 71.9% both a quantitative compliance test with case review analysis, this assessment identifies issues in various stages of the medication Overall Rating: Inadequate management process, including ordering and prescribing, transcribing and verifying, dispensing and delivering, administering, and documenting and reporting. Because effective medication management is affected by numerous entities across various departments, this assessment considers internal review and approval processes, pharmacy, nursing, health information systems, custody processes, and actions taken by the PCP prescriber, staff, and patient. For this indicator, the OIG’s case review and compliance review processes yielded different results, with the case review giving an adequate rating and the compliance review resulting in an inadequate score. The OIG’s internal review process considered those factors that led to both scores and ultimately rated this indicator inadequate. The key factors were that the OIG’s compliance testing included 16 objectively scored questions that targeted a broad range of the institution’s pharmacy and medication management operations, while the OIG’s case review analysis only considered pharmacy and medication management to be a secondary factor in determining whether a patient received adequate health care services. As a result, the compliance testing results were deemed a more accurate reflection of the appropriate overall indicator rating. Case Review Results The OIG clinicians evaluated pharmacy and medication management as secondary processes as they relate to the quality of clinical care provided. For case reviews, the clinicians reviewed 37 events related to Pharmacy and Medication Management. While 33 deficiencies were seen, all were minor and unlikely to contribute to patient harm. New Prescriptions In the majority of cases, patients received their medications timely and as prescribed. However, there were three cases where prescriptions were not processed timely:  In case 25, there was a five-day delay in new medication delivery and administration for atorvastatin (cholesterol medication), lisinopril (blood pressure medication), metformin (diabetes medication), and omeprazole (stomach acid blocker). Kern Valley State Prison, Cycle 4 Medical Inspection Page 36 Office of the Inspector General State of California  In case 71, a rheumatology specialist via telemedicine saw the patient with severe arthritis. There was a one-day delay for the patient’s new anti-inflammatory medications, prednisone and sulfasalazine.  In case 5, the provider ordered an antibiotic for a patient with a urinary tract infection. The patient received the medication after four days, when it should have been given immediately due to the urgent nature of the infection. Chronic Care Medication Continuity The majority of patients reviewed received their chronic care medications without interruption. However, two cases suggested problems with chronic care medication continuity:  In case 32, the patient received KOP ibuprofen on August 13, 15, and 27, 2014. The pharmacy filled ibuprofen again on September 14 and 18, 2014. The patient received two additional ibuprofen refills on September 19, 2014. There was no process in place to monitor KOP medication delivery.  In case 72, delivery of KOP ibuprofen to the patient was delayed five days. Intra-System and Intra-Facility Transfers and Medication Continuity Medication continuity was maintained in the majority of transfer cases reviewed. Post-Hospitalization Medication Continuity Medication continuity for patients returning from a hospitalization was generally maintained for the cases reviewed. However, in cases 28, 68, 70, and 71, there were minor medication lapses after return from hospitalization. Medication Administration Case review found the following deficiencies in medication administration. This topic will also be addressed in the indicator Quality of Nursing Performance.  In case 69, the medication administration record (MAR) documented that the patient twice refused hydroxyzine at bedtime for anxiety and agitation. However, there were no signed patient refusals.  In case 5, the nurse did not administer the evening dose of pregabalin (seizure medication used for pain). The MAR was blank without documentation for the missed dose.  In case 29, the nurse did not administer the evening doses of docusate sodium (stool softener), latanoprost (glaucoma treatment), and levetiracetam (seizure medication). There was no indication of medication refusal. Kern Valley State Prison, Cycle 4 Medical Inspection Page 37 Office of the Inspector General State of California  In case 2, the patient’s noon dose of insulin was held due to a low finger-stick blood glucose level of 66. The LVN notified the provider and had the patient stay in the clinic to recheck his blood glucose. The LVN released the patient with a still slightly low blood glucose level of 73, but failed to document presence or absence of signs and symptoms of hypoglycemia. Medication Follow-up Medication line nurses sometimes failed to appropriately document when patients refused or missed medications (cases 29, 71, and 69). Onsite Clinician Inspection During the onsite visit, OIG clinicians met with medical, nursing, and pharmacy representatives regarding case review findings. KVSP nursing and pharmacy management was aware of some of these specific cases, and had conducted interdisciplinary discussions and root cause analysis exercises regarding the issues. The pharmacy demonstrated medication-logging procedures and ensured that medications were well stocked in the TTA Omni-cell (an automated medication dispensing cabinet). Nursing had implemented various educational and training interventions. There were monitoring strategies with nursing staff to address roles and responsibilities for maintaining the continuity of care for patients with new prescriptions and for patients returning after hospital discharge. Compliance Testing Results The institution received an inadequate compliance score of 71.9 percent for 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 average score was 73 percent, which falls in the inadequate range. The following tests are in decreasing order of need for corrective action:  The institution timely provided hospital discharge medications to only 18 of 30 patients sampled who had returned from a community hospital (60 percent). For ten patients, nursing staff provided discharge medications one to four days late; for one other patient, there was no evidence that the patient received his artificial tears medication. The remaining patient continued to receive a medication that had been discontinued after his return from the hospital (MIT 7.003).  Nursing staff timely dispensed long-term chronic care medications to only 16 of the 25 inmate-patients sampled, scoring 64 percent for this test. Six patients did not timely receive Kern Valley State Prison, Cycle 4 Medical Inspection Page 38 Office of the Inspector General State of California refills of one or more of their KOP medications; three patients did not receive their nurse-administered medications on one or more days (MIT 7.001).  When the OIG sampled ten inmate-patients who were in transit to another institution and were temporarily laid over at KVSP, only seven (70 percent) received their medications without interruption. Three patients each missed at least one dose of their required medications (MIT 7.006).  The institution timely administered or delivered new medication orders to 25 of the 30 patients sampled (83 percent). Of the five patients who did not receive their medication timely, the delay was from one to four days (MIT 7.002).  When the OIG sampled 30 inmate-patients who had transferred from one housing unit to another within the institution, 26 of the patients (87 percent) received their prescribed medications without interruption. On the day of their housing relocation, two patients did not receive one dose of their prescribed medication and two other patients did not receive their single-dose prescribed medication (MIT 7.005). Observed Medication Practices and Storage Controls For this sub-indicator, the average score was 81 percent, which fell into the adequate range. There was one poor score, but KVSP scored in the proficient range for the following five areas:  The institution properly stored non-narcotic medications that do not require refrigeration at all 16 applicable clinics and medication line storage locations inspected (MIT 7.102).  When the OIG tested ten clinic locations to determine if non-narcotic medications that required refrigeration were stored properly, all ten locations were in compliance (MIT 7.103).  Nursing staff followed appropriate administrative controls during medication preparation at all seven of the sampled medication preparation and administration locations (MIT 7.105). In addition, at all seven sampled locations, nursing staff followed appropriate administrative controls when distributing medications to inmate-patients (MIT 7.106).  Nursing staff at six of the seven medication preparation and administration locations (86 percent) followed proper hand hygiene contamination control protocols during the medication preparation and administration processes. However, at the administrative segregation unit (ASU), clinical staff told OIG inspectors that they had a difficult time obtaining non-latex gloves for the unit’s medication line (MIT 7.104). Kern Valley State Prison, Cycle 4 Medical Inspection Page 39 Office of the Inspector General State of California The institution needs improvement in the following area:  The OIG interviewed nursing staff and inspected narcotic storage areas at ten applicable clinic and pill line locations. At all ten locations, one or more of the following issues was present: some clinics issued keys to a narcotic storage location to more than one staff member; some facilities’ medication carts used the same key; in two different clinics, medication line nurses did not have a second nurse who assisted at the beginning or end of the shift in reconciling narcotic pill totals. As a result, the institution scored zero for this test (MIT 7.101). Pharmacy Protocols For this sub-indicator, the average score was an inadequate 60 percent. As indicated below, KVSP received a score of zero in two areas:  KVSP received a score of zero for its ability to follow key medication error reporting protocols. The pharmacist-in-charge (PIC) did not properly follow CCHCS’s medication error reporting process for all nurse-reported medication errors. Through interviews with the PIC, an SRN, and other nursing staff, OIG inspectors learned that nursing staff regularly submitted medication error reports directly to CCHCS via an online notification portal rather than first submitting the errors to the PIC. While the system automatically forwarded notifications to the PIC, the PIC did not address the notifications and initiate and process required medication error follow-up reports for any of the medication errors that nursing staff submitted online. As a result, inspectors assigned the institution a score of zero for this test (MIT 7.111).  KVSP’s main pharmacy did not properly store and monitor non-narcotic medications that require refrigeration, scoring zero. More specifically, the pharmacy stored vaccines in the freezer unit of the employee refrigerator where personal food was also stored. Storing medications in an uncontrolled employee refrigeration unit can lead to potential medication theft, contamination, or degradation due to improper temperature controls (MIT 7.109). KVSP scored 100 percent in the remaining three areas:  In its main pharmacy, the institution followed general security, organization, and cleanliness management protocols; properly stored non-refrigerated medications; and maintained adequate controls and properly accounted for narcotic medications. The institution scored 100 percent in each of these areas (MIT 7.107, 7.108, 7.110). Non-Scored Tests In addition to the OIG’s testing of reported medication errors, inspectors follow up on any significant medication errors found during the case reviews or compliance testing to determine Kern Valley State Prison, Cycle 4 Medical Inspection Page 40 Office of the Inspector General State of California whether the errors were properly identified and reported. The OIG provides those results without a score. At KVSP, the OIG did not find any applicable medication errors (MIT 7.998). The OIG tested inmate-patients in isolation units to determine if they had immediate access to their prescribed KOP asthma rescue inhalers and nitroglycerin medications. Fifteen of 17 applicable inmates interviewed (88 percent) indicated they had possession of their rescue medications. However, two inmate-patients did not have their rescue inhalers on their person and they indicated that custody staff took their inhalers along with their other property. While the OIG’s inspectors immediately notified the institution of the concern, health care management did not take timely action to either provide the inmate with a replacement inhaler or document a proper refusal. After the OIG’s notification, it took 22 days for one patient and eight days for the other to receive replacement inhalers (MIT 7.999). CCHCS Dashboard Comparative Data The Dashboard uses various performance measures from the Medication Administration Process Improvement Program (MAPIP) audit tool to calculate the average score for its Medication Administration measure. The OIG compared similar KVSP compliance scores with the July 2015 Dashboard results. As noted in the following table, the OIG test results were based on a review of current documents as well as documents from the preceding 11 months; KVSP’s July Dashboard data reflected only the institution’s June 2015 results. Given these disparate time frames, the OIG’s compliance score was 14 percentage points lower than the Dashboard’s score. Pharmacy and Medication Management — KVSP Dashboard and OIG Compliance Results KVSP DASHBOARD RESULTS OIG COMPLIANCE RESULTS Medication Administration (7.001, 7.002) Medication Management: (Chronic Care & New Meds) Medication Administration Preventive Services (9.001) July 2015 (Administering INH Medication) August 2014 – July 2015 94% 80% Note: The Dashboard results were obtained from the Medication Administration Drilldown data for Chronic Care Meds — Medical, New Outpatient Orders — Medical, New Outpatient Orders — Psychiatric, and Administration — TB Medications. Variances may exist because CCHCS includes medication administration of KOP medications only for the first two drilldown measures, while the OIG tests KOP, DOT, and nurse administered (NA) medication administration. Kern Valley State Prison, Cycle 4 Medical Inspection Page 41 Office of the Inspector General State of California Recommendations  The OIG recommends the institution’s PIC complete a medication error follow-up report for all reported medication errors, including those reported through CCHCS’s online notification portal.  