Mule Creek State Prison Cycle 6 Medical Inspection Report

Amarik K. Singh, Inspector General Neil Robertson, Chief Deputy Inspector General OFFICE of the OIG INSPECTOR GENERAL Independent Prison Oversight November 2022 Cycle 6 Medical Inspection Report Mule Creek State Prison 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 916-255-1131. Cycle 6, Mule Creek State Prison | iii Contents Introduction 1 Summary 3 Overall Rating: Adequate 3 Medical Inspection Results 7 Deficiencies Identified During Case Review 7 Case Review Results 7 Compliance Testing Results 7 Population-Based Metrics 9 HEDIS Results 9 Recommendations 11 Indicators 14 Access to Care 14 Diagnostic Services 21 Emergency Services 25 Health Information Management 29 Health Care Environment 35 Transfers 43 Medication Management 49 Preventive Services 58 Nursing Performance 61 Provider Performance 67 Specialized Medical Housing 73 Specialty Services 77 Administrative Operations 82 Appendix A: Methodology 85 Case Reviews 87 Compliance Testing 90 Indicator Ratings and the Overall Medical Quality Rating 91 Appendix B: Case Review Data 92 Appendix C. Compliance Sampling Methodology 96 California Correctional Health Care Services’ Response 104 Office of the Inspector General, State of California Inspection Period: June 2021 – November 2021 Report Issued: November 2022 Cycle 6, Mule Creek State Prison | iv Illustrations Tables 1. MCSP Summary Table 3 2. MCSP Policy Compliance Scores 4 3. MCSP Master Registry Data as of January 2022 5 4. MCSP Health Care Staffing Resources as of January 2022 6 5. MCSP Results Compared with State HEDIS Scores 10 6. Access to Care 18 7. Other Tests Related to Access to Care 19 8. Diagnostic Services 23 9. Health Information Management 32 10. Other Tests Related to Health Information Management 33 11. Health Care Environment 41 12. Transfers 46 13. Other Tests Related to Transfers 47 14. Medication Management 55 15. Other Tests Related to Medication Management 56 16. Preventive Services 59 17. Specialized Medical Housing 75 18. Specialty Services 79 19. Other Tests Related to Specialty Services 80 20. Administrative Operations 83 A–1. Case Review Definitions 87 B–1. MCSP Case Review Sample Sets 92 B–2. MCSP Case Review Chronic Care Diagnoses 93 B–3. MCSP Case Review Events by Program 94 B–4. MCSP Case Review Sample Summary 94 Figures A–1. Inspection Indicator Review Distribution for MCSP 86 A–2. Case Review Testing 89 A–3. Compliance Sampling Methodology 90 Photographs 1. Indoor Waiting Area 35 2. Individual Patient Waiting Modules 36 3. Expired Medical Supplies Dated August 2021 37 4. Expired Medical Supplies Dated September 25, 2021 37 5. Snellen Eye Chart, Printed and Taped to a Clinic Room Wall 38 Cover: Rod of Asclepius courtesy of Thomas Shafee Office of the Inspector General, State of California Inspection Period: June 2021 – November 2021 Report Issued: November 2022 Cycle 6, Mule Creek State Prison | 1 Introduction Pursuant to California Penal Code section 6126 et seq., the Office of the Inspector General (the OIG) is responsible for periodically reviewing and reporting on the delivery of the ongoing medical care provided to incarcerated people1 in the California Department of Corrections and Rehabilitation (the department).2 In Cycle 6, the OIG continues to apply 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 to assess the performance of the institution in providing sustainable, adequate care.3 We continue to review institutional care using 15 indicators, as in prior cycles. Using each of these indicators, our compliance inspectors collect data in answer to compliance- and performance-related questions as established in the medical inspection tool (MIT).4 We determine a total compliance score for each applicable indicator and consider the MIT scores in the overall conclusion of the institution’s performance. In addition, our clinicians complete document reviews of individual cases and also perform on-site inspections, which include interviews with staff. In reviewing the cases, our clinicians examine whether providers used sound medical judgment in the course of caring for a patient. In the event we find errors, we determine whether such errors were clinically significant or led to a significantly increased risk of harm to the patient.5 At the same time, our clinicians examine whether the institution’s medical system mitigated the error. The OIG rates the indicators as proficient, adequate, or inadequate. 1 In this report, we use the terms patient and patients to refer to incarcerated people. 2 The OIG’s medical inspections are not designed to resolve questions about the constitutionality of care, and the OIG explicitly makes no determination regarding the constitutionality of care the department provides to its population. 3 In addition to our own compliance testing and case reviews, the OIG continues to offer selected Healthcare Effectiveness Data and Information Set (HEDIS) measures for comparison purposes. 4 The department regularly updates its policies. The OIG updates our policy-compliance testing to reflect the department’s updates and changes. 5 If we learn of a patient needing immediate care, we notify the institution’s chief executive officer. Office of the Inspector General, State of California Inspection Period: June 2021 – November 2021 Report Issued: November 2022 Cycle 6, Mule Creek State Prison | 2 The OIG has adjusted Cycle 6 reporting in two ways. First, commencing with this reporting period, we interpret compliance and case review results together, providing a more holistic assessment of the care; and second, we consider whether institutional medical processes lead to identifying and correcting provider or system errors. The review assesses the institution’s medical care on both system and provider levels. As we did during Cycle 5, our office is continuing 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. At the time of the Cycle 6 inspection of Mule Creek State Prison (MCSP), the institution had not been delegated back to the department by the receiver. We completed our sixth inspection of MCSP, and this report presents our assessment of the health care provided at this institution during the inspection period from June 2021 through November 2021.6 The data obtained for MCSP and the on-site inspections occurred during the COVID-19 pandemic.7 Mule Creek State Prison (MCSP) and is located in Ione, in Amador County. MCSP operates six clinics where staff members handle nonurgent requests for medical services, including five facility clinics and a specialty clinic. MCSP also conducts health screenings in its receiving and release clinical area (R&R), treats patients requiring urgent or emergent care in its triage and treatment area (TTA), and treats patients in need of inpatient health services in its correctional treatment center (CTC). MCSP has been designated as an intermediate care institution. These institutions are predominantly located in or near urban areas, close to tertiary care centers and specialty care providers for the most cost- effective care. 6 Samples are obtained per case review methodology shared with stakeholders in prior cycles. The case reviews include emergency cardiopulmonary (CPR) reviews between January 2021 and April 2021, death reviews between December 2020 and January 2022, transfer reviews between March 2020 and October 2021, and RN sick call reviews between June 2021 and December 2021. 7 As of August 24, 2022, the department reports on its public tracker that 71% of its incarcerated population at MCSP is fully vaccinated while 25% of MCSP staff are fully vaccinated: http://www.cdcr.ca.gov/covid19/population-status-tracking/. Office of the Inspector General, State of California Inspection Period: June 2021 – November 2021 Report Issued: November 2022 Cycle 6, Mule Creek State Prison | 3 Summary We completed the Cycle 6 inspection of MCSP in April 2022. OIG inspectors monitored the institution’s delivery of medical care that occurred between June 2021 and November 2021. The OIG rated the overall quality of health care at MCSP as adequate. We list the individual indicators and ratings applicable for this institution in Table 1 below. Table 1. MCSP Summary Table Cycle 6 Cycle 6 Cycle 6 Change Health Care Indicators Case Review Compliance Overall Since Rating Rating Rating Cycle 5 Access to Care Adequate Proficient Adequate Diagnostic Services Adequate Inadequate Inadequate Emergency Services Adequate N/A Adequate Health Information Management Adequate Adequate Adequate Health Care Environment N/A Inadequate Inadequate Transfers Adequate Inadequate Inadequate Medication Management Adequate Inadequate Inadequate Prenatal and Postpartum Care N/A N/A N/A N/A Preventive Services N/A Adequate Adequate Nursing Performance Adequate N/A Adequate Provider Performance Adequate N/A Adequate Reception Center N/A N/A N/A N/A Specialized Medical Housing Adequate Adequate Adequate Specialty Services Adequate Adequate Adequate Administrative Operations† N/A Inadequate Inadequate * The symbols in this column correspond to changes that occurred in indicator ratings between the medical inspections conducted during Cycle 5 and Cycle 6. The equals sign means there was no change in the rating. The single arrow means the rating rose or fell one level, and the double arrow means the rating rose or fell two levels (green, from inadequate to proficient; pink, from proficient to inadequate). † 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 medical inspection results. Office of the Inspector General, State of California Inspection Period: June 2021 – November 2021 Report Issued: November 2022 Cycle 6, Mule Creek State Prison | 4 To test the institution’s policy compliance, our compliance inspectors, (a team of registered nurses) monitored the institution’s compliance with its medical policies by answering a standardized set of questions that measure specific elements of health care delivery. Our compliance inspectors examined 390 patient records and 1,222 data points and used the data to answer 92 policy questions. In addition, we observed MCSP processes during an on-site inspection in February 2022. Table 2 below lists MCSP’s average scores from Cycles 4, 5, and 6. Table 2. MCSP Policy Compliance Scores Scoring Ranges 100%–85.0% 84.9%–75.0% 74.9%–0 Medical Cycle 4 Cycle 5 Cycle 6 Inspection Policy Compliance Category Average Average Average Tool (MIT) Score Score Score 1 Access to Care 67.9% 69.4% 85.0% 2 Diagnostic Services 84.4% 70.0% 58.5% 4 Health Information Management 68.9% 68.0% 77.7% 5 Health Care Environment 61.1% 81.9% 61.1% 6 Transfers 82.7% 87.4% 55.4% 7 Medication Management 58.3% 77.3% 47.1% 8 Prenatal and Postpartum Care N/A N/A N/A 9 Preventive Services 66.5% 82.7% 80.3% 12 Reception Center N/A N/A N/A 13 Specialized Medical Housing 84.0% 87.5% 79.2% 14 Specialty Services 62.6% 52.1% 75.9% 15 Administrative Operations 54.7%* 83.3% 62.9% * In Cycle 4, there were two secondary (administrative) indicators, and this score reflects the average of those two scores. In Cycle 5 and moving forward, the two indicators were merged into one, with only one score as the result. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: June 2021 – November 2021 Report Issued: November 2022 Cycle 6, Mule Creek State Prison | 5 The OIG clinicians (a team of physicians and nurse consultants) reviewed 67 cases, which contained 1,081 patient-related events. After examining the medical records, our clinicians conducted a follow-up on-site inspection in April 2022 to verify their initial findings. The OIG physicians rated the quality of care for 25 comprehensive case reviews. Of these 25 cases, our physicians rated one proficient, 20 adequate, and four inadequate. Our physicians found one adverse deficiency during this inspection. The OIG then considered the results from both case review and compliance testing, and drew overall conclusions, which we report in the 13 health care indicators.8 Multiple OIG physicians and nurses performed quality control reviews; their subsequent collective deliberations ensured consistency, accuracy, and thoroughness. Our OIG clinicians acknowledged institutional structures that catch and resolve mistakes which may occur throughout the delivery of care. As noted above, we listed the individual indicators and ratings applicable for this institution in the MCSP Summary Table. In January 2022, the Health Care Services Master Registry showed that MCSP had a total population of 3,837. A breakdown of the medical risk level of the MCSP population as determined by the department is set forth in Table 3 below.9 Table 3. MCSP Master Registry Data as of January 2022 Medical Risk Level Number of Patients Percentage* High 1 829 21.6% High 2 854 22.3% Medium 1,614 42.1% Low 540 14.1% * Percentages may not total 100 percent due to rounding. Source: Data for the population medical risk level were obtained from the CCHCS Master Registry dated 1-21-22. 8 The indicators for Reception Center and Prenatal Care did not apply to MCSP. 9 For a definition of medical risk, see CCHCS HCDOM 1.2.14, Appendix 1.9. Office of the Inspector General, State of California Inspection Period: June 2021 – November 2021 Report Issued: November 2022 Cycle 6, Mule Creek State Prison | 6 Based on staffing data the OIG obtained from California Correctional Health Care Services (CCHCS), as identified in Table 4 below, MCSP had 1.0 vacant executive leadership positions, 3.0 primary care provider vacancies, 0.7 nursing supervisor vacancies, and 8.0 nursing staff vacancies. Table 4. MCSP Health Care Staffing Resources as of January 2022 Executive Primary Care Nursing Nursing Positions Leadership* Providers Supervisors Staff† Total Authorized Positions 6.0 17.5 18.7 177.2 214.4 Filled by Civil Service 5.0 14.5 18.0 164.0 201.5 Vacant 1.0 3.0 0.7 8.0 12.7 Percentage Filled by Civil Service 83.3% 82.9% 96.3% 95.2% 94.0% Filled by Telemedicine 0 2.0 0 0 2.0 Percentage Filled by Telemedicine 0% 18.2% 0% 0% 1.9% Filled by Registry 0 1.5 0 26.5 28.0 Percentage Filled by Registry 0% 13.6% 0% 34.1% 26.0% Total Filled Positions 5.0 15.5 18.0 175.0 213.5 Total Percentage Filled 83.3% 88.6% 96.3% 101.6% 99.6% Appointments in Last 12 Months 0 0 0 0 0 Redirected Staff 0 0 0 0 0 Staff on Extended Leave‡ 0 0 0 8.0 8.0 Adjusted Total: Filled Positions 5.0 15.5 18.0 167.0 205.5 Adjusted Total: Percentage Filled 83.3% 88.6% 96.3% 97.0% 95.8% * Executive Leadership includes the Chief Physician and Surgeon. † Nursing Staff includes Senior Psychiatric Technician and Psychiatric Technician. ‡ In Authorized Positions. Notes: The OIG does not independently validate staffing data received from the department. Positions are based on fractional time-base equivalents. Source: Cycle 6 medical inspection preinspection questionnaire received January 2022, from California Correctional Health Care Services. Office of the Inspector General, State of California Inspection Period: June 2021 – November 2021 Report Issued: November 2022 Cycle 6, Mule Creek State Prison | 7 Medical Inspection Results Deficiencies Identified During Case Review Deficiencies are medical errors that increase the risk of patient harm. Deficiencies can be minor or significant, depending on the severity of the deficiency. An adverse event occurs when the deficiency caused harm to the patient. All major health care organizations identify and track adverse events. We identify deficiencies and adverse events to highlight concerns regarding the provision of care and for the benefit of the institution’s quality improvement program to provide an impetus for improvement.10 We identified one adverse deficiency in the case reviews at MCSP: • In case 7, the provider was informed by the nurse that the patient had chest pain and changes on an electrocardiogram, suggesting abnormalities with the heart. The provider did not send the patient to the hospital. The patient suffered a cardiac arrest within 24 hours and died. Case Review Results OIG case reviewers (a team of physicians and nurse consultants) assessed 10 of the 13 indicators applicable to MCSP. Of these 10 indicators, OIG clinicians rated ten adequate. The OIG physicians also rated the overall adequacy of care for each of the 25 detailed case reviews they conducted. Of these 25 cases, one was proficient, 20 were adequate, and four were inadequate. In the 1,081events reviewed, there were 222 deficiencies, 36 of which the OIG clinicians considered to be of such magnitude that, if left unaddressed, would likely contribute to patient harm. Our clinicians found the following strengths at MCSP: • Providers reported improved morale and that medical leadership was stable. • Staff provided necessary provider and specialty access to patients. • Providers, nurses, and custody staff responded well in emergency medical responses and cardiopulmonary resuscitation. • Staff performed well in completing tests and diagnostic studies. • CTC providers saw patients timely.11 10 For a further discussion of an adverse event, see Table A-1. 