Kern Valley State Prison Medical Inspection Report Cycle 5

Roy W. Wesley Office of the Inspector General Inspector General Kern Valley State Prison Medical Inspection Results Cycle 5 January 2018 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 5 Roy W. Wesley Inspector General Bryan Beyer Chief Deputy Inspector General Shaun R. Spillane Public Information Officer January 2018 T C ABLE OF ONTENTS Foreword .............................................................................................................................................. i Executive Summary ............................................................................................................................ ii Overall Assessment: Adequate ......................................................................................................... ii Clinical Case Review and OIG Clinician Inspection Results ............................................... iv Compliance Testing Results .................................................................................................. iv Recommendations ................................................................................................................. vi Population-Based Metrics ..................................................................................................... vi Introduction ......................................................................................................................................... 1 About the Institution ........................................................................................................................ 1 Objectives, Scope, and Methodology .................................................................................................. 3 Case Reviews ................................................................................................................................... 4 Patient Selection for Retrospective Case Reviews ................................................................. 4 Benefits and Limitations of Targeted Subpopulation Review ............................................... 5 Case Reviews Sampled .......................................................................................................... 6 Compliance Testing ......................................................................................................................... 7 Sampling Methods for Conducting Compliance Testing ....................................................... 7 Scoring of Compliance Testing Results ................................................................................. 8 Overall Quality Indicator Rating for Case Reviews and Compliance Testing ................................ 8 Population-Based Metrics ................................................................................................................ 8 Medical Inspection Results ................................................................................................................. 9 Access to Care ................................................................................................................. 10 Case Review Results ............................................................................................................ 10 Compliance Testing Results ................................................................................................. 13 Diagnostic Services ......................................................................................................... 15 Case Review Results ............................................................................................................ 15 Compliance Testing Results ................................................................................................. 16 Emergency Services ......................................................................................................... 18 Case Review Results ............................................................................................................ 18 Health Information Management .................................................................................... 20 Case Review Results ............................................................................................................ 20 Compliance Testing Results ................................................................................................. 21 Health Care Environment ............................................................................................... 24 Compliance Testing Results ................................................................................................. 24 Inter- and Intra-System Transfers ................................................................................... 28 Case Review Results ............................................................................................................ 28 Compliance Testing Results ................................................................................................. 29 Pharmacy and Medication Management ........................................................................ 31 Case Review Results ............................................................................................................ 31 Compliance Testing Results ................................................................................................. 32 Prenatal and Post-Delivery Services .............................................................................. 36 Kern Valley State Prison, Cycle 5 Medical Inspection Table of Contents Office of the Inspector General State of California Preventive Services .......................................................................................................... 37 Compliance Testing Results ................................................................................................. 37 Quality of Nursing Performance ................................................................................... 39 Case Review Results ............................................................................................................ 39 Quality of Provider Performance .................................................................................. 42 Case Review Results ............................................................................................................ 42 Reception Center Arrivals ............................................................................................. 45 Specialized Medical Housing ........................................................................................ 46 Case Review Results ............................................................................................................ 46 Compliance Testing Results ................................................................................................. 48 Specialty Services .......................................................................................................... 49 Case Review Results ............................................................................................................ 49 Compliance Testing Results ................................................................................................. 50 Administrative Operations (Secondary) ........................................................................ 52 Compliance Testing Results ................................................................................................. 52 Recommendations ............................................................................................................................. 55 Population-Based Metrics ................................................................................................................. 56 Appendix A — Compliance Test Results ......................................................................................... 59 Appendix B — Clinical Data ............................................................................................................ 72 Appendix C — Compliance Sampling Methodology ....................................................................... 76 California Correctional Health Care Services’ Response ................................................................. 83 Kern Valley State Prison, Cycle 5 Medical Inspection Table of Contents Office of the Inspector General State of California L T F IST OF ABLES AND IGURES KVSP Executive Summary Table ...................................................................................................... iii KVSP Health Care Staffing Resources as of May 2017 ..................................................................... 2 KVSP Master Registry Data as of May 26, 2017 ................................................................................ 2 KVSP Results Compared to State and National HEDIS Scores ....................................................... 58 Table B-1: KVSP Sample Sets .......................................................................................................... 72 Table B-2: KVSP Chronic Care Diagnoses ...................................................................................... 73 Table B-3: KVSP Event – Program .................................................................................................. 74 Table B-4: KVSP Review Sample Summary .................................................................................... 75 Kern Valley State Prison, Cycle 5 Medical Inspection List of Tables and Figures Office of the Inspector General State of California F OREWORD Pursuant to California Penal Code Section 6126 et seq., which assigns the Office of the Inspector General (OIG) responsibility for oversight of the California Department of Corrections and Rehabilitation (CDCR), the OIG conducts a comprehensive inspection program to evaluate the delivery of medical care at each of CDCR’s 35 adult prisons. The OIG explicitly makes no determination regarding the constitutionality of care in the prison setting. That determination is left to the Receiver and the federal court. The assessment of care by the OIG is just one factor in the court’s determination whether care in the prisons meets constitutional standards. The OIG’s inspections are mandated by the Penal Code and not aimed at specifically resolving the court’s questions on constitutional care. To the degree that they provide another factor for the court to consider, the OIG is pleased to provide added value to the taxpayers of California. In Cycle 5, for the first time, the OIG will be inspecting institutions delegated back to CDCR from the Receivership. There is no difference in the standards used for assessment of a delegated institution versus an institution not yet delegated. The receiver delegated Kern Valley State Prison back to CDCR in May 2017. This fifth cycle of inspections will continue evaluating the areas addressed in Cycle 4, which included clinical case review, compliance testing, and a population-based metric comparison of selected Healthcare Effectiveness Data Information Set (HEDIS) measures. In agreement with stakeholders, the OIG made changes to both the case review and compliance components. The OIG found that in every inspection in Cycle 4, larger samples were taken than were needed to assess the adequacy of medical care provided. As a result, the OIG reduced the number of case reviews and sample sizes for compliance testing. Also, in Cycle 4, compliance testing included two secondary (administrative) indicators (Internal Monitoring, Quality Improvement, and Administrative Operations; and Job Performance, Training, Licensing, and Certifications). For Cycle 5, these have been combined into one secondary indicator, Administrative Operations. Kern Valley State Prison, Cycle 5 Medical Inspection Page i Office of the Inspector General State of California E S XECUTIVE UMMARY The OIG performed its Cycle 5 medical inspection at Kern Valley State Prison (KVSP) from June to August 2017. The inspection OVERALL RATING: included in-depth reviews of 52 patient files conducted by clinicians, as well as reviews of documents from 411 patient files, Adequate covering 91 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 13 health care quality indicators applicable to the institution. To conduct clinical case reviews, the OIG employs a clinician team consisting of a physician and a registered nurse consultant, while compliance testing is done by a team of registered nurses trained in monitoring medical policy compliance. Of the indicators, seven were rated by both case review clinicians and compliance inspectors, three were rated by case review clinicians only, and three were rated by compliance inspectors only. The KVSP Executive Summary Table on the following page identifies the applicable individual indicators and scores for this institution. Kern Valley State Prison, Cycle 5 Medical Inspection Page ii Office of the Inspector General State of California KVSP Executive Summary Table Cycle 5 Cycle 4 Case Review Compliance Inspection Indicators Overall Overall Rating Rating Rating Rating 1—Access to Care Adequate Adequate Adequate Proficient 2—Diagnostic Services Proficient Adequate Adequate Adequate 3—Emergency Services Adequate Not Applicable Adequate Adequate 4—Health Information Adequate Inadequate Adequate Inadequate Management 5—Health Care Environment Not Applicable Inadequate Inadequate Proficient 6—Inter- and Intra-System Adequate Inadequate Adequate Adequate Transfers 7—Pharmacy and Medication Inadequate Inadequate Inadequate Inadequate Management 8—Prenatal and Post-Delivery Not Applicable Not Applicable Not Applicable Not Applicable Services 9—Preventive Services Not Applicable Proficient Proficient Proficient 10—Quality of Nursing Adequate Not Applicable Adequate Adequate Performance 11—Quality of Provider Adequate Not Applicable Adequate Adequate Performance 12—Reception Center Arrivals Not Applicable Not Applicable Not Applicable Not Applicable 13—Specialized Medical Housing Adequate Proficient Adequate Adequate 14—Specialty Services Adequate Proficient Adequate Adequate 15—Administrative Operations Not Applicable Adequate Adequate Adequate* (Secondary) *In Cycle 4, there were two secondary (administrative) indicators. This score reflects the average of those two scores. Kern Valley State Prison, Cycle 5 Medical Inspection Page iii Office of the Inspector General State of California Clinical Case Review and OIG Clinician Inspection Results The clinicians’ case reviews sampled patients with high medical needs and included a review of more than 924 patient care events.1 Of the 13 indicators applicable to KVSP, 10 were evaluated by clinician case review; one was proficient, eight were adequate, and one was inadequate. When determining the overall adequacy of care, the OIG paid particular attention to the clinical nursing and provider quality indicators, as adequate health care staff can sometimes overcome suboptimal processes and programs. However, the opposite is not true; inadequate health care staff cannot provide adequate care, even though the established processes and programs onsite may be adequate. The OIG clinicians identify inadequate medical care based on the risk of significant harm to the patient, not the actual outcome. Program Strengths — Clinical • KVSP had well-respected medical leaders who actively participated in patient care. The chief medical executive (CME) was integral to the daily provider morning report and provided updates for each hospitalized patient. Every provider interviewed praised KVSP’s medical leadership. • The nurses and providers worked collaboratively to reduce the backlog that resulted from the transition to the Electronic Health Record System (EHRS). Program Weaknesses — Clinical • Medication management was poor. On multiple occasions, nurses failed to notify providers when patients were not taking important medications, and sometimes did not give medications as ordered. Occasionally nurses did not properly monitor the blood sugar of diabetic patients. There were several instances in which patients did not get any medications because nurses requested medications through the central-fill pharmacy instead of properly obtaining them through the Omnicell (automatic medication dispenser). Compliance Testing Results Of the 13 health care indicators applicable to KVSP, 10 were evaluated by compliance inspectors.2 Three were proficient, three were adequate, and four were inadequate. There were 91 individual compliance questions within those 10 indicators, generating 1,132 data points, testing KVSP’s 1 Each OIG clinician team includes a board-certified physician and registered nurse consultant with experience in correctional and community medical settings. 2 The OIG’s compliance inspectors are trained registered nurses with expertise in CDCR policies regarding medical staff and processes. Kern Valley State Prison, Cycle 5 Medical Inspection Page iv Office of the Inspector General State of California compliance with California Correctional Health Care Services (CCHCS) policies and procedures.3 Those 91 questions are detailed in Appendix A — Compliance Test Results. Program Strengths — Compliance • Nursing staff reviewed patient health care service requests the same day they were received and conducted face-to-face encounters with those patients within required time frames. • The institution provided patients with radiology and laboratory services within the ordered time frames. • KVSP performed well providing patients with preventive services, specifically in offering patients timely immunizations and colorectal cancer screenings. • The institution received high-priority and routine specialty service reports timely, and providers reviewed those specialty service reports within the required time frames. • The institution performed well with administrative operations. KVSP addressed patient health care appeals timely and regularly held Quality Management Committee meetings that addressed the accuracy of Dashboard data. Program Weaknesses — Compliance • Several of KVSP’s clinic locations did not have essential core medical equipment and supplies available, and equipment had expired calibration dates. Some clinic exam rooms did not have an environment conducive to a comprehensive examination; one exam room had medical storage cabinets in disrepair, and other exam rooms had torn vinyl on the exam tables. • Patients who transferred into KVSP from other CDCR institutions did not always receive their prescribed medications timely. • At medication line locations, the institution did a poor job accounting for narcotic medication and displayed inventory control problems. In addition, KVSP did not always store non-narcotic medications properly. 