To help ensure adequate medication controls, the OIG recommends the institution ensure that only one nurse maintains control of a particular narcotics storage area and that each location requires a different access key. Kern Valley State Prison, Cycle 4 Medical Inspection Page 42 Office of the Inspector General State of California PREVENTIVE SERVICES This indicator assesses whether various preventive medical Case Review Rating: services are offered or provided to inmate-patients. These include Not Applicable cancer screenings, tuberculosis screenings, and influenza and Compliance Score: chronic care immunizations. This indicator also assesses whether 90.1% certain institutions take preventive actions to relocate Overall Rating: inmate-patients identified as being at higher risk for contracting Proficient coccidioidomycosis (valley fever). Compliance Testing Results The institution performed in the proficient range in the Preventive Services indicator, with a compliance score of 90.1 percent. The institution scored at the adequate to proficient level in five of the seven tests. The stronger areas are described below:  The institution was 100 percent compliant in offering annual influenza vaccinations to all 30 sampled inmate-patients (MIT 9.004).  The institution scored high in monitoring and administering anti-tuberculosis (INH) medications to inmate-patients with tuberculosis. The institution monitored the condition and treatment for the 12 patients sampled, and all received their required monthly monitoring during a three-month review period (MIT 9.002). Also, 11 of the 12 patients sampled (92 percent) received all required doses of INH medication timely. One exception was when the institution did not administer two INH doses to a patient; however, once the public health nurse identified the missed doses, the patient’s treatment was extended (MIT 9.001).  The institution offered colorectal cancer screenings to 29 of 30 sampled inmate-patients subject to the annual screening requirement (97 percent). For one patient, there was no eUHR evidence either that health care staff offered a fecal occult blood test within the previous 12 months or that the patient had a normal colonoscopy within the last ten years (MIT 9.005).  The OIG tested whether inmate-patients who suffered from a chronic care condition were offered vaccinations for influenza, pneumonia, and hepatitis. At KVSP, 14 of 17 chronic care patients sampled (82 percent) received all recommended vaccinations at the required interval for their chronic care conditions. Three patients had no evidence of pneumonia or hepatitis immunizations (MIT 9.008). Kern Valley State Prison, Cycle 4 Medical Inspection Page 43 Office of the Inspector General State of California One key area could be easily improved:  Twenty-one of 30 inmate-patients sampled (70 percent) received proper tuberculosis screenings within the preceding year. There were eight exceptions because required tuberculosis test results were read by an LVN or psychiatric technician rather than by an RN, PHN, or PCP. In addition, one inmate-patient did not receive a tuberculosis screening within the past 12 months (MIT 9.003). CCHCS Dashboard Comparative Data As indicated below, the OIG’s proficient compliance results for colon cancer screening were consistent with the data reported within the CCHCS Dashboard for KVSP. Preventive Services — KVSP Dashboard and OIG Compliance Results KVSP DASHBOARD RESULTS OIG COMPLIANCE RESULTS Colon Cancer Screening Colon Cancer Screening (9.005) July 2015 July 2015 99% 97% Recommendations No specific recommendations. Kern Valley State Prison, Cycle 4 Medical Inspection Page 44 Office of the Inspector General State of California QUALITY OF NURSING PERFORMANCE The Quality of Nursing Performance indicator is a qualitative Case Review Rating: evaluation of the institution’s nursing services. The evaluation is Adequate completed entirely by OIG nursing clinicians within the case Compliance Score: review process, and, therefore, does not have a score under the Not Applicable compliance testing component. The OIG nurses conduct case reviews that include reviewing face-to-face encounters related to Overall Rating: nursing sick call requests identified on the Health Care Services Adequate Request form (CDCR Form 7362), urgent walk-in visits, referrals for medical services by custody staff, registered nurse (RN) case management, RN utilization management, clinical encounters by licensed vocational nurses (LVNs) and licensed psychiatric technicians (LPTs), and any other nursing service performed on an outpatient basis. The OIG case review also includes activities and processes performed by nursing staff that are not considered direct patient encounters, such as the initial receipt and review of CDCR Form 7362 service requests and follow-up with primary care providers and other staff on behalf of the patient. Key focus areas for evaluation of outpatient nursing care include appropriateness and timeliness of patient triage and assessment, identification and prioritization of health care needs, use of the nursing process to implement interventions including patient education and referrals, and documentation that is accurate, thorough, and legible. Nursing services provided in the outpatient housing unit (OHU), correctional treatment center (CTC), or other inpatient units are reported under the Specialized Medical Housing indicator. Nursing services provided in the triage and treatment area (TTA) or related to emergency medical responses are reported under Emergency Services. Case Review Results The Quality of Nursing Performance at KVSP was adequate. The OIG evaluated 250 outpatient nursing encounters for KVSP, mostly nursing sick call requests. All of the 103 deficiencies were minor and unlikely to contribute to patient harm. Sick call nurses generally made appropriate primary care provider (PCP) contact and referrals, and appropriately coordinated primary care services with the PCP; however, documentation of nursing assessments and interventions by some sick call nurses was illegible. Nursing Sick Call In general, outpatient nursing performance related to sick call requests was adequate. Nurses generally reviewed sick call requests appropriately, triaged sick call patients adequately, saw patients quickly, and made proper assessments, interventions, and dispositions. The majority of the nursing assessment and intervention deficiencies were due to inadequate subjective or objective physical assessment for complaints of medical symptoms, and failure to conduct face-to-face assessment visits. The majority of the documentation deficiencies were for incomplete documentation per requirements established by CCHCS nursing protocols in the Inmate Medical Services Program Policies and Procedures. Kern Valley State Prison, Cycle 4 Medical Inspection Page 45 Office of the Inspector General State of California Nursing Sick Call Triage CCHCS policy requires an RN to review every sick call request on the day it is received. The purpose of this review is to identify patients requiring same-day RN assessment for serious complaints and symptoms, or to schedule the RN assessment for the next business day. Nursing sick call triage was adequate. The following are examples of minor deficiencies:  In case 32, the patient submitted a health care request for complaint of extreme pain after something “tweaked” his tailbone, and he was barely able to stand up. The reviewing nurse did not see the urgency of the complaint. The patient was scheduled to see the nurse five days later, at which time the patient refused the visit.  In case 57, the patient was seen for a “bump that hurts” on his upper back that was growing in size. A same-day nurse assessment should have occurred, but the assessment was scheduled for the following day.  In case 3, a paraplegic patient submitted a health care request for pressure sores on three toes of his left foot. A same-day nurse assessment should have occurred, but the assessment was scheduled for the following day.  In case 5, the patient submitted a sick call request for symptoms of a urinary tract infection and blood coming out of his catheter. A same-day nurse assessment should have occurred, but the assessment was scheduled for the following day. Nursing Assessment The majority of nursing encounters demonstrated adequate assessment. All deficiencies were minor and unlikely to contribute to patient harm. In many of these cases, the encounter form was partially completed. The OIG clinicians could not determine if the nurse asked important questions, performed necessary measurements, or examined pertinent areas of the body. Nurses also failed to document the presence or absence of common accompanying signs and symptoms. Although nursing assessments were generally rated adequate, the following cases demonstrate areas for nursing assessment improvement. Referrals without nursing assessments:  In case 51, the patient submitted a request to see medical staff due to jaw pain. The nurse reviewed and processed the request and referred the patient for a dental evaluation that same day. The nurse failed to assess the patient’s physical complaint prior to making the referral to the dentist. The presenting complaint was vague; it did not clearly specify a dental problem (bleeding gums, broken tooth, obvious signs of infection, etc.). Kern Valley State Prison, Cycle 4 Medical Inspection Page 46 Office of the Inspector General State of California  In case 5, the nurse failed to see a patient with burning on urination despite being on antibiotics for a urinary tract infection. However, the nurse did note a PCP visit was scheduled in two days. Inadequate or incomplete assessments or interventions:  In case 4, the sick call nurse noted white lesions in the patient’s mouth. The nurse documented “possible thrush” and made a PCP referral for one week later. The nurse should have consulted with the PCP that same day for this possible thrush.  In case 1, on several occasions, nurses did not perform urine dip tests for complaints of flank pain, declined to assess the patient, and did not notify a provider of elevated blood pressures (up to 160/93).  In case 38, the patient was seen in the clinic for continued “excruciating” pain in his left shoulder. The nurse failed to perform an assessment to evaluate the pain. The nurse only noted that the x-ray was done and that the physician ordered medications for pain.  In case 5, the patient with an indwelling catheter complained of symptoms of a urinary tract infection. The nurse failed to perform an adequate assessment and did not perform a urinalysis test to screen for bleeding and infection. Nurses failed on two other occasions to perform adequate assessments for this complaint.  In case 33, the nurse saw a patient in the clinic for drainage coming from a previously healed bed sore. While the nurse did note that the patient was wheelchair bound for 21 years, the nurse failed to take his vital signs, assess his pain level, or examine the area.  In case 35, the patient was seen in the clinic for chest pain. The nurse did not adequately obtain information such as how often this symptom occurred, when the last occurrence was, other symptoms (dyspnea, nausea, vomiting, syncope, palpitation, and cough), or past medical history of heart disease, stroke, chronic obstructive pulmonary disease, substance abuse, or any drug allergies. The nurse did not inspect the chest or palpate the area in question. The one-week referral to the PCP was inappropriate.  In case 72, the patient was seen in the clinic for severe lower left back pain, inability to sleep, and urinary problems. The patient also had difficulty going from a sitting to a standing position. The nurse failed to obtain a urinalysis, and the nursing diagnosis only covered the musculoskeletal complaints. It did not cover urinary issues.  In case 58, the nurse saw a patient in the clinic for morning stomach “bloating.” The patient thought he might have a stomach ulcer. The nurse failed to document important details, such as bowel sounds and the date of the patient’s last bowel movement. Kern Valley State Prison, Cycle 4 Medical Inspection Page 47 Office of the Inspector General State of California  In case 29, the patient asked for a medication refill for his severe arthritis. The nurse documented “Prescription already being processed for refill.” The RN failed to assess the patient’s physical complaint. Nursing Documentation Most of the nursing documentation deficiencies were minor and unlikely to contribute to patient harm. However, the following demonstrate deficiencies in the documentation requirements clearly established by CCHCS nursing policy and protocols. They are part of the institutional nursing education and training orientation.  Cases 1, 2, 3, 4, 29, 32, 37, 51, 68, and 72 demonstrated incomplete or missing documentation, including inadequate nursing care plans that did not comply with CCHCS policy.  