11 CTC is the correctional treatment center. Office of the Inspector General, State of California Inspection Period: June 2021 – November 2021 Report Issued: November 2022 Cycle 6, Mule Creek State Prison | 8 Our clinicians found the following weaknesses at MCSP: • Providers did not always send complete patient result notification letters. • Staff did not always ensure that new medication were administered timely or that there was continuity of chronic medications without any delays. Compliance Testing Results Our compliance inspectors assessed 10 of the 13 indicators applicable to MCSP. Of these 10 indicators, our compliance inspectors rated one proficient, four adequate, and five inadequate. We tested policy compliance in the Health Care Environment, Preventative Services, and Administrative Operations indicators as they do not have a case review component. MCSP demonstrated a high rate of policy compliance in the following areas: • Nursing staff at MCSP reviewed health care services request forms and conducted face-to-face encounters within the required time frame. In addition, MCSP housing units contained adequate supplies of health care service request forms. • MCSP provided timely appointments for chronic care patients, patients returning from hospital admission, and patients returning from specialty services. Moreover, patients were referred to their providers upon arrival at the institution. • The institution offered influenza vaccinations and provided colorectal cancer screenings to patients timely. MCSP demonstrated a low rate of policy compliance in the following areas: • Patients did not always receive their chronic care medications within the required time frame. There was poor medication continuity for patients returning from hospitalizations, for patients admitted to special medical housing, and for patients transferring within MCSP. • Providers did not often communicate the results of diagnostic services timely. Most patient letters communicating these results were missing the date of the diagnostic service, the date of the results, and whether the results were within normal limits. In some instances, patient results letters were not generated. • Health care staff did not consistently follow universal hand hygiene precautions before or after patient encounters. • MCSP medical clinics lacked properly calibrated medical equipment and medical supplies needed to provide standard medical care. Some Office of the Inspector General, State of California Inspection Period: June 2021 – November 2021 Report Issued: November 2022 Cycle 6, Mule Creek State Prison | 9 medical supplies were found to be expired at the time of our inspection. Population-Based Metrics In addition to our own compliance testing and case reviews, as noted above, the OIG presents selected measures from the Healthcare Effectiveness Data and Information Set (HEDIS) for comparison purposes. The HEDIS is a set of standardized quantitative performance measures designed by the National Committee for Quality Assurance to ensure that the public has the data it needs to compare the performance of health care plans. Because the Veterans Administration no longer publishes its individual HEDIS scores, we removed them from our comparison for Cycle 6. Likewise, Kaiser (commercial plan) no longer publishes HEDIS scores. However, through the California Department of Health Care Services’ Medi-Cal Managed Care Technical Report, the OIG obtained Kaiser Medi-Cal HEDIS scores for three of five diabetic measures to use in conducting our analysis, and we present them here for comparison. HEDIS Results We used population-based metrics in considering MCSP’s performance to assess the macroscopic view of the institution’s health care delivery. MCSP’s results compared favorably with those found in State health plans for diabetic care measures. We list the applicable HEDIS measures in Table 5. Comprehensive Diabetes Care When compared with statewide Medi-Cal programs—California Medi-Cal, Kaiser Northern California (Medi-Cal), and Kaiser Southern California (Medi-Cal)—MCSP performed better in two diabetic measures that have statewide comparative data: HbA1c screening and poor HbA1c control. Kaiser Southern California performed better in blood pressure control. Immunizations Statewide comparative data were also not available for immunization measures; however, we include this data for informational purposes. MCSP had a 67 percent influenza immunization rate for adults 18 to 64 years old and an 88 percent influenza immunization rate for adults 65 years of age and older.12 The pneumococcal vaccine rate was 98 percent.13 12 The HEDIS sampling methodology requires a minimum sample of 10 patients to have a reportable result. 13 The pneumococcal vaccines administered are the 13, 15, and 20 valent pneumococcal vaccines (PCV13, PCV 15, and PCV 20), or 23 valent pneumococcal vaccine (PPSV23), depending on the patient’s medical conditions. For the adult population, the influenza or pneumococcal vaccine may have been administered at a different institution other than the one in which the patient was currently housed during the inspection period. Office of the Inspector General, State of California Inspection Period: June 2021 – November 2021 Report Issued: November 2022 Cycle 6, Mule Creek State Prison | 10 Cancer Screening Statewide comparative data were not available for colorectal cancer screening; however, we include these data for informational purposes. MCSP had a 76 percent colorectal cancer screening rate. Table 5.MCSP Results Compared with State HEDIS Scores California California MCSP Kaiser Kaiser California NorCal SoCal Cycle 6 Medi-Cal Medi-Cal Medi-Cal HEDIS Measure Results* 2018† 2018† 2018† HbA1c Screening 100% 90% 94% 96% Poor HbA1c Control (> 9.0%) ‡, § 17% 34% 25% 18% HbA1c Control (< 8.0%) ‡ 68% – – – Blood Pressure Control (< 140/90) ‡ 79% 65% 78% 84% Eye Examinations 70% – – – Influenza – Adults (18–64) 67% – – – Influenza – Adults (65+) 88% – – – Pneumococcal – Adults (65+) 98% – – – Colorectal Cancer Screening 76% – – – Notes and Sources * Unless otherwise stated, data were collected in October 2021 by reviewing medical records from a sample of MCSP’s population of applicable patients. These random statistical sample sizes were based on a 95 percent confidence level with a 15 percent maximum margin of error. † HEDIS Medi-Cal data were obtained from the California Department of Health Care Services publication titled Medi-Cal Managed Care External Quality Review Technical Report, dated July 1, 2019–June 30, 2020 (published April 2021). www.dhcs.ca.gov/documents/MCQMD/CA2019-20-EQR-Technical-Report-Vol3-F2.pdf ‡ For this indicator, the entire applicable MCSP population was tested. § For this measure only, a lower score is better. Source: Institutional information provided by the California Department of Corrections and Rehabilitation. Health care plan data were obtained from the CCHCS Master Registry. Office of the Inspector General, State of California Inspection Period: June 2021 – November 2021 Report Issued: November 2022 Cycle 6, Mule Creek State Prison | 11 Recommendations As a result of our assessment of MCSP’s performance, we offer the following recommendations to the department: Diagnostic Services • The department should consider developing strategies to ensure that providers create patient letters at the time of review or endorsement and that patient letters should contain all elements required per CCHCS policy. • Medical leadership should ascertain causative factors related to the untimely collecting or receiving of STAT laboratory results and should implement remedial measures as appropriate. 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 challenges in reviewing or endorsing pathology reports timely and implement remedial measures as appropriate. Emergency Services • Nursing leadership should consider completing an audit of staff documentation after TTA encounters to provide training to staff regarding how to properly create documentation in the electronic health record system (EHRS). • The Emergency Medical Response Review Committee (EMRRC) should thoroughly review emergency response events and accurately detail findings. Health Information Management • The department should consider adjusting the default drop-down menu on the results letter in the EHRS, so the menu defaults to Patient Letter instead of DDP-Scan; the department should train providers to generate the results letters appropriately.14 14 DDP is the Developmental Disability Program. Office of the Inspector General, State of California Inspection Period: June 2021 – November 2021 Report Issued: November 2022 Cycle 6, Mule Creek State Prison | 12 Health Care Environment • Medical leadership should remind staff to follow universal hand hygiene precautions. Implementing random spot checks could improve compliance. • Nursing leadership should consider performing random spot checks to ensure staff follow equipment and medical supply management protocols. • Nursing leadership should direct each clinic nursing supervisor to review the monthly emergency medical response bag (EMRB) logs to ensure the EMRBs are regularly inventoried and sealed. Transfers • Nursing leadership should educate nursing staff to thoroughly complete the initial health screening before patients are transferred to the housing unit. • Nursing leadership should consider developing strategies to ensure that nursing staff administer medications without interruption to newly arrived patients and patients returning from hospitalizations. Medication Management • Medical and nursing leadership should ensure that chronic care, newly ordered, hospital discharge, yard-to-yard transfer, and en- route patients receive their medications timely without interruption. Preventive Services • Nursing leadership should consider developing and implementing measures to ensure that CCHCS policy is followed when nursing staff monitor patients who are prescribed TB medications. • Medical leadership should investigate and resolve any challenges that can affect the timely provision of chronic care vaccinations. Nursing Performance • Nursing leadership should ensure that thorough assessments, intervention, and documentation are completed for all face-to-face encounters and that patients are provided patient education for clinic nursing encounters. Office of the Inspector General, State of California Inspection Period: June 2021 – November 2021 Report Issued: November 2022 Cycle 6, Mule Creek State Prison | 13 Provider Performance • The department should define the process of nurse-to-provider co- consultation and should provide specific guidance to the providers on when provider progress notes are required for TTA and emergency phone calls, co-consultations, provider orders, and appointments. Specialized Medical Housing • Nursing leadership should determine the root cause of challenges to patients receiving all ordered medications within the required time frame and should implement remedial measures as appropriate. Specialty Services • Medical leadership should ensure that patients receive their previously scheduled specialty appointments, when transferred, within the required time frame. Office of the Inspector General, State of California Inspection Period: June 2021 – November 2021 Report Issued: November 2022 Cycle 6, Mule Creek State Prison | 14 Access to Care In this indicator, OIG inspectors evaluated the institution’s performance in providing patients with timely clinical appointments. Our inspectors reviewed Overall the scheduling and appointment timeliness for newly arrived patients, sick calls, Rating and nurse follow-up appointments. We examined referrals to primary care Adequate providers, provider follow-ups, and specialists. Furthermore, we evaluated the follow-up appointments for patients who received specialty care or returned from Case Review an off-site hospitalization. Rating Adequate Results Overview Compliance Score Compared with Cycle 5, MCSP improved significantly and provided good access Proficient to care. Compliance testing found very good access to nurses, providers, follow- (85.0%) ups after specialist appointments, follow-ups after hospitalizations, and follow- ups after emergency care. However, specialty access needs improvement. Case review found good access across the different areas. After reviewing all aspects of access to care, including the challenges due to the COVID-19 pandemic, the OIG rated this indicator adequate. Case Review and Compliance Testing Results OIG clinicians reviewed 379 provider, nursing, urgent or emergent care (TTA), specialty, and hospital events that required the institution to generate appointments. We identified 10 deficiencies relating to Access to Care, four of which were significant.15 Access to Care Providers MCSP provided good access to clinic providers in Cycle 6. This was a significant improvement from the serious delays encountered in Cycle 5. Several factors may have contributed to the improved access. There were more providers available for appointments. The COVID-19 interim guidance allowed for rescheduling of appointments or for providing chart review for patients who had nonurgent appointments that could be deferred, or low- to medium-risk chronic care appointments in patients who had stable chronic conditions.16 Between Cycle 5 and Cycle 6, providers no longer had to have a follow-up visit with patients who returned from a routine-priority or medium-priority specialty visit. As a result, there were fewer provider visits during Cycle 6. In addition, the institution utilized co-consults to ensure provider involvement without a formal provider encounter. Notwithstanding the aforementioned factors and policies, MCSP provider saw their patients appropriately. 15 Deficiencies occurred in cases 2,3, 15, 23, 25, 28, 59, and 68. Significant deficiencies occurred in cases 2, 15, and 23. 16 See https://cchcs.ca.gov/covid-19-interim-guidance/. Office of the Inspector General, State of California Inspection Period: June 2021 – November 2021 Report Issued: November 2022 Cycle 6, Mule Creek State Prison | 15 However, we found a pattern whereby nurses were either co-consulted or planned to refer the patient to the provider, but the provider did not document a note or did not see the patient. This occurred in cases 2, 23, and the following example: • In case 21, the patient with a recent hospitalization for an intestinal obstruction was seen by the nurse for complaint of abdominal pain. The nurse documented that she co-consulted the provider. However, at the on-site inspection, the provider stated he was not notified by the nurse, so the provider did not document a note or see the patient. Case review clinicians also found reduced access to MAT providers17 as in the following example: • In case 15, an ISUDT provider from headquarters evaluated the patient several times for medication assisted treatment and requested a follow- up appointment three times.18 All three times, the appointments occurred late. Compliance testing showed chronic care face-to-face follow-up appointments occurred 76.0 percent of the time (MIT 1.001), and nursing to primary care provider sick call referrals, nearly 79 percent of the time (MIT 1.005, 78.6%). Due to movement restrictions related to the COVID-19 pandemic, as long as the appointments were not clinically indicated, we considered most cases of provider chart reviews to have been triages of nonurgent, low- or medium-risk chronic care appointments and an acceptable alternative to face-to-face or telephonic visits. Access to Specialized Medical Housing Providers MCSP provided excellent access to specialized medical housing providers in the correctional treatment center (CTC). The case review clinicians did not find any deficiencies regarding access to CTC providers. Access to Clinic Nurses MCSP performed well in access to nursing sick calls and provider-to-nurse referrals. Compliance testing showed very good performance. Clinic nurses reviewed the patient’s sick call the same day it was received (MIT 1.003, 100%) and often performed a face-to-face visit within one business day as required (MIT 1.004, 94.3%). Case review findings were similar. Provider to nurse referrals occurred five times in three cases without delay. Significant deficiencies related to clinic nurse access occurred in the following cases: • In case 2, the nurse did not evaluate the patient the same day. The nurse triaged a sick call for a patient who developed a rash after starting an antibiotic three days earlier. The nurse evaluated the patient on the 17 MAT is the Medication Assisted Treatment program for substance use disorder. 18 ISUDT is the Integrated Substance Use Disorder Treatment program. Office of the Inspector General, State of California Inspection Period: June 2021 – November 2021 Report Issued: November 2022 Cycle 6, Mule Creek State Prison | 16 following day. The nurse should have evaluated the patient for a possible allergic reaction to the antibiotic the same day the sick call was triaged instead of waiting until the following day. • In case 9, the nurse did not evaluate the patient on the same day a symptomatic sick call request was made. The patient submitted a sick call request for a week, complaining of feeling weak, tired, and experiencing chest pain radiating to the left arm. The nurse evaluated the patient the following day. Access to Specialty Services MCSP’s performance was mixed in referrals to specialty services. Compliance testing showed a low completion rate of high-priority (MIT 14.001, 73.3%), medium-priority (MIT 14.004, 73.3%), and routine-priority (MIT 14.007, 66.7%) appointments. However, case review clinicians found most specialty appointment took place within requested time frames. We identified three deficiencies and have included here the following example: • In case 25, the patient had thyroid cancer and needed to see the medical oncologist as well as the ENT specialist.19 Initially, the oncology appointment was supposed to occur on the same day as the ENT appointment. However, the medical oncology appointment could not occur due to scheduling issues. Because the oncology appointment could not occur, this referral appointment request was routed to the telemedicine specialty scheduler. The oncology appointment was scheduled on a day after the patient was admitted for a thyroidectomy and as a result of this scheduling, the patient did not receive the oncology appointment. Follow-Up After Specialty Services MCSP’s performance was acceptable with follow-ups after specialty services. Compliance testing showed that 78.6 percent of provider appointments after specialty services occurred within the required time frame (MIT 1.008). Case review clinicians reviewed records to ensure that specialty recommendations were followed and did not find any deficiencies in this area. Follow-Up After Hospitalization OIG clinicians reviewed 19 instances in which patients were transferred to the hospital and emergency department. We found no deficiencies with access to providers after these events. 