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 5 Medical Inspection Page v Office of the Inspector General State of California Recommendations Based on the results of the Cycle 5 medical inspection at KVSP, the OIG recommends the institution do the following: • Provide cross-training to staff members in specialty services access, and arrange periodic cross-training updates. Access to specialty services was problematic when the regular nurse was on medical leave. Periodic cross-training may have helped the covering staff to perform the work properly. Population-Based Metrics In general, KVSP performed sufficiently as measured by population-based metrics. In comprehensive diabetes care, KVSP outperformed all state and national health care plans in four of the five measures. However, KVSP scored lower than all other health care plans for diabetic eye exams, but a 19 percent patient refusal rate affected the institution’s score in this measure. With regard to immunization measures, KVSP’s results were mixed; for influenza immunizations for both younger and older adults, patient refusals negatively affected KVSP’s scores. However, KVSP scored higher than all applicable health care plans for pneumococcal immunizations. Finally, the institution’s score for colorectal cancer screening was mixed in comparison to the other state and national health care plans, again with patient refusals affecting the institution’s score. KVSP performed well as measured by population-based metrics in comparison to the other health care plans reviewed. The institution may improve its scores for diabetic eye exams, influenza vaccinations for both younger and older adults, and colorectal cancer screenings by reducing patient refusals through educating patients on the benefits of these preventive services. Kern Valley State Prison, Cycle 5 Medical Inspection Page vi Office of the Inspector General State of California I NTRODUCTION Pursuant to California Penal Code Section 6126 et seq., which assigns the Office of the Inspector General (OIG) responsibility for oversight of the California Department of Corrections and Rehabilitation (CDCR), and at the request of the federal Receiver, the OIG developed a comprehensive medical inspection program to evaluate the delivery of medical care at each of CDCR’s 35 adult prisons. The OIG conducts a clinical case review and a compliance inspection, ensuring a thorough, end-to-end assessment of medical care within CDCR. Kern Valley State Prison (KVSP) was the 16th medical inspection of Cycle 5. During the inspection process, the OIG assessed the delivery of medical care to patients using the primary clinical health care indicators applicable to the institution. The Administrative Operations indicator is secondary because it does not reflect the actual clinical care provided. ABOUT THE INSTITUTION Located in Delano, Kern County, KVSP is a Level IV (maximum-security) facility consisting of four semi-autonomous 180-bed facilities and two stand-alone administrative segregation units. KVSP operates several medical clinics where staff handle non-urgent requests for medical services. The institution also treats patients who need urgent or emergency care in its triage and treatment area (TTA) and treats patients who require inpatient care in their correctional treatment center (CTC). The institution screens patients in its receiving and release location (R&R) and provides specialized clinical services in its specialty service/telemedicine clinic. KVSP has been designated by CDCR as a “basic care prison,” as its location is rural, far from tertiary care centers and specialty care providers whose services would likely be used frequently by higher-risk patients. In August 2014, KVSP received national accreditation from the Commission on Accreditation for Corrections, and received recertification in March 2017. This accreditation program is a professional peer review process based on national standards set by the American Correctional Association. Based on staffing data the OIG obtained from the institution, KVSP’s vacancy rate among medical managers, primary care providers, supervisors, and rank-and-file nurses was 6 percent in May 2017, with the highest vacancy percentage among primary care providers at 11 percent. At the time of the OIG’s inspection, 12 clinical staff members were on long-term medical leave. Kern Valley State Prison, Cycle 5 Medical Inspection Page 1 Office of the Inspector General State of California KVSP Health Care Staffing Resources as of May 2017 Primary Care Nursing Management Nursing Staff Totals Providers Supervisors Description Number % Number % Number % Number % Number % Authorized 5 4% 9 8% 10 9% 90.8 79% 114.8 100% Positions Filled Positions 5 100% 8 89% 9 90% 86 95% 108 94% Vacancies 0 0% 1 11% 1 10% 4.8 5% 6.8 6% Recent Hires (within 12 0 0% 1 13% 1 11% 19 22% 21 19% months) Staff Utilized 0 0% 0 0% 0 0% 14 16% 14 13% from Registry Redirected Staff (to Non-Patient 0 0% 0 0% 0 0% 0 0% 0 0% Care Areas) Staff on Long-term 0 0% 1 13% 2 22% 9 10% 12 11% Medical Leave Note: KVSP Health Care Staffing Resources data was not validated by the OIG. As of May 26, 2017, the Master Registry for KVSP showed that the institution had a total population of 3,749. Within that total population, 1.1 percent were designated as high medical risk, Priority 1 (High 1), and 3.5 percent were designated as high medical risk, Priority 2 (High 2). Patients’ assigned risk levels are based on the complexity of their required medical care related to their specific diagnoses, frequency of higher levels of care, age, and abnormal laboratory results and procedures. High 1 has at least two high-risk conditions; High 2 has only one. Patients at high medical risk are more susceptible to poor health outcomes than those at medium or low medical risk. Patients at high medical risk also typically require more health care services than do patients with lower assigned risk levels. The chart below illustrates the breakdown of the institution’s medical risk levels at the start of the OIG medical inspection. KVSP Master Registry Data as of May 26, 2017 Medical Risk Level Number of Patients Percentage High 1 41 1.1% High 2 130 3.5% Medium 1,620 43.2% Low 1,958 52.2% Total 3,749 100% Kern Valley State Prison, Cycle 5 Medical Inspection Page 2 Office of the Inspector General State of California O , S , M BJECTIVES COPE AND ETHODOLOGY In designing the medical inspection program, the OIG reviewed CCHCS policies and procedures, relevant court orders, and guidance developed by the American Correctional Association. The OIG also reviewed professional literature on correctional medical care; reviewed standardized performance measures used by the health care industry; consulted with clinical experts; and met with stakeholders from the court, the Receiver’s office, CDCR, the Office of the Attorney General, and the Prison Law Office to discuss the nature and scope of the OIG’s inspection program. With input from these stakeholders, the OIG developed a medical inspection program that evaluates medical care delivery by combining clinical case reviews of patient files, objective tests of compliance with policies and procedures, and an analysis of outcomes for certain population-based metrics. To maintain a metric-oriented inspection program that evaluates medical care delivery consistently at each State prison, the OIG identified 15 indicators (14 primary (clinical) indicators and one secondary (administrative) indicator) of health care to measure. The primary quality indicators cover clinical categories directly relating to the health care provided to patients, whereas the secondary quality indicator address the administrative functions that support a health care delivery system. These 15 indicators are identified in the KVSP Executive Summary Table on page iii of this report. The OIG rates each of the quality indicators applicable to the institution under inspection based on case reviews conducted by OIG clinicians and compliance tests conducted by OIG registered nurses. The 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 done by clinicians, while the ratings for the primary quality indicators Health Care Environment and Preventive Services are derived entirely from compliance testing done by registered nurse inspectors. As another example, primary quality indicators such as Diagnostic Services and Specialty Services receive ratings derived from both sources. Consistent with the OIG’s agreement with the Receiver, this report only addresses the conditions found related to medical care criteria. The OIG does not review for efficiency and economy of operations. Moreover, if the OIG learns of a patient needing immediate care, the OIG notifies the chief executive officer of health care services and requests a status report. Additionally, if the OIG learns of significant departures from community standards, it may report such departures to the institution’s chief executive officer or to CCHCS. Because these matters involve confidential medical information protected by State and federal privacy laws, 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 Kern Valley State Prison, Cycle 5 Medical Inspection Page 3 Office of the Inspector General State of California quality indicator; therefore, recommendations for improvement should not necessarily be interpreted as indicative of deficient medical care delivery. CASE REVIEWS The OIG added case reviews to the Cycle 4 medical inspections at the recommendation of its stakeholders, which continues in Cycle 5 medical inspections. 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; 11 percent of the total patient population are considered high-risk and account for more than half of the institution’s pharmaceutical, specialty, community hospital, and emergency costs. 2. Selecting this target group for chart review provides a significantly greater opportunity to evaluate all the various aspects of the health care delivery system at an institution. Underlying the choice of high-risk patients for detailed case review, the OIG clinical experts made the following three assumptions: 1. If the institution is able to provide adequate clinical care to the most challenging patients with multiple complex and interdependent medical problems, it will be providing adequate care to patients with less complicated health care issues. Because clinical expertise is required to determine whether the institution has provided adequate clinical care, the OIG utilizes experienced correctional physicians and registered nurses to perform this analysis. 2. The health of less complex patients is more likely to be affected by processes such as timely appointment scheduling, medication management, routine health screening, and Kern Valley State Prison, Cycle 5 Medical Inspection Page 4 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 (unexpected occurrences involving death or serious injury, or risk thereof), and hospitalizations are mostly of high-risk patients. Benefits and Limitations of Targeted Subpopulation Review Because the selected patients utilize the broadest range of services offered by the health care system, the OIG’s retrospective chart review provides adequate data for a qualitative assessment of the most vital system processes (referred to as “primary quality indicators”). Retrospective chart review provides an accurate qualitative assessment of the relevant primary quality indicators as applied to the targeted subpopulation of high-risk and high-utilization patients. While this targeted subpopulation does not represent the prison population as a whole, the ability of the institution to provide adequate care to this subpopulation is a crucial and vital indicator of how the institution provides health care to its whole patient population. Simply put, if the institution’s medical system does not adequately care for those patients needing the most care, then it is not fulfilling its obligations, even if it takes good care of patients with less complex medical needs. 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. Kern Valley State Prison, Cycle 5 Medical Inspection Page 5 Office of the Inspector General State of California Case Reviews Sampled As indicated in Appendix B, Table B–1: KVSP Sample Sets, the OIG clinicians evaluated medical charts for 52 unique patients. Appendix B, Table B–4: KVSP Case Review Sample Summary, clarifies that both nurses and physicians reviewed charts for 12 of those patients, for 64 reviews in total. Physicians performed detailed reviews of 20 charts, and nurses performed detailed reviews of 12 charts, totaling 32 detailed reviews. For detailed case reviews, physicians or nurses looked at all encounters occurring in approximately six months of medical care. Nurses also performed a limited or focused review of medical records for an additional 32 patients. These generated 924 clinical events for review (Appendix B, Table B–3: KVSP Event–Program). The inspection tool provides details on whether the encounter was adequate or had significant deficiencies, and identifies deficiencies by programs and processes to help the institution focus on improvement areas. While the sample method specifically pulled only five chronic care patient records, i.e., three diabetes patients and two anticoagulation patients (Appendix B, Table B–1: KVSP Sample Sets), the 52 unique patients sampled included patients with 147 chronic care diagnoses, including 11 additional patients with diabetes (for a total of 14) (Appendix B, Table B–2: KVSP Chronic Care Diagnoses). The OIG’s sample selection tool allowed evaluation of many chronic care programs because the complex and high-risk patients selected from the different categories often had multiple medical problems. While the OIG did not evaluate every chronic disease or health care staff member, the 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 found the Cycle 4 medical inspection physician sample size of 30 detailed reviews far exceeded the saturation point necessary for an adequate qualitative review. At the end of Cycle 4 inspections, the case review results were re-analyzed using 50 percent of the cases, finding no significant differences in the ratings. To improve inspection efficiency, while preserving the quality of the inspection, the samples for Cycle 5 medical inspections were reduced in number of cases. For Cycle 5 inspections, basic institutions, with low high-risk populations, case review will use 67 percent of the case review samples used in Cycle 4 inspection, for both physician and nurse reviewed cases. For intermediate institutions, or basic institutions housing many high-risk patients, the case review samples will use 83 percent. Finally, the most medically complex institution, CHCF, has retained the full 100 percent samples of Cycle 4 inspections. KVSP is a basic facility, and the physician sample was 67 percent (20 physician case reviews) of the Cycle 4 sample. With regard to reviewing charts from different providers, the case review is not intended to be a focused search for poorly performing providers; rather, it is focused on how the system cares for those patients who need care the most. Nonetheless, while not sampling cases by each provider at the institution, the OIG inspections adequately review most providers. Providers would only escape OIG case review if institutional management successfully mitigated patient risk by having the more poorly performing providers care for the less complicated, low-utilizing, and lower-risk patients. Kern Valley State Prison, Cycle 5 Medical Inspection Page 6 Office of the Inspector General State of California The OIG’s clinicians concluded that the case review sample size was more than adequate to assess the quality of services provided. Based on the collective results of clinicians’ case reviews, the OIG rated each quality indicator as either proficient (excellent), adequate (passing), inadequate (failing), or not applicable. A separate confidential 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. COMPLIANCE TESTING Sampling Methods for Conducting Compliance Testing From June to August 2017, registered nurse inspectors attained answers to 91 objective medical inspection test (MIT) questions designed to assess the institution’s compliance with critical policies and procedures applicable to the delivery of medical care. To conduct most tests, inspectors randomly selected samples of patients for whom the testing objectives were applicable and reviewed their electronic medical records. In some cases, inspectors used the same samples to conduct more than one test. In total, inspectors reviewed health records for 411 individual patients and analyzed specific transactions within their records for evidence that critical events occurred. Inspectors also reviewed management reports and meeting minutes to assess certain administrative operations. In addition, during the week of June 12, 2017, field registered nurse 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 1,132 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 Cycle 5 medical inspection testing, the OIG reduced the number of compliance samples tested for 18 indicator tests from a sample of 30 patients to a sample of 25 patients. The OIG also removed some inspection tests upon stakeholder agreement that either were duplicated in the case reviews or had limited value. Lastly, for Cycle 4 medical inspections, the OIG tested two secondary (administrative) indicators: Internal Monitoring, Quality Improvement, and Administrative Operations; and Job Performance, Training, Licensing, and Certifications. These tests have been combined into one Administrative Operations indicator for Cycle 5 inspections. For details of the compliance results, see Appendix A — Compliance Test Results. For details of the OIG’s compliance sampling methodology, see Appendix C — Compliance Sampling Methodology. Kern Valley State Prison, Cycle 5 Medical Inspection Page 7 Office of the Inspector General State of California Scoring of Compliance Testing Results After compiling the answers to the 91 questions for the 10 applicable indicators, the OIG derived a score for each quality indicator by calculating the percentage score of all Yes answers for each of the questions applicable to a particular indicator, then averaging those scores. Based on those results, the OIG assigned a rating to each quality indicator of proficient (greater than 85 percent), adequate (between 75 percent and 85 percent), or inadequate (less than 75 percent). OVERALL QUALITY INDICATOR RATING FOR CASE REVIEWS AND COMPLIANCE TESTING The OIG derived the final rating for each quality indicator by combining the ratings from the case reviews and from the compliance testing, as applicable. When combining these ratings, the case review evaluations and the compliance testing results usually agreed, but there were instances when the rating differed for a particular quality indicator. In those instances, the inspection team assessed the quality indicator based on the collective ratings from both components. Specifically, the OIG clinicians and registered nurse inspectors discussed the nature of individual exceptions found within that indicator category and considered the overall effect on the ability of patients to receive adequate medical care. To derive an overall assessment rating of the institution’s medical inspection, the OIG evaluated the various rating categories assigned to each of the quality indicators applicable to the institution, giving more weight to the rating results of the primary quality indicators, which directly relate to the health care provided to patients. Based on that analysis, OIG experts made a considered and measured overall opinion about the quality of health care observed. POPULATION-BASED METRICS The OIG identified a subset of Healthcare Effectiveness Data Information Set (HEDIS) measures applicable to the CDCR patient population. To identify outcomes for KVSP, the OIG reviewed some of the compliance testing results, randomly sampled additional patients’ records, and obtained KVSP data from the CCHCS Master Registry. The OIG compared those results to HEDIS metrics reported by other statewide and national health care organizations. Kern Valley State Prison, Cycle 5 Medical Inspection Page 8 Office of the Inspector General State of California M I R EDICAL NSPECTION ESULTS The quality indicators assess the clinical aspects of health care. As shown on the KVSP Executive Summary Table on page iii of this report, 13 of the OIG’s indicators were applicable to KVSP. Of those 13 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 three were rated by the compliance component alone. The Administrative Operations indicator is a secondary indicator, and, therefore, was not relied upon for the overall score for the institution. Based on the analysis and results in all the primary indicators, the OIG experts made a considered and measured opinion that the quality of health care at KVSP was adequate. Summary of Case Review Results: The clinical case review component assessed ten primary (clinical) indicators applicable to KVSP. Of these ten indicators, OIG clinicians rated one proficient, eight adequate, and one inadequate. The OIG physicians rated the overall adequacy of care for each of the 20 detailed case reviews they conducted. Of these 20 cases, 17 were adequate, and 3 were inadequate. In the 924 events reviewed, there were 211 deficiencies, of which 74 were considered to be of such magnitude that, if left unaddressed, they would likely contribute to patient harm. Adverse Events Identified During Case Review: Adverse events are medical errors which cause serious patient harm. Medical care is a complex dynamic process with many moving parts, subject to human error even within the best health care organizations. Adverse events are typically identified and tracked by all major health care organizations for the purpose of quality improvement. They are not generally representative of medical care delivered by the organization. The OIG identified adverse events for the dual purposes of quality improvement and the illustration of problematic patterns of practice found during the inspection. Because of the anecdotal description of these events, the OIG cautions against drawing inappropriate conclusions regarding the institution based solely on adverse events. There were no adverse events identified in the case reviews at KVSP. Summary of Compliance Results: The compliance component assessed 10 of the 13 indicators applicable to KVSP. Of these ten indicators, OIG inspectors rated three proficient, three adequate, and four inadequate. The results of those assessments are summarized within this section of the report. The test questions used to assess compliance for each indicator are detailed in Appendix A. Kern Valley State Prison, Cycle 5 Medical Inspection Page 9 Office of the Inspector General State of California ACCESS TO CARE This indicator evaluates the institution’s ability to provide patients Case Review Rating: with timely clinical appointments. Areas specific to patients’ access Adequate to care are reviewed, such as initial assessments of newly arriving Compliance Score: inmates, acute and chronic care follow-ups, face-to-face nurse Adequate appointments when a patient requests to be seen, provider referrals (82.3%) from nursing lines, and follow-ups after hospitalization or specialty Overall Rating: care. Compliance testing for this indicator also evaluates whether Adequate patients have Health Care Services Request forms (CDCR Form 7362) available in their housing units. Case Review Results The OIG clinicians reviewed 214 provider, nurse, specialty, and hospital events that required a follow-up appointment and identified 33 deficiencies relating to the Access to Care indicator, 23 of which were