Medical Inspection Cycle 6 Summary Report

Amarik K. Singh, Inspector General Neil Robertson, Chief Deputy Inspector General of the OFFICE OIG INSPECTOR GENERAL Independent Prison Oversight November 2023 Cycle 6 Medical Inspection Unit Summary Report Electronic copies of reports published by the Office of the Inspector General are available free in portable document format (PDF) on our website. We also offer an online subscription service. For information on how to subscribe, visit www.oig.ca.gov. For questions concerning the contents of this report, please contact Shaun Spillane, Public Information Officer, at 916-288-4233. Connect with us on social media STATE of CALIFORNIA OIG OFFICE of the Amarik K. Singh, Inspector General INSPECTOR GENERAL Neil Robertson, Chief Deputy Inspector General Independent Prison Oversight Regional Offices Sacramento November 6, 2023 Bakersfield Rancho Cucamonga The Governor of California President pro Tempore of the Senate Speaker of the Assembly State Capitol Sacramento, California Dear Governor and Legislative Leaders: Enclosed is the Office of the Inspector General’s (the OIG) report summarizing the Cycle 6 medical inspections. This publication offers a brief overview of our sixth cycle of medical inspections, which began in March 2019 and concluded in September 2023, for each of the 34 adult prisons operated by the California Department of Corrections and Rehabilitation (the department). We rated 23 of the 34 adult institutions adequate during this inspection cycle. We rated 11 institutions inadequate. Compared with Cycle 5, two additional institutions received adequate ratings. We found the majority of institutions in Cycle 6 obtained an adequate or proficient rating in the following medical indicators: Access to Care, Emergency Services, Health Information Management, Transfers, Prenatal and Postpartum Care, Nursing Performance, Provider Performance, Reception Center, Specialized Medical Housing, and Specialty Services. Conversely, we found the majority of institutions in Cycle 6 obtained inadequate ratings in the following medical indicators: Diagnostic Services, Health Care Environment, Medication Management, Preventive Services, and Administrative Operations. By Cycle 6, the department had completed the transition to an Electronic Health Record System (EHRS). This transition resulted in improved statewide performance in two indicators: Diagnostic Services and Health Information Management. As a result, through this cycle, the OIG conducted all medical chart reviews through the EHRS, and is no longer reviewing paper health records. Table 1 shows that, when comparing Cycle 5 and Cycle 6, on the one hand, the performance of eight institutions declined. Two fell from an overall assessment of proficient to adequate and six fell from adequate to inadequate. On the other hand, the performance of nine institutions improved from Cycle 5 to Cycle 6, with their overall assessment rising from inadequate to adequate. Of those institutions that remained unchanged from Cycle 5 to Cycle 6, 12 retained their adequate rating, and five saw no change from their inadequate rating. During Cycle 6, nine institutions received ratings that demonstrated overall improvement, a notable achievement considering the challenges that beset the prison system over the past three years. This movement from inadequate to adequate occurred despite the presence of COVID-19 in the institutions, beginning in 2020. Sincerely, Amarik K. Singh Inspector General Gavin Newsom, Governor 10111 Old Placerville Road, Suite 110 Sacramento, California 95827 Telephone: (916) 288-4212 www.oig.ca.gov Return to Contents ii | Medical Inspection Unit: Summary Report for Cycle 6 (This page left blank for reproduction purposes.) Office of the Inspector General, State of California Return to Contents Medical Inspection Unit: Summary Report for Cycle 6 | iii Contents Illustrations iv Summary Report for Cycle 6 1 Background 1 Introduction 1 Methodology 1 Findings 2 Medical Inspection Indicator Ratings 7 Recommendations 9 Office of the Inspector General, State of California Return to Contents iv | Medical Inspection Unit: Summary Report for Cycle 6 Illustrations Figure 1. Cycle 6 Overall Institution Ratings 2 2. Overall Ratings of Cycle 6 and Cycle 5: A Comparison 5 Tables 1. Cycles 5 and 6 Institution Ratings 3 2. Institutional Medical Rating Distribution by Indicator 7 3. OIG Indicator Recommendations by Indicator 10 Office of the Inspector General, State of California Return to Contents Medical Inspection Unit: Summary Report for Cycle 6 | 1 Summary Report for Cycle 6 Background California Penal Code section 6126 et seq. assigns the Office of the Inspector General (the OIG) responsibility for oversight of the California Department of Corrections and Rehabilitation (the department). We conduct an objective medical inspection program and are responsible for periodically reviewing and reporting on the delivery of the ongoing medical care provided to incarcerated people in the institutions. Introduction This report summarizes the results of the OIG’s sixth cycle of medical inspections, which began in March 2019 and concluded in September 2023, for each of the 34 adult institutions operated by the department. Readers desiring a more detailed review of the individual institutions should refer to the individually published Cycle 6 reports on our website (www.oig.ca.gov). Methodology In Cycle 6, the OIG applied the same assessment methodologies used in Cycle 5, including clinical case review and compliance testing. These methods provide an accurate assessment of how the institution’s health care systems function regarding patients with the highest medical risk who tend to access services at the highest rate. This information helps us to assess the performance of the institution in its objective of providing sustainable, quality care. We continued to review institutional care using 15 indicators, as in prior cycles. Using each of these indicators, our compliance inspectors collected data in answer to compliance- and performance-related questions as established in the medical inspection tool (MIT). The department regularly updates its policies. The OIG updates our policy- compliance testing to reflect the department’s updates and changes. We determined a total compliance score for each applicable indicator and considered the MIT scores in the overall conclusion of the institution’s performance. In addition, our clinicians completed document reviews of individual cases and performed on-site inspections, which included interviews with staff at the institutions. In reviewing the cases, our clinicians examined whether providers used sound medical judgment while caring for patients. The review assesses the institution’s medical care on both individual and system levels. We consider whether institutional medical processes lead to identifying and correcting individual or system errors. We interpret compliance and case review results together, providing a Office of the Inspector General, State of California Return to Contents 2 | Medical Inspection Unit: Summary Report for Cycle 6 holistic assessment of the care. The OIG rates the indicators as proficient, adequate, or inadequate. As we did during Cycle 5, we continue to inspect both those institutions remaining under federal receivership and those delegated back to the department. There is no difference in the standards used for assessing a delegated institution versus an institution not yet delegated. Findings During Cycle 6, the preeminent challenge that departmental institutions faced was the novel coronavirus (COVID-19) pandemic. As a result, in Cycle 6, we observed most institutions experienced a decline in performance in most compliance indicators compared with what we observed in Cycle 5. Provider performance was also variable. Some of this can be explained by the unexpected COVID-19 pandemic, which resulted in some patients not being seen in a timely way. In addition, some care was delayed, and some services were not provided. Nursing performance was placed under considerable stress during the COVID-19 pandemic as nursing staff were often the first to see and respond to the health care needs of patients in the institutions. The implementation of the Integrated Substance Use Disorder Treatment program (ISUDT) during Cycle 6 resulted in a significant increase in workload for nursing staff. No institutions received an overall proficient rating in Cycle 6. Although many institutions slipped in the scores that we assigned for rates of compliance, we concluded 23 provided adequate care to patients. In our opinion, medical care quality across the department’s 34 adult institutions varied as it had in Cycle 5. In Cycle 6, we saw the positive impact of the full implementation of the Electronic Health Record System (the EHRS) on the performance across the system. Although complicated and sometimes difficult to use, the EHRS is a powerful and effective tool to integrate the delivery of care to patients. We found 23 of the 34 institutions (68 percent) performed at an adequate or a proficient level. We rated 23 institutions adequate and 11 institutions inadequate (Figure 1, below, and Table 1 on the following page). In Figure 1. Cycle 6 Overall Institution Ratings N = 34 Institutions Adequate 23 Inadequate 11 0 5 10 15 20 25 Source: The Office of the Inspector General medical Inspection report data. Office of the Inspector General, State of California Return to Contents Medical Inspection Unit: Summary Report for Cycle 6 | 3 Table 1. Cycles 5 and 6 Institution Ratings Rating