In cases 3, 4, and 53, nurses failed to complete a refusal form. Medication Management and Administration Outpatient medication administration was generally timely and reliable. During the onsite inspection visit, all the clinic and medication LVNs participated in the primary care morning huddles. See the Pharmacy and Medication Management and Emergency Services indicators for specific findings. Emergency Care Nurses working in KVSP’s TTA and emergency responders at KVSP were knowledgeable and skillful in providing emergency nursing care. Documentation demonstrated adequate nursing decision-making and good performance during challenging cases. A few deficiencies were found: inconsistent documentation in various TTA forms, failure to administer medication per nursing urgent/emergent protocols, failure to obtain EKG readings, and inadequate assessments. However, none of these was significant or likely to contribute to patient harm. Nursing emergency care was adequate. The specific findings are described in the Emergency Services indicator. Onsite Clinician Inspection During the onsite visit by the OIG clinicians, the nurses in D Yard were active participants in morning huddles, coordinating and communicating care management needs of patients. The clinic PCP effectively facilitated the morning huddle by efficiently covering such topics as recent TTA patients, transfers out and in, patients who were noncompliant with medications, patients who returned from outside hospitals, significant labs or diagnostic reports, PCP or RN line backlogs, and add-ons and referrals from the previous day. The morning huddle started on time with good attendance, including clinic providers, RNs, clinic LVNs, custody officers, medication LVNs, and office technicians. The primary care team had a huddle script, and the participants maintained a sign-in sheet to ensure tracking of the daily morning huddle. Kern Valley State Prison, Cycle 4 Medical Inspection Page 48 Office of the Inspector General State of California The OIG clinicians visited various clinical areas and freely spoke with nursing staff during walking rounds, including in specialty services, preventive services, the CTC, the TTA, facilities A, B, C, and D, the minimum security area, and the administrative segregation unit. The supervising registered nurses, RNs, and LVNs were knowledgeable about their duties and responsibilities and the patient populations within their assigned clinical areas. Nursing had specific communication channels for making requests and reporting issues, as well as improvement strategies for nursing performance. Nursing staff at all levels stated there were no major barriers to communication with providers, nursing supervisors, or custody staff. The OIG clinicians reviewed 15 supervisory files for nurses assigned to yard clinics, receiving and release, and public health, and one file for the nurse instructor. Three of the 15 files lacked a current annual performance evaluation. Recommendations The OIG’s case review process revealed that the quality of nursing care for outpatient services and specialized medical housing patients at the institution was adequate. However, KVSP’s health care management can benefit from continued annual monitoring and competency evaluations for nursing quality improvement. The OIG recommends implementation of the following:  Educational sessions for nursing staff that address prioritizing sick call requests, conducting subjective and objective assessments, and documenting nursing diagnoses and conclusions in accordance with current NANDA4 taxonomy.  Oversight and monitoring strategies for nursing managers to evaluate individual nursing competencies, performance in assigned clinical areas, and quality of documentation.  Assessment processes and quality improvement projects targeting patient access to care systems such as the nursing sick call process. 4 Previously North American Nursing Diagnosis Association, now officially NANDA International, Inc. Kern Valley State Prison, Cycle 4 Medical Inspection Page 49 Office of the Inspector General State of California QUALITY OF PROVIDER PERFORMANCE In this indicator, the OIG physicians provide a qualitative Case Review Rating: evaluation of the adequacy of provider care at the institution. Adequate Appropriate evaluation, diagnosis, and management plans are Compliance Score: reviewed for programs including, but not limited to, nursing sick Not Applicable call, chronic care programs, TTA, specialized medical housing, and specialty services. The assessment of provider care is Overall Rating: performed entirely by OIG physicians. There is no compliance Adequate testing component associated with this quality indicator. Case Review Results Clinicians with the OIG reviewed 357 medical provider encounters and identified 75 deficiencies related to provider performance. Most deficiencies were minor and unlikely to contribute to patient harm. There were 13 significant deficiencies. As a whole, KVSP provider performance was adequate. Assessment and Decision-Making In general, the providers made appropriate assessments and sound medical plans. There were six significant deficiencies:  In case 4, the patient’s anemia was stable with two recent hemoglobin readings of 14.3 and 14.4. The provider should have discontinued iron supplements, since patients with chronic liver disease can accumulate excessive iron in their livers and are at risk for liver damage.  In case 5, a provider documented labs as within normal limits; however, the potassium level was elevated at 5.9 (critically high being above 5.9).  In case 5, on another encounter, a provider diagnosed the patient as having a urinary tract infection. The provider failed to order a urinalysis and culture on the same day to assess whether the bacteria were sensitive to the antibiotic ciprofloxacin. Furthermore, a recent urine culture grew Enterococcus bacteria, which are resistant to ciprofloxacin; the provider should have prescribed a different antibiotic.  In case 18, the patient had coronary artery disease. The provider should not have discontinued under-the-tongue nitroglycerine for emergent use.  In case 21, on the patient’s admission to the CTC, the provider did not correct the patient’s Problem List, which incorrectly listed congenital syphilis as an active problem.  In case 21, on another encounter, a provider failed to address a urinalysis with white blood cells, indicating an infection, as well as a urine culture growing Escherichia coli (E.coli) Kern Valley State Prison, Cycle 4 Medical Inspection Page 50 Office of the Inspector General State of California bacteria. The patient subsequently developed urosepsis (bacterial infection of the blood from the urinary source) and required hospitalization. Anticoagulation Management KVSP providers generally managed anticoagulation appropriately. There was one significant deficiency:  In case 13, the patient had an inadequate level of warfarin prescribed (blood-thinning medication) as measured by a lab test (INR of 1.8). The provider prescribed an excessive increase of the warfarin dose from 31 mg to 45 mg weekly. This 45 percent increase was higher than sliding scale, 10 percent increase recommended in the CCHCS–Anticoagulation Care Guide for that INR level, and placed the patient at risk of over-anticoagulation and bleeding. There were two minor deficiencies.  In case 12, the patient had an inadequate level of warfarin as measured by a lab test (INR of 1.3). The provider failed to make a change to the warfarin dose. The Anticoagulation Care Guide recommended a sliding scale increase of 15 percent for that INR level.  In case 13, the patient had an elevated blood coagulation level (INR of 4.2). The provider decreased the warfarin dose from 38 mg to 20 mg weekly. This 47 percent decrease was more than the 10 percent decrease recommended by the Anticoagulation Care Guide. Emergency Care Providers generally made appropriate triage decisions when patients presented emergently to the TTA, and providers were generally available for consultation with the TTA nursing staff. In general, the care provided was adequate; however, there were two minor deficiencies:  In case 30, the patient was unconscious with a presumptive diagnosis of grand mal seizure. The provider failed to check the blood glucose for possible hypoglycemia.  In case 32, the provider failed to check an EKG and finger-stick glucose level for possible arrhythmia and hypoglycemia in an unconscious patient. Chronic Care Chronic care performance was generally adequate as most providers demonstrated good care with regard to hypertension, asthma, hepatitis C infection, and cardiovascular disease. There were four significant deficiencies identified:  In case 4, for a patient with hypertension, the provider failed to the address elevated blood pressure on five different patient encounters. The patient also had suboptimal medication Kern Valley State Prison, Cycle 4 Medical Inspection Page 51 Office of the Inspector General State of California management for his varices (swollen blood vessels in the esophagus) with prior bleeding and banding treatment.  In case 5, the patient had a persistent urinary tract infection for more than four months. This increased the risk for kidney infections, septicemia, and renal stones. Even though an indwelling urethral catheter can cause recurrent infections, imaging studies would have been appropriate to rule out other causes, such as kidney or bladder stones, prostate infection, malignancy, or bladder fistula. Also, the provider should have considered intermittent catheterization as an alternative to indwelling urethral catheterization to reduce the chance of catheter-associated infection.  In case 21, the patient was admitted to the CTC after a fall caused a pelvic fracture. The provider who admitted the patient to the CTC failed to review the eUHR and failed to address the patient’s altered mental status, which may have contributed to the patient’s recent fall.  On another encounter in case 21, the provider failed to consider osteoporosis (thin bones) for this patient with a pelvic fracture, and failed to order a bone density scan. The management of diabetes was adequate, with proper adjustments of insulin and medications to assure glucose control. Most diabetic patients had pneumococcal vaccines and yearly retina exams. Their blood pressure and cholesterol levels were at goal. However, there was one significant deficiency:  In case 16, the patient complained of low blood glucose (hypoglycemia). The provider should have reviewed all his medications, as the combination of sulfonylurea and long-acting insulin increased the risk of hypoglycemia. Furthermore, the provider increased the basal insulin without assessment of the fasting blood glucose, placing the patient at risk of further hypoglycemic episodes. There were two minor deficiencies:  In case 15, the patient had poorly controlled diabetes with a HbA1c of 10.0 percent (a lab test showing a moderately high three-month average blood glucose level) and an average fasting blood glucose of 261 mg/dl. The provider should have increased the basal insulin regimen and had a follow-up appointment sooner than 60 to 90 days later to assure optimal glycemic control.  In case 16, the patient’s last retinal exam was more than one and one-half years earlier. The provider should have ordered yearly screening for diabetic retinopathy. Kern Valley State Prison, Cycle 4 Medical Inspection Page 52 Office of the Inspector General State of California Specialty Services KVSP providers generally referred appropriately and reviewed specialty reports timely; however, not all the reports were properly signed by the providers. KVSP’s Institutional Utilization Management Committee reviewed referrals and ensured appropriate referrals. The providers reviewed the consultation reports and recommendations and implemented those recommendations as appropriate. There were two minor deficiencies:  In cases 19 and 20, the providers failed to address orthopedic recommendations for starting pendulum exercise and physical therapy, respectively. Hospital Return Although the providers failed to properly sign several hospital discharge summaries, the providers were aware of and implemented the recommendations from the hospital. However, there was one significant deficiency:  In case 21, a provider failed to order vancomycin antibiotic blood levels as recommended. There were two other deficiencies:  In case 69, a provider failed to prescribe crucial heart disease medications (clopidogrel and carvedilol) as ordered by the hospital.  In case 70, the patient had recently returned from hospitalization for acute hepatitis. Despite the gastroenterologist’s recommendation to avoid nonsteroidal anti-inflammatory drugs, a provider prescribed naproxen. Pain Management Providers at KVSP appropriately managed acute pain, chronic arthritic pain, neuropathic pain, and cancer pain. KVSP had a Pain Management Committee, which assisted providers in managing chronic pain. There were no significant deficiencies identified in pain management. Health Information Management The providers generally documented outpatient, TTA, and CTC encounters on the same day. Most progress notes were typed or dictated. The handwritten notes were generally legible. There were two isolated deficiencies:  In cases 30 and 68, provider progress notes were not found in the eUHR. Onsite Inspection There were no provider vacancies at the time of the OIG inspection. Most KVSP providers were enthusiastic about their work. The chief medical executive (CME) was committed to patient care Kern Valley State Prison, Cycle 4 Medical Inspection Page 53 Office of the Inspector General State of California and quality improvement, and most of the providers were supportive of the CME. Each provider was assigned mainly to one clinic to assure continuity of care. There were four mid-level providers, and each mid-level provider worked closely with a physician as a patient care team. The providers expressed satisfaction with ancillary services such as Specialty Services and Diagnostic Services. All providers attended the daily provider meeting, where they discussed significant TTA encounters and hospital returns that occurred on the previous day. Morning huddles were productive, led by the providers and attended by nurses, custody staff, and office technicians. Most providers expressed general job satisfaction with their positions, and the overall morale was good. Case Review Conclusion KVSP providers delivered good care in the majority of the physician-reviewed cases. One case was proficient, 24 cases were adequate, and five were inadequate. The OIG rated KVSP provider performance adequate. Recommendations  The OIG recommends that providers at KVSP improve their patient care with continuing medical education on the management of diabetes, chronic liver diseases, and anticoagulation.  