significant. Provider-to-Provider Follow-up Appointments In most instances, follow-up appointments were scheduled timely and providers kept their appointments. There was only one minor deficiency whereby a requested provider follow-up appointment occurred late. Sick Call Access KVSP performed well with regard to nursing sick call access. The majority of sick call appointments were scheduled timely, and there were no reported backlogs of nursing appointments. The OIG clinicians reviewed 69 sick call events and identified seven deficiencies, four of which were significant (in case 5 and the following): • In case 3, the diabetic patient requested to speak to someone regarding his knee pain and diabetes, but the nurse did not perform a face-to-face assessment. • In case 4, the patient complained of severe pain and inability to walk and stated his pain medication was not working, but the nurse did not perform a face-to-face assessment. On a separate occasion, the nurse again did not perform a face-to-face assessment when the patient complained of severe hip and pelvic pain with numbness. Nurse-to-Provider Referrals KVSP did well for most nurse-to-provider referrals requested when patients required higher levels of care. The OIG clinicians reviewed 34 nurse-to-provider referrals and found in six instances the Kern Valley State Prison, Cycle 5 Medical Inspection Page 10 Office of the Inspector General State of California patient was seen late or not at all. All six deficiencies were significant and occurred in cases 32, 34, 43, 48, and the following: • In case 5, the nurse evaluated the patient for back, arm, and leg pain. The nurse requested a provider appointment in 14 days, but the appointment did not occur. • In case 10, the nurse evaluated the patient for chronic back pain. The nurse requested a provider appointment in 14 days, but the appointment did not occur. Nursing Follow-up Appointments KVSP performed well with scheduling nurse follow-up appointments. The OIG clinicians reviewed 11 of these events and identified two deficiencies, both of which were significant: • In case 4, the nurse evaluated the patient after a fall and requested a follow-up with a nurse, but the appointment did not occur. • In case 38, the nurse and provider evaluated the patient for a sick call request for a sore on his finger. The nurse and provider wanted the patient to have a follow-up appointment with a nurse at different time intervals, but neither the nurse nor the provider ordered the follow- up, and there was a lapse in care. Provider Follow-up After Specialty Services KVSP providers generally saw their patients timely after specialty appointments. The OIG reviewed 46 specialty appointments that required a provider follow-up and identified only one deficiency whereby the follow-up appointment was not scheduled within the requested time frame: • In case 3, the patient saw an orthopedic surgeon and was supposed to follow up with a provider within 14 days, but the appointment did not occur for 28 days. Intra-System Transfers KVSP performed well with ensuring patients who transferred in from other CDCR institutions were given timely appointments. This is further discussed in the Inter- and Intra-System Transfers indicator. Follow-up After Hospitalization The institution ensured that providers timely saw their patients after outside hospitalizations or emergency department visits. There were 20 such events reviewed and only one deficiency whereby the patient was scheduled late: • In case 12, the patient was seen in an outside emergency department for chest pain. A follow-up appointment was requested within 5 days, but it did not occur for 11 days. Kern Valley State Prison, Cycle 5 Medical Inspection Page 11 Office of the Inspector General State of California Follow-up After Urgent/Emergent Care KVSP performed acceptably in scheduling patients with their providers after they were evaluated in the TTA. The OIG clinicians reviewed 23 urgent or emergent encounters, eight of which required a provider or nurse follow-up. There were two deficiencies, both of which were significant: • In case 12, the patient returned from the outside emergency department should have been seen by his regular provider within five days. The appointment did not occur. • Also in case 12, the patient was seen in the TTA for recurrent chest pain. The on-call provider recommended a follow-up within five days, but it did not occur for ten days. Specialized Medical Housing KVSP performed very well with provider access in the correctional treatment center (CTC). No deficiencies were identified. Specialty Access and Follow-up The institution performed well ensuring appointments with specialists and with primary care providers after specialty consultations. The OIG clinicians reviewed 46 specialty consultations and procedures. There was a delay in six instances. Performance in this area is also discussed in the Specialty Services indicator. Diagnostic Results Follow-up KVSP excelled at providing follow-ups for abnormal diagnostic results. There were no deficiencies identified. Clinician Onsite Inspection The OIG clinicians met with the scheduling supervisors and discussed the deficiencies found during case reviews. Prior to the Electronic Health Record System (EHRS) transition, doctors and LVNs generated a close-out form containing the follow-up instructions after each appointment. Schedulers used the information from the close-out forms to determine whether or not to schedule follow-up appointments. The vast majority of the deficiencies occurred because clinic staff did not properly complete close-out forms and schedulers were unaware that follow-up appointments were needed. The transition to EHRS reduced the number of provider appointments available and resulted in a backlog of provider appointments. KVSP solved this problem by triaging the appointments and scheduling nurse appointments instead. For the follow-ups that required uncomplicated provider involvement, such as discussing diagnostic test results or recent medication changes, the nurse evaluated the patient and discussed the case with the provider. The provider then saw the patient, performed a basic examination, and documented the plan. This process successfully reduced the backlog of patients in one of the clinics from over 200 to less than 30 over a period of three months. Kern Valley State Prison, Cycle 5 Medical Inspection Page 12 Office of the Inspector General State of California Case Review Conclusion Overall, KVSP performed well with scheduling and seeing patients. Of the deficiencies that were identified, the vast majority were related to delays in follow-up due to clinic staff who did not complete the close-out forms properly after each appointment. Fortunately, in many cases, the patients were seen for separate concerns and the providers were still able to address their patients’ needs, albeit with some delay. With the arrival of EHRS, the providers ordered the follow-up appointments directly into the medical record. This new process eliminated scheduling lapses by effectively bypassing clinical staff who did not complete close-out forms. KVSP successfully reduced the backlog of provider appointments by converting the clinically straightforward provider appointments into nurse appointments with provider consultation. KVSP performed well with regard to the Access to Care indicator, and the case review rating was adequate. Compliance Testing Results The institution earned an adequate compliance score of 82.3 percent in the Access to Care indicator. The following tests earned scores in the proficient range: • Inspectors sampled 30 health care services request forms submitted by patients across all facility clinics. Nursing staff reviewed all service request forms on the same day they were received (MIT 1.003). • For 28 of the 30 patients sampled who submitted health care services request forms (93 percent), nursing staff completed the face-to-face encounter within one business day of reviewing the service request form. For the remaining two sampled patients, nursing staff completed the face-to-face encounter one day late (MIT 1.004). • Among 25 sampled patients discharged from a community hospital back to KVSP, 23 (92 percent) received their provider follow-up appointments timely. Two patients received their follow-up appointments 2 and 15 days late (MIT 1.007). • Among 12 sampled health care services request forms on which nursing staff referred the patient for a provider appointment, 11 of the patients (92 percent) received a timely appointment. For one patient, the provider did not address the patient’s complaint as specified on the request form (MIT 1.005). • Among 25 sampled patients who transferred into KVSP from other institutions and were referred to a provider based on the nursing staff’s initial health care screening, 22 patients (88 percent) were seen timely. Three patients received their provider appointments from one to eight days late (MIT 1.002). Kern Valley State Prison, Cycle 5 Medical Inspection Page 13 Office of the Inspector General State of California One test received an adequate score: • Inspectors sampled 23 patients who received a high-priority or routine specialty service; 18 of them (78 percent) received a timely follow-up appointment with a provider. Three patients received follow-up appointments from one to three days late. The remaining two patients did not receive their follow-up appointments (MIT 1.008). With scores in the inadequate range, the following tests showed areas for improvement: • Inspectors sampled 25 patients with one or more chronic care conditions; only 16 patients timely received their provider-ordered follow-up appointments (64 percent). Four patients’ follow-up appointments occurred 17, 37, 49, and 51 days late, and five patients’ appointments did not occur at all (MIT 1.001). • Of the three sampled patients referred to a provider by nursing staff and for whom the provider subsequently ordered a follow-up appointment, two (67 percent) received their follow-up appointments timely. For one patient, the appointment occurred 18 days late (MIT 1.006). • Patients had access to health care services request forms at four of the six housing units inspected (67 percent). Two inspected housing units did not have a supply of the forms available for patients’ use (MIT 1.101). Kern Valley State Prison, Cycle 5 Medical Inspection Page 14 Office of the Inspector General State of California DIAGNOSTIC SERVICES This indicator addresses several types of diagnostic services. Case Review Rating: Specifically, it addresses whether radiology and laboratory services Proficient were timely provided to patients, whether the primary care provider Compliance Score: timely reviewed the results, and whether the results were Adequate communicated to the patient within the required time frames. In (81.4%) addition, for pathology services, the OIG determines whether the Overall Rating: institution received a final pathology report and whether the provider Adequate 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. In this indicator, the OIG’s case review and compliance review processes yielded different results, with the case review giving a proficient rating and compliance review resulting in an adequate score. Compliance testing had a more robust pathology sample, and was deemed to be a more accurate representation of the institution’s performance. The OIG’s internal review process considered the factors that led to both scores and ultimately rated this indicator adequate. Case Review Results The OIG clinicians reviewed 93 diagnostic events and found nine deficiencies, one of which was significant. Of the nine deficiencies, seven were related to delayed review of results and two were related to the delayed completion of ordered tests. Test Completion KVSP did very well with diagnostic test completion. Of 93 diagnostic events, there were two delays, only one of which was significant. • In case 44, the provider ordered an electrocardiogram (EKG), a test to record the electrical activity of the heart. The provider needed the information to determine the next steps in diagnosing the patient’s condition. The test was completed six weeks later, resulting in a delay in the diagnosis. Health Information Management KVSP performed well in relaying test results to providers and ensuring that providers reviewed, signed, and communicated the results to patients. There were occasional minor delays in reviewing diagnostic results. There was one significant deficiency as discussed below: • In case 8, the patient’s pathology report was not obtained, reviewed, and scanned timely. It was also scanned with the wrong date of service. Kern Valley State Prison, Cycle 5 Medical Inspection Page 15 Office of the Inspector General State of California Clinician Onsite Inspection The OIG clinicians observed the distribution of diagnostic reports during the morning report. There were several computers available for the providers to review patients’ charts in conjunction with the laboratory and radiology reports. This process ensured that the providers had the correct perspective when they review the reports and helped the providers to make good decisions. Case Review Conclusion With only two significant deficiencies and seven minor deficiencies among 93 events, KVSP performed well with regard to the Diagnostic Services indicator, and the rating was thus proficient. Compliance Testing Results The institution received an adequate compliance score of 81.4 percent in the Diagnostic Services indicator, which encompasses radiology, laboratory, and pathology services. For clarity, each type of diagnostic service is discussed separately below. Radiology Services • KVSP timely performed radiology services for all ten patients sampled (MIT 2.001). KVSP providers then timely initialed and dated the corresponding diagnostic services reports as required by CCHCS policy for eight of the ten patients (80 percent); the providers reviewed one patient’s report six days late. For the remaining patient, inspectors found no evidence that providers initialed and dated the reports (MIT 2.002). Providers also timely communicated the test results to eight of the ten patients (80 percent); they communicated two patients’ results two and six days late (MIT 2.003). Laboratory Services • Nine of the ten sampled patients (90 percent) received their provider-ordered laboratory services timely, while the remaining patient received his laboratory service seven days late (MIT 2.004). The institution’s providers also reviewed eight of the ten laboratory reports within the required time frame (80 percent); the providers reviewed two reports one and two days late (MIT 2.005). Finally, providers timely communicated the results to seven of the ten patients (70 percent); for the other three patients, providers communicated the results from one to two days late (MIT 2.006). Kern Valley State Prison, Cycle 5 Medical Inspection Page 16 Office of the Inspector General State of California Pathology Services • The institution timely received final pathology reports for seven of ten patients sampled (70 percent). The institution received one report 12 days late, and no evidence was found of receipt of a report for two other patients (MIT 2.007). In addition, providers timely evidenced their review of the pathology reports for six of the eight applicable samples (75 percent); providers neither initialed nor dated the remaining two reports (MIT 2.008). Finally, providers timely communicated the pathology reports to seven of the eight patients sampled (87 percent). One patient’s report was communicated six days late (MIT 2.009). Kern Valley State Prison, Cycle 5 Medical Inspection Page 17 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 Overall Rating: reviews emergency response services including first aid, basic life 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 23 urgent/emergent events and found 14 deficiencies, 3 of which were significant. Most of these deficiencies were in documentation, usually related to missing flowsheets, incomplete notes, missing signatures, or mislabeled documents. These deficiencies did not affect the quality of patient care. CPR Response In the six emergency medical response cases reviewed, custody staff initiated CPR immediately and promptly notified health care staff. Nursing staff responded to the scene timely and generally performed appropriate emergency interventions. Provider Performance Provider performance in the emergency setting was very good. In urgent and emergent situations, the providers made accurate assessments and good decisions. On-call providers properly documented their telephone encounters. There were no provider deficiencies identified in this area. Nursing Performance and Documentation The nurses at KVSP provided appropriate care during medical emergencies. The OIG clinicians identified minor nursing deficiencies in the form of incomplete or missing documentation. However, there was one significant deficiency identified: • In case 24, during CPR, the TTA nurse applied a non-rebreather mask to deliver oxygen to an unresponsive patient who was not breathing. The mask was ineffective in supplying Kern Valley State Prison, Cycle 5 Medical Inspection Page 18 Office of the Inspector General State of California oxygen into the patient’s lungs because the patient also needed help with breathing, but the nurses did not provide assistance. Emergency Medical Response Review Committee The emergency medical response review committee (EMRRC) met regularly and discussed emergency events. Most deficiencies identified by the OIG clinicians were also identified by the EMRRC. Education and training was provided to the nursing staff. Clinician Onsite Inspection The OIG clinicians found the TTA patient care environment to be sufficient. The TTA had three available rooms for providing emergent medical care. One provider staffed both the TTA and CTC. Two nurses per shift were assigned to the TTA. The TTA nurses were knowledgeable about their job duties. The nurses said their supervisor was very supportive and assisted during medical emergencies when needed. Case Review Conclusion Patients requiring urgent or emergent services at KVSP received appropriate care. The OIG clinicians rated the Emergency Services indicator adequate. Kern Valley State Prison, Cycle 5 Medical Inspection Page 19 Office of the Inspector General State of California HEALTH INFORMATION MANAGEMENT Health information management is a crucial link in the delivery of Case Review Rating: medical care. Medical personnel require accurate information in Adequate order to make sound judgments and decisions. This indicator Compliance Score: examines whether the institution adequately manages its health care Inadequate information. This includes determining whether the information is (72.5%) correctly labeled and organized and available in the electronic Overall Rating: medical record; whether the various medical records (internal and Adequate external, e.g., hospital and specialty reports and progress notes) are obtained and scanned timely into the patient’s electronic medical record; whether records routed to clinicians include legible signatures or stamps; and whether hospital discharge reports include key elements and are timely reviewed by providers. For this indicator, the case review and compliance scores yielded different results, with case review providing an adequate rating and compliance testing resulting in an inadequate score. The primary reason for the inadequate compliance score was the poor performance in scanning documents into the electronic medical record. However, the OIG determined that the poor scanning performance did not affect the quality of care, and ultimately determined the overall score for this indicator to be adequate. During the OIG’s testing period, KVSP had converted to the new Electronic Health Record System (EHRS) (April 2017); therefore, this institution was considered a hybrid, with testing occurring in both the EHRS and the electronic Unit Health Record (eUHR). Case Review Results The OIG clinicians reviewed 924 events and found 27 deficiencies related to health information management, 6 of which were significant. Inter-Departmental Transmission KVSP performed well regarding inter-departmental transmission. There were no deficiencies identified. Hospital Records KVSP did well with retrieving emergency department and hospitalization reports. The OIG reviewed 28 outside emergency department and community hospital events. There were no deficiencies identified. Kern Valley State Prison, Cycle 5 Medical Inspection Page 20 Office of the Inspector General State of California Specialty Services KVSP performed extremely well with specialty reports. The OIG clinicians reviewed 78 specialty appointments and procedures. There were no deficiencies identified. Performance in this area is also discussed in the Specialty Services indicator. Diagnostic Reports The institution performed well with diagnostic reports with few exceptions. Performance in this area is further discussed in the Diagnostic Services indicator. Urgent/Emergent Records KVSP did well with maintaining urgent and emergent records. There were minor deficiencies identified in four cases. Performance in this area is also discussed in the