19 An ENT specialist is an Ear Nose and Throat specialist. Office of the Inspector General, State of California Inspection Period: June 2021 – November 2021 Report Issued: November 2022 Cycle 6, Mule Creek State Prison | 17 Follow-Up After Urgent or Emergent Care (TTA) We reviewed 27 urgent or emergent events at MCSP and did not find any deficiencies related to access to follow up after each of these events. MCSP providers generally saw their patients following a TTA event as requested. Follow-Up After Transferring Into the Institution Access to care for patients who had recently transferred into the institution was good. Compliance testing showed newly arrived patients timely received a provider appointment (MIT 1.002, 83.3%). OIG clinicians reviewed 11 patients who were transferred into MCSP during the review period and did not find any access deficiencies. Clinician On-Site Inspection Our case review clinicians spoke with MCSP executive leadership, medical and nursing leadership, and schedulers regarding the institution’s access to care. MCSP’s review period occurred during the COVID-19 pandemic and consideration was given for the COVID-19 interim guidance to reduce the spread of the virus.20 These individuals reported backlogs due to the COVID-19 pandemic and that they had worked to reduce those backlogs by reviewing outstanding appointments and booking appointments for those patients who needed to be seen and rescheduling others who did not have an urgent need to be seen during that period. During our on-site visit, MCSP leadership acknowledged our identified deficiencies and provided training to the staff. 20 See https://cchcs.ca.gov/covid-19-interim-guidance/. Office of the Inspector General, State of California Inspection Period: June 2021 – November 2021 Report Issued: November 2022 Cycle 6, Mule Creek State Prison | 18 Compliance Testing Results Table 6. Access to Care Table 6. Access to Care Scored Answer Compliance Questions Yes No N/A Yes % Chronic care follow-up appointments: Was the patient’s most recent chronic care visit within the health care guideline’s maximum 19 6 0 76.0% allowable interval or within the ordered time frame, whichever is shorter? (1.001) * For endorsed patients received from another CDCR institution: Based on the patient’s clinical risk level during the initial health 20 4 1 83.3% screening, was the patient seen by the clinician within the required time frame? (1.002) * Clinical appointments: Did a registered nurse review the patient’s 35 0 0 100% request for service the same day it was received? (1.003) * Clinical appointments: Did the registered nurse complete a face-to- face visit within one business day after the CDCR Form 7362 was 33 2 0 94.3% reviewed? (1.004) * Clinical appointments: If the registered nurse determined a referral to a primary care provider was necessary, was the patient seen within 11 3 21 78.6% the maximum allowable time or the ordered time frame, whichever is the shorter? (1.005) * Sick call follow-up appointments: If the primary care provider ordered a follow-up sick call appointment, did it take place within the time 3 1 31 75.0% frame specified? (1.006) * Upon the patient’s discharge from the community hospital: Did the patient receive a follow-up appointment within the required time 23 1 0 95.8% frame? (1.007) * Specialty service follow-up appointments: Did the clinician follow-up visits occur within required time frames? (1.008) *,† 22 6 17 78.6% Clinical appointments: Do patients have a standardized process to 5 1 0 83.3% obtain and submit health care services request forms? (1.101) Overall percentage (MIT 1): 85.0% * The OIG clinicians considered these compliance tests along with their case review findings when determining the quality rating for this indicator. † CCHCS changed its specialty policies in April 2019, removing the requirement for primary care physician follow-up visits following specialty services. As a result, we tested MIT 1.008 only for high-priority specialty services or when staff ordered follow-ups. The OIG continued to test the clinical appropriateness of specialty follow-ups through its case review testing. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: June 2021 – November 2021 Report Issued: November 2022 Cycle 6, Mule Creek State Prison | 19 Table 7. Other Tests Related to Access to Care Table 7. Other Tests Related to Access to Care Scored Answer Compliance Questions Yes No N/A Yes % For patients received from a county jail: If, during the assessment, the nurse referred the patient to a provider, was the patient seen within the N/A N/A N/A N/A required time frame? (12.003) * For patients received from a county jail: Did the patient receive a history and physical by a primary care provider within seven calendar N/A N/A N/A N/A days? (12.004) * For CTC and SNF only (effective 4/2019, include OHU): Was a written history and physical examination completed within the required time 6 0 0 100% frame? (13.002) * For OHU, CTC, SNF, and Hospice (applicable only for samples prior to 4/2019): Did the primary care provider complete the Subjective, Objective, N/A N/A 6 N/A Assessment, and Plan notes on the patient at the minimum intervals required for the type of facility where the patient was treated? (13.003) *,† Did the patient receive the high-priority specialty service within 14 calendar days of the primary care provider order or the Physician 11 4 0 73.3% Request for Service? (14.001) * Did the patient receive the subsequent follow-up to the high-priority specialty service appointment as ordered by the primary care provider? 7 4 4 63.6% (14.003) * Did the patient receive the medium-priority specialty service within 15-45 calendar days of the primary care provider order or the Physician 11 4 0 73.3% Request for Service? (14.004) * Did the patient receive the subsequent follow-up to the medium- priority specialty service appointment as ordered by the primary care 5 3 7 62.5% provider? (14.006) * Did the patient receive the routine-priority specialty service within 90 calendar days of the primary care provider order or Physician 10 5 0 66.7% Request for Service? (14.007) * Did the patient receive the subsequent follow-up to the routine-priority specialty service appointment as ordered by the primary care provider? 7 0 8 100% (14.009) * * The OIG clinicians considered these compliance tests along with their case review findings when determining the quality rating for this indicator. † CCHCS changed its policies and removed mandatory minimum rounding intervals for patients located in specialized medical housing. After April 2, 2019, MIT 13.003 only applied to CTCs that still had state- mandated rounding intervals. OIG case reviewers continued to test the clinical appropriateness of provider follow-ups within specialized medical housing units through case reviews. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: June 2021 – November 2021 Report Issued: November 2022 Cycle 6, Mule Creek State Prison | 20 Recommendations The OIG offers no recommendations for this indicator. Office of the Inspector General, State of California Inspection Period: June 2021 – November 2021 Report Issued: November 2022 Cycle 6, Mule Creek State Prison | 21 Diagnostic Services In this indicator, OIG inspectors evaluated the institution’s performance in timely completing radiology, laboratory, and pathology tests. Our inspectors Overall determined whether the institution properly retrieved the resultant reports and Rating whether providers reviewed the results correctly. In addition, in Cycle 6, we Inadequate examined the institution’s performance in timely completing and reviewing immediate (STAT) laboratory tests. Case Review Rating Results Overview Adequate Compliance In this indicator, MCSP had a mixed performance as compliance testing showed Score a low score while case review had an adequate rating. The poor compliance Inadequate scores were due to STAT laboratory performance as well as a lack of the (58.5%) communication of test results. We considered all factors in diagnostics services, and acknowledge that compliance testing assessed more facets of the diagnostics indicator and thus its assessment should receive more consideration, we rated this indicator inadequate. Case Review and Compliance Testing Results We reviewed 260 diagnostic events and found 40 deficiencies, four of which were significant.21 All of these deficiencies were due to health information management. Test Completion MCSP demonstrated a mixed performance with completing tests. Performance in case reviews was excellent; our clinicians did not identify any delays or incomplete diagnostic tests. Compliance testing also showed a high completion rate of x-rays (MIT 2.001, 90.0%), but low completion rates for standard laboratory tests (MIT 2.004, 60.0%), and STAT laboratory tests (MIT 2.007, 30.0%). Case review did not have any applicable cases with STAT laboratory tests available for us to review. Health Information Management Staff performed well for the retrieval of health information, but poorly for notifications of patient results. Compliance testing showed that providers timely endorsed 90.0 percent of x-rays (MIT 2.002) and 100 percent of laboratory tests (MIT 2.005). Our case review found only four instances in which reports were not endorsed or were endorsed with a delay. In contrast, patient test result notification is an area that needed improvement. Compliance scores for communicating radiology and laboratory results were very poor (MIT 2.003, 20.0%, and MIT 2.006, 30.0%). Our case review found five diagnostic events in two 21 Deficiencies occurred in cases 2, 3, 8, 10, 14, 15, 16, 21, 22, 23, 24, 26, 27, and 28. Significant deficiencies occurred in cases 2, 10, and 14. Office of the Inspector General, State of California Inspection Period: June 2021 – November 2021 Report Issued: November 2022 Cycle 6, Mule Creek State Prison | 22 cases that did not have a letter and 34 patient notification letters that were missing at least one of the required elements. Compliance testing showed that although retrieval of pathology reports was very good (MIT 2.010, 90.0%), provider review was marginal (MIT 2.011, 70.0%), and the sending of notification letters was poor (MIT 2.012, 10.0%). Clinician On-Site Inspection We interviewed diagnostic supervisors and staff. Laboratory staff reviewed pending tests daily and looked for results within three to five days of test completion to see whether test results were received. In the radiology department, there is one technician and one scheduler, and they reported no issues with scheduling x-ray appointments. After off-site imaging studies are performed, the report is entered into the imaging center, and a notification is sent to the patient’s electronic health record. Providers needed to request images if they wanted them to appear in the electronic health record system. Office of the Inspector General, State of California Inspection Period: June 2021 – November 2021 Report Issued: November 2022 Cycle 6, Mule Creek State Prison | 23 Compliance Testing Results Table 8. Diagnostic Services Table 8. Diagnostic Services Scored Answer Compliance Questions Yes No N/A Yes % Radiology: Was the radiology service provided within the time frame 9 1 0 90.0% specified in the health care provider’s order? (2.001) * Radiology: Did the ordering health care provider review and endorse 9 1 0 90.0% the radiology report within specified time frames? (2.002) * Radiology: Did the ordering health care provider communicate the results of the radiology study to the patient within specified time 2 8 0 20.0% frames? (2.003) Laboratory: Was the laboratory service provided within the time 6 4 0 60.0% frame specified in the health care provider’s order? (2.004) * Laboratory: Did the health care provider review and endorse the 10 0 0 100% laboratory report within specified time frames? (2.005) * Laboratory: Did the health care provider communicate the results of the laboratory test to the patient within specified time frames? 3 7 0 30.0% (2.006) Laboratory: Did the institution collect the STAT laboratory test and 3 7 0 30.0% receive the results within the required time frames? (2.007) * Laboratory: Did the provider acknowledge the STAT results, OR did nursing staff notify the provider within the required time frames? 1 7 2 12.5% (2.008) * Laboratory: Did the health care provider endorse the STAT laboratory 8 0 2 100% results within the required time frames? (2.009) Pathology: Did the institution receive the final pathology report 9 1 0 90.0% within the required time frames? (2.010) * Pathology: Did the health care provider review and endorse the 7 3 0 70.0% pathology report within specified time frames? (2.011) * Pathology: Did the health care provider communicate the results of the pathology study to the patient within specified time frames? 1 9 0 10.0% (2.012) Overall percentage (MIT 2): 58.5% * The OIG clinicians considered these compliance tests along with their case review findings when determining the quality rating for this indicator. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: June 2021 – November 2021 Report Issued: November 2022 Cycle 6, Mule Creek State Prison | 24 Recommendations • The department should consider developing strategies to ensure that providers create patient letters at the time of review or endorsement and that patient letters should contain all elements required per CCHCS policy. • Medical leadership should ascertain causative factors related to the untimely collecting or receiving of STAT laboratory results and should implement remedial measures as appropriate. 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 challenges in reviewing or endorsing pathology reports timely and implement remedial measures as appropriate. Office of the Inspector General, State of California Inspection Period: June 2021 – November 2021 Report Issued: November 2022 Cycle 6, Mule Creek State Prison | 25 Emergency Services In this indicator, OIG clinicians evaluated the quality of emergency medical care. Our clinicians reviewed emergency medical services by examining the timeliness Overall and appropriateness of clinical decisions made during medical emergencies. Our Rating evaluation included examining the emergency medical response, Adequate cardiopulmonary resuscitation (CPR) quality, triage and treatment area (TTA) care, provider performance, and nursing performance. Our clinicians also Case Review evaluated the Emergency Medical Response Review Committee’s (EMRRC) Rating performance in identifying problems with its emergency services. The OIG Adequate assessed the institution’s emergency services mainly through case review. Compliance Results Overview Score (N/A) Compared with Cycle 5, MCSP improved in providing emergency services in this cycle. Nursing staff generally responded immediately to emergencies, generally made good patient assessments, and activated emergency medical services (EMS) timely. For those patients who required CPR, custody and nursing staff frequently worked together to initiate CPR and call 9-1-1. Nursing staff provided interventions and communicated with providers as required. While opportunities to improve were noted for documentation and patient education, overall, we rated this indicator adequate. Case Review Results We reviewed 26 urgent or emergent events and found 25 emergency care deficiencies in 16 cases.22 Of these 25 deficiencies, two were significant.23 Emergency Medical Response Staff responded promptly to emergencies throughout the institution. Medical and custody staff worked cohesively to provide care. They initiated CPR appropriately, frequently activated EMS immediately, and notified TTA clinical staff in a timely manner. We reviewed 16 first responder events and identified two significant deficiencies related to nursing care.24 There was a delay in initiating oxygen and activating EMS in the following cases: • In case 5, the nurse responded to an emergency for a patient having breathing problems. His breathing was labored, and his skin was pale, cool, and damp. The nurse did not assess the patient’s oxygen saturation rate or intervene immediately by initiating oxygen. 22 For emergency care, we reviewed cases 1–9, 13, 16, 21–24, and 26. 23 Deficiencies occurred in cases 1–3, 5–7, 9, 16, 21, 23, 24, 26, 28, and 66. Cases 5 and 9 had significant deficiencies. 