The OIG recommends that KVSP implement a Coumadin clinic with standardized ordering, dispensing, administration, monitoring, and education. Kern Valley State Prison, Cycle 4 Medical Inspection Page 54 Office of the Inspector General State of California SPECIALIZED MEDICAL HOUSING Case Review Rating: This indicator addresses whether the institution follows appropriate Adequate policies and procedures when admitting inmate-patients to onsite Compliance Score: inpatient facilities, including completion of timely nursing and 96.0% provider assessments. The chart review assesses all aspects of medical care related to these housing units, including quality of Overall Rating: Adequate provider and nursing care. KVSP’s only specialized medical housing unit is the correctional treatment center (CTC). For this indicator, the OIG’s case review and compliance review processes yielded different results, with the case review giving an adequate rating and the compliance testing resulting in a proficient score. The OIG’s internal review process considered those factors that led to both scores and ultimately rated this indicator adequate. The key factors were that the case review had a larger sample size, and the case review focused on the quality of care provided. As a result, the case review testing results were deemed a more accurate reflection of the appropriate overall rating. Case Review Results KVSP had 22 CTC beds on site (12 beds designated for mental health and 10 beds for medical). At the time of the OIG clinicians’ visit, patients occupied all the medical beds. In total, OIG clinicians reviewed 266 provider and nursing encounters. There were 92 nursing events reviewed in the CTC, with 33 deficiencies. All but one, case 3 below, were minor deficiencies. These deficiencies related to inadequate documentation, poor care coordination with other clinical staff, and untimely communication with providers on urgent cases. Although nursing services in the CTC were only marginally adequate, the minor nature for most deficiencies, along with the adequate provider performance, allowed an adequate case review rating for the Specialized Medical Housing indicator. Provider Performance The OIG identified 26 deficiencies related to provider performance, most of which were minor and unlikely to contribute to patient harm. Two cases (18 and 21) had significant deficiencies. For patients who returned from outside hospital care, the providers were generally aware of the pertinent diagnoses and recommendations and appropriately addressed them. However, for two cases, the providers failed to implement the hospitalist’s recommendations.  In case 21, the provider failed to monitor the blood levels for the antibiotic vancomycin.  In case 69, the provider failed to prescribe the recommended clopidogrel (blood thinner) and carvedilol (blood pressure medication) for a patient with coronary artery disease. Kern Valley State Prison, Cycle 4 Medical Inspection Page 55 Office of the Inspector General State of California During the period of review, the CTC continuity of care was suboptimal, with eight providers rotating in the CTC. The following cases demonstrate the types of deficiencies caused by this large number of providers and their lack of proper communication:  In case 21, one CTC provider appropriately discontinued blood pressure medication, losartan, after a patient had lost weight. Hypertension was removed as a chronic care diagnosis. Three weeks later, a different provider failed to recognize that blood pressure medication was discontinued and that the patient no longer had hypertension. This provider planned to continue the no-longer-needed medication.  In case 69, one CTC provider decreased glipizide (diabetes medication) to 10 mg twice daily. Six days later, a different provider incorrectly documented in a progress note that the patient continued the previous higher dose. No harm occurred, however. The following deficiencies showed inadequate assessment and decision-making:  In case 17, a provider failed to address an elevated blood pressure of 120/91 and an elevated heart rate of 120.  In case 18, the patient had coronary artery disease, and the provider inappropriately discontinued under-the-tongue nitroglycerine for emergent use.  In case 21, a provider failed to review labs to address pyuria (urine containing pus) and urine culture positive for E.coli bacteria.  In case 69, the provider failed to address the concerns of a patient with poorly controlled diabetes related to why his diabetes medication was reduced. Nursing Performance Nursing performance in the CTC was deemed adequate, but still had several areas where it could improve. Nursing deficiencies such as failure to initiate appropriate nursing care plans, failure to communicate and follow or implement providers’ orders, inadequate nursing assessments, and incomplete documentation resulted in this rating. Of the 92 nursing encounters reviewed, there were 33 deficiencies. Of the 33 deficiencies, 29 involved the quality of nursing care, two involved medication administration and delivery, and the remaining two cases involved health information management. Only case 3 had a significant deficiency. Kern Valley State Prison, Cycle 4 Medical Inspection Page 56 Office of the Inspector General State of California The following are examples of deficiencies in nursing performance in this indicator:  In case 3, the nursing care plans were not comprehensive, failing to address the patient’s colostomy or impaired bladder function. The care plans were pre-printed and were not individualized. For example, on the care plan for impaired mobility, the nurses did not indicate which of the listed interventions applied to the patient. The patient assessment was inadequate, and the care plans were not revised as the patient’s condition changed, such as when the patient fell, had head trauma, or developed skin breakdown.  In case 68, a nurse did not document important information about the care provided for a seizure, such as vital signs, how oxygen was administered, the site of the intravenous line, or the specific times the provider and emergency medical services were called.  In case 69, the nursing care plan failed to reflect a doctor’s order to get the patient out of bed every shift (excluding night shift) for an hour, including on shower day. In addition, while one plan encouraged weight loss for this morbidly obese patient, another plan had a weight gain goal. On some occasions, nurses failed to weigh the patient as ordered, failed to adequately assess the effectiveness of pain medications, and failed to assess the effect of nitroglycerin when given to this patient with chest pain. For the entire time the patient received medication for a skin rash, the nursing assessments failed to address the patient’s skin condition. The utilization management (UM) nurse used pre-printed progress notes and filed the same information weekly into the eUHR. The UM nurse’s documentation did not reflect that the patient was discharged and readmitted to the CTC.  In case 30, the patient had a seizure. The nurse documented starting an intravenous line but failed to note the type of fluid and flow rate. The nurse failed to document any communication with the on-call physician or mental health staff. The TTA nurse was assisting the CTC nurse for approximately 50 minutes, but recorded only one set of vital signs. The nurse failed to record the blood glucose, timeline, or reassessment of the patient after the seizure ended.  In case 73, a complex patient with end-stage liver disease and edema was admitted to the CTC from another facility. The nurse assessed the patient but failed to perform a nutritional assessment, note dietary restrictions or food intolerance, or obtain an accurate current weight. Health Information Management The health information management services related to Specialized Medial Housing were adequate. The provider and most nursing progress notes were legible and timely scanned into the eUHR. Some nurses’ signatures were illegible. Consultation reports were generally available for the providers to review and timely scanned into the eUHR. The CTC discharge summaries were timely completed and scanned into the eUHR. Kern Valley State Prison, Cycle 4 Medical Inspection Page 57 Office of the Inspector General State of California Onsite Visit Leadership had recently assigned one primary care provider to the CTC. This change was implemented two months prior and would likely improve the future continuity of care. The CTC staff reported that they held weekly huddles to review all cases and daily huddles for significant patient-specific cases. OIG inspectors noted adequate CTC equipment, clinical space, and unit cleanliness. In fact, during the OIG visit, an issue about replacing a Hoyer Lift was resolved by KVSP purchasing another. Compliance Testing Results The institution received a proficient score of 96.0 percent for the Specialized Medical Housing indicator, which focused on the institution’s correctional treatment center (CTC). As indicated below, KVSP scored at the proficient level in four of the five test areas:  For all ten inmate-patients sampled, nursing staff timely completed an initial assessment on the day the patient was admitted to the CTC (MIT 13.001).  Providers evaluated all ten inmate-patients within 24 hours of admission and completed a history and physical within 72 hours of admission (MIT 13.002, 13.003).  Call buttons were in good working condition in CTC patient rooms, based on sampling conducted during the OIG’s onsite inspection. Also, according to knowledgeable staff working in the CTC, custody officers and clinicians respond and access inmate-patients’ rooms in less than one minute when an emergent event occurs (MIT 13.101). The institution scored within the adequate range in the following area:  When the OIG tested whether providers completed their Subjective, Objective, Assessment, Plan, and Education (SOAPE) notes at required three-day intervals, providers completed timely SOAPE notes for eight of the ten sampled patients (80 percent). Providers missed one required three-day interval for each of the remaining two patients by one or two days (MIT 13.004). Recommendations No specific recommendations. Kern Valley State Prison, Cycle 4 Medical Inspection Page 58 Office of the Inspector General State of California SPECIALTY SERVICES This indicator focuses on specialist care from the time a request for Case Review Rating: services or physician’s order for specialist care is completed to the Proficient time of receipt of related recommendations from specialists. This Compliance Score: indicator also evaluates the providers’ timely review of specialist 74.5% records and documentation reflecting the patients’ care plans, including course of care when specialist recommendations were Overall Rating: Adequate not 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 inmate-patient is updated on the plan of care. For this indicator, the case review and compliance review processes yielded different results, with the case review giving a proficient rating and the compliance review resulting in an inadequate score. The OIG’s internal review process considered those factors that led to both scores and ultimately rated this indicator adequate. The key factors were that the case review showed most deficiencies were minor, and the compliance score of 74.5 percent was very close to the adequate range. As a result, the OIG’s inspection team concluded that the appropriate overall rating for this indicator was adequate. Case Review Results The OIG clinicians reviewed 84 events related to Specialty Services, and there were 43 deficiencies related to this indicator. All of the deficiencies involved the health information management process. In general, Specialty Services assigned staff were very knowledgeable about their roles and responsibilities, as well as the tracking process to ensure specialty appointments were completed. Even though the providers did not properly sign many specialty reports, the providers were aware of the specialist records and appropriately addressed the recommendations. The case review rating for Specialty Services was proficient. Provider Performance Case review showed that patients were generally referred to specialists appropriately by the providers. The providers addressed specialist recommendations except on two occasions. These episodes are discussed further in the indicator Quality of Provider Performance. Specialty Access Specialty services were provided within excellent time frames for both routine and urgent services. Recommendations were generally addressed and done timely. Kern Valley State Prison, Cycle 4 Medical Inspection Page 59 Office of the Inspector General State of California Health Information Management Specialty reports were usually retrieved, sent to providers for review and signature, and scanned into the eUHR in timely manner. However, the OIG identified the following deficiencies:  Specialty reports were sometimes not properly signed by a provider. This deficiency was found in cases 2, 3, 4, 15, 17, 18, 19, 20, 21, 22, 25, 68, and 71. Most cases showed that the providers were aware of the specialty reports and their recommendations at follow-up visits.  For case 18, the specialty report was not scanned into the eUHR. Compliance Testing Results The institution received a marginally inadequate compliance score of 74.5 percent in the Specialty Services indicator. Although KVSP scored in the proficient range for three of seven tests, it received inadequate scores for four other tests. The institution has room for improvement in the following areas:  Providers timely reviewed specialists’ reports for high-priority specialty services for only 9 of 15 patients sampled (60 percent) and timely reviewed specialists’ reports for routine services for only 6 of 15 patients sampled (40 percent). For all but one of the 15 exceptions, there was no clear evidence on the Physician Request for Services (CDCR Form 7243), a progress note, or the consultant’s report that the provider reviewed the report results. For the remaining exception, the provider reviewed the report two days late (MIT 14.002, 14.004).  When inmate-patients are approved or scheduled for specialty services appointments from one institution and then transfer to another institution, policy requires that the receiving institution ensure that a patient’s appointment is timely rescheduled or scheduled, and held. Only 11 of the 20 patients sampled (55 percent) received their specialty service appointment within the required action date. Although five inmate-patients received their appointments from 2 to almost 20 weeks late, there was no evidence that the four other patients received their appointments or that providers had determined that the specialty service was no longer needed (MIT 14.005).  