Emergency Services indicator. Scanning Performance The institution’s performance for scanning documents was poor. There were three missing documents: a TTA nursing flow sheet, an Initial Health Screening form, and a Health Care Transfer Information form (CDCR Form 7371). Also, there were 4 documents with the wrong date of service, 4 mislabeled documents, 2 documents that were not signed by the nurse, 11 documents that were not signed by the provider, and one document scanned into the wrong chart. • In case 11, the physician’s order was mislabeled as “property receipts” in the electronic medical record. Legibility Legibility of progress notes was generally not a problem as most providers dictated or typed their notes, but some signatures were illegible. Clinician Onsite Inspection The OIG clinicians discussed the missing documents with medical records supervisors. The supervisor stated they scanned every document they received. They did not receive the documents and, therefore, had nothing to scan. The supervisor could not explain the reason for the missing documents. Case Review Conclusion In comparison to its performance in Cycle 4, KVSP improved in one area, but still demonstrated poor performance in scanning. The major improvement was in the retrieval and scanning of hospital records and specialty reports. Scanning performance in other areas was still problematic, with missing, mislabeled, and erroneously dated records. In general, KVSP performed satisfactorily with Kern Valley State Prison, Cycle 5 Medical Inspection Page 21 Office of the Inspector General State of California regard to the Health Information Management indicator and received an adequate case review rating. Compliance Testing Results The institution received an inadequate score of 72.5 percent for this indicator, with room for improvement in the following areas: • The institution’s staff timely scanned medication administration records (MARs) into the patients’ electronic medical records in one of three samples tested (33 percent). KVSP staff scanned the other two MARs 26 days late (MIT 4.005). • KVSP scored 67 percent for timely scanning of dictated or transcribed provider progress notes into patients’ electronic medical records. Timely scanning occurred within five days of the provider’s visit with the patient for two of the three sampled documents; the institution scanned one dictated progress note one day late (MIT 4.002). • For 14 of 20 specialty service consultant reports sampled (70 percent), the institution’s medical record staff scanned the reports into the patients’ electronic medical records within five calendar days. However, staff scanned the remaining six specialty reports from one to 12 days late (MIT 4.003). The institution scored in the adequate range in the following tests: • The institution timely scanned hospital discharge reports or treatment records into patients’ medical records for 17 of the 20 sampled reports (85 percent); two reports were scanned one day late, and one report was scanned 81 days late (MIT 4.004). • Inspectors reviewed hospital discharge reports and treatment records for 25 sampled patients sent by KVSP to an outside hospital. For 21 of the 25 patients (84 percent), the discharge summary reports were complete and timely reviewed by the institution’s providers. For two patients, providers reviewed the hospital discharge summary reports one and two days late. For one patient, the provider did not date the document. For one final patient, no evidence of a discharge summary was found in the medical record (MIT 4.007). • The institution scored 75 percent in its labeling and filing of documents scanned into patients’ electronic medical records. The OIG scores this test on a scale by which zero errors would result in a 100 percent score, and 24 errors would result in a score of zero; during testing for KVSP, inspectors found four mislabeled documents, one document scanned under the wrong date, and one document missing from the patient’s electronic medical file (MIT 4.006). Kern Valley State Prison, Cycle 5 Medical Inspection Page 22 Office of the Inspector General State of California KVSP received a proficient score in the following test: • The institution timely scanned 14 of 15 sampled non-dictated progress notes, initial health screening forms, and requests for health care services into the electronic medical record (93 percent). The institution scanned one patient’s initial health screening form 30 days late (MIT 4.001). Kern Valley State Prison, Cycle 5 Medical Inspection Page 23 Office of the Inspector General State of California HEALTH CARE ENVIRONMENT This indicator addresses the general operational aspects of the Case Review Rating: institution’s clinics, including certain elements of infection control Not Applicable and sanitation, medical supplies and equipment management, the Compliance Score: availability of both auditory and visual privacy for patient visits, and Inadequate (73.7%) the sufficiency of facility infrastructure to conduct comprehensive medical examinations. Rating of this component is based entirely on Overall Rating: the compliance testing results from the visual observations inspectors Inadequate make at the institution during their onsite visit. This indicator is evaluated entirely by compliance testing. There is no case review portion. Compliance Testing Results The institution received an inadequate compliance score of 73.7 percent in the Health Care Environment indicator, showing room for improvement in the following areas: • Only 5 of the 11 clinic locations (45 percent) met compliance requirements for essential core medical equipment and supplies. The remaining six clinics were missing one or more functional pieces of properly calibrated core equipment or other medical supplies necessary to conduct a comprehensive exam. The missing items included a demarcation line for the Snellen eye exam chart, a biohazard receptacle or bag, a nebulization unit, an otoscope and ophthalmoscope, hemoccult cards, lubricating jelly, and a glucometer and strips. In addition, an EKG and nebulization unit did not have current calibration stickers (MIT 5.108). Figure 1: Bulk Supplies stored on the • Only five of the ten clinics inspected followed floor appropriate medical supply storage and management protocols (50 percent). Medical supplies at five clinics had one or more of the following deficiencies: germicidal disposable cloths were stored together with medical supplies, bulk medical supplies were stored directly on the floor (Figure 1), medical supplies were stored beyond the manufacturers’ guidelines, and personal belongings and food items were stored long term in the bulk medical supply storage location (MIT 5.107). • Inspectors examined emergency response bags and crash carts to determine if institution staff inspected the bags daily and inventoried them monthly, and whether the bags contained all essential items. Emergency response bags and crash carts were compliant at five of the Kern Valley State Prison, Cycle 5 Medical Inspection Page 24 Office of the Inspector General State of California eight applicable clinical locations (63 percent). At two locations, randomly inventoried medical supplies were stocked at below- minimum levels. At another location, the emergency response bag’s log was missing multiple entries from staff verifying the bag’s compartments were sealed and intact (MIT 5.111). • Seven of the 11 clinic exam rooms observed (64 percent) had appropriate space, configuration, supplies, and equipment to allow clinicians to perform proper clinical examinations. In four clinics, the following deficiencies were identified: confidential Figure 2: Medical storage drawer in records were visible and easily accessible to disrepair patients and porters who cleaned the room; medical storage cabinets were not in proper working order (Figure 2); exam tables had torn vinyl covers (Figure 3); and exam tables were situated such that patients could not lie in a fully extended position (MIT 5.110). • OIG inspectors observed health care clinicians in each applicable clinic to ensure they employed proper hand hygiene protocols. In 8 of the 11 clinics (73 percent), clinicians followed good hand hygiene practices. At three clinic locations, clinicians failed to wash their hands before or after patient contact, or before applying gloves (MIT 5.104). Figure 3: Exam table with torn vinyl Kern Valley State Prison, Cycle 5 Medical Inspection Page 25 Office of the Inspector General State of California The institution scored in the adequate range on the following tests: • Clinical health care staff at 9 of the 11 applicable clinics (82 percent) ensured that reusable invasive and non-invasive medical equipment was properly sterilized or disinfected. In one clinic, inspectors identified several examples of previously sterilized surgical equipment missing date stamps and improperly packaged. In one other clinic, staff during the interview process reported that they relied on patient-porters for disinfecting exam tables prior to the start of shifts; however, patient-porters did not always clean prior to the shift. Therefore, the exam tables were not always cleaned (MIT 5.102). • Out of 11 clinic locations inspected, 9 clinics (82 percent) had operable sinks and sufficient quantities of hand hygiene supplies in the exam areas. In one clinic, the patient restroom did not have hand soap and disposable hand towels available. In another clinic, KVSP health care staff expressed concerns regarding the availability of proper hand hygiene supplies (MIT 5.103). • Health care staff at 9 of the 11 applicable clinics (82 percent) followed proper protocols to mitigate exposure to blood borne pathogens and contaminated waste. In one clinic, the sharps container in the exam room was found overfilled. In another clinic, staff did not have immediate access to personal protective equipment because it was not reasonably accessible in the clinic (MIT 5.105). • Clinic common areas at only eight of ten clinics (80 percent) had an environment conducive to providing medical services. In two clinics, the location of vital signs station compromised patients’ auditory privacy (MIT 5.109). KVSP received proficient scores on the following tests: • The non-clinic bulk medical supply storage areas met the supply management process and support needs of the medical health care program, earning KVSP a score of 100 percent on this test (MIT 5.106). • Ten of the 11 clinics examined (91 percent) were appropriately disinfected, cleaned, and sanitary. At one clinic, the exam room floor was visibly stained and unsanitary (Figure 4) (MIT 5.101). Figure 4: Stained and unsanitary exam room floor Kern Valley State Prison, Cycle 5 Medical Inspection Page 26 Office of the Inspector General State of California Non-Scored Results • The OIG gathered information to determine if the institution’s physical infrastructure was maintained in a manner that supported health care management’s ability to provide timely or adequate health care. The OIG does not score this question. When OIG inspectors interviewed health care managers, they did not identify any significant concerns about the institution’s infrastructure or its effect on the staff’s ability to provide adequate health care. At the time of the OIG’s medical inspection, KVSP had several significant infrastructure projects underway, which included increasing clinic space at five yards, renovating a new pharmacy, and expanding medication distribution areas. These projects started throughout 2016, and the institution estimated that these projects would be completed by the end of fall 2018 (MIT 5.999). Kern Valley State Prison, Cycle 5 Medical Inspection Page 27 Office of the Inspector General State of California INTER- AND INTRA-SYSTEM TRANSFERS This indicator focuses on the management of patients’ medical needs Case Review Rating: and continuity of patient care during the inter- and intra-system Adequate transfer process. The patients reviewed for this indicator include Compliance Score: those received from, as well as those transferring out to, other CDCR Inadequate (66.9%) institutions. The OIG review includes evaluation of the institution’s ability to provide and document health screening assessments, Overall Rating: initiation of relevant referrals based on patient needs, and the Adequate continuity of medication delivery to patients arriving from another institution. For those patients, the OIG clinicians also review the timely completion of pending health appointments, tests, and requests for specialty services. For patients who transfer out of the institution, the OIG evaluates the ability of the institution to document transfer information that includes pre-existing health conditions, pending appointments, tests and requests for specialty services, medication transfer packages, and medication administration prior to transfer. The OIG clinicians also evaluate the care provided to patients returning to the institution from an outside hospital and check to ensure appropriate implementation of the hospital assessment and treatment plans. In this indicator, the OIG’s case review and compliance testing 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 that led to both scores. Although compliance found some problems with medications during the patient transfers into the institution and out of the institution, those issues did not significantly affect the quality of patient care. As a result, an overall rating of adequate was deemed appropriate for this indicator. Case Review Results The OIG clinicians reviewed 46 events related to inter- and intra-system transfers, which included information from both the sending and receiving institutions. These included 21 outside hospitalization and emergency room events, each of which resulted in a transfer back to the institution. There were 12 deficiencies, 5 of which were significant. Transfers In The transfer-in process was sufficient. There were four patients who transferred in and 20 events for review. There were seven deficiencies, four of which were significant. KVSP sometimes implemented orders late and occasionally failed to implement them at all, as illustrated by the following case: • In case 27, the provider ordered a pneumonia vaccine and a thyroid test for the newly arrived patient. The support staff did not process the order. The patient received neither the vaccine nor the thyroid test. Kern Valley State Prison, Cycle 5 Medical Inspection Page 28 Office of the Inspector General State of California Transfers Out Nursing staff performed well in facilitating the transfer of patients out of KVSP to other institutions. There were two deficiencies identified in the five cases reviewed, one of which was significant: • In case 30, the patient was transferred to another institution, and KVSP did not scan the heath care transfer information form. The receiving institution had to scan the form into the electronic medical records due to KVSP staff’s oversight. Hospitalizations Patients returning from hospitalizations are some of the highest-risk encounters due to two factors. First, these patients are generally hospitalized for a severe illness or injury. Second, they are at risk due to potential lapses in care that can occur during any transfer. KVSP performed well with hospital transfers back to the institution. The OIG clinicians reviewed 21 events and found three minor deficiencies. Nursing and provider assessments were appropriate. The providers and nurses properly reviewed the discharge summaries, and there were no lapses in medication administration. Case Review Conclusion KVSP performed appropriately for patients transferring into the institution. For patients transferring out, performance was good. For hospital transfers, the TTA nurses made accurate patient assessments, reviewed hospital discharge recommendations thoroughly with the provider, and made appropriate follow-up referrals. The OIG clinicians rated the Inter- and Intra-System Transfers indicator adequate. Compliance Testing Results The institution obtained an inadequate score of 66.9 percent in the Inter- and Intra-System Transfers indicator, showing room for improvement in the following areas: • KVSP scored zero when the OIG tested the one patient who transferred out of KVSP during the onsite inspection to determine whether the patient’s transfer package included required medications and related documentation. The transfer package was missing all medications listed on the medication reconciliation form (MIT 6.101). • Among the 15 patients sampled who transferred into KVSP from other CDCR institutions with existing medication orders, 11 (73 percent) received their medications without interruption. Two of the remaining four patients did not receive their directly observed therapy (DOT) medication within one or more dosing periods upon their arrival. For one patient, nursing staff did not document the reason for his refusal of his medications, and for the final patient, nursing staff did not timely administer keep on person (KOP) medications (MIT 6.003). Kern Valley State Prison, Cycle 5 Medical Inspection Page 29 Office of the Inspector General State of California KVSP scored in the adequate range on the following two tests: • Inspectors sampled 20 patients who transferred out of KVSP to another CDCR institution to determine whether the institution listed their scheduled specialty service appointments on the health care information transfer form. KVSP nursing staff documented the previously approved and still pending specialty service appointments for 17 patients (85 percent), but failed to do so for three others (MIT 6.004). • Inspectors tested 25 patients who transferred into KVSP from other CDCR institutions to determine if they received a complete initial health screening assessment from nursing staff on their day of arrival. KVSP received a score of 76 percent on this test because nursing staff timely completed the assessment for 19 of the sampled patients. For the remaining six patients, nursing staff neglected to answer one or more of the screening form questions (MIT 6.001). One test earned KVSP a proficient score: • Nursing staff timely completed the assessment and disposition sections of the initial health screening form for all 25 patients sampled (MIT 6.002). Kern Valley State Prison, Cycle 5 Medical Inspection Page 30 Office of the Inspector General State of California PHARMACY AND MEDICATION MANAGEMENT This indicator is an evaluation of the institution’s ability to provide Case Review Rating: appropriate pharmaceutical administration and security Inadequate management, encompassing the process from the written Compliance Score: prescription to the administration of the medication. By combining Inadequate (67.0%) both a quantitative compliance test with case review analysis, this assessment identifies issues in various stages of the medication Overall Rating: management process, including ordering and prescribing, Inadequate 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 prescriber, staff, and patient. Case Review Results The OIG clinicians evaluated 123 events related to medications and found 22 deficiencies, 14 of which were significant. Medication Continuity KVSP performed well with ensuring medication continuity. There was no lapse in medication continuity for patients transferring into or out of the institution, or returning from community hospitals or emergency departments. Medication Administration Nursing staff did not perform well in administering medications accurately or timely, and sometimes did not administer ordered medications at all. Nurses did not always notify providers when patients’ blood sugar was low or high, or when patients refused blood sugar checks or insulin. • In case 3, the medication nurse did not administer the patient’s pain medication for three consecutive days twice. Additionally, the nurse did not notify the provider after the diabetic patient refused blood sugar checks and insulin three consecutive times. • In case 4, the nurse did not administer the diabetic patient’s insulin on one occasion, and on a separate occasion, the nurse did not notify the provider when the patient had a dangerously low blood sugar. The nurse administered sugar tablets for the patient’s low blood sugar, but did not recheck the blood sugar level to see if the sugar tablets were effective. On another occasion, the nurse did not implement the provider’s new insulin order for two days and did not notify the provider that the patient had a severely elevated blood sugar. On other occasions, the nurse did not administer the patient’s pain or blood pressure medications. Kern Valley State Prison, Cycle 5 Medical Inspection Page 31 Office of the Inspector General State of California • In case 9, the patient had low blood sugar. Despite orders not to administer insulin when the blood sugar levels were low, the nurse still administered the insulin. On separate occasions, the nurse did not notify the provider that the patient had low or severely high blood sugar. Pharmacy Errors There was one significant pharmacy deficiency: • In case 37, the pharmacist dispensed the wrong medication. The provider ordered a medication for the patient’s complaint of itchiness. However, the pharmacy dispensed a blood pressure medication instead. The nurse