24 First-responder events occurred in cases 1–9, 16, and 21. Significant deficiencies related to nursing care occurred in cases 5 and 9. Both deficiencies were identified by MCSP leadership during the emergency review process, and MCSP leadership reported that they provided training to the nursing staff. Office of the Inspector General, State of California Inspection Period: June 2021 – November 2021 Report Issued: November 2022 Cycle 6, Mule Creek State Prison | 26 Eighteen minutes later, when the patient arrived in the TTA, he required CPR with oxygen. • In case 9, the patient was experiencing shortness of breath and had low oxygen levels. The nursing staff delayed care by administering oxygen 13 minutes later and calling 9-1-1, 31 minutes later. Cardiopulmonary Resuscitation Quality Nursing staff often performed well in this area. Our OIG clinicians reviewed five cases in which the patient required cardiopulmonary resuscitation (CPR).25 Nursing and custody staff worked together to provide care. They requested 9-1-1 without delay. Custody staff initiated CPR immediately. Nursing staff responded timely, assessed the patient, and intervened appropriately. Nursing staff utilized the automated external defibrillator (AED) and provided oxygen to the patient. The following case is an example of appropriate emergency response and interventions: • In case 7, custody staff found an unresponsive patient, notified the clinical nursing staff, called 9-1-1, and initiated CPR. Nursing staff arrived on scene and assessed the patient. The patient remained without a pulse, staff continued CPR, and transported the patient to the TTA. Nursing staff utilized the AED, administered oxygen, and a narcotic reversal medication. EMS personnel arrived on scene, assumed care of the patient, and administered life-saving measures. Despite the timely and appropriate medical care provided by MCSP staff and EMS, the patient died. Provider Performance Providers performance was acceptable with urgent and emergent situations, and after-hours care with one major exception, seen below: • In case 7, the provider did not personally evaluate or send the patient out for a higher level of care when notified about signs and symptoms of a heart attack. This case is discussed further in the Provider Performance indicator. Case review clinicians identified two instances in which providers did not perform physical exams. While the omission of physical exams did not meet medical standards of care, their lack did not significantly increase the risk of harm to the patients at MCSP. Nursing Performance Nurses generally performed well during emergent events. TTA nurses frequently provided appropriate and timely interventions, and communicated with the 25 The patients required CPR in cases 4–8. Office of the Inspector General, State of California Inspection Period: June 2021 – November 2021 Report Issued: November 2022 Cycle 6, Mule Creek State Prison | 27 providers as required. However, we identified a pattern of deficiencies related to a delay in oxygen administration.26 The areas of nursing documentation and patient education also needed improvement. TTA nurses did not always provide patient education during patient encounters.27 Nursing Documentation TTA nurses generally prepared thorough documentation for emergent events. However, we identified a few documentation issues. Examples of documentation deficiencies include missing orders on a transfer to a higher level of care, a missing order on performing an EKG, and a missing time entry in the medication administration record (MAR).28 Inconsistent documentation of time lines occurred in cases 6 and 7. However, these documentation deficiencies did not affect overall patient care. Emergency Medical Response Review Committee We reviewed 18 emergency response events during the review period.29 The EMRRC generally performed reviews within the required time frame, identified deficiencies, and provided staff training. Compliance findings showed the EMRRC did not always review emergency cases within the required time frame (MIT 15.003, 8.3%). Our clinicians found the EMRRC did not review cases 2 and 3 within the required time frame. Clinician On-Site Inspection MCSP had two TTAs. One TTA was located in the main facility and the other was located in the newer facility, called the Mule Creek Infill Complex (MCIC). The TTA located in the main facility had four beds and was staffed with two RN staff on each watch. Nursing staff reported that the nurses responded to yards A, B, and C, and the minimum-facility. In addition to the TTA nurses responding to emergencies, recently, psychiatric technician (PT) staff responded to the restricted housing and enhanced outpatient (EOP) buildings. LVN staff were the first responders to all other buildings along with the TTA nurse. The nurses assigned to the TTA located in the MCIC responded to medical emergencies in yards D and E. These yards were also staffed with two RNs on each watch. This TTA had one bed assigned for triage and the others were used by specialties, such as gastroenterology and podiatry. The nurses in both areas reported their administration was generally supportive and they had a good rapport with custody staff. However, nurses reported morale was low due to short staffing. 26 The deficiencies occurred in cases 5 and 9. 27 TTA nurses did not provide patient education in cases 3, 16, and 24. 28 Deficiencies in TTA nursing documentation occurred in cases 1–3, 16, and 23. 29 Emergency response events occurred in cases 1–9, 16, and 21. Office of the Inspector General, State of California Inspection Period: June 2021 – November 2021 Report Issued: November 2022 Cycle 6, Mule Creek State Prison | 28 Recommendations • Nursing leadership should consider completing an audit of staff documentation after TTA encounters to provide training to staff regarding how to properly create documentation in the electronic health record system (EHRS). • The Emergency Medical Response Review Committee (EMRRC) should thoroughly review emergency response events and accurately detail findings. Office of the Inspector General, State of California Inspection Period: June 2021 – November 2021 Report Issued: November 2022 Cycle 6, Mule Creek State Prison | 29 Health Information Management In this indicator, OIG inspectors evaluated the flow of health information, a crucial link in high-quality medical care delivery. Our inspectors examined Overall whether the institution retrieved and scanned critical health information Rating (progress notes, diagnostic reports, specialist reports, and hospital discharge Adequate reports) into the medical record in a timely manner. Our inspectors also tested Case Review whether clinicians adequately reviewed and endorsed those reports. In addition, Rating our inspectors checked whether staff labeled and organized documents in the medical record correctly. Adequate Compliance Results Overview Score Adequate Overall, MCSP performed satisfactorily when managing health information. The (77.7%) institution managed hospital discharge reports, specialty reports, and urgent and emergent records. Diagnostic reports management needed improvement. Scanning performance was an area whereby the case review clinicians and the compliance testing showed different performance. In compliance testing, samples showed that the patient letters were labeled erroneously; however, these concern did not affect the care that the patients received. After considering all aspects of health information management, we rated this indicator adequate. Case Review and Compliance Results We reviewed 1081 events and found 44 deficiencies related to health information management. Of these 44 deficiencies, six were significant.30 Hospital Discharge Reports MCSP performed very well with retrieval and review of hospital discharge reports. Case review clinicians examined 19 off-site emergency discharge department and hospital visits. Staff timely retrieved hospital records, scanned them into the medical record, and reviewed them properly. Compliance testing also showed excellent performance with retrieval of hospital records (MIT 4.003, 95.0%) and had complete discharge records (MIT 4.005, 100%). Our case review identified the following deficiency: • In case 66, the patient went to the emergency department. The report for this visit was not endorsed by a provider until more than one month later. Specialty Reports MCSP performed acceptably with the handling of specialty reports. Compliance testing showed excellent retrieval of specialty reports (MIT 4.002, 93.3%) and 30 HIM deficiencies occurred in cases 2, 3, 8, 10, 14, 15, 16, 21, 22, 23, 24, 25, 26, 27, 28, and 66. Significant deficiencies occurred in cases 2, 10, 14, 15, and 66. Office of the Inspector General, State of California Inspection Period: June 2021 – November 2021 Report Issued: November 2022 Cycle 6, Mule Creek State Prison | 30 provider endorsement of medium-priority reports (MIT 14.005, 80.0%) and routine reports (MIT 14.008, 86.7%), but poor provider endorsement of high- priority reports (MIT 14.002, 73.3%). Our clinicians reviewed 60 specialty reports and identified only one deficiency. We also discuss these findings in the Specialty Services indicator. Diagnostic Reports MCSP’s performance in managing diagnostic reports was mixed. The institution retrieved the reports timely and, generally, providers endorsed the reports timely. However, the process of notifying patients needed improvement. Our case reviewers found incomplete notification letters for patient test results in 34 of the diagnostic results we reviewed. Compliance testing found very poor performance for STAT records reviewed in the proper time frames (MIT 2.008, 12.5%), poor review of pathology results (MIT 2.011, 70.0%), and very poor communication of pathology results (MIT 2.012, 10.0%). Please refer to the Diagnostic Services indicator for a further detailed discussion concerning diagnostics. Urgent and Emergent Records OIG clinicians reviewed 27 emergency care events and found that nurses and providers recorded these events well. In one case, the nurse performed an EKG on the patient, but the EKG was not described in the patient’s electronic health record. Providers generally recorded the emergency care they delivered. In one case, however, the provider did not document orders for respiratory treatment. Please refer to the Emergency Services indicator for additional information regarding emergency care documentation. Scanning Performance MCSP showed a mixed performance for scanning. Our case review clinicians only found one deficiency in which an EKG was not scanned into the EHRS; otherwise, performance was excellent. However, compliance testing found no evidence of correct performance having occurred with patient letters that were mislabeled (MIT 4.004, zero). Although patient notification letters were generated, they were mislabeled in patients’ electronic health records, and were often mislabeled as “DDP – Scan” instead of “patient letter.”31 Clinician On-Site Inspection We discussed health information management processes with MCSP office technicians, health information management supervisors, ancillary staff, diagnostic staff, nurses, and providers. The medical records supervisor described the process of retrieving specialty reports. The staff worked with the specialty department and reviewed a daily list of patients that went off-site. Staff compared the list with information in the electronic health record to look for the reports and request reports that were not returned. Once it became available, the health 31 DDP is the Developmental Disability Program. Office of the Inspector General, State of California Inspection Period: June 2021 – November 2021 Report Issued: November 2022 Cycle 6, Mule Creek State Prison | 31 record technician forwarded the report to the provider. Staff had the capability to log into message center to determine if reports were endorsed, and discussed unsigned reports with the chief physician and surgeon. Office of the Inspector General, State of California Inspection Period: June 2021 – November 2021 Report Issued: November 2022 Cycle 6, Mule Creek State Prison | 32 Compliance Testing Results Table 9. Health Information Management Table 9. Health Information Management Scored Answer Compliance Questions Yes No N/A Yes % Are health care service request forms scanned into the patient’s electronic health record within three calendar days of the encounter 20 0 15 100% date? (4.001) Are specialty documents scanned into the patient’s electronic health 28 2 15 93.3% record within five calendar days of the encounter date? (4.002) * Are community hospital discharge documents scanned into the patient’s electronic health record within three calendar days of 19 1 4 95.0% hospital discharge? (4.003) * During the inspection, were medical records properly scanned, 0 24 0 0 labeled, and included in the correct patients’ files? (4.004) * For patients discharged from a community hospital: Did the preliminary or final hospital discharge report include key elements 24 0 0 100% and did a provider review the report within five calendar days of discharge? (4.005) * Overall percentage (MIT 4): 77.7% * The OIG clinicians considered these compliance tests along with their case review findings when determining the quality rating for this indicator. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: June 2021 – November 2021 Report Issued: November 2022 Cycle 6, Mule Creek State Prison | 33 Table 10. Other Tests Related to Health Information Management Table 10. Other Tests Related to Health Information Management Scored Answer Compliance Questions Yes No N/A Yes % Radiology: Did the ordering health care provider review and endorse 9 1 0 90.0% the radiology report within specified time frames? (2.002) * Laboratory: Did the health care provider review and endorse the 10 0 0 100% laboratory report within specified time frames? (2.005) * Laboratory: Did the provider acknowledge the STAT results, OR did nursing staff notify the provider within the required time frame? 1 7 2 12.5% (2.008) * Pathology: Did the institution receive the final pathology report within 9 1 0 90.0% the required time frames? (2.010) * Pathology: Did the health care provider review and endorse the 7 3 0 70.0% pathology report within specified time frames? (2.011) * Pathology: Did the health care provider communicate the results of the 1 9 0 10.0% pathology study to the patient within specified time frames? (2.012) Did the institution receive and did the primary care provider review the high-priority specialty service consultant report within the required time 11 4 0 73.3% frame? (14.002) * Did the institution receive and did the primary care provider review the medium-priority specialty service consultant report within the required 12 3 0 80.0% time frame? (14.005) * Did the institution receive and did the primary care provider review the routine-priority specialty service consultant report within the required 13 2 0 86.7% time frame? (14.008) * * The OIG clinicians considered these compliance tests along with their case review findings when determining the quality rating for this indicator. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: June 2021 – November 2021 Report Issued: November 2022 Cycle 6, Mule Creek State Prison | 34 Recommendations • The department should consider adjusting the default drop-down menu on the results letter in the EHRS, so the menu defaults to Patient Letter instead of DDP-Scan; the department should train providers to generate the results letters appropriately. Office of the Inspector General, State of California Inspection Period: June 2021 – November 2021 Report Issued: November 2022 Cycle 6, Mule Creek State Prison | 35 Health Care Environment In this indicator, OIG compliance inspectors tested clinics’ waiting areas, infection control, sanitation procedures, medical supplies, equipment Overall management, and examination rooms. Inspectors also tested clinics’ performance Rating in maintaining auditory and visual privacy for clinical encounters. Compliance Inadequate inspectors asked the institution’s health care administrators to comment on their facility’s infrastructure and its ability to support health care operations. The OIG Case Review rated this indicator solely on the compliance score, using the same scoring Rating thresholds as in the Cycle 4 and Cycle 5 medical inspections. Our case review (N/A) clinicians do not rate this indicator. Compliance Score Results Overview Inadequate (61.1%) For this indicator, MCSP’s performance declined compared with its performance in Cycle 5. In the present cycle, multiple aspects of MCSP’s health care environment were found to need improvement: multiple clinics contained expired medical supplies; multiple clinics lacked medical supplies or contained improperly calibrated medical equipment; emergency medical response bag (EMRB) logs either were missing staff verification or inventory was not performed; and staff did not regularly sanitize their hands before or after examining patients. These factors resulted in an inadequate rating for this indicator. Compliance Testing Results Outdoor Waiting Areas The institution had no waiting areas that required patients to wait outside. Indoor Waiting Areas We inspected indoor waiting areas. Health care and custody staff reported that existing waiting areas contained sufficient seating capacity (see Photo 1). Depending on the population, patients were either placed in the clinic waiting area or held in individual modules (see Photo 2, next page). Custody staff also reported they brought in only a few patients at a time to prevent overcrowding the indoor waiting areas and to maintain safe social distancing. During our inspection, we did not observe overcrowding in the clinics’ waiting areas. Photo 1. Indoor waiting area (photographed on February 9, 2022). Office of the Inspector General, State of California Inspection Period: June 2021 – November 2021 Report Issued: November 2022 Cycle 6, Mule Creek State Prison | 36 Photo 2. Individual patient waiting modules (photographed on February 9, 2022). Clinic Environment Of 13 clinic environments, 12 were sufficiently conducive for medical care. They provided reasonable auditory privacy, appropriate waiting areas, wheelchair accessibility, and nonexamination room workspace (MIT 5.109, 92.3%). In one clinic, we observed nursing staff provided services to multiple patients at the same time in the vital sign check stations, which hampered auditory privacy. Of the 13 clinics we observed, 11 contained appropriate space, configuration, supplies, and equipment to allow clinicians to perform proper clinical examinations (MIT 5.110, 84.6%). In one clinic, the examination room table had a torn cover. The remaining clinic’s equipment configuration did not allow adequate space for clinicians to conduct proper patient examination. Clinic Supplies Only one of the 13 clinics followed adequate medical supply storage and management protocols (MIT 5.107, 7.7%). We found one or more of the following deficiencies in 12 clinics: expired medical supplies, unidentified medical supplies, compromised sterile medical supply packaging, and cleaning materials stored with medical supplies (see Photos 3 and 4, next page). Office of the Inspector General, State of California Inspection Period: June 2021 – November 2021 Report Issued: November 2022 Cycle 6, Mule Creek State Prison | 37 Photo 3. Expired medical supplies dated August 2021 (photographed on February 10, 2022). Photo 4. Expired medical supplies dated September 25, 2021 (photographed on February 10, 2022). Office of the Inspector General, State of California Inspection Period: June 2021 – November 2021 Report Issued: November 2022 Cycle 6, Mule Creek State Prison | 38 Only four of the 13 clinics met the requirements for essential core medical equipment and supplies (MIT 5.108, 30.8%). The remaining nine clinics lacked medical supplies or contained improperly calibrated or nonfunctional equipment. Several clinics were missing an AED at the time of our inspection. The chief nursing executive reported that the institution had placed an order for AEDs prior to the period of our on-site inspection. The staff had not properly calibrated a pulse oximeter and an overhead light. We found the Snellen eye chart did not have a corresponding distance line marked on either the floor or the wall. In addition, we found one clinic utilized a printed-out Snellen chart (see Photo 5, below). We also found nonfunctional oto-ophthalmoscopes. CTC staff did not properly log the results of the defibrillator performance test within the last 30 days. In addition, CTC staff