When the institution denied a request for specialty services, providers did not always communicate the denial status to the inmate-patient within 30 calendar days in order to provide the patient with alternate treatment strategies. Denials were timely communicated to the patient for 8 of the 12 specialty service denials sampled (67 percent). For three of the samples, providers communicated the denials five days, five weeks, and two months late. For a fourth sample, inspectors did not find any evidence that the provider ever discussed the denial with the patient (MIT 14.007). Kern Valley State Prison, Cycle 4 Medical Inspection Page 60 Office of the Inspector General State of California The institution performed in the proficient range for the following areas:  The institution received a score of 100 percent when the OIG tested the timeliness of KVSP’s denials of providers’ specialty services requests for 12 inmate-patients (MIT 14.006).  For all 15 of the inmate-patients sampled, a high-priority specialty service appointment or service occurred within 14 calendar days of the provider’s order (MIT 14.001).  For all 15 of the inmate-patients sampled, a routine specialty service appointment or service occurred within 90 calendar days of the provider’s order (MIT 14.003). Recommendations No specific recommendations. Kern Valley State Prison, Cycle 4 Medical Inspection Page 61 Office of the Inspector General State of California SECONDARY (ADMINISTRATIVE) QUALITY INDICATORS OF HEALTH CARE The last two quality indicators (Internal Monitoring, Quality Improvement, and Administrative Operations and Job Performance, Training, Licensing, and Certifications) involve health care administrative systems and processes. Testing in these areas applies only to the compliance component of the process. Therefore, there is no case review assessment associated with either of the two indicators. As part of the compliance component for the first of these two indicators, the OIG did not score several questions. Instead, the OIG presented the findings for informational purposes only. For example, the OIG described certain local processes in place at KVSP. To test both the scored and non-scored areas within these two secondary quality indicators, OIG inspectors interviewed key institutional employees and reviewed documents during their onsite visit to KVSP in June 2015. They also reviewed documents obtained from the institution and from CCHCS prior to the start of the inspection. Kern Valley State Prison, Cycle 4 Medical Inspection Page 62 Office of the Inspector General State of California INTERNAL MONITORING, QUALITY IMPROVEMENT, AND ADMINISTRATIVE OPERATIONS This indicator focuses on the institution’s administrative health care Case Review Rating: oversight functions. The OIG evaluates whether the institution Not Applicable promptly processes inmate-patient medical appeals and addresses Compliance Score: all appealed issues. Inspectors also verify that the institution follows 73.7% reporting requirements for adverse/sentinel events and inmate deaths, and whether the institution is making progress toward its Overall Rating: Inadequate Performance Improvement Work Plan initiatives. In addition, the OIG verifies that the Emergency Medical Response Review Committee (EMRRC) performs required reviews and that staff perform required emergency response drills. Inspectors also assess whether the Quality Management Committee (QMC) meets regularly and adequately addresses program performance. For those institutions with licensed facilities, inspectors also verify that required committee meetings are held. Compliance Testing Results The institution received a compliance score of 73.7 percent in the Internal Monitoring, Quality Improvement, and Administrative Operations indicator. Although seven of the nine scored tests were in the adequate to proficient range, including five tests that received a score of 100 percent, KVSP received a score of zero for two other tests. The low-scoring areas are described below:  KVSP did not improve or reach performance objectives for any of the five quality improvement initiatives targeted in its 2014 Performance Improvement Work Plan, resulting in a score of zero. For three of the five initiatives, there was insufficient information to assess whether KVSP made program improvement; for two other initiatives, the institution did not document any progress-to-date information (MIT 15.005).  Inspectors reviewed KVSP’s Emergency Medical Response Review Committee (EMRRC) meeting minutes, covering a recent nine-month period, for evidence of timely incident reviews and use of required documentation. The institution’s EMRRC only convened during three of those nine months. For the remaining six months, the institution indicated that either no “Code 3” emergency cases had occurred during the month, no EMRRC cases had occurred at all during the month, or one Code 3 emergency had occurred during the prior 30-day period but the case preparation was incomplete and would be deferred until the following month. While prior policy only required that EMRRC meetings be convened to review Code 3 emergencies, the CCHCS July 2012 EMRRC policy requires that EMRRC meetings be convened monthly and include reviews of suicide attempts, deaths, and all unscheduled transfers out of the institution that occur after the prior review. In addition, for the three months when the EMRRC convened, inspectors found one or more of the following deficiencies: incident review packages were not completed for Code 3 emergencies that occurred, the warden and CEO allowed designees to approve the meeting Kern Valley State Prison, Cycle 4 Medical Inspection Page 63 Office of the Inspector General State of California minutes, or the required EMRRC incident review checklist was not used. As a result, KVSP received a score of zero for this test (MIT 15.007). The institution performed in the proficient to adequate range in the following seven test areas:  KVSP promptly processed all inmate medical appeals timely in each of the most recent 12 months. Based on data received from the institution, there were no medical appeals categorized as overdue during the test period (MIT 15.001).  Inspectors reviewed six recent months of Quality Management Committee (QMC) meeting minutes and confirmed that the institution’s QMC met monthly in all six months reviewed. However, the QMC only adequately evaluated program performance or took action when improvement opportunities were identified in five of the six months. The committee’s February 2015 meeting deferred all subcommittee reviews until the following month. As a result, KVSP scored 83 percent for this test (MIT 15.003). However, KVSP took adequate steps to ensure the accuracy of its Dashboard data reporting. Specifically, there were documented discussions of data validation, methodologies used when evaluating data, or communication of data accuracy. Consequently, the institution received a score of 100 percent for this test (MIT 15.004).  Inspectors reviewed the last 12 months of KVSP’s local governing body (LGB) meeting minutes and determined that the LGB met at least quarterly and exercised responsibility for the quality management of patient heath care each quarter, as documented in the meeting minutes. As a result, the institution scored 100 percent for this test (MIT 15.006).  The institution properly completed a medical emergency response drill for each watch and included participation of both health care and custody staff during the most recent quarter. The drill packages’ support documentation also included the necessary and properly completed forms applicable for the drills. Therefore, the institution received a score of 100 percent for this test (MIT 15.101).  Medical staff timely sent the Initial Inmate Death Report (CDCR Form 7229A) to CCHCS’s Death Review Unit for the seven deaths that occurred within the OIG’s 12-month test period, resulting in a score of 100 percent (MIT 15.103).  Inspectors sampled ten second-level inmate medical appeals; eight of the ten appeals (80 percent) had responses that addressed the inmate’s initial complaint. Two inmate medical appeals had responses that did not address every issue in the inmate’s original appeal (MIT 15.102). Kern Valley State Prison, Cycle 4 Medical Inspection Page 64 Office of the Inspector General State of California Other Information Obtained from Non-Scored Areas  The OIG gathered non-scored data regarding the completion of death review reports and found that the Death Review Committee at CCHCS headquarters did not timely complete its death review summary for any of the seven deaths that occurred during the testing period. The Death Review Committee is required to complete a death review summary within 30 business days of the death and submit it to the institution’s CEO. The committee completed the seven KVSP death review summaries from 15 to 70 days late (61 to 112 calendar days after the deaths). Consequently, the committee did not submit any of the summaries to KVSP timely (MIT 15.996).  Inspectors met with the institution’s CEO to inquire about KVSP’s protocols for tracking appeals. The CEO stated that the institution’s health care appeals coordinator provides appeal information to CCHCS to include in its monthly appeals tracking log. The log, which CCHCS sends out to health care management statewide, tracks the aging of all appeals. The monthly health care appeal reports are provided to KVSP management staff and are also available on the Dashboard. The reports show statistics on appeals filed, including the disposition of each appeal. The reports also indicate how many appeals the institution filed, bypassed, cancelled, denied, or granted during the month, along with overdue appeals and categories of appeal issues. Management uses complaint category information to identify trends or problem areas. Once health care management substantiates a problem area, the CEO will focus on the identified issue and develop a remedy. KVSP’s CEO reported no knowledge of problem areas in the last six months (MIT 15.997).  Non-scored data gathered regarding the institution’s practices for implementing local operating procedures (LOPs) indicated that the institution had a good process in place for developing LOPs. When CCHCS sends out new policies and procedures, KVSP’s health program specialist (HPS) meets with the institution’s source expert (usually the policy area supervisor) to discuss whether a new LOP is needed, and to prepare recommendations to submit to the health care executive committee that oversees program changes. The committee and other key stakeholders determine if an LOP is needed, and what areas need to be covered in the LOP. Once the LOP is approved and completed, it is placed on the shared drive and emailed to the institution’s department heads; it is their responsibility to disseminate the policy to staff. Currently, the institution has implemented 45 of 50 applicable stakeholder-recommended LOPs (90 percent) (MIT 15.998).  The OIG discusses the institution’s health care staffing resources in the About the Institution section on page 1 (MIT 15.999). Kern Valley State Prison, Cycle 4 Medical Inspection Page 65 Office of the Inspector General State of California CCHCS Dashboard Comparative Data Both the Dashboard and the OIG testing results show that KVSP demonstrates a high level of compliance for processing its medical appeals. Internal Monitoring, Quality Improvement, and Administrative Operations — KVSP Dashboard and OIG Compliance Results KVSP DASHBOARD RESULTS OIG COMPLIANCE RESULTS Medical Appeals-Timely Processing Timely Appeals (15.001) July 2015 12-months ending May 2015 100% 100% Note: The CCHCS Dashboard data includes appeal data for: American Disability Act (ADA), mental health, dental, and staff complaint areas, whereas the OIG excluded these appeal areas. Recommendations No specific recommendations. Kern Valley State Prison, Cycle 4 Medical Inspection Page 66 Office of the Inspector General State of California JOB PERFORMANCE, TRAINING, LICENSING, AND CERTIFICATIONS In this indicator, the OIG examines whether the institution Case Review Rating: adequately manages its health care staffing resources by evaluating Not Applicable whether job performance reviews are completed as required; Compliance Score: specified staff possess current, valid credentials and professional 97.5% licenses or certifications; nursing staff receive new employee orientation training and annual competency testing; and clinical and Overall Rating: Proficient custody staff have current medical emergency response certifications. Compliance Testing Results The institution received a proficient compliance score of 97.5 percent in the Job Performance, Training, Licensing, and Certifications indicator. For seven of the eight tests in this indicator, the institution scored 100 percent. Those tests consisted of the following:  All providers at KVSP were current with their professional licenses (MIT 16.001). Similarly, all nursing staff and the pharmacist-in-charge were current with their professional licenses and certification requirements (MIT 16.105).  All of the ten nurses sampled who administered medications had current clinical competency validations (MIT 16.102).  The institution performed complete and timely structured clinical performance appraisals for its primary care providers. As of the onsite inspection date, KVSP was timely with all seven applicable providers who were due for a probationary or annual review (MIT 16.103).  All provider, nursing, and custody staff had current emergency response certifications (MIT 16.104).  The institution’s pharmacy and providers who prescribed controlled substances were current with their Drug Enforcement Agency registration (MIT 16.106).  