administered the incorrect medication. Six days later, the error was discovered and the correct medication was given. Clinician Onsite Inspection During the onsite visit, the OIG clinicians met with providers, nursing, and pharmacy representatives to discuss the case review findings. Nursing administration acknowledged the deficiencies and indicated that on-the-job training would be provided to nursing staff. Case Review Conclusion The OIG clinicians rated the Pharmacy and Medication Management indicator inadequate. Compliance Testing Results The institution received an inadequate compliance score of 67.0 percent in the Pharmacy and Medication Management indicator. For discussion purposes below, this indicator is divided into three sub-indicators: medication administration, observed medication practices and storage controls, and pharmacy protocols. Medication Administration In this sub-indicator, the institution received an average score of 64.8 percent, which falls into the inadequate range. The following tests showed areas for needed improvement: • Nursing staff administered medications without interruption to only three of ten patients who were en route from one institution to another with a temporary layover at KVSP (30 percent). For seven patients, there was no medical record evidence that the nursing staff administered medications as ordered (MIT 7.006). • Of 19 sampled patients, 11 (58 percent) timely received their chronic care medications. Among the compliance errors noted by inspectors, nursing staff indicated a refusal on the medication administration record (MAR) for two of the patients; however, the refusals were not properly documented as specified by CCHCS policy. Nursing staff did not properly indicate receipt or refusal of chronic care medication for five other patients. Nursing staff Kern Valley State Prison, Cycle 5 Medical Inspection Page 32 Office of the Inspector General State of California did not refer another two patients who missed three consecutive days of their DOT medications to their providers for counseling. Finally, three patients received extra supplies of their monthly KOP chronic care medications, which could have led to over-dosage (MIT 7.001). • For 18 of 25 sampled patients, staff timely administered provider-ordered medications upon the patient’s return to the institution after discharge from a community hospital (72 percent). For the other seven patients, staff did not administer, make available, or deliver medications within the required period. Five of those seven patients missed from one to four doses of their DOT medications. For one other patient, the institution made KOP medication available one day late, and for one final patient, the institution did not make available or administer his medications at all (MIT 7.003). The following tests earned scores in the adequate range: • The institution ensured that 21 of 25 patients (84 percent) sampled who transferred from one housing unit to another received their ordered medications without interruption. For two patients, nursing staff documented a “no show” on MAR without any further explanation. For one other patient, nursing staff did not properly document the patient’s refusal of medication as specified by CCHCS policy. For one final patient, there was no evidence found that nursing staff administered his medication (MIT 7.005). • Nursing staff timely administered or delivered new medication orders to 20 of the 25 patients sampled (80 percent). For four patients, nursing staff administered the medications one day late. For the remaining patient, nursing staff administered the medication 30 days late (MIT 7.002). Observed Medication Practices and Storage Controls In this sub-indicator, the institution received an inadequate score of 41.3 percent. Five of the six tests in this sub-indicator received inadequate scores, as follows: • The OIG interviewed nursing staff and inspected storage areas specifically for the storage of narcotics at nine applicable medication line locations to assess whether strong narcotics security controls existed. All nine areas had problems, including the following: missing signatures in the narcotics log books over a two-month period, which indicated there was a lack of physical shift inventories performed by nursing staff who safeguard the narcotics storage areas; missing signatures for destruction of narcotic medication; supervising nurses’ failure to mention an appropriate reporting process of narcotics discrepancies to the chief nurse executive and pharmacist in charge; and a narcotics discrepancy found during a spontaneous physical count of medications. As a result, the institution scored zero on this test (MIT 7.101). Kern Valley State Prison, Cycle 5 Medical Inspection Page 33 Office of the Inspector General State of California • KVSP properly stored non-narcotic medications not requiring refrigeration in only two of the nine applicable clinic and medication line storage locations (22 percent). In seven locations, one or more of the following deficiencies were observed: the medication area lacked a designated area for return-to-pharmacy medications; topical and oral medications were not properly separated when stored; multi-use medication was not labeled with the date it was opened; and a medication was stored beyond its expiration date (MIT 7.102). • Only two of seven inspected medication preparation and administration areas demonstrated appropriate administrative controls and protocols (29 percent). At five different medication line locations, the following deficiencies were identified: patients did not have sufficient protection from extreme heat or inclement weather at the outdoor medication line, and medication nurses did not always ensure patients swallowed their DOT medications (MIT 7.106). • Inspectors observed the medication preparation and administration processes at seven applicable medication line locations. Nursing staff were compliant regarding proper hand hygiene and contamination control protocols at three of the seven locations (43 percent). At four locations, not all nursing staff washed or sanitized their hands when required, such as prior to putting on gloves or before re-gloving (MIT 7.104). • Non-narcotic refrigerated medications were properly stored at 6 of 11 clinics and medication line storage locations (55 percent). At five locations, one or more of the following deficiencies were identified: staff did not have a process in place to separate refrigerated medication pending return to pharmacy, and medication refrigerators remained unlocked when not in active use (MIT 7.103). One test in this indicator received a proficient score of 100 percent: • Nursing staff at all seven of the inspected medication line locations employed appropriate administrative controls and followed appropriate protocols during medication preparation (MIT 7.105). Pharmacy Protocols In this sub-indicator, the institution received a proficient score of 100 percent in every test, as follows: • In its main pharmacy, the institution followed general security, organization, and cleanliness management protocols; properly stored and monitored non-narcotic medications that required refrigeration and those that did not; and maintained adequate controls over and properly accounted for narcotic medications (MIT 7.107, 7.108, 7.109, 7.110). • KVSP’s pharmacist in charge timely processed all 24 sampled medication error reports (MIT 7.111). Kern Valley State Prison, Cycle 5 Medical Inspection Page 34 Office of the Inspector General State of California Non-Scored Tests • In addition to the OIG’s testing of reported medication errors, inspectors follow up on any significant medication errors found during compliance testing to determine whether the errors were properly identified and reported. The OIG provides those results for information purposes only. At KVSP, the OIG did not find any applicable medication errors (MIT 7.998). • The OIG interviewed patients in isolation units to determine if they had immediate access to their prescribed KOP rescue inhalers and nitroglycerin medications. All 19 of the sampled patients had access to their asthma inhalers or nitroglycerin medications (MIT 7.999). Kern Valley State Prison, Cycle 5 Medical Inspection Page 35 Office of the Inspector General State of California PRENATAL AND POST-DELIVERY SERVICES This indicator evaluates the institution’s capacity to provide timely Case Review Rating: and appropriate prenatal, delivery, and postnatal services to Not Applicable pregnant patients. This includes the ordering and monitoring of Compliance Score: indicated screening tests, follow-up visits, referrals to higher Not Applicable levels of care, e.g., high-risk obstetrics clinic, when necessary, and Overall Rating: postnatal follow-up. Not Applicable Because KVSP was a male-only institution, this indicator did not apply. Kern Valley State Prison, Cycle 5 Medical Inspection Page 36 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 patients. These include cancer Not Applicable screenings, tuberculosis screenings, and influenza and chronic Compliance Score: care immunizations. This indicator also assesses whether certain Proficient institutions take preventive actions to relocate patients identified (88.0%) as being at higher risk for contracting coccidioidomycosis Overall Rating: (valley fever). Proficient The OIG rates this indicator entirely through the compliance testing component; the case review process does not include a separate qualitative analysis for this indicator. Compliance Testing Results The institution performed in the proficient range in the Preventive Services indicator, with a compliance score of 88.0 percent. Five tests earned proficient scores, as follows: • During the most recent influenza season, KVSP nursing staff administered or offered influenza vaccinations to all 25 sampled patients (MIT 9.004). • The institution offered colorectal cancer screenings to all 25 sampled patients subject to the annual screening requirement (MIT 9.005). • The OIG tested whether patients who suffered from a chronic care condition were offered vaccinations for influenza, pneumonia, and hepatitis. Among the 17 sampled patients with applicable chronic conditions, all were timely offered the vaccinations (MIT 9.008). • OIG inspectors found that 13 of the 15 sampled patients taking tuberculosis (TB) medication (87 percent) received the requisite monthly or weekly monitoring by medical staff. For two patients, staff did not appropriately scan the TB monitoring form into the patients’ medical records as required by CCHCS policy (MIT 9.002). • Of 30 patients sampled by OIG inspectors, 26 had received a TB screening within the last year (87 percent). For four patients, nursing staff did not complete the signs and symptoms section of the TB screening form (MIT 9.003). The following test received a score in the adequate range: • KVSP scored 80 percent for the timely administration of TB medications to 12 of the 15 patients inspectors sampled. One patient did not receive or properly refuse several doses of his TB medication. For another patient, nursing staff documented “I/P Failed to Report” on the medication administration record (MAR) without any further explanation. For one final Kern Valley State Prison, Cycle 5 Medical Inspection Page 37 Office of the Inspector General State of California patient, nursing staff administered the wrong TB medication during the last nine weeks of the patient’s scheduled course of TB medications (MIT 9.001). • Inspectors sampled eight patients identified to be at high risk for contracting the coccidioidomycosis infection (valley fever) and thus ineligible to reside at KVSP to ascertain if they were transferred out of the institution within 60 days from the time they were initially deemed ineligible. The institution was compliant for five of the eight patients sampled (62 percent). One patient, who was initially identified on January 17, 2017, as ineligible to be housed at KVSP, was still residing there as of August 8, 2017. Even after the 60-day grace period allowed for the institution to transfer these patients out of the institution, the patient was still housed there after 203 days. The institution transferred two other ineligible patients out 5 and 86 days late (MIT 9.009). Kern Valley State Prison, Cycle 5 Medical Inspection Page 38 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 review Compliance Score: process and does not have a score under the OIG compliance testing Not Applicable component. Case reviews include face-to-face encounters and Overall Rating: indirect activities performed by nursing staff on behalf of the Adequate patient. Review of nursing performance includes all nursing services performed on site, such as outpatient, inpatient, urgent/emergent, inmate transfers, care coordination, and medication management. The key focus areas for evaluation of nursing care include appropriateness and timeliness of patient triage and assessment, identification and prioritization of health care needs, use of the nursing process to implement interventions, and accurate, thorough, and legible documentation. Although nursing services provided in specialized medical housing units are reported in the Specialized Medical Housing indicator, and those provided in the TTA or related to emergency medical responses are reported in the Emergency Services indicator, all areas of nursing services are summarized in this Quality of Nursing Performance indicator. Case Review Results The quality of nursing performance at KVSP was adequate. The OIG clinicians reviewed 267 nursing encounters, of which 134 were in the outpatient setting. Most outpatient nursing encounters were for sick call requests, walk-in visits, and nurse follow-up visits. In all, there were 105 deficiencies identified related to nursing care performance, 21 of which were significant. Nursing Assessment The provision of adequate nursing care requires high-quality nursing assessments, which include both subjective (patient interview) and objective (evaluation and observation) components. The majority of nurses at KVSP included both subjective and objective nursing assessments when assessing patients. However, some cases demonstrated areas to target for staff education and other quality improvement strategies. The following cases showed significant deficiencies in the provision of nursing services: • In case 1, the TTA nurse did not reassess a patient with an elevated pulse and high blood pressure who complained of worsening dizziness after reporting that a needle had broken off in his neck a few days earlier when he injected drugs. • In case 3, the nurse did not address the diabetic patient’s complaint of sore heels and feet. The nurse should have performed an assessment for skin breakdown because diabetic patients are at risk for developing pressure ulcers. Kern Valley State Prison, Cycle 5 Medical Inspection Page 39 Office of the Inspector General State of California Nursing Intervention The nurses generally provided appropriate interventions, but there was one significant deficiency: • In case 5, nurses did not implement a new order for wound care for the patient with pressure ulcers, and instead continued to implement a discontinued order. Nursing Documentation Nursing documentation at KVSP was generally appropriate. Although there were several minor deficiencies that demonstrated areas to target for staff education and other quality improvement strategies, nursing documentation supported the provision of adequate nursing care at KVSP. Nursing Sick Call While most nurses performed appropriately and utilized CCHCS nursing protocols, sick call nurses did not always perform face-to-face assessments for patients with symptoms. There were areas to target for quality improvement, as illustrated in the following examples: • In case 43, the sick call nurse did not perform a face-to-face assessment the same day the sick call request was reviewed for a patient who complained of not being able to breathe properly due to back pain. • In case 48, the sick call nurse did not provide a face-to-face assessment for a patient with chronic arm and hand pain and inability to sleep. Urgent/Emergent Care Nurses in the TTA and first medical responders provided appropriate care to patients during emergency medical responses. However, there was one significant nursing deficiency, which is discussed in the Emergency Services indicator. Care Coordinators In general, licensed vocational nurse (LVN) care coordinators performed well and were knowledgeable about their job duties and patient population. The role of the care coordinator was to monitor patients with chronic health needs and those at risk for developing serious health complications. The LVN care coordinators provided appropriate interventions to support their patients’ goals and treatment plans. In addition, these nurses collected pertinent patient information, including previous laboratory results and pending laboratory tests, prior to a patient arriving at his clinic appointment. Care coordinator documentation included discussion of providing patient education and the current plan of care. These nurses also facilitated the delivery of medical supplies and monitored their patients closely when the patient’s health was not at goal levels. Kern Valley State Prison, Cycle 5 Medical Inspection Page 40 Office of the Inspector General State of California Returns from Hospital Patients returning to KVSP after hospital discharge were appropriately assessed by TTA nurses and received follow-up interventions and evaluations. These patients are further discussed in the Inter- and Intra-System Transfers indicator. Specialized Medical Housing Nurses in the CTC did not perform well. They did not always recognize the need for reassessment or timely intervention for patients in the CTC. These deficiencies are further discussed in the Specialized Medical Housing indicator. Inter- and Intra-System Transfers Nurses provided appropriate care for incoming patients and documented pertinent information for patients transferring out of KVSP. This is further discussed in the Inter- and Intra-System Transfers indicator. Offsite Specialty Services Returns The patients returning from offsite specialty appointments were assessed by the nurses in the TTA upon their return to KVSP. TTA nurses routinely communicated follow-up recommendations from the specialty consultants to the provider without delays. See the Specialty Services indicator for additional information. Clinician Onsite Inspection The OIG clinicians visited several clinical areas and spoke with nursing administrators and staff in the receiving and release clinic, outpatient clinics, specialty services, telemedicine, medication lines, the TTA, and the CTC. The huddles were well organized, attended by various members of the multidisciplinary team, and demonstrated active participation by team members. The general consensus among nursing staff was that morale at KVSP was good. Case Review Conclusion Nurses at KVSP provided appropriate and timely nursing care to the patients. All nurses interviewed were very familiar with their patient population, responsibilities, and duties. The Quality of Nursing Performance indicator at KVSP was adequate. Kern Valley State Prison, Cycle 5 Medical Inspection Page 41 Office of the Inspector General State of California QUALITY OF PROVIDER PERFORMANCE In this indicator, the OIG physicians provide a qualitative evaluation Case Review Rating: of the adequacy of provider care at the institution. Appropriate Adequate evaluation, diagnosis, and management plans are reviewed for Compliance Score: programs including, but not limited to, nursing sick call, chronic Not Applicable care programs, TTA, specialized medical housing, and specialty Overall Rating: services. The assessment of provider care is performed entirely by Adequate OIG physicians. There is no compliance testing component associated with this quality indicator. Case Review Results The OIG clinicians reviewed 246 provider encounters and identified 22 deficiencies related to provider performance, 9 of which were significant. Assessment and Decision-Making KVSP providers made good assessments and decisions. Providers appropriately reviewed laboratory results and requested follow-up appointments. There were exceptions related to diabetic management, discussed below in the chronic care section. There was only one significant deficiency in this area: • In case 6, the provider reviewed a gallbladder imaging study for a patient who complained of abdominal pain. The provider attributed an abnormal test result to a wrong assumption that the patient had had his gallbladder removed. Consequently, the provider failed to consider gallbladder problems when the patient continued to have symptoms. The provider did not order any further consultations or diagnostic tests to determine the source of the abdominal pain. Review of Records The providers reviewed patients’ electronic medical records with appropriate attention except in the following case: • In case 8, the patient had a serious bloodstream infection and diabetes, which put him at a higher risk of worsening infection and poor healing. The provider was not careful enough in reviewing the patient’s MAR and did not realize the patient had missed multiple