Institution Inspected Abbreviation Cycle 5 Cycle 6 California State Prison, Los Angeles County LAC Inadequate Adequate Wasco State Prison WSP Adequate Adequate Valley State Prison VSP Adequate Adequate California State Prison, Solano SOL Inadequate Adequate California Correctional Center CCC Adequate Adequate California Rehabilitation Center CRC Inadequate Adequate California State Prison, Corcoran COR Adequate Inadequate California Medical Facility CMF Inadequate Inadequate North Kern State Prison NKSP Inadequate Adequate Salinas Valley State Prison SVSP Inadequate Inadequate Richard J. Donovan State Prison RJD Adequate Adequate Substance Abuse Treatment Facility SATF Adequate Inadequate California Correctional Institution CCI Adequate Inadequate Folsom State Prison FSP Adequate Adequate Avenal State Prison ASP Adequate Adequate Central California Women’s Facility CCWF Inadequate Adequate Centinela State Prison CEN Adequate Adequate Kern Valley State Prison KVSP Adequate Inadequate Pelican Bay State Prison PBSP Proficient Adequate California Institution for Women CIW Adequate Adequate California Men’s Colony CMC Adequate Adequate High Desert State Prison HDSP Adequate Inadequate Calipatria State Prison CAL Adequate Adequate Correctional Training Facility CTF Inadequate Inadequate California State Prison, Sacramento SAC Inadequate Inadequate Pleasant Valley State Prison PVSP Inadequate Adequate Mule Creek State Prison MCSP Inadequate Adequate Chuckawalla Valley State Prison CVSP Adequate Adequate Sierra Conservation Center SCC Adequate Adequate California Institution for Men CIM Inadequate Adequate San Quentin State Prison SQ Adequate Inadequate California City Correctional Facility CAC Proficient Adequate Ironwood State Prison ISP Inadequate Adequate California Health Care Facility, Stockton CHCF Inadequate Inadequate Note: During Cycle 6, the department closed Deuel Vocational Institution (DVI). In Cycle 5, the OIG rated DVI inadequate. Source: The Office of the Inspector General medical inspection report data. The entries in this table are listed in the order in which the reports were released to each institution and published on our website during Cycle 6. Office of the Inspector General, State of California Return to Contents 4 | Medical Inspection Unit: Summary Report for Cycle 6 Table 1, we show the overall ratings of the medical inspections in Cycles 5 and 6. Table 1 shows that, when comparing Cycle 5 and Cycle 6, on the one hand, the performance of eight institutions declined. The performance of two fell from an overall assessment of proficient to adequate, and that of six fell from adequate to inadequate. On the other hand, the performance of nine institutions improved from Cycle 5 to Cycle 6, with their overall assessment rising from inadequate to adequate. Of those institutions that remained unchanged from Cycle 5 to Cycle 6, 12 retained their adequate rating, and five saw no change from their inadequate rating. While ratings for two institutions, which had received proficient ratings during Cycle 5, fell to adequate during Cycle 6, several others received a rating that demonstrated overall improvement, a notable achievement considering the challenges that beset the prison system over the past three years (Figure 2, next page). This movement from inadequate to adequate occurred despite the presence of COVID-19 in most if not all the institutions, beginning in 2020. The virus moved rapidly among the State’s prison population, infecting both incarcerated people and departmental staff during that first year of the outbreak, then waned in 2021, and became less of a threat in 2022. Office of the Inspector General, State of California Return to Contents Medical Inspection Unit: Summary Report for Cycle 6 | 5 Figure 2. Overall Ratings of Cycle 6 and Cycle 5: A Comparison Proficient 11 32% Adequate Cycle 6 Inadequate N = 34 Institutions 23 68% 2 6% 20 15 Cycle 5 57% 43% N = 35 Institutions 18 51% Note: The department permanently closed Deuel Vocational Institution during Cycle 6, so the total number of prisons was reduced from 35 to 34. Source: The Office of the Inspector General Cycle 6 medical inspection report data. Office of the Inspector General, State of California Return to Contents 6 | Medical Inspection Unit: Summary Report for Cycle 6 (This page left blank for reproduction purposes.) Office of the Inspector General, State of California Return to Contents Medical Inspection Unit: Summary Report for Cycle 6 | 7 Medical Inspection Indicator Ratings The OIG clinicians assessed between 12 and 15 separate indicators for each institution over the course of Cycle 6. The overall results from those assessments are shown below in Table 2. The grand total of all our ratings is 442, with a distribution across the indicators as follows: 30 proficient, 