did not perform and log glucometer quality control results for one of the two glucometers in the clinic. Photo 5. Snellen eye chart, printed and taped to a clinic room wall (photographed on February 8, 2022). Office of the Inspector General, State of California Inspection Period: June 2021 – November 2021 Report Issued: November 2022 Cycle 6, Mule Creek State Prison | 39 We examined the emergency medical response bags (EMRBs) to determine whether they contained all essential items. We checked whether staff inspected the bags daily and inventoried them monthly. Only two of the nine EMRBs passed our test (MIT 5.111, 22.2%). We found one or more of the following deficiencies with seven EMRBs: staff failed to ensure the EMRB’s compartments were sealed and intact; staff did not perform and document the daily EMRB AED performance check; staff had not inventoried the EMRBs when the seal tags were replaced; staff failed to log EMRB daily glucometer quality-control results; and staff inaccurately logged the EMRB glucometer control-solution range when performing the daily glucometer quality-control check. Staff in the room for minor procedures did not always document that the treatment cart was sealed and intact. At the time of our on-site inspection, the treatment cart in the TTA did not meet the minimum inventory level, nor was there documentation that reasonable substitutions were made. Medical Supply Management MCSP staff proficiently stored clinic medical supplies in the medical supply storage areas outside the clinics (e.g., warehouse, Conex containers, etc.) (MIT 5.106, 100%). According to the chief executive officer, the institution did not have any issues with the medical supply process. Health care and warehouse managers expressed no concerns about either the medical supply chain or their communication process with the existing system that was in place. Infection Control and Sanitation Staff appropriately cleaned, disinfected, and sanitized seven of 13 clinics (MIT 5.101, 53.9%). In six clinics, cleaning logs were not maintained. In addition, one of the six clinics did not have a cleaning log at the time of our inspection. Staff in nine of 13 clinics (MIT 5.102, 69.2%) properly sterilized or disinfected medical equipment. In four clinics, we found one or more of the following deficiencies: staff did not mention disinfecting the examination table as part of their daily start-up protocol and relied on incarcerated person-porters to perform the cleaning; we observed that the clinician did not remove and replace the examination table paper in between patient encounters; and staff did not initial the packaging of sterilized medical equipment. We found operating sinks and hand-hygiene supplies in the examination rooms in eight of 13 clinics (MIT 5.103, 61.5%). In five clinics, patient restrooms lacked either antiseptic soap or disposable hand towels. We observed patient encounters in six clinics. In three clinics, clinicians did not wash their hands before applying gloves, after examining their patients, during subsequent regloving, or did not wash their hands with an antiseptic soap before performing an invasive procedure (MIT 5.104, 50.0%). Health care staff in all clinics followed proper protocols to mitigate exposure to blood-borne pathogens and contaminated waste (MIT 5.105,100%). Office of the Inspector General, State of California Inspection Period: June 2021 – November 2021 Report Issued: November 2022 Cycle 6, Mule Creek State Prison | 40 Physical Infrastructure At the time of our medical inspection, the institution’s administrative team reported no ongoing health care facility improvement program construction projects. The institution’s health care management and plant operations manager reported all clinical area infrastructures were in good working order (MIT 5.999). Office of the Inspector General, State of California Inspection Period: June 2021 – November 2021 Report Issued: November 2022 Cycle 6, Mule Creek State Prison | 41 Compliance Testing Results TTaabbllee 1111.. HHeeaalltthh CCaarree EEnnvviirroonnmmeenntt Scored Answer Compliance Questions Yes No N/A Yes % Infection control: Are clinical health care areas appropriately 7 6 1 53.9% disinfected, cleaned, and sanitary? (5.101) Infection control: Do clinical health care areas ensure that reusable invasive and noninvasive medical equipment is properly sterilized or 9 4 1 69.2% disinfected as warranted? (5.102) Infection control: Do clinical health care areas contain operable sinks 8 5 1 61.5% and sufficient quantities of hygiene supplies? (5.103) Infection control: Does clinical health care staff adhere to universal 3 3 8 50.0% hand hygiene precautions? (5.104) Infection control: Do clinical health care areas control exposure to 13 0 1 100% blood-borne pathogens and contaminated waste? (5.105) Warehouse, conex, and other nonclinic storage areas: Does the medical supply management process adequately support the needs 1 0 0 100% of the medical health care program? (5.106) Clinical areas: Does each clinic follow adequate protocols for 1 12 1 7.7% managing and storing bulk medical supplies? (5.107) Clinical areas: Do clinic common areas and exam rooms have 4 9 1 30.8% essential core medical equipment and supplies? (5.108) Clinical areas: Are the environments in the common clinic areas 12 1 1 92.3% conducive to providing medical services? (5.109) Clinical areas: Are the environments in the clinic exam rooms 11 2 1 84.6% conducive to providing medical services? (5.110) Clinical areas: Are emergency medical response bags and emergency crash carts inspected and inventoried within required time frames, 2 7 5 22.2% and do they contain essential items? (5.111) Does the institution’s health care management believe that all clinical This is a nonscored test. Please areas have physical plant infrastructures that are sufficient to provide see the indicator for discussion of adequate health care services? (5.999) this test. Overall percentage (MIT 5): 61.1% * The OIG clinicians considered these compliance tests along with their case review findings when determining the quality rating for this indicator. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: June 2021 – November 2021 Report Issued: November 2022 Cycle 6, Mule Creek State Prison | 42 Recommendations • Medical leadership should remind staff to follow universal hand hygiene precautions. Implementing random spot checks could improve compliance. • Nursing leadership should consider performing random spot checks to ensure staff follow equipment and medical supply management protocols. • Nursing leadership should direct each clinic nursing supervisor to review the monthly emergency medical response bag (EMRB) logs to ensure the EMRBs are regularly inventoried and sealed. Office of the Inspector General, State of California Inspection Period: June 2021 – November 2021 Report Issued: November 2022 Cycle 6, Mule Creek State Prison | 43 Transfers In this indicator, OIG inspectors examined the transfer process for those patients who transferred into the institution as well as for those who transferred to other Overall institutions. For newly arrived patients, our inspectors assessed the quality of Rating health screenings and the continuity of provider appointments, specialist Inadequate referrals, diagnostic tests, and medications. For patients who transferred out of the institution, inspectors checked whether staff reviewed patient medical Case Review records and determined the patient’s need for medical holds. They also assessed Rating whether staff transferred patients with their medical equipment and gave correct Adequate medications before patients left. In addition, our inspectors evaluated the performance of staff in communicating vital health transfer information, such as Compliance preexisting health conditions, pending appointments, tests, and specialty Score referrals; and inspectors confirmed whether staff sent complete medication Inadequate transfer packages to the receiving institution. For patients who returned from (55.4%) off-site hospitals or emergency rooms, inspectors reviewed whether staff appropriately implemented the recommended treatment plans, administered necessary medications, and scheduled appropriate follow-up appointments. Results Overview MCSP’s performance was mixed in this indicator. Compared with Cycle 5, MCSP showed improvement in case review findings; however, compliance testing scored low overall. Although the R&R nurses performed well with the transfer- out process, MCSP did not always ensure medication continuity when patients arrived at their institution. Furthermore, when patients returned from the hospital, there was poor continuity of hospital-recommended medications. Taking all factors into account, the OIG rated this indicator inadequate. Case Review and Compliance Testing Results We reviewed 38 events in 21 cases in which patients transferred into or out of the institution or returned from an off-site hospital or emergency room. We identified 10 deficiencies, none of which were significant.32 Transfers In MCSP’s performance for the transfer-in process was variable. MCSP had satisfactory performance in case review. R&R nurses frequently completed the health screening thoroughly. Our clinicians reviewed 11 events in four cases in which patients transferred into the facility from other institutions. We identified four deficiencies, none of which were significant.33 R&R nurses frequently completed the health screening thoroughly. 32 We reviewed cases 1–3, 8, 9, 22–26, 29, 30–34, and 63–66. Deficiencies occurred in cases 1, 8, 21, 23, 29–31, 34, 64, and 66. 33 Transfer-in events occurred in cases 8 and 29–31. Office of the Inspector General, State of California Inspection Period: June 2021 – November 2021 Report Issued: November 2022 Cycle 6, Mule Creek State Prison | 44 Compliance results, on the other hand, were poor. MCSP nurses performed poorly in completing the initial nurse screening (MIT 6.001, 12.0%). MCSP had problems with ensuring medication continuity when patients arrived at the institution at a rate of 54.2 percent (MIT 6.003), when patients transferred from yard to yard within the institution at a rate of 68.0 percent (MIT 7.005), but for en-route patients, there was no medication continuity (MIT 7.006, zero). Both case review and compliance found patients who arrived at MCSP were frequently seen by the provider within the required time frame at a rate of 83.3 percent (MIT 1.002). Transfers Out Performance in this area was based mainly on case review findings as compliance did not have sample patients (MIT 6.101, N/A). At the time of our inspection, MCSP did not have any patients transferring out for compliance testing. Case review found MCSP’s performance for the transfer-out process was good. The R&R nurses completed the transfer screening, which included a check of the patient’s current vital signs and COVID-19 testing. Nurses ensured that patients transferred out with all durable medical equipment, and communicated significant medical and mental health conditions. OIG clinicians reviewed eight events in seven cases and found one deficiency, detailed below:34 • In case 34, the nurse did not ensure the patient had his keep-on-person asthma inhaler and nitroglycerin tablets when he transferred out of MCSP. Hospitalizations Patients returning from an off-site hospitalization or emergency room are at high risk for lapses in care quality. These patients typically experienced severe illness or injury. They required more care and placed a strain on the institution’s resources. In addition, because these patients have complex medical issues, successful health information transfer was necessary for good quality care. Any transfer lapse can result in serious consequences for these patients. Nurses frequently completed thorough assessments when patients returned from the hospital. Our clinicians reviewed 19 events in 14 cases in which patients returned from an off-site hospitalization or emergency room visit.35 We identified five deficiencies.36 The following is an example: • In cases 1 and 23, medication continuity was not maintained. The patients did not receive an evening dose of insulin. Compliance findings showed poor continuity of hospital-recommended medications (MIT 7.003, 16.7%). Case review did not identify any deficiencies 34 Transfer-out events occurred in cases 32–34, 63, 65, and 66. 35 Patients returned from a hospitalization or emergency room visit in cases 1–3, 9, 21–26, and 63–66. 36 For hospitalizations, deficiencies occurred in cases 1, 21, 23, 64, and 66. Office of the Inspector General, State of California Inspection Period: June 2021 – November 2021 Report Issued: November 2022 Cycle 6, Mule Creek State Prison | 45 related to the availability of hospital or emergency room summary reports; MCSP scored well in this area (MIT 4.003, 95.0%). Providers reviewed hospital documents within the required time frame (MIT 4.005, 100%). Case review did not identify any deficiencies with primary care provider follow-up appointments. Compliance findings corroborated these findings with a high score (MIT 1.007, 95.8%). Clinician On-Site Inspection MCSP has two R&R areas. One is located in the main facility and the other in the Mule Creek Infill Complex (MCIC). Our clinicians toured the R&R located in the main facility, in which staffing consisted of one RN assigned to each watch. R&R staff reported the number of patients arriving at MCSP varied from five to 26 people daily and the number of patients transferring out ranged from four to 20 daily. For patients who transferred out of MCSP, the third-watch R&R nurse performed a face-to-face interview with the patient in the TTA where the patient had a scheduled appointment. If a patient did not arrive at the TTA for the appointment, the R&R nurse would go out to the cell side to perform the patient interview. When patients arrived at MCSP with pending appointments, the nurse communicated the information to both the primary care physician and the specialty staff via the message pool. The staff reported receiving good administrative support and experiencing good nursing morale. In addition, they reported having a good rapport with custody staff. Office of the Inspector General, State of California Inspection Period: June 2021 – November 2021 Report Issued: November 2022 Cycle 6, Mule Creek State Prison | 46 Compliance Testing Results Table 12. Transfers Table 12. Transfers Scored Answer Compliance Questions Yes No N/A Yes % For endorsed patients received from another CDCR institution or COCF: Did nursing staff complete the initial health screening and 3 22 0 12.0% answer all screening questions within the required time frame? (6.001) * For endorsed patients received from another CDCR institution or COCF: When required, did the RN complete the assessment and disposition section of the initial health screening form; refer the 25 0 0 100% patient to the TTA if TB signs and symptoms were present; and sign and date the form on the same day staff completed the health screening? (6.002) For endorsed patients received from another CDCR institution or COCF: If the patient had an existing medication order upon arrival, 13 11 1 54.2% were medications administered or delivered without interruption? (6.003) * For patients transferred out of the facility: Do medication transfer packages include required medications along with the corresponding N/A N/A N/A N/A transfer packet required documents? (6.101) * Overall percentage (MIT 6): 55.4% * The OIG clinicians considered these compliance tests along with their case review findings when determining the quality rating for this indicator. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: June 2021 – November 2021 Report Issued: November 2022 Cycle 6, Mule Creek State Prison | 47 TTaabbllee 1133.. OOtthheerr TTeessttss RReellaatteedd ttoo TTrarannssfefersrs Scored Answer Compliance Questions Yes No N/A Yes % For endorsed patients received from another CDCR institution: Based on the patient’s clinical risk level during the initial health screening, was the 20 4 1 83.3% patient seen by the clinician within the required time frame? (1.002) * Upon the patient’s discharge from the community hospital: Did the patient receive a follow-up appointment with a primary care provider 23 1 0 95.8% within the required time frame? (1.007) * Are community hospital discharge documents scanned into the patient’s electronic health record within three calendar days of hospital 19 1 4 95.0% discharge? (4.003) * For patients discharged from a community hospital: Did the preliminary or final hospital discharge report include key elements and did a 24 0 0 100% provider review the report within five calendar days of discharge? (4.005) * Upon the patient’s discharge from a community hospital: Were all ordered medications administered, made available, or delivered to the 4 20 0 16.7% patient within required time frames? (7.003) * Upon the patient’s transfer from one housing unit to another: Were 17 8 0 68.0% medications continued without interruption? (7.005) * For patients en route who lay over at the institution: If the temporarily housed patient had an existing medication order, were medications 0 10 0 0 administered or delivered without interruption? (7.006) * For endorsed patients received from another CDCR institution: If the patient was approved for a specialty services appointment at the 10 10 0 50.0% sending institution, was the appointment scheduled at the receiving institution within the required time frames? (14.010) * * The OIG clinicians considered these compliance tests along with their case review findings when determining the quality rating for this indicator. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: June 2021 – November 2021 Report Issued: November 2022 Cycle 6, Mule Creek State Prison | 48 Recommendations • Nursing leadership should educate nursing staff to thoroughly complete the initial health screening before patients are transferred to the housing unit. • Nursing leadership should consider developing strategies to ensure that nursing staff administer medications without interruption to newly arrived patients and patients returning from hospitalizations. Office of the Inspector General, State of California Inspection Period: June 2021 – November 2021 Report Issued: November 2022 Cycle 6, Mule Creek State Prison | 49 Medication Management In this indicator, OIG inspectors evaluated the institution’s performance in administering prescription medications on time and without interruption. The Overall inspectors examined this process from the time a provider prescribed medication Rating until the nurse administered the medication to the patient. When rating this Inadequate indicator, the OIG strongly considered the compliance test results, which tested medication processes to a much greater degree than case review testing. In Case Review addition to examining medication administration, our compliance inspectors also Rating tested many other processes, including medication handling, storage, error Adequate reporting, and other pharmacy processes. Compliance Score Results Overview Inadequate (47.1%) Overall, MCSP performed poorly with medication management. Compliance testing showed low scores in medication administration and medications with hospital discharge, specialized medical housing, and transfers. Case review found acceptable performance in these areas. New medication starts and chronic medication continuity showed a need for improvement in both compliance testing and case review. After factoring in all aspects of medication management, as well as the breadth of areas needing improvement, we rated this indicator inadequate. Case Review and Compliance Testing Results We reviewed 168 events in 33 cases related to medications and found 22 medication deficiencies, two of which were significant.37 New Medication Prescriptions MCSP’s performance with new medications could have been better. Compliance findings resulted in 72.0 percent of new prescriptions administered timely (MIT 7.002). In these compliance samples, patients received their ordered medications from one dose to six days late. Case review identified nine deficiencies related to new medications with one significant deficiency. An example follows: • In case 22, the patient, with a history of coronary artery disease and hypertension, received his newly ordered keep-on-person medications, aspirin and lisinopril, one day late. Additional deficiencies which demonstrated a pattern of delays were mostly related to noncritical medications such as Lidocaine topical gel, antacids 37 We reviewed cases 1–3, 7–28, 35, 39, 40, 43, and 63–66. Deficiencies occurred in cases 1, 3, 8, 16, 17, 19, 22–24, 27, 29, 35, 39, 43, 46, 47, 63, 64, and 66. Cases 22, 23, and 66 had significant deficiencies. Office of the Inspector General, State of California Inspection Period: June 2021 – November 2021 Report Issued: November 2022 Cycle 6, Mule Creek State Prison | 50 (TUMS), and Fiber Lax.38 We also saw a pattern wherein patients did not receive new prn medications, such as pain medications.39 Chronic Medication Continuity MCSP had difficulty ensuring medication continuity for patients with chronic conditions. There is an opportunity for improvement in this area. Our clinicians identified six deficiencies, one of which was significant.40 An example is below: • In case 23, the patient’s blood pressure medication, hydrochlorothiazide, expired. The patient received the medication over a month after it was renewed. Additional deficiencies included patients receiving their medication from one dose to five days late. These include blood pressure, ulcer, and seizure medications. Compliance testing showed low performance in chronic medication timeliness with a score of 4.8 percent (MIT 7.001). The low score was mostly due to patients not receiving their keep-on-person medications one business day before the prescription was exhausted. Hospital-Discharge Medications Overall, MCSP performed poorly in this area. MCSP showed a below average score of 16.7 percent (MIT 7.003) for patients receiving their discharge medications upon return from an off-site hospitalization. Our clinicians reviewed 19 hospitalization events in 14 cases and identified three deficiencies.41 Our case review found MCSP’s performance was acceptable. We discuss this further in the Transfers indicator. Specialized Medical Housing Medications Case review and compliance testing found different results. Case review findings were good. Our clinicians found one significant deficiency in case 63 as discussed in the Specialized Medical Housing indicator. In contrast, compliance testing performance was low at a rate of 33.3 percent (MIT 13.004). In these compliance samples, prn asthma and heart medications were not made available to patients upon admission to the CTC. 38 Deficiencies related to new medications occurred in cases 3, 8, 16, 22, 27, 39, 43, 46, and 47. 39 Prn means as needed. A prn medication as a medication that is taken as needed per the medication instructions. 40 Deficiencies related to chronic medications occurred in cases 3, 17, 19, 23, 24, and 35. A significant deficiency occurred in case 23. 41 Hospitalization events occurred in cases 1–3, 9, 21-26, and 63–66. Cases 1, 23, and 64 had deficiencies. Office of the Inspector General, State of California Inspection Period: June 2021 – November 2021 Report Issued: November 2022 Cycle 6, Mule Creek State Prison | 51 Transfer Medications MCSP had mixed results in ensuring medication continuity for patients who transferred into the institution. Our clinicians identified one deficiency in the following case: • In case 29, when the patient arrived at MCSP, he received an extra dose of one of his ordered medications, which he had already received at the sending institution. Compliance testing showed poor performance (MIT 6.003, 54.2 %). Out of 24 patients tested, 11 patients did not receive their medications without interruption. When patients transferred within the institution, compliance results were low (MIT 7.005, 68.0%). However, this low score mostly resulted for the following reason: the nurse did not document on the medication administration record (MAR) the reason why the patient refused the medication. Patients en route to another institution also did not receive their medications without interruption (MIT 7.006, zero). During the week of inspection, MCSP had no patients transfer out of the institution (MIT 6.101, N/A). Medication Administration Our clinicians found the nurses generally administered medications as ordered and timely. Although, MCSP performed well in administering TB medications (MIT 9.001, 100%), nurses did not always monitor patients’ prescribed TB medications (MIT 9.002, 44.4%). Clinician On-Site Inspection During our on-site visit, we attended several huddles. The huddles were well- organized, thorough, and started timely. The LVN staff did not attend the huddles as they were busy administering medications to patients. However, before the huddles started each morning, the supervisor or RN staff checked in with the medication LVN for any medication issues. The nursing staff were very familiar with their patients. During the huddles, patients who were noncompliant with medications were identified and an appointment was scheduled for a follow- up appointment with either the provider or nursing staff. The medication LVNs we interviewed were familiar with medication-related processes such as the keep-on-person medications, patient no-shows, and the transfer processes. In one of the clinics we toured, the nurses reported their staffing was reduced from three LVNs to two LVNs, but the workload had remained the same. The medication nurses informed us during the height of the COVID-19 pandemic, the medication pass was challenging as the internet connection at MCSP was not reliable. RNs were utilized to pass out medications due to a Office of the Inspector General, State of California Inspection Period: June 2021 – November 2021 Report Issued: November 2022 Cycle 6, Mule Creek State Prison | 52 shortage of LVNs. Both RNs and LVNs went to the buildings to perform medication administration. In addition to medication administration, the LVNs responded to medical emergencies in their assigned areas. The LVNs we interviewed were familiar with their roles as first responders and could give us a verbal description of their responsibilities. We discussed the deficiencies in which the providers ordered new pain medications and how the patient had never received them. Staff indicated that because it was for a prescription to be given as needed, the patient needed to request that it be given. This is an area in which the institution needs to further clarify between providers ordering the medication and who will dispense the initial medication. Compliance Testing Results Medication Practices and Storage Controls The institution adequately stored and secured narcotic medications in 10 of 11 clinic and medication line locations (MIT 7.101, 90.9%). In one location, nurses did not describe the narcotic-medication discrepancy reporting process, and narcotic medications were not securely stored as required by CCHCS policy. MCSP appropriately stored and secured nonnarcotic medications in 11 of 13 clinic and medication line locations (MIT 7.102, 84.6%). In two locations, the clinic did not have a system in place to either separate patient-returned medications from clinic floor stock medications or medications with expired pharmacy labels that can potentially be restocked, reissued, or relabeled by the pharmacy. Staff kept medications protected from physical, chemical, and temperature contamination in four of the 13 clinic and medication line locations (MIT 7.103, 30.8%). In nine locations, we found one or more of the following deficiencies: staff did not consistently record the room and the refrigerator temperatures; staff did not store oral and topical medications separately; staff did not separate medications from disinfectants; and the medication refrigerator was unsanitary. Staff correctly stored valid unexpired medications in three of the 13 applicable clinic and medication line locations (MIT 7.104, 23.1%). In 10 locations, we found one or more of the following deficiencies: medication nurses did not label the multiple-use medication; medication was stored beyond the manufacturer’s expiration date; and a multiple-dose insulin vial was stored beyond the expiration date on the label. Nurses exercised proper hand-hygiene and contamination-control protocols in five of eight locations (MIT 7.105, 62.5%). In three locations, some nurses neglected to wash or sanitize their hands before donning gloves or before each subsequent regloving. Office of the Inspector General, State of California Inspection Period: June 2021 – November 2021 Report Issued: November 2022 Cycle 6, Mule Creek State Prison | 53 In four of eight medication preparation and administration areas, staff demonstrated appropriate administrative controls and protocols (MIT 7.106, 50.0%). In four locations, nurses did not maintain unissued medication in its original labeled packaging. Staff in six of eight medication areas used appropriate administrative controls and protocols when distributing medications to their patients (MIT 7.107, 75.0%). In one clinic, medication nurses did not reliably observe patients while they swallowed direct observation therapy medications. In another clinic, we observed some medication nurses did not properly disinfect the vial’s port prior to withdrawing medication during insulin administration. Pharmacy Protocols MCSP followed general security, organization, and cleanliness management protocols and properly stored nonrefrigerated medications in its main and remote pharmacies (MITs 7.108 and 7.109, 100%). Both pharmacies did not have an identifiable designated area for refrigerated medications returned to the pharmacy. As a result, MCSP scored zero for this test (MIT 7.110). The pharmacist-in-charge (PIC) did not adequately manage narcotic medications stored in MCSP’s pharmacies. The PIC did not complete a monthly physical inventory of controlled substances in each automated dispensing cabinet for the month of January 2022 due to the COVID-19 outbreak. Furthermore, the PIC did not correctly review monthly inventories of controlled substances in the institution’s clinic and medication storage locations. Specifically, the nurses present at the time of inspection did not correctly complete several medication- area inspection checklists (CDCR form 7477). These errors resulted in a score of zero for this test (MIT 7.111). We examined 13 medication error reports. The PIC timely or correctly processed only three of these 13 reports (MIT 7.112, 23.1%). For 10 medication errors, the PIC did not complete a Medication Error Follow-up form at the time of our inspection. Nonscored Tests In addition to testing the institution’s self-reported medication errors, our inspectors also followed up on any significant medication errors found during compliance testing. We did not score this test; we provide these results for informational purposes only. At MCSP, the OIG did not find any applicable medication errors (MIT 7.998). The OIG interviewed patients in restricted housing units to determine whether they had immediate access to their prescribed rescue medications. Nine of 10 applicable patients interviewed indicated they had access to their rescue medications. One patient reported that he did not have his prescribed rescue inhaler for approximately one month. He verbalized that he did not know what had happened to his medication and did not notify custody or medical staff. We Office of the Inspector General, State of California Inspection Period: June 2021 – November 2021 Report Issued: November 2022 Cycle 6, Mule Creek State Prison | 54 promptly notified the chief executive officer of this concern, and health care management immediately reissued a replacement rescue inhaler to the patient (MIT 7.999). Office of the Inspector General, State of California Inspection Period: June 2021 – November 2021 Report Issued: November 2022 Cycle 6, Mule Creek State Prison | 55 Compliance Testing Results TaTabblele 1 144.. MMeeddiiccaattiioonn MMaannaaggeemmenetnt Scored Answer Compliance Questions Yes No N/A Yes % Did the patient receive all chronic care medications within the required time frames or did the institution follow departmental policy for refusals or 1 20 4 4.8% no-shows? (7.001) * Did health care staff administer, make available, or deliver new order 18 7 0 72.0% prescription medications to the patient within the required time frames? (7.002) Upon the patient’s discharge from a community hospital: Were all ordered medications administered, made available, or delivered to the patient within 4 20 0 16.7% required time frames? (7.003) * For patients received from a county jail: Were all medications ordered by the institution’s reception center provider administered, made available, or N/A N/A N/A N/A delivered to the patient within the required time frames? (7.004) * Upon the patient’s transfer from one housing unit to another: Were 17 8 0 68.0% medications continued without interruption? (7.005) * For patients en route who lay over at the institution: If the temporarily housed patient had an existing medication order, were medications administered or 0 10 0 0 delivered without interruption? (7.006) * All clinical and medication line storage areas for narcotic medications: Does the institution employ strong medication security controls over narcotic 10 1 4 90.9% medications assigned to its storage areas? (7.101) All clinical and medication line storage areas for nonnarcotic medications: Does the institution properly secure and store nonnarcotic medications in the 11 2 2 84.6% assigned storage areas? (7.102) All clinical and medication line storage areas for nonnarcotic medications: Does the institution keep nonnarcotic medication storage locations free of 4 9 2 30.8% contamination in the assigned storage areas? (7.103) All clinical and medication line storage areas for nonnarcotic medications: Does the institution safely store nonnarcotic medications that have yet to expire in 3 10 2 23.1% the assigned storage areas? (7.104) Medication preparation and administration areas: Do nursing staff employ and follow hand hygiene contamination control protocols during medication 5 3 7 62.5% preparation and medication administration processes? (7.105) Medication preparation and administration areas: Does the institution employ appropriate administrative controls and protocols when preparing medications 4 4 7 50.0% for patients? (7.106) Medication preparation and administration areas: Does the institution employ appropriate administrative controls and protocols when administering 6 2 7 75.0% medications to patients? (7.107) Pharmacy: Does the institution employ and follow general security, organization, and cleanliness management protocols in its main and remote 2 0 0 100% pharmacies? (7.108) Pharmacy: Does the institution’s pharmacy properly store nonrefrigerated 2 0 0 100% medications? (7.109) Pharmacy: Does the institution’s pharmacy properly store refrigerated or frozen 0 2 0 0 medications? (7.110) Pharmacy: Does the institution’s pharmacy properly account for narcotic 0 1 1 0 medications? (7.111) Pharmacy: Does the institution follow key medication error reporting 3 10 0 23.1% protocols? (7.112) Pharmacy: For Information Purposes Only: During compliance testing, did the This is a nonscored test. Please OIG find that medication errors were properly identified and reported by the see the indicator for discussion of institution? (7.998) this test. Pharmacy: For Information Purposes Only: Do patients in restricted housing This is a nonscored test. Please units have immediate access to their KOP prescribed rescue inhalers and see the indicator for discussion of nitroglycerin medications? (7.999) this test. Overall percentage (MIT 7): 47.1% * The OIG clinicians considered these compliance tests along with their case review findings when determining the quality rating for this indicator. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: June 2021 – November 2021 Report Issued: November 2022 Cycle 6, Mule Creek State Prison | 56 Table 15. Other Tests Related to Medication Management Table 15. Other Tests Related to Medication Management Scored Answer Compliance Questions Yes No N/A Yes % For endorsed patients received from another CDCR institution or COCF: If the patient had an existing medication order upon arrival, 13 11 1 54.2% were medications administered or delivered without interruption? (6.003) * For patients transferred out of the facility: Do medication transfer packages include required medications along with the corresponding N/A N/A N/A N/A transfer-packet required documents? (6.101) * Patients prescribed TB medication: Did the institution administer the 18 0 0 100% medication to the patient as prescribed? (9.001) * Patients prescribed TB medication: Did the institution monitor the patient per policy for the most recent three months he or she was on 8 10 0 44.4% the medication? (9.002) * Upon the patient’s admission to specialized medical housing: Were all medications ordered, made available, and administered to the patient 2 4 0 33.3% within required time frames? (13.004) * * The OIG clinicians considered these compliance tests along with their case review findings when determining the quality rating for this indicator. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: June 2021 – November 2021 Report Issued: November 2022 Cycle 6, Mule Creek State Prison | 57 Recommendations • Medical and nursing leadership should ensure that chronic care, newly ordered, hospital discharge, yard-to-yard transfer, and en- route patients receive their medications timely without interruption. Office of the Inspector General, State of California Inspection Period: June 2021 – November 2021 Report Issued: November 2022 Cycle 6, Mule Creek State Prison | 58 Preventive Services In this indicator, OIG compliance inspectors tested whether the institution offered or provided cancer screenings, tuberculosis (TB) screenings, influenza Overall vaccines, and other immunizations. If the department designated the institution Rating as high risk for coccidioidomycosis (valley fever), we tested the institution’s Adequate performance in transferring out patients quickly. The OIG rated this indicator solely according to the compliance score, using the same scoring thresholds as in Case Review the Cycle 4 and Cycle 5 medical inspections. Our case review clinicians do not Rating rate this indicator. (N/A) Results Overview Compliance Score MCSP performed well in administering TB medications, screening patients Adequate annually for TB, offering patients an influenza vaccine for the most recent (80.3%) influenza season, and offering colorectal cancer screening for patients from ages 45 through 75. However, MCSP did not always monitor patients taking prescribed TB medications or offer required immunizations to chronic care patients. The OIG rated this indicator adequate. Office of the Inspector General, State of California Inspection Period: June 2021 – November 2021 Report Issued: November 2022 Cycle 6, Mule Creek State Prison | 59 Compliance Testing Results TTaabblele 1 166. .P Prerevveennttivivee S Seerrvviciceess Scored Answer Compliance Questions Yes No N/A Yes % Patients prescribed TB medication: Did the institution administer the 18 0 0 100% medication to the patient as prescribed? (9.001) Patients prescribed TB medication: Did the institution monitor the patient per policy for the most recent three months he or she was on 8 10 0 44.4% the medication? (9.002) † Annual TB screening: Was the patient screened for TB within the last 22 3 0 88.0% year? (9.003) Were all patients offered an influenza vaccination for the most recent 25 0 0 100% influenza season? (9.004) All patients from the age of 45 through the age of 75: Was the 23 2 0 92.0% patient offered colorectal cancer screening? (9.005) Female patients from the age of 50 through the age of 74: Was the N/A N/A N/A N/A patient offered a mammogram in compliance with policy? (9.006) Female patients from the age of 21 through the age of 65: Was N/A N/A N/A N/A patient offered a pap smear in compliance with policy? (9.007) Are required immunizations being offered for chronic care patients? 8 6 11 57.1% (9.008) Are patients at the highest risk of coccidioidomycosis (valley fever) N/A N/A N/A N/A infection transferred out of the facility in a timely manner? (9.009) Overall percentage (MIT 9): 80.3% * The OIG clinicians considered these compliance tests along with their case review findings when determining the quality rating for this indicator. † In April 2020, after our review but before this report was published, CCHCS reported adding the symptom of fatigue into the electronic health record system (EHRS) PowerForm for tuberculosis (TB)-symptom monitoring. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: June 2021 – November 2021 Report Issued: November 2022 Cycle 6, Mule Creek State Prison | 60 Recommendations • Nursing leadership should consider developing and implementing measures to ensure that CCHCS policy is followed when nursing staff monitor patients who are prescribed TB medications. • Medical leadership should investigate and resolve any challenges that can affect the timely provision of chronic care vaccinations. Office of the Inspector General, State of California Inspection Period: June 2021 – November 2021 Report Issued: November 2022 Cycle 6, Mule Creek State Prison | 61 Nursing Performance In this indicator, the OIG clinicians evaluated the quality of care delivered by the institution’s nurses, including registered nurses (RNs), licensed vocational nurses Overall (LVNs), psychiatric technicians (PTs), and certified nursing assistants (CNAs). Rating Our clinicians evaluated nurses’ performance in making timely and appropriate Adequate assessments and interventions. We also evaluated the institution’s nurses’ documentation for accuracy and thoroughness. Clinicians reviewed nursing Case Review performance in many clinical settings and processes, including sick call, Rating outpatient care, care coordination and management, emergency services, Adequate specialized medical housing, hospitalizations, transfers, specialty services, and medication management. The OIG assessed nursing care through case review Compliance only and performed no compliance testing for this indicator. Score When summarizing overall nursing performance, our clinicians understand that (N/A) nurses perform numerous aspects of medical care. As such, specific nursing quality issues are discussed in other indicators, such as Emergency Services, Specialty Services, and Specialized Medical Housing. Results Overview MCSP provided acceptable nursing care overall. Compared with Cycle 5, MCSP improved with fewer significant deficiencies. Nursing care was generally appropriate and timely. Although nurses usually performed good nursing assessments, interventions, and documentation, our clinicians identified opportunities for improvement in several areas as discussed in this indicator. We rated this indicator as adequate. Case Review Results We reviewed 224 nursing encounters in 59 cases. Of the nursing encounters we reviewed, 136 occurred in the outpatient setting. We identified 82 nursing performance deficiencies, five of which were significant.42 Nursing Assessment and Interventions Overall, nursing assessments and interventions were acceptable. A critical component of nursing care is the quality of nursing assessment, which includes both subjective (patient interviews) and objective (observation and examination) elements. MCSP nurses normally provided appropriate nursing assessments and interventions. Nurses generally performed good assessments in the TTA, specialty, transfers, and hospitalizations. However, CTC and outpatient clinic assessments could be 42 Deficiencies occurred in cases 1–3, 5–9, 12, 14–16, 18, 21–25, 27, 30, 31, 35, 37, 39, 41, 45, 48, 56–58, and 63–67. Significant deficiencies occurred in cases 2, 5, 9, and 25. Office of the Inspector General, State of California Inspection Period: June 2021 – November 2021 Report Issued: November 2022 Cycle 6, Mule Creek State Prison | 62 more thorough.43 Please refer to the Specialized Medical Housing indicator for details. When nurses assessed patients for sick call complaints, our review showed that components of patient assessments were missing. Examples included range of motion, visual acuity, length of time for loss of appetite, description of rash, and assessment of recent injuries. Nurses mostly intervened timely and appropriately in all areas. However, in the TTA and the outpatient clinics, some cases had delays. In TTA cases 5 and 9, there were delays in initiating oxygen and activating EMS. For the outpatient clinics, the patients in the following cases should have been assessed the same day for their sick call complaints: • In case 2, the nurse triaged a sick call for a patient who developed a rash after starting an antibiotic three days prior. Instead, the nurse evaluated the patient the following day. The nurse should have assessed the patient on the same day for a possible allergic reaction to the antibiotic. • In case 9, the patient submitted a sick call after seven days of feeling weak, tired, and experiencing chest pain radiating to the left arm. Instead of seeing the patient on the same day, the nurse assessed the patient the next day. During our on-site visit, MCSP nursing leadership acknowledged the above deficiencies and provided training to their staff. Nursing Documentation Nurses documented sufficiently. Complete and accurate nursing documentation is an essential component of patient care. Without proper documentation, health care staff can overlook changes in patients’ conditions. Although MCSP staff generally documented well in all areas, the performance of outpatient clinic and TTA nurses showed room for improvement as seen in the examples below:44 • In case 24, clinic staff provided care to a patient with a left-elbow infection and referred the patient to the TTA. However, there was no documentation from the clinic staff of the initial encounter with the patient. • In case 56, the nurse provided protocol medication (Tylenol) to the patient, but the nurse did not document the administration of medication on the medication administration report. For additional information, please refer to the Emergency Services indicator. 43 In the outpatient clinics, assessment deficiencies occurred in cases 1, 8, 15, 18, 21, 23, 24, 27, 35, 37, 41, and 48. 44 In the outpatient clinics, documentation deficiencies occurred in cases 14, 22, 24, 25, 27, 39, 45, 56, 57, and 67. Office of the Inspector General, State of California Inspection Period: June 2021 – November 2021 Report Issued: November 2022 Cycle 6, Mule Creek State Prison | 63 Nursing Sick Call Our clinicians reviewed 53 sick call requests in 34 cases and identified 29 deficiencies, two of which were significant.45 The significant deficiencies are discussed in the Access to Care indicator. The clinic nurses often performed timely face-to-face triage and assessments. However, there were patterns of deficiencies in the following areas: patient assessments, interventions, documentation, and patient education.46 Examples of deficiencies include the following: • In case 1, the nurse inappropriately triaged the sick call as asymptomatic. The patient submitted a sick call request form reporting bumps on his skin. The patient should have been evaluated within one business day for this symptomatic sick call. The nurse evaluated the patient three days later. The clinic nurse also did not provide patient education for this encounter. • In case 18, the clinic nurse evaluated the patient for a rash in his groin area, but did not thoroughly assess the rash. The nurse also did not provide patient education for this encounter. • In case 56, the clinic nurse evaluated the patient for increased swelling of the fifth toe on the right foot and used the joint pain nursing protocol. The nurse did not document the administered medication on the medication administration record and did not provide patient education for this encounter. Case Management OIG clinicians reviewed eight cases in which patients were evaluated by a care manager.47 Our case review did not identify any deficiencies in scheduling or evaluating patients for care management appointments. Care managers evaluated patients with chronic conditions such as Hepatitis C, diabetes, new arrivals, and provider ordered follow-ups for various assessments. At times, due to COVID-19 restrictions, the nurses performed chart reviews instead of evaluating the patients in person. 45 We reviewed sick call events in cases 1–3, 7-9, 16, 18, 21–24, 37, 38, 40, 41, 43, 45–49, 52–60, 62, 68, and 69. 46 A component of assessments was missing in cases 1, 8, 15, 16, 18, 21, 23, 24, 27, 35, 37, 41, and 48. Intervention deficiencies occurred in cases 1, 8, 12, 16, 23, and 27. Documentation deficiencies occurred in cases 24, 25, 27, 39, 45, 56, 57, and 67. Patient education was not provided in cases 3, 18, 21, 24, 56, and 58. 47 Patients were evaluated by a care manager in cases 8, 9, 16, 21, and 29–31. Office of the Inspector General, State of California Inspection Period: June 2021 – November 2021 Report Issued: November 2022 Cycle 6, Mule Creek State Prison | 64 Wound Care We reviewed nine events in which wound care was provided by the nurses.48 During case review, OIG clinicians identified five deficiencies. The following three are examples. • In cases 24 and 63, the nurse did not record the external measurement of the PICC catheter.49 This is important in case the PICC line becomes dislodged. • In case 27 on two occasions, the patient had drainage from a facial biopsy site, and the nurse did not notify the provider or obtain orders for dressing changes. • In case 63, the nurse did not perform dressing changes as ordered for the right-upper chest surgical site on a patient diagnosed with osteomyelitis.50 Emergency Services MCSP generally provided adequate emergency care. We reviewed 24 urgent or emergent events. Nurses responded promptly to emergent events and usually intervened timely. However, areas that showed room for improvement are interventions, documentation, and patient education. Please see the Emergency Services indicator for further details. Hospital Returns We reviewed 19 events in which patients returned from off-site hospitalizations or emergency room visits. The nurses mostly performed good nursing assessments. Please refer to the Transfers indicator for details. Transfers Nurses frequently evaluated patients as required and initiated provider appointments within appropriate time frames. We reviewed 11 cases involving transfer-in and transfer-out processes. For further details, please refer to the Transfers indicator. Specialized Medical Housing Nurses provided good patient care in the CTC. We reviewed six CTC cases with 34 nursing events. We did not identify any significant nursing deficiencies. CTC 48 We reviewed the following cases for wound care: 2, 24, 27, 63, and 64. Deficiencies occurred in cases 2, 24, 27, and 63. 49 A PICC is a peripherally inserted central catheter line, which is used to provide intravenous access and administer fluids and medication. 50 Osteomyelitis is an infection of the bone. Office of the Inspector General, State of California Inspection Period: June 2021 – November 2021 Report Issued: November 2022 Cycle 6, Mule Creek State Prison | 65 nurses performed timely assessments and carried out provider orders as required. For more specific details, please refer to the Specialized Medical Housing indicator. Specialty Services Specialty services nursing care was acceptable. We reviewed 24 events in 11 cases in which patients returned from off-site specialty procedures or consultations. Case review identified five deficiencies, none of which were significant. Please refer to the Specialty Services indicator for additional details. Medication Management Nursing medication management at MCSP was acceptable. MCSP nurses generally administered medications timely. Our clinicians reviewed 168 events in 33 cases involving medication management and identified 22 deficiencies, two of which were significant. Please refer to the Medication Management indicator for additional details. Clinician On-Site Inspection Our OIG clinicians interviewed staff in the TTA, CTC, outpatient clinics, R&R, utilization management, specialty services, as well as nurse instructors and medication LVN staff. We attended clinic huddles which were timely, organized, and well-attended. The nursing and medical staff were very familiar with their patients. The clinic nurses reported the nurse lines have an average of 14 patients scheduled per RN and up to four patients can be added to the daily line. The clinic staff reported having good rapport with custody and support from their administration. Due to the COVID-19 pandemic, the clinics had a backlog for RN and provider appointments. The staff reported they were addressing the backlogs by bundling appointments and by adding appointments to the daily RN and provider lines. During the COVID-19 outbreaks, clinic nurses reported that they evaluated patients with urgent/emergent issues at cell side or obtained permission to bring the patient to the clinic for further evaluation. Staff had supplies available to take to the cell side. They utilized kits with blood pressure cuffs, thermometers, and pulse oximeters. Staff reported they were never fully out of any needed supplies such as personal protective equipment (PPE) and hand sanitizers. We were informed staffing was stable during the first COVID-19 outbreak, but during the second outbreak, staffing was at a critical level. MCSP utilized registry LVN staff to make rounds on COVID-19 quarantine or isolation patients. Nearly all MCSP providers were all working on-site during this time. Nursing staff were redirected from noncritical areas such as R&R and specialty. RN staff assisted with medication administration due to the LVN shortage. We also interviewed the director of nursing and the acting chief nursing executive. They reported having two quality improvement projects in progress, which were the co-consultation documentation project and the intrasystem Office of the Inspector General, State of California Inspection Period: June 2021 – November 2021 Report Issued: November 2022 Cycle 6, Mule Creek State Prison | 66 transfer process. They borrowed analysts for the new hire process and reported it was challenging to hire nursing staff in a timely manner. Recommendations • Nursing leadership should ensure that