doses of his antibiotic and antifungal medications. Without finishing the medications, the patient was at high risk of reinfection. The provider should have extended the treatment time for the medications, but did not. Kern Valley State Prison, Cycle 5 Medical Inspection Page 42 Office of the Inspector General State of California Chronic Care Providers gave good care for most of their chronic care patients. They made good decisions with regard to hypertension, asthma, hepatitis C infection, and cardiovascular disease. However, in two of the cases reviewed, the diabetes management was poor: • In case 3, after reviewing the patient’s blood sugar levels, other laboratory results, and medications, the provider decided to check more blood sugar levels. The provider wanted more information before changing the patient’s medications, but the provider failed to order a follow-up appointment. This oversight resulted in a lapse in diabetes care. • Also in case 3, on a later date, the provider found the patient’s blood sugar levels to be poorly controlled. Instead of increasing or adding new medications, the provider made no changes to the diabetes therapy and wanted to revisit it one year. Annual follow-up was not an appropriate plan of action for uncontrolled diabetes. Prolonged uncontrolled diabetes placed the patient at increased risk of complications such as heart disease, kidney failure, or stroke. • Again in case 3, the provider saw the patient a third time and the patient’s diabetes had worsened. The provider increased the insulin dose, but requested a follow-up in four to six months. The prolonged follow-up interval further increased the patient’s risk of diabetic complications. • In case 18, the patient had a laboratory test that showed worsening diabetes. The provider reviewed the report and ordered a follow-up. When the patient saw the provider, the provider failed to review the laboratory results. The provider increased the insulin by a negligible amount and ordered an inappropriately lengthy follow-up. Specialty Services The providers referred patients to specialists properly, reviewed reports timely, and followed specialty recommendations appropriately. This is further discussed in the Specialty Services indicator. Emergency Care Providers performed well in emergency care. They made appropriate triage decisions when patients presented emergently to the TTA, and providers were available for consultation with the TTA nursing staff. There were no deficiencies identified. Clinician Onsite Inspection The institution’s providers started their daily work with a provider morning report, attended by the chief medical executive (CME), chief physician and surgeon, and the providers. They reviewed patients that were currently hospitalized, sent to the hospital, returned from the hospital, received Kern Valley State Prison, Cycle 5 Medical Inspection Page 43 Office of the Inspector General State of California overnight care, and those housed in the CTC. The providers demonstrated good familiarity with their patients and their medical needs. After the morning report, each provider attended a clinic huddle with specific clinic staff. They discussed the patients on their panels and reviewed the events that happened overnight. They discussed medications that would expire. They demonstrated good teamwork and worked together to reduce the backlogs introduced by the transition to the EHRS. Every provider praised the medical leadership and credited the CME as being the major reason they remained. Several providers stated that they would have left State service to work in the private sector had it not been for the CME’s leadership. Every provider felt that the leadership was approachable, listened to their concerns, and made decisions in their best interest. Morale among providers was high. With regard to diabetes care, one provider suggested that the patients’ blood sugar levels were being followed closely by nurse case managers. The nurse care coordinator and the provider were in close contact, and the provider reviewed the logs weekly. Even though one provider demonstrated a strategy with the potential to manage diabetes effectively, the OIG clinicians found that the provider did not manage diabetes well in cases 3 and 18. Case Review Conclusion The provider group at KVSP performed well. The daily provider morning report allowed the providers to keep abreast of their sicker patients; the providers were well aware of the patients who required close monitoring and frequent treatment decisions. This allowed them to make well- informed assessments and good decisions. Of the 20 cases reviewed, 17 cases were adequate and 3 were inadequate. Therefore, the Quality of Provider Performance indicator was rated adequate. Kern Valley State Prison, Cycle 5 Medical Inspection Page 44 Office of the Inspector General State of California RECEPTION CENTER ARRIVALS This indicator focuses on the management of medical needs and continuity of care for patients arriving from outside the CDCR Case Review Rating: system. The OIG review includes evaluation of the ability of the Not Applicable Compliance Score: institution to provide and document initial health screenings, initial Not Applicable health assessments, continuity of medications, and completion of required screening tests; address and provide significant Overall Rating: Not Applicable accommodations for disabilities and health care appliance needs; and identify health care conditions needing treatment and monitoring. The patients reviewed for reception center cases are those received from non-CDCR facilities, such as county jails. Because KVSP did not have a reception center, this indicator did not apply. Kern Valley State Prison, Cycle 5 Medical Inspection Page 45 Office of the Inspector General State of California SPECIALIZED MEDICAL HOUSING This indicator addresses whether the institution follows appropriate Case Review Rating: policies and procedures when admitting patients to onsite inpatient Adequate facilities, including completion of timely nursing and provider Compliance Score: assessments. The chart review assesses all aspects of medical care Proficient related to these housing units, including quality of provider and (95.0%) nursing care. KVSP’s only specialized medical housing unit/units Overall Rating: was a correctional treatment center (CTC). Adequate 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. While each area’s results are discussed in detail below, the result variance is due to the testing approaches. Because the case review process contained a more detailed review, the OIG inspection team determined the final overall rating was adequate. Case Review Results The CTC at KVSP had 22 beds, of which 12 were mental health beds and 10 were medical beds. The OIG clinicians reviewed seven admissions and 174 provider and nursing encounters. There were 57 deficiencies, 15 of which were significant. Provider Performance The CTC providers usually gave their patients good care. The OIG identified nine deficiencies related to provider performance, most of which were minor and unlikely to contribute to patient harm. The following were significant deficiencies: • In case 8, the patient had recently returned from the hospital after a bloodstream infection. The hospital recommended a five-day drug regimen to treat the infection. The provider did not adequately review the medication administration record to see that the patient had refused four doses of the treatment for the infection. This put the patient at risk of a worsening infection. This deficiency is also described in the Quality of Provider Performance indicator. • In case 9, there was poor provider continuity that contributed to a pattern of poor record review. On one occasion, the provider did not adequately review the chart and did not recognize that the patient had two recent hypoglycemic episodes that required nurses to administer glucose tablets. On another occasion, a laboratory test report showed that the patient had a critically low blood sugar, but the provider did not timely review the report. Fortunately, some of the providers performed well and were able to intervene before serious harm occurred. Kern Valley State Prison, Cycle 5 Medical Inspection Page 46 Office of the Inspector General State of California Nursing Performance KVSP nurses performed poorly in the CTC. There were 40 deficiencies found in nursing care, 7 of which were significant and all occurred in cases 8 and 9. In multiple instances, the nurses did not notify the provider when the patient’s blood sugar was low or severely elevated. Some nursing assessments were incomplete, sometimes assessments were not performed at all, and some interventions were not provided timely. Three significant deficiencies occurred in case 8, and four occurred in case 9. • In case 8, the nurse did not perform an assessment after the patient returned from the hospital after a leg infection. The patient had an intravenous line for administering antibiotics, and CTC nurses did not always assess the insertion site for signs and symptoms of an infection. Additionally, nursing staff only changed the dressing once in three weeks, which increased the patient’s risk for developing an infection. The nurses should have changed the dressing at least weekly. • In case 9, the patient had low blood sugar and the nurse administered sugar tablets. The nurse waited 75 minutes before rechecking the patient’s blood sugar, instead of the appropriate 15 minutes. Seven days later, the patient’s morning blood sugar was low again, but the nurse did not recheck the blood sugar for three hours, at which time the blood sugar remained low. After five more days, the patient was transferred to the community hospital due to confusion. Nursing staff continued to chart their provision of patient care activities for 10 hours after the patient had left the institution. Clinician Onsite Inspection During the onsite visit, all ten medical beds were occupied. There was one primary provider and three RNs. CTC clinical staff also included one LVN, one psychiatric technician, and two certified nursing attendants. The staffing in the CTC was appropriate. The CTC team demonstrated a thorough understanding of their patients via the daily provider huddle and the CTC team huddle. Case Review Conclusion While nursing care was problematic, the CTC providers performed well enough to ensure that most patients received their necessary care. The OIG clinicians rated the Specialized Medical Housing indicator adequate. Kern Valley State Prison, Cycle 5 Medical Inspection Page 47 Office of the Inspector General State of California Compliance Testing Results The institution earned a proficient compliance score of 95.0 percent in this indicator, with three of four tests receiving 100 percent scores, as follows: • For all ten patients sampled by OIG inspectors, nursing staff completed an initial health assessment on the day the patient was admitted to the CTC (MIT 13.001). • Providers evaluated all ten patients sampled within 24 hours of admission and completed the required history and physical documentation (MIT 13.002). • Inspectors tested the working order of the institution’s CTC patient room call buttons and found that call buttons were not operational. However, buttons were clearly labeled and identified, and a local operating procedure was in place to document 30-minute welfare checks. KVSP Nursing staff conducted 30-minute welfare checks in the CTC. According to knowledgeable staff who regularly worked in the CTC, during an emergent event, responding staff were able to access a patient’s room immediately, which KVSP’s management believed to be reasonable. As a result, KVSP received a score of 100 percent (MIT 13.101). One test in this indicator earned an adequate score: • When inspectors tested whether providers at KVSP completed their Subjective, Objective, Assessment, Plan, and Education (SOAPE) notes at the required three-day intervals, it was found that providers timely completed SOAPE notes for eight of the ten sampled patients (80 percent). For one patient, the provider documentation was one day late, and for another patient, provider documentation was three and four days late (MIT 13.003). Kern Valley State Prison, Cycle 5 Medical Inspection Page 48 Office of the Inspector General State of California SPECIALTY SERVICES This indicator focuses on specialist care from the time a request for Case Review Rating: services or physician’s order for specialist care is completed to the Adequate time of receipt of related recommendations from specialists. This Compliance Score: indicator also evaluates the providers’ timely review of specialist Proficient records and documentation reflecting the patients’ care plans, (85.6%) including course of care when specialist recommendations were not Overall Rating: ordered, and whether the results of specialists’ reports are Adequate communicated to the patients. For specialty services denied by the institution, the OIG determines whether the denials are timely and appropriate, and whether the patient is updated on the plan of care. For this indicator, the OIG’s case review and compliance review process 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 those factors that led to both scores. The OIG was concerned by the case review finding of a pattern that indicated potential problems with access to specialty services. Ultimately, the OIG rated this indicator adequate. Case Review Results The OIG clinicians reviewed 65 events related to Specialty Services, the majority of which were specialty consultations and procedures. Eight deficiencies were found in this category, with six of them significant. Most of the significant deficiencies were due to access to specialty services with one deficiency each for provider performance and health information management. Access to Specialty Services Most of the time, KVSP scheduled specialty appointments within the time frames requested bythe providers. Scheduling deficiencies occurred in the following cases: • In case 7, the provider ordered an urgent follow-up with the oncologist to determine a chemotherapy treatment course, but this appointment was scheduled 17 days late. • In case 14, the provider requested a follow-up appointment with the ophthalmologist in one week. The appointment did not occur until almost one month later. • In case 42, the patient went to the emergency department for slurred speech. The emergency department provider recommended a two-week follow-up with a neurologist. Upon the patient’s return to the institution, the primary care provider requested a follow-up appointment with the neurologist. However, this appointment was scheduled over four weeks late. Kern Valley State Prison, Cycle 5 Medical Inspection Page 49 Office of the Inspector General State of California Nursing Performance KVSP nurses performed appropriately for patients returning from offsite specialty appointments. Nurses properly assessed patients, reviewed specialty recommendations, and scheduled provider follow-ups. Provider Performance Providers properly recognized needs for referrals and ordered correct referrals with the appropriate priority. The providers also addressed specialist recommendations without any pattern of deficiencies. Health Information Management Specialty reports were usually retrieved, sent to providers for review and signature, and scanned into the electronic medical record in a timely fashion. Clinician Onsite Inspection The nurse responsible for the offsite specialty appointments explained that all of the deficiencies occurred when she was on medical leave and she did not know why the delays or the lack of appointments occurred. When asked who was covering for her when she was out, she was not forthcoming with any further information. Case Review Conclusion KVSP scheduled most specialty appointments timely and processed the specialty reports properly. There was a period when specialty appointments did not occur correctly when the regular nurse went on medical leave. The OIG clinicians rated the Specialty Services indicator adequate. Compliance Testing Results The institution received a proficient compliance score of 85.6 percent in the Specialty Services indicator. Four tests earned proficient scores, as follows: • The institution timely denied all 20 provider requests for specialty services (MIT 14.006). • Providers timely received and reviewed the high priority specialists’ reports for 12 of 13 patients sampled (92 percent). For one patient, there was no evidence found that his report was scanned into the electronic medical record (MIT 14.002). • Providers timely received and reviewed the routine priority specialists’ reports for 12 of 13 patients sampled (92 percent). For one patient, the report was never received (MIT 14.004). Kern Valley State Prison, Cycle 5 Medical Inspection Page 50 Office of the Inspector General State of California • Among 15 sampled patients, 13 received or refused their routine specialty service appointments within 90 calendar days of the provider’s order (87 percent). Two patients received their specialty service 10 and 15 days late (MIT 14.003). Two tests scored in the adequate range: • Twelve of the 15 patients sampled (80 percent) received or refused their high priority specialty services appointment or service within 14 calendar days of the provider’s order. Three patients received their specialty service one or two days late (MIT 14.001). • Among 18 patients sampled for whom KVSP’s health care management denied a specialty service, 14 (78 percent) received a timely notification of the denied service, including the provider meeting with the patient within 30 days to discuss alternate treatment strategies. For one patient, the provider’s follow-up visit occurred 12 days late. For three other patients, there was no evidence found of a provider follow-up to discuss the denial at all (MIT 14.007). One test earned the institution an inadequate score: • Among the 20 patients sampled, only 14 who transferred to KVSP with an approved specialty service from another CDCR institution received the service within the required time frame (70 percent). The remaining six sampled patients did not timely receive their previously approved services or did not receive the service at all. One patient received his specialty service four days late; two patients received their specialty services 27 and 49 days late; and three patients never received their specialty services (MIT 14.005). Kern Valley State Prison, Cycle 5 Medical Inspection Page 51 Office of the Inspector General State of California ADMINISTRATIVE OPERATIONS (SECONDARY) This indicator focuses on the institution’s administrative health care Case Review Rating: oversight functions. The OIG evaluates whether the institution Not Applicable promptly processes patient medical appeals and addresses all Compliance Score: appealed issues. Inspectors also verify that the institution follows Adequate reporting requirements for adverse/sentinel events and inmate (75.6%) deaths. The OIG verifies that the Emergency Medical Response Overall Rating: Review Committee (EMRRC) performs required reviews and that Adequate staff perform required emergency response drills. Inspectors also assess whether the Quality Management Committee (QMC) meets regularly and adequately addresses program performance. For those institutions with licensed facilities, inspectors also verify that required committee meetings are held. In addition, OIG examines whether the institution adequately manages its health care staffing resources by evaluating whether job performance reviews are completed as required; specified staff possess current, valid credentials and professional licenses or certifications; nursing staff receive new employee orientation training and annual competency testing; and clinical and custody staff have current medical emergency response certifications. The Administrative Operations indicator is a secondary indicator, and, therefore, was not relied on for the overall score for the institution. Compliance Testing Results The institution received an adequate compliance score of 75.6 percent in the Administrative Operations indicator, with several tests yielding proficient scores, as follows: • KVSP promptly processed all inmate medical appeals in each of the most recent 12 months (MIT 15.001). • The institution’s QMC met monthly, evaluated program performance, and took action when management identified areas for improvement opportunities. In addition, the institution took adequate steps to ensure the accuracy of its Dashboard data reporting (MIT 15.003, 15.004). • All providers at the institution were current with their professional licenses. Similarly, all nursing staff and the pharmacist in charge were current with their professional licenses and certification requirements (MIT 15.107, 15.109). • All active-duty providers and nurses were current with their emergency response certifications (MIT 15.108). • All pharmacy staff and providers who prescribed controlled substances had current Drug Enforcement Agency registrations (MIT 15.110). Kern Valley State Prison, Cycle 5 Medical Inspection Page 52 Office of the Inspector General State of California • All nursing staff hired within the last year timely received new employee orientation training (MIT 15.111). • The institution properly processed second level medical appeals for nine of the ten sampled patients (90 percent). For one second level medical appeal, the patient’s appeal issues were not all addressed (MIT 15.102). • Eight of nine KVSP providers had a proper clinical performance appraisal completed by their supervisor (89 percent). One provider’s evaluation was overdue by 10 months (MIT 15.106) One test scored in the adequate range: • Medical staff reviewed and timely submitted the Initial Inmate Death Report (CDCR Form 7229A or 7229B) to CCHCS’s Death Review Unit for seven of nine deaths that occurred during the testing period, resulting in a score of 78 percent. In two cases, KVSP’s medical staff incorrectly submitted the Initial Inmate Death Report (CDCR Form 7229A); because the deaths were by suicide, the Initial Inmate Suicide Report (CDCR Form 7229B) should have been utilized (MIT 15.103). The institution showed room for improvement with five tests earning inadequate scores: • The OIG inspected records from April 2017 for five nurses to determine if their nursing supervisors properly completed monthly performance reviews. Inspectors identified the following deficiencies for the five nurses’ monthly nursing reviews (MIT 15.104): o No nursing reviews were provided for four nurses; o The supervisor’s review did not summarize aspects that were well done for one nurse; o The nursing review did not confirm if the supervising nurse discussed the findings on a monthly basis for one nurse. • Only two of the ten nurses sampled (20 percent) held current clinical competency validations. Eight nurses did not receive a clinical competency validation within the required time frame (MIT 15.105). • Inspectors reviewed drill packages for three medical emergency response drills conducted in the prior quarter. Only one of the three drill packages (first watch) was properly completed (33 percent). The second watch emergency drill did not include all the required elements— specifically, the synopsis of the event and recommendations for improvement or additional training. In addition, the drill package did not include a Crime/Incident Report Kern Valley State Prison, Cycle 5 Medical Inspection Page 53 Office of the Inspector General State of California (CDCR Form 837). In addition, the institution did not complete a separate emergency response drill for third watch (MIT 15.101). • The OIG inspected the incident package documentation for 12 emergency medical responses reviewed by KVSP’s EMRRC during the prior six-month period; 6 of 12 sampled packages (50 percent) complied with policy. The other six sampled packages did not include the required EMRRC documentation (MIT 15.005). • The inspectors reviewed the last 12 months of KVSP’s local governing body (LGB) meeting minutes and determined that the LGB met monthly and exercised responsibility for the quality management of patient heath care each quarter, as documented in the meeting minutes. However, in the quarters ending September 2016 and March 2017, the LGB meeting minutes were not timely signed by the CEO or warden. As a result, KVSP scored 50 percent on this test (MIT 15.006). Non-Scored Results • The OIG gathered non-scored data regarding the completion of death review reports. CCHCS’ Death Review Committee (DRC) did not timely complete its death review summary for nine KVSP deaths that occurred during the OIG’s inspection period. The DRC is generally required to complete a death review summary within 30 or 60 days of death, depending on whether the death was expected or unexpected, and then notify the institution’s CEO of the review results within 7 days so that the institution can take any corrective action if needed. For five patients’ deaths, the committee completed its summary from 43 to 92 days late (from 103 to 152 days after death), and the institution’s CEO was notified of the results from 49 to 100 days late. In one case, the committee completed the death summary 23 days late (83 days after death) but did not notify the institution’s CEO of its results. For three other patients’ deaths, which occurred on January 1, 2017, March 18, 2017, and March 22, 2017, the final reports were not yet available as of September 6, 2017 (MIT 15.998). • The OIG discusses the institution’s health care staffing resources in the About the Institution section of this report (MIT 15.999). Kern Valley State Prison, Cycle 5 Medical Inspection Page 54 Office of the Inspector General State of California R ECOMMENDATIONS Based on the results of the Cycle 5 medical inspection at KVSP, the OIG recommends the institution do the following: • Provide cross-training to staff members across several responsibility areas and have periodic cross-training updates. Access to specialty services was problematic when the regular nurse was on medical leave. Periodic cross-training may have helped the covering staff to perform the work properly. Kern Valley State Prison, Cycle 5 Medical Inspection Page 55 Office of the Inspector General State of California P -B M OPULATION ASED ETRICS The compliance testing and the case reviews give an accurate assessment of how the institution’s health care systems are functioning with regard to the patients with the highest risk and utilization. This information is vital to assess the capacity of the institution to provide sustainable, adequate care. However, one significant limitation of the case review methodology is that it does not give a clear assessment of how the institution performs for the entire population. For better insight into this performance, the OIG has turned to population-based metrics. For comparative purposes, the OIG has selected several Healthcare Effectiveness Data and Information Set (HEDIS) measures for disease management to gauge the institution’s effectiveness in outpatient health care, especially chronic disease management. The Healthcare Effectiveness Data and Information Set is a set of standardized performance measures developed by the National Committee for Quality Assurance with input from over 300 organizations representing every sector of the nation’s health care industry. It is used by over 90 percent of the nation’s health plans as well as many leading employers and regulators. It was designed to ensure that the public (including employers, the Centers for Medicare and Medicaid Services, and researchers) has the information it needs to accurately compare the performance of health care plans. Healthcare Effectiveness Data and Information Set data is often used to produce health plan report cards, analyze quality improvement activities, and create performance benchmarks. Methodology For population-based metrics, the OIG used a subset of HEDIS measures applicable to the CDCR patient population. Selection of the measures was based on the availability, reliability, and feasibility of the data required for performing the measurement. The OIG collected data utilizing various information sources, including the electronic Unit Health Record (eUHR), the Electronic Health Record System (EHRS), 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 5 Medical Inspection Page 56 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 well with its management of diabetes. When compared statewide, KVSP outperformed both Medi-Cal and Kaiser Permanente (North and South regions) in four of the five diabetic care measures. The institution scored lower than both Medi-Cal and Kaiser for diabetic eye exams. However, a 19 percent refusal rate for eye exams negatively affected the institution for this measure. When compared nationally, KVSP outperformed Medicaid, Medicare, and commercial plans in four of the five diabetic care measures, with KVSP again scoring lower in diabetic eye exams. The institution outperformed the United States Department of Veterans Affairs (VA) in two of four measures, but scored lower for diabetic monitoring and eye exams. Again, the high refusal rate for eye exams negatively affected the institution’s score in comparison to national plans. Immunizations Comparative data for immunizations was only fully available for the VA and partially available for Kaiser, commercial plans, Medicaid, and Medicare. With respect to administering influenza vaccinations to younger adults, KVSP scored lower than Kaiser and the VA, and higher than Medicaid and commercial plans. When administering influenza vaccinations to older adults, KVSP scored lower than both Medicare and the VA. KVSP’s scores would have been significantly higher for influenza vaccinations for both younger and older adults if not for the high refusal rates among patients. With regard to administering pneumococcal vaccines to older adults, KVSP scored higher than Medicare and lower than the VA. Cancer Screening With respect to colorectal cancer screening, KVSP scored lower than Kaiser and the VA, and higher than Medicaid and commercial plans. However, KVSP would have scored higher than all health plans if not for the 29 percent refusal rate. Summary KVSP performed well with regard to population-based metrics in comparison to the other health care plans reviewed. The institution may improve its scores for diabetic eye exams, influenza vaccinations for both young and older adults, and colorectal cancer screenings by reducing patient refusals through educating patients on the benefits of these preventive services. Kern Valley State Prison, Cycle 5 Medical Inspection Page 57 Office of the Inspector General State of California KVSP Results Compared to State and National HEDIS Scores California National HEDIS KVSP HEDIS Kaiser HEDIS HEDIS Clinical Measures Medi- (No. Kaiser HEDIS Com- HEDIS VA Cycle 5 Cal CA) (So.CA) Medicaid mercial Medicare Average Results1 20152 20163 20163 20164 20164 20164 20155 Comprehensive Diabetes Care HbA1c Testing (Monitoring) 97% 86% 94% 94% 86% 90% 93% 98% Poor HbA1c Control (>9.0%)6, 7 15% 39% 20% 23% 45% 34% 27% 19% HbA1c Control (<8.0%)6 71% 49% 70% 63% 46% 55% 63% - Blood Pressure Control (<140/90)6 87% 63% 83% 83% 59% 60% 62% 74% Eye Exams 52% 53% 68% 81% 53% 54% 69% 89% Immunizations Influenza Shots - Adults (18–64) 51% - 56% 57% 39% 48% - 55% Influenza Shots - Adults (65+) 65% - - - - - 72% 76% Immunizations: Pneumococcal 82% - - - - - 71% 93% Cancer Screening Colorectal Cancer Screening 71% - 79% 82% - 63% 67% 82% 1. Unless otherwise stated, data was collected in June 2017 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 2015 HEDIS Aggregate Report for Medi-Cal Managed Care. 3. Data was obtained from Kaiser Permanente November 2016 reports for the Northern and Southern California regions. 4. National HEDIS data for Medicaid, commercial plans, and Medicare was obtained from the 2016 State of Health Care Quality Report, available on the NCQA website: www.ncqa.org. The results for commercial plans were based on data received from various health maintenance organizations. 5. The Department of Veterans Affairs (VA) data was obtained from the VA's website, www.va.gov. For the Immunizations: Pneumococcal measure only, the data was obtained from the VHA Facility Quality and Safety Report - Fiscal Year 2012 Data. 6. For this indicator, the entire applicable 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. Kern Valley State Prison, Cycle 5 Medical Inspection Page 58 Office of the Inspector General State of California A A — C T R PPENDIX OMPLIANCE EST ESULTS KVSP Range of Summary Scores: 66.87% - 95.00% Indicator Compliance Score (Yes %) 1–Access to Care 82.29% 2–Diagnostic Services 81.39% 3–Emergency Services Not Applicable 4–Health Information Management (Medical Records) 72.48% 5–Health Care Environment 73.70% 6–Inter- and Intra-System Transfers 66.87% 7–Pharmacy and Medication Management 67.01% 8–Prenatal and Post-Delivery Services Not Applicable 9–Preventive Services 87.98% 10–Quality of Nursing Performance Not Applicable 11–Quality of Provider Performance Not Applicable 12–Reception Center Arrivals Not Applicable 13–Specialized Medical Housing (OHU, CTC, SNF, Hospice) 95.00% 14–Specialty Services 85.58% 15–Administrative Operations 75.63% Kern Valley State Prison, Cycle 5 Medical Inspection Page 59 Office of the Inspector General State of California Scored Answers Yes Reference + 1–Access to Care Number Yes No No Yes % N/A Chronic care follow-up appointments: Was the patient’s most recent chronic care visit within the health care guideline’s 1.001 16 9 25 64.00% 0 maximum allowable interval or within the ordered time frame, whichever is shorter? For endorsed patients received from another CDCR institution: If 1.002 the nurse referred the patient to a provider during the initial health 22 3 25 88.00% 0 screening, was the patient seen within the required time frame? Clinical appointments: Did a registered nurse review the patient’s 1.003 30 0 30 100% 0 request for service the same day it was received? Clinical appointments: Did the registered nurse complete a face- 1.004 to-face visit within one business day after the CDCR Form 7362 28 2 30 93.33% 0 was reviewed? Clinical appointments: If the registered nurse determined a referral to a primary care provider was necessary, was the patient 1.005 11 1 12 91.67% 18 seen within the maximum allowable time or the ordered time frame, whichever is the shorter? Sick call follow-up appointments: If the primary care provider 1.006 ordered a follow-up sick call appointment, did it take place within 2 1 3 66.67% 27 the time frame specified? Upon the patient’s discharge from the community hospital: Did 0 1.007 the patient receive a follow-up appointment within the required 23 2 25 92.00% time frame? Specialty service follow-up appointments: Do specialty service 1.008 primary care physician follow-up visits occur within required time 18 5 23 78.26% 7 frames? Clinical appointments: Do patients have a standardized process to 1.101 4 2 6 66.67% 0 obtain and submit health care services request forms? Overall percentage: 82.29% Kern Valley State Prison, Cycle 5 Medical Inspection Page 60 Office of the Inspector General State of California Scored Answers Yes Reference + 2–Diagnostic Services Number Yes No No Yes % N/A Radiology: Was the radiology service provided within the time 2.001 10 0 10 100% 0 frame specified in the provider’s order? Radiology: Did the primary care provider review and initial the 2.002 8 2 10 80.00% 0 diagnostic report within specified time frames? Radiology: Did the primary care provider communicate the results 2.003 8 2 10 80.00% 0 of the diagnostic study to the patient within specified time frames? Laboratory: Was the laboratory service provided within the time 2.004 9 1 10 90.00% 0 frame specified in the provider’s order? Laboratory: Did the primary care provider review and initial the 2.005 8 2 10 80.00% 0 diagnostic report within specified time frames? Laboratory: Did the primary care provider communicate the 2.006 results of the diagnostic study to the patient within specified time 7 3 10 70.00% 0 frames? Pathology: Did the institution receive the final diagnostic report 2.007 7 3 10 70.00% 0 within the required time frames? Pathology: Did the primary care provider review and initial the 2.008 6 2 8 75.00% 2 diagnostic report within specified time frames? Pathology: Did the primary care provider communicate the results 2.009 7 1 8 87.50% 2 of the diagnostic study to the patient within specified time frames? Overall percentage: 81.39% 3–Emergency Services This indicator is evaluated only by case review clinicians. There is no compliance testing component. Kern Valley State Prison, Cycle 5 Medical Inspection Page 61 Office of the Inspector General State of California Scored Answers Yes Reference + 4–Health Information Management Number Yes No No Yes % N/A Are non-dictated healthcare documents (provider progress notes) 4.001 14 1 15 93.33% 0 scanned within 3 calendar days of the patient encounter date? Are dictated/transcribed documents scanned into the patient’s 4.002 electronic health record within five calendar days of the encounter 2 1 3 66.67% 0 date? Are High-Priority specialty notes (either a Form 7243 or other 4.003 scanned consulting report) scanned within the required time 14 6 20 70.00% 0 frame? Are community hospital discharge documents scanned into the 4.004 patient’s electronic health record within three calendar days of 17 3 20 85.00% 0 hospital discharge? Are medication administration records (MARs) scanned into the 4.005 1 2 3 33.33% 0 patient’s electronic health record within the required time frames? During the inspection, were medical records properly scanned, 4.006 18 6 24 75.00% 0 labeled, and included in the correct patients’ files? For patients discharged from a community hospital: Did the preliminary hospital discharge report include key elements and 4.007 21 4 25 84.00% 0 did a primary care provider review the report within three calendar days of discharge? Overall percentage: 72.48% Kern Valley State Prison, Cycle 5 Medical Inspection Page 62 Office of the Inspector General State of California Scored Answers Yes Reference + 5–Health Care Environment Number Yes No No Yes % N/A Are clinical health care areas appropriately disinfected, cleaned 5.101 10 1 11 90.91% 0 and sanitary? Do clinical health care areas ensure that reusable invasive and 5.102 non-invasive medical equipment is properly sterilized or 9 2 11 81.82% 0 disinfected as warranted? Do clinical health care areas contain operable sinks and sufficient 5.103 9 2 11 81.82% 0 quantities of hygiene supplies? Does clinical health care staff adhere to universal hand hygiene 5.104 8 3 11 72.73% 0 precautions? Do clinical health care areas control exposure to blood-borne 5.105 9 2 11 81.82% 0 pathogens and contaminated waste? Warehouse, Conex and other non-clinic storage areas: Does the 5.106 medical supply management process adequately support the needs 1 0 1 100% 0 of the medical health care program? Does each clinic follow adequate protocols for managing and 5.107 5 5 10 50.00% 1 storing bulk medical supplies? Do clinic common areas and exam rooms have essential core 5.108 5 6 11 45.45% 0 medical equipment and supplies? Do clinic common areas have an adequate environment conducive 5.109 8 2 10 80.00% 1 to providing medical services? Do clinic exam rooms have an adequate environment conducive 5.110 7 4 11 63.64% 0 to providing medical services? Emergency response bags: Are TTA and clinic emergency 5.111 medical response bags inspected daily and inventoried monthly, 5 3 8 62.50% 3 and do they contain essential items? Overall percentage: 73.70% Kern Valley State Prison, Cycle 5 Medical Inspection Page 63 Office of the Inspector General State of California Scored Answers Yes Reference + 6–Inter- and Intra-System Transfers Number Yes No No Yes % N/A For endorsed patients received from another CDCR institution or COCF: Did nursing staff complete the initial health screening and 6.001 19 6 25 76.00% 0 answer all screening questions on the same day the patient arrived at the institution? For endorsed patients received from another CDCR institution or COCF: When required, did the RN complete the assessment and disposition section of the health screening form; refer the patient 6.002 25 0 25 100% 0 to the TTA, if TB signs and symptoms were present; and sign and date the form on the same day staff completed the health screening? For endorsed patients received from another CDCR institution or COCF: If the patient had an existing medication order upon 6.003 11 4 15 73.33% 10 arrival, were medications administered or delivered without interruption? For patients transferred out of the facility: Were scheduled 6.004 specialty service appointments identified on the patient’s health 17 3 20 85.00% 0 care transfer information form? For patients transferred out of the facility: Do medication transfer 6.101 packages include required medications along with the 0 1 1 0.00% 0 corresponding transfer packet required documents? Overall percentage: 66.87% Kern Valley State Prison, Cycle 5 Medical Inspection Page 64 Office of the Inspector General State of California Scored Answers 7–Pharmacy and Medication Yes Reference + Management Number Yes No No Yes % N/A Did the patient receive all chronic care medications within the 7.001 required time frames or did the institution follow departmental 11 8 19 57.89% 6 policy for refusals or no-shows? Did health care staff administer, make available, or deliver new 7.002 order prescription medications to the patient within the required 20 5 25 80.00% 0 time frames? Upon the patient’s discharge from a community hospital: Were all 7.003 ordered medications administered, made available, or delivered to 18 7 25 72.00% 0 the patient within required time frames? For patients received from a county jail: Were all medications ordered by the institution’s reception center provider 7.004 Not Applicable administered, made available, or delivered to the patient within the required time frames? Upon the patient’s transfer from one housing unit to another: 7.005 21 4 25 84.00% 0 Were medications continued without interruption? For patients en route who lay over at the institution: If the 7.006 temporarily housed patient had an existing medication order, were 3 7 10 30.00% 0 medications administered or delivered without interruption? All clinical and medication line storage areas for narcotic 7.101 medications: Does the Institution employ strong medication 0 9 9 