Inspectors reviewed training records for nursing staff hired within the last year; all nurses completed new employee orientation training specific to their job assignments (MIT 16.107). Kern Valley State Prison, Cycle 4 Medical Inspection Page 67 Office of the Inspector General State of California The institution scored within the adequate range in the following area:  When inspectors examined records to determine if nursing supervisors were completing the required number of monthly case reviews on subordinate nurses, as well as discussing the results of those reviews, only four of five sampled nurse supervisors properly completed their reviews. As a result, the institution scored 80 percent for this test. One of the reviewing nurses did not properly follow protocols by documenting evidence that the reviewing nurse discussed the review results with the subordinate nurse (MIT 16.101). Recommendations No specific recommendations. Kern Valley State Prison, Cycle 4 Medical Inspection Page 68 Office of the Inspector General State of California POPULATION-BASED METRICS The compliance testing and the case reviews give an accurate assessment of how the institution’s health care systems are functioning with regard to the patients with the highest risk and utilization. This information is vital to assess the capacity of the institution to provide sustainable, adequate care. However, one significant limitation of the case review methodology is that it does not give a clear assessment of how the institution performs for the entire population. For better insight into this performance, the OIG has turned to population-based metrics. For comparative purposes, the OIG has selected several Healthcare Effectiveness Data and Information Set (HEDIS) measures for disease management to gauge the institution’s effectiveness in outpatient health care, especially chronic disease management. The Healthcare Effectiveness Data and Information Set is a set of standardized performance measures developed by the National Committee for Quality Assurance with input from over 300 organizations representing every sector of the nation’s health care industry. It is used by over 90 percent of the nation’s health plans as well as many leading employers and regulators. It was designed to ensure that the public (including employers, the Centers for Medicare and Medicaid Services, and researchers) has the information it needs to accurately compare the performance of health care plans. Healthcare Effectiveness Data and Information Set data is often used to produce health plan report cards, analyze quality improvement activities, and create performance benchmarks. Methodology For population-based metrics, the OIG used a subset of HEDIS measures applicable to the CDCR inmate-patient population. Selection of the measures was based on the availability, reliability, and feasibility of the data required for performing the measurement. The OIG collected data utilizing various information sources, including the eUHR, the Master Registry (maintained by CCHCS), as well as a random sample of patient records analyzed and abstracted by trained personnel. Data obtained from the CCHCS Master Registry and Diabetic Registry was not independently validated by the OIG and is presumed to be accurate. For some measures, the OIG used the entire population rather than statistically random samples. While the OIG is not a certified HEDIS compliance auditor, the OIG uses similar methods to ensure that measures are comparable to those published by other organizations. Comparison of Population-Based Metrics For Kern Valley State Prison, nine HEDIS measures were selected and are listed in the following KVSP 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. Kern Valley State Prison, Cycle 4 Medical Inspection Page 69 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. KVSP performed very well with its management of diabetes. When compared statewide, KVSP significantly outperformed Medi-Cal and slightly outperformed or matched Kaiser Permanente in four of the five diabetic measures selected; diabetic patient eye exams were the exception. Similarly, KVSP outperformed national averages for Medicaid, Medicare, commercial health plans (based on data obtained from health maintenance organizations), and the U.S. Department of Veterans Affairs (VA) in those same diabetic measures. Again, KVSP did not perform as well as the other entities in diabetic patient eye exams. In fact, when compared to the VA, the institution scored 45 percentage points lower for eye exams. However, inspectors noted that while KVSP scored low in the number of diabetic patients who actually received eye exams, 7 of the 29 patients tested (24 percent) were offered the eye exam but refused it. Immunizations Comparative data for immunizations was only fully available for the VA and partially available for Kaiser Permanente, commercial plans, and Medicare. With respect to administering influenza shots to adults aged 18 to 64, KVSP’s rate was higher than the average rates for Kaiser and commercial plans and lower than the VA’s rate. For administering influenza shots to adults 65 and older, the institution scored significantly lower than the VA and Medicare. In addition, with regard to administering pneumococcal vaccines, KVSP scored significantly lower than both Medicare and the VA. The OIG found that all of KVSP’s sampled patients were offered influenza shots, but many refused the immunization; with respect to pneumonia vaccinations, an additional 25 percent of the sampled patients were offered the immunization but refused it. Cancer Screening With respect to colorectal cancer screening, KVSP scored lower than Kaiser’s statewide scores. Nationally, KVSP performed significantly better than both commercial plans and Medicare, but performed 8 percentage points lower than the VA. However, similar to other measures, patient refusals impacted the institution’s performance for this measure; all but one of the KVSP patients who did not receive the screening timely had refused it. Kern Valley State Prison, Cycle 4 Medical Inspection Page 70 Office of the Inspector General State of California Summary Kern Valley State Prison’s population-based performance exceeded or matched the comparative State and national results in four of the nine comparative measures. Compared statewide, KVSP’s scores were higher than or matched Medi-Cal’s and Kaiser Permanente’s in four of the five diabetic measures, diabetic patient eye exams being the exception. The institution’s scores were higher than Kaiser’s for influenza shots but lower for colorectal cancer screenings. Similar to the statewide comparison, nationally KVSP outperformed Medicaid, commercial plans, Medicare, and the VA in all diabetic measures except diabetic patient eye exams. Regarding immunizations and cancer screenings, for flu shots, KVSP scored higher than commercial plans but lower than the VA and Medicare; similarly, for pneumococcal immunizations, KVSP scored lower than both Medicare and the VA; for colorectal cancer screenings, KVSP scored higher than commercial plans and Medicare, but lower than the VA. Overall, KVSP’s performance reflects a well-performing chronic care program, corroborated by the institution’s adequate ratings in the Quality of Provider Performance and Quality of Nursing Performance indicators, and its proficient ratings in the Preventive Services and Access to Care indicators. Regarding to the institution’s low scores for diabetic patient eye exams, immunizations (influenza and pneumonia), and colorectal cancer screenings, the institution should make interventions to lower the rate of patient refusals. Kern Valley State Prison, Cycle 4 Medical Inspection Page 71 Office of the Inspector General State of California KVSP Results Compared to State and National HEDIS Scores California National KVSP HEDIS HEDIS HEDIS HEDIS Clinical Measures Medi- Kaiser Kaiser HEDIS Com- HEDIS VA Cycle 4 Cal (No.CA) (So.CA) Medicaid mercial Medicare Average Results 2014 2015 2015 2015 2015 2015 2012 1 2 3 3 4 4 4 5 Comprehensive Diabetes Care HbA1c Testing (Monitoring) 100% 83% 95% 94% 86% 91% 93% 99% Poor HbA1c Control (>9.0%) 6,7 18% 44% 18% 24% 44% 31% 25% 19% HbA1c Control (<8.0%) 6 73% 47% 70% 62% 47% 58% 65% - Blood Pressure Control (<140/90) 88% 60% 84% 85% 62% 65% 65% 80% Eye Exams 45% 51% 69% 81% 54% 56% 69% 90% Immunizations Influenza Shots - Adults (18–64) 8 58% - 54% 55% - 50% - 65% Influenza Shots - Adults (65+) 50% - - - - - 72% 76% Immunizations: Pneumococcal 50% - - - - - 70% 93% Cancer Screening Colorectal Cancer Screening 74% - 80% 82% - 64% 67% 82% 1. Unless otherwise stated, data was collected in June 2015 by reviewing medical records from a sample of KVSP's population of applicable inmate-patients. These random statistical sample sizes were based on a 95 percent confidence level with a 15 percent maximum margin of error. 2. HEDIS Medi-Cal data was obtained from the California Department of Health Care Services 2014 HEDIS Aggregate Report for the Medi-Cal Managed Care Program. 3. Data was obtained from Kaiser Permanente November 2015 reports for the Northern and Southern California regions. 4. National HEDIS data for Medicaid, commercial plans, and Medicare was obtained from the 2015 State of Health Care Quality Report, available on the NCQA website: www.ncqa.org. The results for commercial plans were based on data received from various health maintenance organizations. 5. The Department of Veterans Affairs (VA) data was obtained from the VHA Facility Quality and Safety Report - Fiscal Year 2012 Data. 6. For this measure, the entire applicable KVSP population was tested. 7. For this measure only, a lower score is better. For Kaiser, the OIG derived the Poor HbA1c Control indicator using the reported data for the <9.0% HbA1c control indicator. 8. The VA data is for the age range 50-64. Kern Valley State Prison, Cycle 4 Medical Inspection Page 72 Office of the Inspector General State of California APPENDIX A — COMPLIANCE TEST RESULTS Kern Valley State Prison Range of Summary Scores: 61.11% – 97.50% Indicator Score (Yes %) Access to Care 93.31% Diagnostic Services 61.11% Emergency Services Not Applicable Health Information Management (Medical Records) 65.68% Health Care Environment 86.78% Inter- and Intra-System Transfers 74.67% Pharmacy and Medication Management 71.86% Prenatal and Post-Delivery Services Not Applicable Preventive Services 90.11% Quality of Nursing Performance Not Applicable Quality of Provider Performance Not Applicable Reception Center Arrivals Not Applicable Specialized Medical Housing (OHU, CTC, SNF, Hospice) 96.00% Specialty Services 74.52% Internal Monitoring, Quality Improvement, and Administrative Operations 73.70% Job Performance, Training, Licensing, and Certifications 97.50% Kern Valley State Prison, Cycle 4 Medical Inspection Page 73 Office of the Inspector General State of California Scored Answers Yes Reference + Access to Care Number Yes No No Yes % N/A 1.001 Chronic care follow-up appointments: Was the inmate-patient's most 24 6 30 80.00% 0 recent chronic care visit within the health care guideline's maximum allowable interval or within the ordered time frame, whichever is shorter? 1.002 For endorsed inmate-patients received from another CDCR 20 2 22 90.91% 8 institution: If the nurse referred the inmate-patient to a provider during the initial health screening, was the inmate-patient seen within the required time frame? 1.003 Clinical appointments: Did a registered nurse review the 35 0 35 100.00% 0 inmate-patient's request for service the same day it was received? 1.004 Clinical appointments: Did the registered nurse complete a 33 2 35 94.29% 0 face-to-face visit within one business day after the CDCR Form 7362 was reviewed? 1.005 Clinical appointments: If the registered nurse determined a referral to 11 2 13 84.62% 22 a primary care provider was necessary, was the inmate-patient seen within the maximum allowable time or the ordered time frame, whichever is the shorter? 1.006 Sick call follow-up appointments: If the primary care provider 5 0 5 100.00% 30 ordered a follow-up sick call appointment, did it take place within the time frame specified? 1.007 Upon the inmate-patient's discharge from the community hospital: 29 1 30 96.67% 0 Did the inmate-patient receive a follow-up appointment within the required time frame? 1.008 Specialty service follow-up appointments: Do specialty service 28 2 30 93.33% 0 primary care physician follow-up visits occur within required time frames? 1.101 Clinical appointments: Do inmate-patients have a standardized 6 0 6 100.00% 0 process to obtain and submit health care services request forms? Overall Percentage: 93.31% Kern Valley State Prison, Cycle 4 Medical Inspection Page 74 Office of the Inspector General State of California Scored Answers Yes Reference + Diagnostic Services Number Yes No No Yes % N/A 2.001 Radiology: Was the radiology service provided within the time 10 0 10 100.00% 0 frame specified in the provider's order? 2.002 Radiology: Did the primary care provider review and initial the 2 8 10 20.00% 0 diagnostic report within specified time frames? 2.003 Radiology: Did the primary care provider communicate the 10 0 10 100.00% 0 results of the diagnostic study to the inmate-patient within specified time frames? 2.004 Laboratory: Was the laboratory service provided within the time 8 2 10 80.00% 0 frame specified in the provider's order? 2.005 Laboratory: Did the primary care provider review and initial the 5 5 10 50.00% 0 diagnostic report within specified time frames? 2.006 Laboratory: Did the primary care provider communicate the 9 1 10 90.00% 0 results of the diagnostic study to the inmate-patient within specified time frames? 2.007 Pathology: Did the institution receive the final diagnostic report 9 1 10 90.00% 0 within the required time frames? 2.008 Pathology: Did the primary care provider review and initial the 0 10 10 0.00% 0 diagnostic report within specified time frames? 2.009 Pathology: Did the primary care provider communicate the 2 8 10 20.00% 0 results of the diagnostic study to the inmate-patient within specified time frames? Overall Percentage: 61.11% Emergency Services Scored Answers Assesses reaction times and responses to emergency situations. The OIG RN clinicians will use detailed information obtained from the institution's incident Not Applicable packages to perform focused case reviews. Kern Valley State Prison, Cycle 4 Medical Inspection Page 75 Office of the Inspector General State of California Scored Answers Health Information Management (Medical Yes Reference + Records) Number Yes No No Yes % N/A 4.001 Are non-dictated progress notes, initial health screening forms, and 19 1 20 95.00% 0 health care service request forms scanned into the eUHR within three calendar days of the inmate-patient encounter date? 4.002 Are dictated / transcribed documents scanned into the eUHR within five Not Applicable calendar days of the inmate-patient encounter date? 4.003 Are specialty documents scanned into the eUHR within five calendar 11 9 20 55.00% 0 days of the inmate-patient encounter date? 4.004 Are community hospital discharge documents scanned into the eUHR 19 1 20 95.00% 0 within three calendar days of the inmate-patient date of hospital discharge? 4.005 Are medication administration records (MARs) scanned into the eUHR 12 8 20 60.00% 0 within the required time frames? 4.006 During the eUHR review, did the OIG find that documents were 0 12 12 0.00% 0 correctly labeled and included in the correct inmate-patient's file? 4.007 Did clinical staff legibly sign health care records, when required? 