209 adequate, and 203 inadequate. Table 2. Institutional Medical Rating Distribution by Indicator Indicator Rating Totals Indicator Proficient Adequate Inadequate Access to Care 10 18 6 Diagnostic Services 0 11 23 Emergency Services 0 24 10 Health Information Management 10 21 3 Health Care Environment 0 4 30 Transfers 1 19 14 Medication Management 0 1 33 Prenatal and Postpartum Care 2 0 0 Preventive Services 0 15 19 Nursing Performance 0 24 10 Provider Performance 0 25 9 Reception Center 1 1 1 Specialized Medical Housing 3 17 9 Specialty Services 1 18 15 Administrative Operations * 2 11 21 TOTALS 30 209 203 * Administrative Operations is a secondary indicator and is not considered when rating the institution’s overall medical quality. Source: The Office of the Inspector General Cycle 6 medical inspection report data. Office of the Inspector General, State of California Return to Contents 8 | Medical Inspection Unit: Summary Report for Cycle 6 (This page left blank for reproduction purposes.) Office of the Inspector General, State of California Return to Contents Medical Inspection Unit: Summary Report for Cycle 6 | 9 Recommendations During Cycle 6, we made recommendations for process improvement or performance improvement at each institution. We also made recommendations for significant deficiencies or, if we noted them, patterns of deficiencies. We offer suggestions in areas for which we see opportunities for improvement. On the next page, Table 3 shows the most frequently cited recommendations based on deficiencies we identified during our inspections. Office of the Inspector General, State of California Return to Contents 10 | Medical Inspection Unit: Summary Report for Cycle 6 Table 3. OIG Recommendations by Indicator Indicator Deficiency Category Recommendations Medical leadership should remind staff to follow universal hand Hand Washing hygiene precautions. Implementing random spot checks could improve compliance. Nursing leadership should direct each clinic nurse supervisor Emergency Medical Health Care to review the monthly emergency medical response bag Response Bag Environment (EMRB) and treatment cart logs to ensure that the EMRBs and (EMRB) treatment carts are regularly inventoried and sealed. Nursing leadership should consider performing random spot Medical Supply checks to ensure that staff follow equipment and medical Storage supply management protocols. The department should consider developing strategies to ensure that providers create patient letters at the time of review or Patient Letters endorsement and that patient letters should contain all elements required per CCHCS policy. Diagnostic Medical leadership should ascertain causative factors related to Services the untimely collecting or receiving of STAT laboratory results and should implement remedial measures as appropriate. STAT Laboratory Medical leadership should consider developing strategies to ensure STAT test results are acknowledged by providers or that providers are notified within the required time frames. Medical leadership should determine the root cause(s) of High-, Medium-, and challenges to the timely provision of specialty appointments Routine Priority and specialty service follow-up visits and should implement Specialty remedial measures as appropriate. Services Medical leadership should ensure that patients receive their Preapproved previously scheduled specialty appointments, when transferred, Specialty Services within the required time frame. Completion of Initial Nursing leadership should educate nursing staff on the Transfers Health Screening requirements for documenting an initial health screening. Form The institution should consider developing and implementing Medication measures to ensure that staff timely make available and Availability and administer medications to patients and that staff document Administration their actions in the medication administration record as Medication required by CCHCS policy and procedures. Management Nursing leadership should educate nursing staff on the proper documentation of medication refusal in the patient’s Medication Refusal medication administration record, as described in CCHCS policy. Nursing leadership should ensure that thorough assessments, Nursing Nursing Assessment intervention, and documentation are completed for all face-to- Performance and Documentation face encounters and that patients are provided patient education for clinic nursing encounters. Source: The Office of the Inspector General medical inspection report data from Cycle 6. Office of the Inspector General, State of California Return to Contents Cycle 6 Medical Inspection Unit Summary Report OFFICE of the INSPECTOR GENERAL Amarik K. Singh Inspector General Neil Robertson Chief Deputy Inspector General STATE of CALIFORNIA November 2023 OIG