0.00% 2 security over narcotic medications assigned to its clinical areas? All clinical and medication line storage areas for non-narcotic medications: Does the Institution properly store non-narcotic 7.102 2 7 9 22.22% 2 medications that do not require refrigeration in assigned clinical areas? All clinical and medication line storage areas for non-narcotic 7.103 medications: Does the institution properly store non-narcotic 6 5 11 54.55% 0 medications that require refrigeration in assigned clinical areas? Medication preparation and administration areas: Do nursing staff employ and follow hand hygiene contamination control protocols 7.104 3 4 7 42.86% 4 during medication preparation and medication administration processes? Medication preparation and administration areas: Does the 7.105 institution employ appropriate administrative controls and 7 0 7 100% 4 protocols when preparing medications for patients? Medication preparation and administration areas: Does the 7.106 Institution employ appropriate administrative controls and 2 5 7 28.57% 4 protocols when distributing medications to patients? Pharmacy: Does the institution employ and follow general 7.107 security, organization, and cleanliness management protocols in 1 0 1 100% 0 its main and satellite pharmacies? Kern Valley State Prison, Cycle 5 Medical Inspection Page 65 Office of the Inspector General State of California Scored Answers 7–Pharmacy and Medication Yes Reference + Management Number Yes No No Yes % N/A Pharmacy: Does the institution’s pharmacy properly store non- 7.108 1 0 1 100% 0 refrigerated medications? Pharmacy: Does the institution’s pharmacy properly store 7.109 1 0 1 100% 0 refrigerated or frozen medications? Pharmacy: Does the institution’s pharmacy properly account for 7.110 1 0 1 100% 0 narcotic medications? Does the institution follow key medication error reporting 7.111 24 0 24 100% 1 protocols? Overall percentage: 67.01% 8–Prenatal and Post-Delivery Services The institution has no female patients, so this indicator is not applicable. Kern Valley State Prison, Cycle 5 Medical Inspection Page 66 Office of the Inspector General State of California Scored Answers Yes Reference + 9–Preventive Services Number Yes No No Yes % N/A Patients prescribed TB medication: Did the institution administer 9.001 12 3 15 80.00% 0 the medication to the patient as prescribed? Patients prescribed TB medication: Did the institution monitor the 9.002 patient monthly for the most recent three months he or she was on 13 2 15 86.67% 0 the medication? Annual TB Screening: Was the patient screened for TB within the 9.003 26 4 30 86.67% 0 last year? Were all patients offered an influenza vaccination for the most 9.004 24 0 25 100% 0 recent influenza season? All patients from the age of 50 - 75: Was the patient offered 9.005 25 0 25 100% 0 colorectal cancer screening? Female patients from the age of 50 through the age of 74: Was the 9.006 Not Applicable patient offered a mammogram in compliance with policy? Female patients from the age of 21 through the age of 65: Was 9.007 Not Applicable patient offered a pap smear in compliance with policy? Are required immunizations being offered for chronic care 9.008 17 0 17 100% 0 patients? Are patients at the highest risk of coccidioidomycosis (valley 9.009 5 3 8 62.50% 0 fever) infection transferred out of the facility in a timely manner? Overall percentage: 87.98% 10–Quality of Nursing Performance This indicator is evaluated only by case review clinicians. There is no compliance testing component. 11–Quality of Provider Performance This indicator is evaluated only by case review clinicians. There is no compliance testing component. Kern Valley State Prison, Cycle 5 Medical Inspection Page 67 Office of the Inspector General State of California 12–Reception Center Arrivals The institution has no reception center, so this indicator is not applicable. Scored Answers Yes Reference + 13–Specialized Medical Housing Number Yes No No Yes % N/A For OHU, CTC, and SNF: Did the registered nurse complete an 13.001 initial assessment of the patient on the day of admission, or within 10 0 10 100% 0 eight hours of admission to CMF’s Hospice? For CTC and SNF only: Was a written history and physical 13.002 10 0 10 100% 0 examination completed within the required time frame? For OHU, CTC, SNF, and Hospice: Did the primary care provider complete the Subjective, Objective, Assessment, Plan, and 13.003 8 2 10 80.00% 0 Education (SOAPE) notes on the patient at the minimum intervals required for the type of facility where the patient was treated? For OHU and CTC Only: Do inpatient areas either have properly working call systems in its OHU & CTC or are 30-minute patient 13.101 1 0 1 100.00% 0 welfare checks performed; and do medical staff have reasonably unimpeded access to enter patient’s cells? Overall percentage: 95.00% Kern Valley State Prison, Cycle 5 Medical Inspection Page 68 Office of the Inspector General State of California Scored Answers Yes Reference + 14–Specialty Services Number Yes No No Yes % N/A Did the patient receive the high priority specialty service within 14.001 14 calendar days of the primary care provider order or the 12 3 15 80.00% 0 Physician Request for Service? Did the primary care provider review the high priority specialty 14.002 12 1 13 92.31% 2 service consultant report within the required time frame? Did the patient receive the routine specialty service within 90 14.003 calendar days of the primary care provider order or Physician 13 2 15 86.67% 0 Request for Service? Did the primary care provider review the routine specialty service 14.004 12 1 13 92.31% 2 consultant report within the required time frame? For endorsed patients received from another CDCR institution: If the patient was approved for a specialty services appointment at 14.005 14 6 20 70.00% 0 the sending institution, was the appointment scheduled at the receiving institution within the required time frames? Did the institution deny the primary care provider request for 14.006 20 0 20 100% 0 specialty services within required time frames? Following the denial of a request for specialty services, was the 14.007 14 4 18 77.78% 2 patient informed of the denial within the required time frame? Overall percentage: 85.58% Kern Valley State Prison, Cycle 5 Medical Inspection Page 69 Office of the Inspector General State of California Scored Answers Yes Reference 15–Administrative Operations + Number Yes No No Yes % N/A Did the institution promptly process inmate medical appeals 15.001 12 0 12 100% 0 during the most recent 12 months? Does the institution follow adverse / sentinel event reporting 15.002 Not Applicable requirements? Did the institution Quality Management Committee (QMC) meet at least monthly to evaluate program performance, and did the 15.003 6 0 6 100% 0 QMC take action when improvement opportunities were identified? Did the institution’s Quality Management Committee (QMC) or 15.004 other forum take steps to ensure the accuracy of its Dashboard 1 0 1 100% 0 data reporting? Does the Emergency Medical Response Review Committee 15.005 perform timely incident package reviews that include the use of 6 6 12 50.00% 0 required review documents? For institutions with licensed care facilities: Does the Local Governing Body (LGB), or its equivalent, meet quarterly and 15.006 2 2 4 50.00% 0 exercise its overall responsibilities for the quality management of patient health care? Did the institution complete a medical emergency response drill 15.101 for each watch and include participation of health care and 1 2 3 33.33% 0 custody staff during the most recent full quarter? Did the institution’s second level medical appeal response address 15.102 9 1 10 90.00% 0 all of the patient’s appealed issues? Did the institution’s medical staff review and submit the initial 15.103 7 2 9 77.78% 0 inmate death report to the Death Review Unit in a timely manner? Does the institution’s Supervising Registered Nurse conduct 15.104 0 5 5 0.00% 0 periodic reviews of nursing staff? Are nursing staff who administer medications current on their 15.105 2 8 10 20.00% 0 clinical competency validation? 15.106 Are structured clinical performance appraisals completed timely? 8 1 9 88.89% 0 15.107 Do all providers maintain a current medical license? 12 0 12 100% 0 Are staff current with required medical emergency response 15.108 2 0 2 100% 0 certifications? Are nursing staff and the Pharmacist-in-Charge current with their professional licenses and certifications, and is the pharmacy licensed as a correctional pharmacy by the California State Board 15.109 6 0 6 100% 0 of Pharmacy? Kern Valley State Prison, Cycle 5 Medical Inspection Page 70 Office of the Inspector General State of California Scored Answers Yes Reference 15–Administrative Operations + Number Yes No No Yes % N/A Do the institution’s pharmacy and authorized providers who 15.110 prescribe controlled substances maintain current Drug 1 0 1 100% 0 Enforcement Agency (DEA) registrations? 15.111 Are nursing staff current with required new employee orientation? 1 0 1 100% 0 Overall percentage: 75.63% Kern Valley State Prison, Cycle 5 Medical Inspection Page 71 Office of the Inspector General State of California A B — C D PPENDIX LINICAL ATA Table B-1: KVSP Sample Sets Sample Set Total Anticoagulation 2 Death Review/Sentinel Events 2 Diabetes 3 Emergency Services — CPR 5 Emergency Services — Non-CPR 2 High Risk 4 Hospitalization 4 Intra-System Transfers In 3 Intra-System Transfers Out 3 RN Sick Call 21 Specialty Services 3 52 Kern Valley State Prison, Cycle 5 Medical Inspection Page 72 Office of the Inspector General State of California Table B-2: KVSP Chronic Care Diagnoses Diagnosis Total Anemia 4 Anticoagulation 2 Arthritis/Degenerative Joint Disease 1 Asthma 6 COPD 3 Cancer 2 Cardiovascular Disease 7 Chronic Kidney Disease 2 Chronic Pain 18 Cirrhosis/End-Stage Liver Disease 1 Coccidioidomycosis 3 Deep Venous Thrombosis/Pulmonary Embolism 1 Diabetes 14 Gastroesophageal Reflux Disease 7 Hepatitis C 20 Hyperlipidemia 13 Hypertension 24 Mental Health 9 Migraine Headaches 1 Seizure Disorder 7 Thyroid Disease 2 147 Kern Valley State Prison, Cycle 5 Medical Inspection Page 73 Office of the Inspector General State of California Table B-3: KVSP Event – Program Program Total Diagnostic Services 97 Emergency Care 34 Hospitalization 27 Intra-System Transfers In 20 Intra-System Transfers Out 5 Not Specified 1 Outpatient Care 432 Specialized Medical Housing 230 Specialty Services 78 924 Kern Valley State Prison, Cycle 5 Medical Inspection Page 74 Office of the Inspector General State of California Table B-4: KVSP Review Sample Summary Total MD Reviews Detailed 20 MD Reviews Focused 0 RN Reviews Detailed 12 RN Reviews Focused 32 Total Reviews 64 Total Unique Cases 52 Overlapping Reviews (MD & RN) 12 Kern Valley State Prison, Cycle 5 Medical Inspection Page 75 Office of the Inspector General State of California A C — C S M PPENDIX OMPLIANCE AMPLING ETHODOLOGY Kern Valley State Prison (KVSP) Sample Category Quality (number of Indicator samples) Data Source Filters Access to Care MIT 1.001 Chronic Care Patients Master Registry • Chronic care conditions (at least one condition per patient—any risk level) (25) • Randomize MIT 1.002 Nursing Referrals OIG Q: 6.001 • See Intra-system Transfers (25) MITs 1.003-006 Nursing Sick Call MedSATS • Clinic (each clinic tested) (5 per clinic) • Appointment date (2–9 months) (30) • Randomize MIT 1.007 Returns from OIG Q: 4.007 • See Health Information Management (Medical Community Hospital Records) (returns from community hospital) (25) MIT 1.008 Specialty Services OIG Q: 14.001 & • See Specialty Services Follow-up 14.003 (30) MIT 1.101 Availability of Health OIG onsite • Randomly select one housing unit from each yard Care Services review Request Forms (6) Diagnostic Services MITs 2.001–003 Radiology Radiology Logs • Appointment date (90 days–9 months) • Randomize (10) • Abnormal MITs 2.004–006 Laboratory Quest • Appt. date (90 days–9 months) • Order name (CBC or CMPs only) • Randomize (10) • Abnormal MITs 2.007–009 Pathology InterQual • Appt. date (90 days–9 months) • Service (pathology related) (10) • Randomize Kern Valley State Prison, Cycle 5 Medical Inspection Page 76 Office of the Inspector General State of California Sample Category Quality (number of Indicator samples) Data Source Filters Health Information Management MIT 4.001 Timely Scanning OIG Qs: 1.001, • Non-dictated documents (15) 1.002, & 1.004 • 1st 10 IPs MIT 1.001, 1st 5 IPs MITs 1.002, 1.004 MIT 4.002 OIG Q: 1.001 • Dictated documents (3) • First 20 IPs selected MIT 4.003 OIG Qs: 14.002 • Specialty documents (20) & 14.004 • First 10 IPs for each question MIT 4.004 OIG Q: 4.007 • Community hospital discharge documents (20) • First 20 IPs selected MIT 4.005 OIG Q: 7.001 • MARs (3) • First 20 IPs selected MIT 4.006 Documents for • Any misfiled or mislabeled document identified (6) any tested inmate during OIG compliance review (24 or more = No) MIT 4.007 Returns From Inpatient claims • Date (2–8 months) Community Hospital data • Most recent 6 months provided (within date range) • Rx count • Discharge date • Randomize (each month individually) • First 5 patients from each of the 6 months (if not 5 in a month, supplement from another, as needed) (25) Health Care Environment MIT 5.101–105 Clinical Areas OIG inspector • Identify and inspect all onsite clinical areas. MIT 5.107–111 (11) onsite review Inter- and Intra-System Transfers MIT 6.001–003 Intra-System SOMS • Arrival date (3–9 months) Transfers • Arrived from (another CDCR facility) • Rx count • Randomize (25) MIT 6.004 Specialty Services MedSATS • Date of transfer (3–9 months) Send-Outs • Randomize (20) MIT 6.101 Transfers Out OIG inspector • R&R IP transfers with medication (1) onsite review Kern Valley State Prison, Cycle 5 Medical Inspection Page 77 Office of the Inspector General State of California Sample Category Quality (number of Indicator samples) Data Source Filters Pharmacy and Medication Management MIT 7.001 Chronic Care OIG Q: 1.001 See Access to Care Medication • At least one condition per patient—any risk level • Randomize (25) MIT 7.002 New Medication Master Registry • Rx count Orders • Randomize (25) • Ensure no duplication of IPs tested in MIT 7.001 MIT 7.003 Returns from OIG Q: 4.007 • See Health Information Management (Medical Community Hospital Records) (returns from community hospital) (25) MIT 7.004 RC Arrivals – OIG Q: 12.001 • See Reception Center Arrivals Medication Orders (N/A at this institution) or (N/A) MIT 7.005 Intra-Facility Moves MAPIP transfer • Date of transfer (2–8 months) data • To location/from location (yard to yard and to/from ASU) • Remove any to/from MHCB • NA/DOT meds (and risk level) (25) • Randomize MIT 7.006 En Route SOMS • Date of transfer (2–8 months) • Sending institution (another CDCR facility) • Randomize (10) • NA/DOT meds MITs 7.101–103 Medication Storage OIG inspector • Identify and inspect clinical & med line areas that Areas onsite review store medications (varies by test) MITs 7.104–106 Medication OIG inspector • Identify and inspect onsite clinical areas that Preparation and onsite review prepare and administer medications Administration Areas (varies by test) MITs 7.107–110 Pharmacy OIG inspector • Identify & inspect all onsite pharmacies (1) onsite review MIT 7.111 Medication Error Monthly • All monthly statistic reports with Level 4 or higher Reporting medication error • Select a total of 5 months (24) reports MIT 7.999 Isolation Unit KOP Onsite active • KOP rescue inhalers & nitroglycerin medications Medications medication for IPs housed in isolation units (9) listing Prenatal and Post-Delivery Services MIT 8.001–007 Recent Deliveries OB Roster • Delivery date (2–12 months) (N/A at this • Most recent deliveries (within date range) institution) or (XX) Pregnant Arrivals OB Roster • Arrival date (2–12 months) (N/A at this • Earliest arrivals (within date range) institution) or (XX) Kern Valley State Prison, Cycle 5 Medical Inspection Page 78 Office of the Inspector General State of California Sample Category Quality (number of Indicator samples) Data Source Filters Preventive Services MITs 9.001–002 TB Medications Maxor • Dispense date (past 9 months) • Time period on TB meds (3 months or 12 weeks) (30) • Randomize MIT 9.003 TB Evaluation, SOMS • Arrival date (at least 1 year prior to inspection) Annual Screening • Birth Month (30) • Randomize MIT 9.004 Influenza SOMS • Arrival date (at least 1 year prior to inspection) Vaccinations • Randomize (25) • Filter out IPs tested in MIT 9.008 MIT 9.005 Colorectal Cancer SOMS • Arrival date (at least 1 year prior to inspection) Screening • Date of birth (51 or older) (25) • Randomize MIT 9.006 Mammogram SOMS • Arrival date (at least 2 yrs prior to inspection) (N/A at this • Date of birth (age 52–74) institution) or • Randomize (XX) MIT 9.007 Pap Smear SOMS • Arrival date (at least three yrs prior to inspection) (N/A at this • Date of birth (age 24–53) institution) or • Randomize (XX) MIT 9.008 Chronic Care OIG Q: 1.001 • Chronic care conditions (at least 1 condition per Vaccinations IP—any risk level) • Randomize (17) • Condition must require vaccination(s) MIT 9.009 Valley Fever Cocci transfer • Reports from past 2–8 months (number will vary) status report • Institution (N/A at this • Ineligibility date (60 days prior to inspection date) institution) or • All (XX) Kern Valley State Prison, Cycle 5 Medical Inspection Page 79 Office of the Inspector General State of California Sample Category Quality (number of Indicator samples) Data Source Filters Reception Center Arrivals MITs 12.001–008 RC SOMS • Arrival date (2–8 months) (N/A at this • Arrived from (county jail, return from parole, etc.) institution) or • Randomize (XX) Specialized Medical Housing MITs 13.001–004 CTC CADDIS • Admit date (1–6 months) • Type of stay (no MH beds) • Length of stay (minimum of 5 days) (10) • Randomize MIT 13.101 Call Buttons OIG inspector • Review by location CTC onsite review (all) Specialty Services MITs 14.001–002 High-Priority MedSATS • Approval date (3–9 months) (15) • Randomize MITs 14.003–004 Routine MedSATS • Approval date (3–9 months) • Remove optometry, physical therapy or podiatry (15) • Randomize MIT 14.005 Specialty Services MedSATS • Arrived from (other CDCR institution) Arrivals • Date of transfer (3–9 months) (20) • Randomize MIT 14.006–007 Denials InterQual • Review date (3–9 months) (11) • Randomize IUMC/MAR • Meeting date (9 months) Meeting Minutes • Denial upheld (9) • Randomize Kern Valley State Prison, Cycle 5 Medical Inspection Page 80 Office of the Inspector General State of California Sample Category Quality (number of Indicator samples) Data Source Filters Administrative Operations MIT 15.001 Medical Appeals Monthly medical • Medical appeals (12 months) (all) appeals reports MIT 15.002 Adverse/Sentinel Adverse/sentinel • Adverse/sentinel events (2–8 months) Events events report (0) MITs 15.003–004 QMC Meetings Quality • Meeting minutes (12 months) Management Committee (6) meeting minutes MIT 15.005 EMRRC EMRRC meeting • Monthly meeting minutes (6 months) (12) minutes MIT 15.006 LGB LGB meeting • Quarterly meeting minutes (12 months) (4) minutes MIT 15.101 Medical Emergency Onsite summary • Most recent full quarter Response Drills reports & • Each watch documentation (3) for ER drills MIT 15.102 2nd Level Medical Onsite list of • Medical appeals denied (6 months) Appeals appeals/closed (10) appeals files MIT 15.103 Death Reports Institution-list of • Most recent 10 deaths deaths in prior 12 • Initial death reports (9) months MIT 15.104 RN Review Onsite supervisor • RNs who worked in clinic or emergency setting Evaluations periodic RN six or more days in sampled month reviews • Randomize (5) MIT 15.105 Nursing Staff Onsite nursing • On duty one or more years Validations education files • Nurse administers medications (10) • Randomize MIT 15.106 Provider Annual Onsite • All required performance evaluation documents Evaluation Packets provider (9) evaluation files MIT 15.107 Provider licenses Current provider • Review all listing (at start of (12) inspection) MIT 15.108 Medical Emergency Onsite • All staff Response certification o Providers (ACLS) Certifications tracking logs o Nursing (BLS/CPR) (all) • Custody (CPR/BLS) MIT 15.109 Nursing staff and Onsite tracking • All required licenses and certifications Pharmacist in system, logs, or Charge Professional employee files Licenses and Certifications (all) Kern Valley State Prison, Cycle 5 Medical Inspection Page 81 Office of the Inspector General State of California Sample Category Quality (number of Indicator samples) Data Source Filters Administrative Operations MIT 15.110 Pharmacy and Onsite listing of • All DEA registrations Providers’ Drug provider DEA Enforcement Agency registration #s & (DEA) Registrations pharmacy registration (all) document MIT 15.111 Nursing Staff New Nursing staff • New employees (hired within last 12 months) Employee training logs • Orientations (all) MIT 15.998 Death Review OIG summary log • Between 35 business days & 12 months prior Committee - deaths • CCHCS death reviews (9) Kern Valley State Prison, Cycle 5 Medical Inspection Page 82 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 5 Medical Inspection Page 83 Office of the Inspector General State of California