25 7 32 78.13% 0 4.008 For inmate-patients discharged from a community hospital: Did the 23 7 30 76.67% 0 preliminary hospital discharge report include key elements and did a PCP review the report within three calendar days of discharge? Overall Percentage: 65.68% Kern Valley State Prison, Cycle 4 Medical Inspection Page 76 Office of the Inspector General State of California Scored Answers Yes Reference + Health Care Environment Number Yes No No Yes % N/A 5.101 Infection Control: Are clinical health care areas appropriately 11 0 11 100.00% 1 disinfected, cleaned and sanitary? 5.102 Infection control: Do clinical health care areas ensure that reusable 11 0 11 100.00% 1 invasive and non-invasive medical equipment is properly sterilized or disinfected as warranted? 5.103 Infection Control: Do clinical health care areas contain operable sinks 11 0 11 100.00% 1 and sufficient quantities of hygiene supplies? 5.104 Infection control: Does clinical health care staff adhere to universal 10 0 10 100.00% 2 hand hygiene precautions? 5.105 Infection control: Do clinical health care areas control exposure to 6 5 11 54.55% 1 blood-borne pathogens and contaminated waste? 5.106 Warehouse, Conex and other non-clinic storage areas: Does the 1 0 1 100.00% 10 medical supply management process adequately support the needs of the medical health care program? 5.107 Clinical areas: Does each clinic follow adequate protocols for 11 0 11 100.00% 1 managing and storing bulk medical supplies? 5.108 Clinical areas: Do clinic common areas and exam rooms have 7 4 11 63.64% 1 essential core medical equipment and supplies? 5.109 Clinical areas: Do clinic common areas have an adequate environment 9 2 11 81.82% 1 conducive to providing medical services? 5.110 Clinical areas: Do clinic exam rooms have an adequate environment 6 5 11 54.55% 1 conducive to providing medical services? 5.111 Emergency response bags: Are TTA and clinic emergency medical 9 0 9 100.00% 3 response bags inspected daily and inventoried monthly, and do they contain essential items? 5.999 For Information Purposes Only: Does the institution's health care management believe that all clinical areas have physical plant Information Only infrastructures sufficient to provide adequate health care services? Overall Percentage: 86.78% Kern Valley State Prison, Cycle 4 Medical Inspection Page 77 Office of the Inspector General State of California Scored Answers Yes Reference + Inter- and Intra-System Transfers Number Yes No No Yes % N/A 6.001 For endorsed inmate-patients received from another CDCR 24 6 30 80.00% 0 institution or COCF: Did nursing staff complete the initial health screening and answer all screening questions on the same day the inmate-patient arrived at the institution? 6.002 For endorsed inmate-patients received from another CDCR 29 1 30 96.67% 0 institution or COCF: When required, did the RN complete the assessment and disposition section of the health screening form; refer the inmate-patient to the TTA, if TB signs and symptoms were present; and sign and date the form on the same day staff completed the health screening? 6.003 For endorsed inmate-patients received from another CDCR 8 2 10 80.00% 20 institution or COCF: If the inmate-patient had an existing medication order upon arrival, were medications administered or delivered without interruption? 6.004 For inmate-patients transferred out of the facility: Were scheduled 10 10 20 50.00% 0 specialty service appointments identified on the Health Care Transfer Information Form 7371? 6.101 For inmate-patients transferred out of the facility: Do medication 2 1 3 66.67% 0 transfer packages include required medications along with the corresponding Medical Administration Record (MAR) and Medication Reconciliation? Overall Percentage: 74.67% Kern Valley State Prison, Cycle 4 Medical Inspection Page 78 Office of the Inspector General State of California Scored Answers Yes Reference + Pharmacy and Medication Management Number Yes No No Yes % N/A 7.001 Did the inmate-patient receive all chronic care medications within the 16 9 25 64.00% 5 required time frames or did the institution follow departmental policy for refusals or no-shows? 7.002 Did health care staff administer or deliver new order prescription 25 5 30 83.33% 0 medications to the inmate-patient within the required time frames? 7.003 Upon the inmate-patient's discharge from a community hospital: 18 12 30 60.00% 0 Were all medications ordered by the institution's primary care provider administered or delivered to the inmate-patient within one calendar day of return? 7.004 For inmate-patients received from a county jail: Were all medications ordered by the institution's reception center provider Not Applicable administered or delivered to the inmate-patient within the required time frames? 7.005 Upon the inmate-patient's transfer from one housing unit to 26 4 30 86.67% 0 another: Were medications continued without interruption? 7.006 For inmate-patients en route who lay over at the institution: If the 7 3 10 70.00% 0 temporarily housed inmate-patient had an existing medication order, were medications administered or delivered without interruption? 7.101 All clinical and medication line storage areas for narcotic 0 10 10 0.00% 8 medications: Does the institution employ strong medication security controls over narcotic medications assigned to its clinical areas? 7.102 All clinical and medication line storage areas for non-narcotic 16 0 16 100.00% 2 medications: Does the institution properly store non-narcotic medications that do not require refrigeration in assigned clinical areas? 7.103 All clinical and medication line storage areas for non-narcotic 10 0 10 100.00% 8 medications: Does the institution properly store non-narcotic medications that require refrigeration in assigned clinical areas? 7.104 Medication preparation and administration areas: Do nursing staff 6 1 7 85.71% 11 employ and follow hand hygiene contamination control protocols during medication preparation and medication administration processes? 7.105 Medication preparation and administration areas: Does the 7 0 7 100.00% 11 institution employ appropriate administrative controls and protocols when preparing medications for inmate-patients? 7.106 Medication preparation and administration areas: Does the 7 0 7 100.00% 10 institution employ appropriate administrative controls and protocols when distributing medications to inmate-patients? 7.107 Pharmacy: Does the institution employ and follow general security, 1 0 1 100.00% 0 organization, and cleanliness management protocols in its main and satellite pharmacies? Kern Valley State Prison, Cycle 4 Medical Inspection Page 79 Office of the Inspector General State of California Scored Answers Yes Reference + Pharmacy and Medication Management Number Yes No No Yes % N/A 7.108 Pharmacy: Does the institution's pharmacy properly store 1 0 1 100.00% 0 non-refrigerated medications? 7.109 Pharmacy: Does the institution's pharmacy properly store refrigerated 0 1 1 0.00% 0 or frozen medications? 7.110 Pharmacy: Does the institution's pharmacy properly account for 1 0 1 100.00% 0 narcotic medications? 7.111 Pharmacy: Does the institution follow key medication error reporting 0 15 15 0.00% 0 protocols? 7.998 For Information Purposes Only: During eUHR compliance testing and case reviews, did the OIG find that medication errors were Information Only properly identified and reported by the institution? 7.999 For Information Purposes Only: Do inmate-patients in isolation housing units have immediate access to their KOP prescribed rescue Information Only inhalers and nitroglycerin medications? Overall Percentage: 71.86% Prenatal and Post-Delivery Services Scored Answers This indicator is not applicable to this institution. Not Applicable Kern Valley State Prison, Cycle 4 Medical Inspection Page 80 Office of the Inspector General State of California Scored Answers Yes Reference + Preventive Services Number Yes No No Yes % N/A 9.001 Inmate-patients prescribed INH: Did the institution administer the 11 1 12 91.67% 0 medication to the inmate-patient as prescribed? 9.002 Inmate-patients prescribed INH: Did the institution monitor the 12 0 12 100.00% 0 inmate-patient monthly for the most recent three months he or she was on the medication? 9.003 Annual TB Screening: Was the inmate-patient screened for TB within 21 9 30 70.00% 0 the last year? 9.004 Were all inmate-patients offered an influenza vaccination for the most 30 0 30 100.00% 0 recent influenza season? 9.005 All inmate-patients from the age 50 through the age of 75: Was the 29 1 30 96.67% 0 inmate-patient offered colorectal cancer screening? 9.006 Female inmate-patients from the age of 50 through the age of 74: Was the inmate-patient offered a mammogram in compliance with Not Applicable policy? 9.007 Female inmate-patients from the age of 21 through the age of 65: Not Applicable Was the inmate-patient offered a pap smear in compliance with policy? 9.008 Are required immunizations being offered for chronic care 14 3 17 82.35% 13 inmate-patients? 9.009 Are inmate-patients at the highest risk of coccidioidomycosis (valley 0 0 0 0.00% 1 fever) infection transferred out of the facility in a timely manner? Overall Percentage: 90.11% Quality of Nursing Performance Scored Answers The quality of nursing performance will be assessed during case reviews, conducted by OIG clinicians, and is not applicable for the compliance portion of the medical inspection. The methodologies OIG clinicians use to evaluate the quality of nursing Not Applicable performance are presented in a separate inspection document entitled OIG MIU Retrospective Case Review Methodology. Quality of Provider Performance Scored Answers The quality of provider performance will be assessed during case reviews, conducted by OIG clinicians, and is not applicable for the compliance portion of the medical inspection. The methodologies OIG clinicians use to evaluate the quality of Not Applicable provider performance are presented in a separate inspection document entitled OIG MIU Retrospective Case Review Methodology. Kern Valley State Prison, Cycle 4 Medical Inspection Page 81 Office of the Inspector General State of California Reception Center Arrivals Scored Answers This indicator is not applicable to this institution. Not Applicable Scored Answers Specialized Medical Housing (OHU, CTC, Yes Reference + SNF, Hospice) Number Yes No No Yes % N/A 13.001 For all higher-level care facilities: Did the registered nurse complete 10 0 10 100.00% 0 an initial assessment of the inmate-patient on the day of admission, or within eight hours of admission to CMF's Hospice? 13.002 For OHU, CTC, & SNF only: Did the primary care provider for OHU 10 0 10 100.00% 0 or attending physician for a CTC & SNF evaluate the inmate-patient within 24 hours of admission? 13.003 For OHU, CTC, & SNF only: Was a written history and physical 10 0 10 100.00% 0 examination completed within 72 hours of admission? 13.004 For all higher level care facilities: Did the primary care provider 8 2 10 80.00% 0 complete the Subjective, Objective, Assessment, Plan, and Education (SOAPE) notes on the inmate-patient at the minimum intervals required for the type of facility where the inmate-patient was treated? 13.101 For OHU and CTC Only: Do inpatient areas either have properly 1 0 1 100.00% 0 working call systems in its OHU & CTC or are 30-minute patient welfare checks performed; and do medical staff have reasonably unimpeded access to enter inmate-patient's cells? Overall Percentage: 96.00% Kern Valley State Prison, Cycle 4 Medical Inspection Page 82 Office of the Inspector General State of California Scored Answers Yes Reference + Specialty Services Number Yes No No Yes % N/A 14.001 Did the inmate-patient receive the high priority specialty service within 15 0 15 100.00% 0 14 calendar days of the PCP order? 14.002 Did the PCP review the high priority specialty service consultant report 9 6 15 60.00% 0 within the required time frame? 14.003 Did the inmate-patient receive the routine specialty service within 90 15 0 15 100.00% 0 calendar days of the PCP order? 14.004 Did the PCP review the routine specialty service consultant report 6 9 15 40.00% 0 within the required time frame? 14.005 For endorsed inmate-patients received from another CDCR 11 9 20 55.00% 0 institution: If the inmate-patient was approved for a specialty services appointment at the sending institution, was the appointment scheduled at the receiving institution within the required time frames? 14.006 Did the institution deny the primary care provider request for specialty 12 0 12 100.00% 1 services within required time frames? 14.007 Following the denial of a request for specialty services, was the 8 4 12 66.67% 1 inmate-patient informed of the denial within the required time frame? Overall Percentage: 74.52% Kern Valley State Prison, Cycle 4 Medical Inspection Page 83 Office of the Inspector General State of California Scored Answers Internal Monitoring, Quality Improvement, and Yes Reference + Administrative Operations Number Yes No No Yes % N/A 15.001 Did the institution promptly process inmate medical appeals during the 12 0 12 100.00% 0 most recent 12 months? 15.002 Does the institution follow adverse/sentinel event reporting Not Applicable requirements? 15.003 Did the institution Quality Management Committee (QMC) meet at 5 1 6 83.33% 0 least monthly to evaluate program performance, and did the QMC take action when improvement opportunities were identified? 15.004 Did the institution's Quality Management Committee (QMC) or other 1 0 1 100.00% 0 forum take steps to ensure the accuracy of its Dashboard data reporting? 15.005 For each initiative in the Performance Improvement Work Plan 0 5 5 0.00% 0 (PIWP), has the institution performance improved or reached the targeted performance objective(s)? 15.006 For institutions with licensed care facilities: Does the local 4 0 4 100.00% 0 governing body (LGB), or its equivalent, meet quarterly and exercise its overall responsibilities for the quality management of patient health care? 15.007 Does the Emergency Medical Response Review Committee perform 0 12 12 0.00% 0 timely incident package reviews that include the use of required review documents? 15.101 Did the institution complete a medical emergency response drill for 3 0 3 100.00% 0 each watch and include participation of health care and custody staff during the most recent full quarter? 15.102 Did the institution's second level medical appeal response address all of 8 2 10 80.00% 0 the inmate-patient's appealed issues? 15.103 Did the institution's medical staff review and submit the initial inmate 7 0 7 100.00% 0 death report to the Death Review Unit in a timely manner? 15.996 For Information Purposes Only: Did the CCHCS Death Review Committee submit its inmate death review summary to the institution Information Only timely? 15.997 For Information Purposes Only: Identify the institution's protocols Information Only for tracking medical appeals. 15.998 For Information Purposes Only: Identify the institution's protocols Information Only for implementing health care local operating procedures. 15.999 For Information Purposes Only: Identify the institution's health care Information Only staffing resources. Overall Percentage: 73.70% Kern Valley State Prison, Cycle 4 Medical Inspection Page 84 Office of the Inspector General State of California Scored Answers Job Performance, Training, Licensing, and Yes Reference + Certifications Number Yes No No Yes % N/A 16.001 Do all providers maintain a current medical license? 15 0 15 100.00% 0 16.101 Does the institution's Supervising Registered Nurse conduct periodic 4 1 5 80.00% 0 reviews of nursing staff? 16.102 Are nursing staff who administer medications current on their clinical 10 0 10 100.00% 0 competency validation? 16.103 Are structured clinical performance appraisals completed timely? 7 0 7 100.00% 3 16.104 Are staff current with required medical emergency response 3 0 3 100.00% 0 certifications? 16.105 Are nursing staff and the Pharmacist-in-Charge current with their 5 0 5 100.00% 1 professional licenses and certifications? 16.106 Do the institution's pharmacy and authorized providers who prescribe 1 0 1 100.00% 0 controlled substances maintain current Drug Enforcement Agency (DEA) registrations? 16.107 Are nursing staff current with required new employee orientation? 1 0 1 100.00% 0 Overall Percentage: 97.50% Kern Valley State Prison, Cycle 4 Medical Inspection Page 85 Office of the Inspector General State of California APPENDIX B — CLINICAL DATA Table B-1: KVSP Sample Sets Sample Set Total Anticoagulation 3 Death Review/Sentinel Events 4 Diabetes 3 Emergency Services — CPR 2 Emergency Services — Non-CPR 5 High Risk 5 Hospitalization 5 Intra-System Transfers in 3 Intra-System Transfers out 3 RN Sick Call 35 Specialty Services 5 73 Kern Valley State Prison, Cycle 4 Medical Inspection Page 86 Office of the Inspector General State of California Table B-2 KVSP Chronic Care Diagnoses Diagnosis Total Anemia 3 Anticoagulation 3 Arthritis/Degenerative Joint Disease 2 Asthma 14 COPD 3 Cancer 1 Cardiovascular Disease 3 Chronic Kidney Disease 2 Chronic Pain 5 Cirrhosis/End-Stage Liver Disease 3 Coccidioidomycosis 3 Deep Venous Thrombosis/Pulmonary Embolism 3 Diabetes 10 Gastroesophageal Reflux Disease 6 Gastrointestinal Bleed 1 Hepatitis C 25 Hyperlipidemia 15 Hypertension 26 Mental Health 16 Rheumatological Disease 1 Seizure Disorder 6 Sleep Apnea 2 Thyroid Disease 4 157 Kern Valley State Prison, Cycle 4 Medical Inspection Page 87 Office of the Inspector General State of California Table B-3 KVSP Event — Program Program Total Diagnostic Services 146 Emergency Care 64 Hospitalization 54 Intra-System Transfers in 14 Intra-System Transfers out 9 Not Specified 1 Outpatient Care 542 Reception Center Care 2 Specialized Medical Housing 262 Specialty Services 79 1,173 Table B-4 KVSP Case Review Sample Summary Total MD Reviews Detailed 30 MD Reviews Focused 0 RN Reviews Detailed 19 RN Reviews Focused 43 Total Reviews 92 Total Unique Cases 73 Overlapping Reviews (MD & RN) 19 Kern Valley State Prison, Cycle 4 Medical Inspection Page 88 Office of the Inspector General State of California APPENDIX C — COMPLIANCE SAMPLING METHODOLOGY Kern Valley State Prison Sample Category Quality (number of Indicator patients) Data Source Filters Access to Care Chronic Care Master Registry  Chronic care conditions (at least one condition per (30—Basic Level) inmate-patient—any risk level) (40—Inter Level)  Randomize Nursing Sick Call MedSATS  Clinic (each clinic tested) (5 per clinic)  Appt. date (2–9 months) (minimum of 30)  Randomize Returns from Inpatient Claims  See Health Information Management (Medical Community Hospital Data Records) (returns from community hospital) (30) Diagnostic Radiology Radiology Logs  Appt. Date (90 days–9 months) Services (10)  Randomize  Abnormal Laboratory Quest  Appt. date (90 days–9 months) (10)  Order name (CBC or CMPs only)  Randomize  Abnormal Pathology InterQual  Appt. date (90 days–9 months) (10)  Service (pathology related)  Randomize Health Timely Scanning OIG Qs: 1.001,  Non-dictated documents Information (20 each) 1.002, 1.006, &  First 5 inmate-patients selected for each question Management 9.004 (Medical OIG Q: 1.001  Dictated documents Records)  First 20 inmate-patients selected OIG Qs: 14.002  Specialty documents & 14.004  First 10 inmate-patients selected for each question OIG Q: 4.008  Community hospital discharge documents  First 20 inmate-patients selected for the question OIG Q: 7.001  MARs  First 20 inmate-patients selected Legible Signatures OIG Qs: 4.008,  First 8 inmates sampled and Review 6.001/6.002,  One source document per inmate-patient (40) 7.001, 12.001/12.002, & 14.002 Complete and Documents for  Any incorrectly scanned eUHR document Accurate Scanning any tested inmate identified during OIG eUHR file review, e.g., mislabeled, misfiled, illegibly scanned, or missing Returns from Inpatient Claims  Date (2–8 months) Community Hospital Data  Most recent 6 months provided (within date range) (30)  Rx count  Discharge date  Randomize (each month individually)  First 5 inmate-patients from each of the 6 months (if not 5 in a month, supplement from another, as needed) Kern Valley State Prison, Cycle 4 Medical Inspection Page 89 Office of the Inspector General State of California Sample Category Quality (number of Indicator patients) Data Source Filters Health Care Clinical Areas OIG Inspector  Identify and inspect all onsite clinical areas. Environment (number varies by Onsite Review institution) Inter- and Intra-System SOMS  Arrival date (3–9 months) Intra-System transfers  Arrived from (another CDCR facility) Transfers (30)  Rx count  Randomize Specialty Service MedSATS  Date of Transfer (3–9 months) Send-outs  Randomize (20) Pharmacy and Chronic Care OIG Q: 1.001 See Access to Care Medication Medication  (At least one condition per inmate-patient—any Management (30—Basic Level) risk level) (40—Inter Level)  Randomize New Medication Master Registry  Rx Count Orders  Randomize (30—Basic Level)  Ensure no duplication of inmate-patients tested in (40—Inter Level) chronic care medications Intra-Facility moves MAPIP Transfer  Date of transfer (2–8 months) (30) Data  To location/from location (yard to yard and to/from ASU)  Remove any to/from MHCB  NA/DOT meds (high–low)–inmate-patient must have NA/DOT meds to qualify for testing  Randomize En Route SOMS  Date of transfer (2–8 months) (10)  Sending institution (another CDCR facility)  Randomize  Length of stay (minimum of 2 days)  NA/DOT meds Returns from Inpatient Claims  See Health Information Management (Medical Community Hospital Data Records) (returns from community hospital) (30) Medication OIG Inspector  Identify and inspect onsite clinical areas that Preparation and Onsite Review prepare and administer medications Administration Areas Pharmacy OIG Inspector  Identify and inspect onsite pharmacies Onsite Review Medication Error OIG Inspector  Any medication error identified during OIG eUHR Reporting Review file review, e.g., case reviews and/or compliance testing Prenatal and Recent Deliveries OB Roster  Delivery date (2–12 months) Post-Delivery (5)  Most recent deliveries (within date range) Services N/A at this institution Pregnant Arrivals OB Roster  Arrival date (2–12 months) (5)  Earliest arrivals (within date range) N/A at this institution Kern Valley State Prison, Cycle 4 Medical Inspection Page 90 Office of the Inspector General State of California Sample Category Quality (number of Indicator patients) Data Source Filters Preventive Chronic Care OIG Q: 1.001  Chronic care conditions (at least 1 condition per Services Vaccinations inmate-patient—any risk level) (30—Basic Level)  Randomize (40—Inter Level)  Condition must require vaccination(s) Not all conditions require vaccinations INH Maxor  Dispense date (past 9 months) (all applicable up to  Time period on INH (at least a full 3 months) 30)  Randomize Colorectal Screening SOMS  Arrival date (at least 1 year prior to inspection) (30)  Date of birth (51 or older)  Randomize Influenza SOMS  Arrival date (at least 1 year prior to inspection) Vaccinations  Randomize (30)  Filter out inmate-patients tested in chronic care vaccination sample TB Code 22, annual SOMS  Arrival date (at least 1 year prior to inspection) TST  TB Code (22) (15)  Randomize TB Code 34, annual SOMS  Arrival date (at least 1 year prior to inspection) screening  TB Code (34) (15)  Randomize Mammogram SOMS  Arrival date (at least 2 years prior to inspection) (30)  Date of birth (age 52–74) N/A at this institution  Randomize Pap Smear SOMS  Arrival date (at least three years prior to (30) inspection) N/A at this institution  Date of birth (age 24–53)  Randomize Valley Fever Cocci Transfer  Reports from past 2–8 months (number will vary, up Status Report  Institution to 20)  Ineligibility date (60 days prior to inspection date)  All Reception RC SOMS  Arrival date (2–8 months) Center Arrivals (20)  Arrived from (county jail, return from parole, etc.)  Randomize N/A at this institution Specialized OHU, CTC, SNF, CADDIS  Admit date (1–6 months) Medical Hospice  Type of stay (no MH beds) Housing (10 per housing area)  Length of stay (minimum of 5 days)  Randomize Kern Valley State Prison, Cycle 4 Medical Inspection Page 91 Office of the Inspector General State of California Sample Category Quality (number of Indicator patients) Data Source Filters Specialty High-Priority MedSATS  Appt. date (3–9 months) Services Access (10)  Randomize Routine MedSATS  Appt. date (3–9 months) (10)  Remove optometry, physical therapy or podiatry  Randomize Specialty Service MedSATS  Arrived from (other CDCR institution) Arrivals  Date of transfer (3–9 months) (20)  Randomize Denials InterQual  Review date (3–9 months) (20)*  Randomize IUMC/MAR  Meeting date (9 months) *Ten InterQual Meeting Minutes  Denial upheld Ten MARs  Randomize Internal Medical Appeals Monthly Medical  Medical appeals (12 months) Monitoring, (all) Appeals Reports Quality Adverse/Sentinel Adverse/Sentinel  Adverse/sentinel events (2–8 months) Improvement, Events Events Report and (5) Administrative QMC Meetings Quality  Meeting minutes (12 months) Operations (12) Management Committee Meeting Minutes Performance Performance  Performance Improvement Work Plan with Improvement Plans Improvement updates (12 months) (12) Work Plan Local Governing Local Governing  Meeting minutes (12 months) Body Body Meeting (12) Minutes EMRRC EMRRC  Meeting minutes (6 months) (6) Meeting Minutes Medical Emergency OIG Inspector  Most recent full quarter Response Drills Onsite Review  Each watch (3) 2nd Level Medical OIG Inspector  Medical appeals denied (6 months) Appeals Onsite Review (10) Death Reports OIG Inspector  Death reports (12 months) (10) Onsite Review Local Operating OIG Inspector  Review all Procedures Onsite Review (all) Kern Valley State Prison, Cycle 4 Medical Inspection Page 92 Office of the Inspector General State of California Sample Category Quality (number of Indicator patients) Data Source Filters Job Performance RN Review OIG Inspector  Current Supervising RN reviews and Training, Evaluations Onsite Review Licensing, and (5) Certifications Nursing Staff OIG Inspector  Review annual competency validations Validations Onsite Review  Randomize (10) Provider Annual OIG Inspector  All required performance evaluation documents Evaluation Packets Onsite Review (all) Medical Emergency OIG Inspector  All staff Response Onsite Review o Providers (ACLS) Certifications o Nursing (BLS/CPR) (all) o Custody (CPR/BLS) Nursing staff and OIG Inspector  All licenses and certifications Pharmacist-in-charge Onsite Review Professional Licenses and Certifications (all) Pharmacy and OIG Inspector  All current DEA registrations Providers’ Drug Onsite Review Enforcement Agency (DEA) Registrations (all) Nursing Staff New OIG Inspector  New employees (within the last 12 months) Employee Onsite Review Orientations (all) Kern Valley State Prison, Cycle 4 Medical Inspection Page 93 Office of the Inspector General State of California C C ALIFORNIA ORRECTIONAL H C S ’ EALTH ARE ERVICES R ESPONSE Kern Valley State Prison, Cycle 4 Medical Inspection Page 94 Office of the Inspector General State of California December 17, 2015 Robert A. Barton, Inspector General Office of the Inspector General 10111 Old Placerville Road, Suite 110 Sacramento, CA 95827 Dear Mr. Barton: The purpose of this letter is to inform you that the Office of the Receiver has reviewed the draft report of the Office of the Inspector General (OIG) Medical Inspection Results for Kern Valley State Prison (KVSP) conducted from June 2015 to August 2015. California Correctional Health Care Services (CCHCS) acknowledges all OIG findings. Thank you for preparing the report. Your efforts have advanced our mutual objective of ensuring transparency and accountability in CCHCS operations. If you have any questions or concerns, please contact me at (916} 691-9573. Sincerely, ~s ;(~ Deputy Director Policy and Risk Management Services California Correctional Health Care Services cc: Clark Kelso, Receiver Diana Toche, Undersecretary, Health Care Services Richard Kirkland, Chief Deputy Receiver Jared Goldman, Counsel to the Receiver Roy Wesley, Chief Deputy Inspector General, OIG Christine Berthold, Deputy Inspector General, Senior, OIG Mark Vollmer, Senior Deputy Inspector General (A), OIG Scott Heatley, M.D., Ph.D., CCHP, Chief Physician and Surgeon, OIG Roscoe Barrow, Chief Counsel, Receiver's Office of legal Affairs, CCHCS Yulanda Mynhier, Director, Health Care Policy and Administration, CCHCS R. Steven Tharratt, M.D., MPVM, FACP, Director, Health Care Operations, CCHCS Renee Kanan, M.D., Chief Quality Officer, Quality Management, CCHCS Ricki Barnett, M.D., Deputy Director, Medical Services, CCHCS Cheryl Schutt, R.N., Deputy Director, Nursing Services Branch, CCHCS Christopher Podratz, Regional Health Care Executive, Region Ill, CCHCS Felix lgbinosa, M.D., Regional Deputy Medical Executive, Region Ill, CCHCS Steven Jones, Regional Nursing Executive, Region Ill, CCHCS CALIFORNIA CORRECT 0 AL P.O. Box 588500 HEALTH CARE SERVICES Elk Grove, CA 95758