thorough assessments, intervention, and documentation are completed for all face-to-face encounters and that patients are provided patient education for clinic nursing encounters. Office of the Inspector General, State of California Inspection Period: June 2021 – November 2021 Report Issued: November 2022 Cycle 6, Mule Creek State Prison | 67 Provider Performance Overall Rating In this indicator, OIG case review clinicians evaluated the quality of care Adequate delivered by the institution’s providers: physicians, physician assistants, and nurse practitioners. Our clinicians assessed the institution’s providers’ performance in evaluating, diagnosing, and managing their patients properly. We Case Review examined provider performance across several clinical settings and programs, Rating including sick call, emergency services, outpatient care, chronic care, specialty Adequate services, intake, transfers, hospitalizations, and specialized medical housing. We assessed provider care through case review only and performed no compliance Compliance testing for this indicator. Score (N/A) Results Overview MCSP providers delivered acceptable care. While we continued to identify deficiencies in decision-making and assessments, these deficiencies were not as severe as those in Cycle 5. Providers needed to improve in following specialists’ recommendations and in documenting clinical decisions they made. Providers should document when they are co-consulted to relay their decision-making and plan. After reviewing all factors, the OIG rated this indicator adequate. Case Review Results OIG clinicians reviewed 197 medical provider encounters and identified 58 deficiencies, 18 of which were significant.51 In addition, our clinicians examined the quality of care in 25 comprehensive case reviews, and found one was proficient, 20 were adequate, and four were inadequate. Decision-Making and Assessments Generally, providers made fair assessments and decisions. For the most part, providers took good histories, formulated differential diagnoses, ordered appropriate tests, provided care with the correct diagnosis, and referred patients to proper specialists when needed. However, we identified nine instances of poor decision-making in seven of the 25 cases we reviewed.52 Some examples of poor decision-making follow: • In case 9, the patient had a history of chronic kidney disease and had laboratory work scheduled. The provider reviewed results that showed kidney failure and metabolic acidosis. Instead of considering emergent dialysis, the provider ordered repeat tests a few days hence and a medium-priority vascular surgery consultation, which could 51 Deficiencies occurred in cases 1, 2, 3 7, 9, 10, 11, 12, 15, 16, 17, 18, 19, 22, 23, 24, 25, 26, 27, 28, and 66. Significant deficiencies occurred in cases 1, 2, 7, 9, 11, 12, 15, 16, 23, 25, 26, and 66. 52 Deficiencies occurred in cases 7, 9, 12, 19, 22, 24, and 25. Office of the Inspector General, State of California Inspection Period: June 2021 – November 2021 Report Issued: November 2022 Cycle 6, Mule Creek State Prison | 68 have taken up to 45 days to schedule. Before the patient saw the vascular surgeon, he was admitted to the hospital. • In case 12, the patient complained of fecal and urinary incontinence. The provider ordered a colonoscopy instead of performing a simple digital rectal exam. On-site, the provider stated the digital rectal examination was not indicated as the patient previously had cauda equina.53 However, the provider did not document specific findings for a patient with cauda equina nor what was the purpose of the colonoscopy referral. The last detailed provider physical examination was almost one year earlier. • In case 25, the patient needed daily blood draws to follow his kidney function. The nurses messaged the provider about collecting labs over the weekend and storing them in the refrigerator to send them out during the next week day. The provider authorized this plan, which led to an inaccurate potassium level due to being stored in a refrigerator for several days. Providers did not always examine patients according to their medical complaints and sometimes ignored their medical conditions. We identified these problems in eight occurrences in six of the 25 detailed cases we reviewed.54 The following examples highlight this problem. • In case 11, the patient complained of joint pain, but the provider did not examine the patient’s joints. In another encounter, this same provider ordered antifungal medication, but did not examine the patient. • In case 23, the provider saw the diabetic patient for the first time and did not perform a physical examination on the patient other than documenting the patient’s morbid obesity. The provider also did not review the patient’s expired hydrochlorothiazide (blood pressure medication). Providers also did not consistently act on abnormal diagnostic tests. In four cases, the providers did not address mild anemia, elevated thyroid stimulating hormone (an indicator of low thyroid function), and elevated LDL (bad cholesterol). • In cases 12 and 18, the patients had abnormal thyroid stimulating hormone values, but providers did not address the abnormalities. 53 Cauda equina syndrome is a condition in which the nerves below the end of the spinal cord are damaged resulting in effects on nerve function such as loss of bladder and bowel control. 54 Providers did not perform pertinent examinations in cases 10, 17, 22, 24, 26, and 28. Office of the Inspector General, State of California Inspection Period: June 2021 – November 2021 Report Issued: November 2022 Cycle 6, Mule Creek State Prison | 69 Review of Records Providers generally reviewed records sufficiently to provide care for the patients. Case review clinicians found two instances whereby diagnostics were not properly reviewed and two vital signs also were not reviewed.55 Emergency Care Generally, providers appropriately managed patients in the TTA with urgent/emergent conditions well. The exception we found was the incident that follows. On-site, the medical leadership agreed that this was poor care: • In case 7, the nurse called the on-call provider, who was given information that the patient had cardiac symptoms and an EKG that suggested acute coronary syndrome. Although the patient required urgent care, the provider did not see the patient, did not send the patient to a higher level of care, and instead ordered blood tests. This patient suffered a cardiac arrest and died within 24 hours. Chronic Care Providers appropriately managed the patient’s chronic health conditions, with some exceptions. Hypertensive care was an area that showed opportunities for improvement. We identified six unique deficiencies related to blood pressure management in two cases. Diabetes care was acceptable with two deficiencies in two cases. We found a minor pattern in which providers did not address the body mass index of the patients on chronic care visits. This occurred in four instances in three of the cases. Specialty Services Providers appropriately referred patients for a specialty consultation when needed. However, when specialists made recommendations, there was a minor pattern of not always following those recommendations: • In case 11, the provider did not order the follow-up with the urologist with the interval recommended by the specialist. • In case 25, the provider did not order the vitamin levels that the dietician recommended. • In case 27, the patient had skin cancer and was followed by a dermatologist. On two separate occasions, the provider did not request the follow up with the dermatologist within the specialist- recommended time frames. 55 Improper review of diagnostics occurred in cases 2 and 19. Improper vital signs review occurred in cases 24 and 26. Office of the Inspector General, State of California Inspection Period: June 2021 – November 2021 Report Issued: November 2022 Cycle 6, Mule Creek State Prison | 70 Documentation Quality Providers generally documented their interactions with the patients. Documentation is important because it shows the provider’s thought process during clinical decision-making. We identified some issues related to the co- consultation system as employed by the staff at this institution. We found three instances wherein nurses documented they had co-consulted with providers, but the providers did not always document or follow through. • In case 16, the nurse co-consulted with the provider about the patient’s epidydimal cysts.56 The nurse documented that the provider planned to send the patient to urology and to follow up with the patient afterward. However, the provider did not place the orders in the patient’s electronic health record. • In case 21, the nurse documented that the provider was co-consulted about a patient with hernia pain after a recent hospital discharge for intestinal obstruction. We did not find a provider note in the patient’s electronic health record. On-site, the provider stated he was not notified by the nurse. • In case 27, the provider was co-consulted about the patient’s skin lesions on both the face and the hand, but the provider only addressed the face lesions. Patient Test Results Notification Letter Providers did not always send complete notification letters to patients concerning test results or even send letters at all. After providers interpret laboratory results, they are responsible for notifying patients of the laboratory results and of the necessary next steps to be taken. This is further discussed in the Diagnostics indicator. Provider Continuity Generally, the patients had provider continuity. However, in cases 15 and 26, the patients were seen by three and five providers, respectively, during the review period. This lack of continuity contributed to a lack of diabetes sugar control and the delay of a hernia repair. Clinician On-Site Inspection We discussed some of the deficiencies we identified with the chief medical executive, the two chief physicians and surgeons, and the individual providers when they were available. The provider who did not address the chest pain in a patient who had died of a cardiac arrest was on leave at the time of our on-site inspection. Medical leadership explained that they expected providers to see the 56 Epididymal cysts are small sacs of fluid located in scrotum. Office of the Inspector General, State of California Inspection Period: June 2021 – November 2021 Report Issued: November 2022 Cycle 6, Mule Creek State Prison | 71 patient and send the patient to the hospital if indicated. They also voiced an expectation of documentation when providers have been co-consulted and verbalized that there is more training to come to help clarify the co-consultation expectations. Leadership expressed that it has been easier to fill vacancies since the last cycle. Most of the providers reported that they enjoyed working at MCSP and appreciated their leadership. Providers stated improved morale was due to steady executive leadership, better provider staffing, and a reduction in the number of required face-to-face appointments. They indicated there were no issues with custody or nursing and no issues with ordering diagnostics or requests for services. Office of the Inspector General, State of California Inspection Period: June 2021 – November 2021 Report Issued: November 2022 Cycle 6, Mule Creek State Prison | 72 Recommendations • The department should define the process of nurse-to-provider co- consultation and should provide specific guidance to providers on when provider progress notes are required for TTA and emergency phone calls, co-consultations, provider orders, and appointments. Office of the Inspector General, State of California Inspection Period: June 2021 – November 2021 Report Issued: November 2022 Cycle 6, Mule Creek State Prison | 73 Specialized Medical Housing Overall Rating In this indicator, OIG inspectors evaluated the quality of care in the specialized Adequate medical housing units. We evaluated the performance of the medical staff in assessing, monitoring, and intervening for medically complex patients requiring Case Review close medical supervision. Our inspectors also evaluated the timeliness and Rating quality of provider and nursing intake assessments and care plans. We assessed Adequate staff members’ performance in responding promptly when patients’ conditions deteriorated, and we looked for good communication when staff consulted one Compliance another while providing continuity of care. Our clinicians also interpreted Score relevant compliance results and incorporated them into this indicator. At the Adequate time of our inspection, MCSP’s specialized medical housing consisted of a (79.2%) correctional treatment center (CTC). Results Overview MCSP performed sufficiently in this indicator and improved from Cycle 5. CTC providers and nurses provided good patient care. Most of the time, they performed good assessments, monitored their patients, and communicated with providers as required. While we identified a pattern of deficiencies in daily nursing assessments, these were not clinically significant. Compliance testing showed poor medication continuity. Considering both compliance testing and case reviews, we rated this indicator adequate. Case Review and Compliance Testing Results We reviewed six CTC cases that included 36 provider events and 34 nursing events. Due to the frequency of nursing and provider contacts in the specialized medical housing, we bundle up to two weeks of patient care into a single event. We identified 17 deficiencies, two of which were significant.57 Provider Performance Providers delivered good care. Compliance testing showed providers completed all admission histories and physical examinations without delay (MIT 13.002, 100%). Our clinicians found providers generally made appropriate assessments and decisions, reviewed medical records thoroughly, and addressed specialists’ recommendations timely. We identified three deficiencies, two of which were significant.58 The two significant deficiencies are discussed in the Provider Performance indicator. 57 We reviewed the following CTC cases: 24, 25, and 63–66. Deficiencies occurred in cases 24, 25, and 63–66. Cases 25 and 66 had significant deficiencies. 58 Specialized Medical Housing provider deficiencies occurred in cases 24, 25, and 66. Significant deficiencies occurred in cases 25 and 66. Office of the Inspector General, State of California Inspection Period: June 2021 – November 2021 Report Issued: November 2022 Cycle 6, Mule Creek State Prison | 74 Nursing Performance Overall, nurses generally delivered good patient care. In compliance testing, the nurses frequently completed initial patient assessments within the required time frame (MIT 13.001, 83.3%). In addition, our clinicians found that nurses, for the most part, conducted regular daily rounds and implemented provider orders. However, we identified a pattern of deficiencies involving daily nursing assessments.59 For example, the nurses did not always assess the patient’s lung sounds or bowel sounds, or measure the length of the PICC line from the insertion site. Compliance findings showed that the CTC maintained an operational nursing call system (MIT 13.101, 100%). Medication Administration Medication continuity performance for patients admitted to the CTC was mixed. Compliance findings showed patients admitted to the CTC received their medication late 33.3 percent of the time (MIT 13.004). Yet our clinicians identified only three deficiencies.60 The following is an example of a significant deficiency: • In case 63, the patient received a newly ordered antibiotic one day late. Clinician On-Site Inspection MCSP’s CTC had 10 beds. Two of the beds were designated for medical patients and the other eight for mental health patients. The CTC had one negative pressure room for respiratory isolation. During our visit, the two medical beds were occupied. Staff reported the type of patients housed in the medical beds included patients with end-stage liver disease, patients receiving chemotherapy, patients with pressure wounds, and patients who were at risk for falls. At the time of our visit, the CTC supervising registered nurse (SRN) had assumed the role five months prior. The CTC had a designated provider. Medical rounds occurred on Mondays, Wednesdays, and Fridays. Staffing consisted of two RNs, one LVN, and one certified nursing assistant (CNA) on the second watch. On the first and the third watches, the CTC had one RN and one licensed psychiatric technician (LPT) assigned. 59 Deficiencies occurred in cases 24 and 63–65. 60 Deficiencies related to medications occurred in cases 63 and 66. Office of the Inspector General, State of California Inspection Period: June 2021 – November 2021 Report Issued: November 2022 Cycle 6, Mule Creek State Prison | 75 Compliance Testing Results Table 17. Specialized Medical Housing Table 17. Specialized Medical Housing Scored Answer Compliance Questions Yes No N/A Yes % For OHU, CTC, and SNF: Prior to 4/2019: Did the registered nurse complete an initial assessment of the patient on the day of admission, or within eight hours of admission to CMF’s Hospice? 5 1 0 83.3% Effective 4/2019: Did the registered nurse complete an initial assessment of the patient at the time of admission? (13.001) * For CTC and SNF only (effective 4/2019, include OHU): Was a written history and physical examination completed within the required time 6 0 0 100% frame? (13.002) * For OHU, CTC, SNF, and Hospice (applicable only for samples prior to 4/2019): Did the primary care provider complete the Subjective, Objective, Assessment, and Plan notes on the patient at the N/A N/A 6 N/A minimum intervals required for the type of facility where the patient was treated? (13.003) *,† Upon the patient’s admission to specialized medical housing: Were all medications ordered, made available, and administered to the 2 4 0 33.3% patient within required time frames? (13.004) * For OHU and CTC only: Do inpatient areas either have properly working call systems in its OHU & CTC or are 30-minute patient 1 0 0 100% welfare checks performed; and do medical staff have reasonably unimpeded access to enter patient’s cells? (13.101) * For specialized health care housing (CTC, SNF, Hospice, OHU): Do health care staff perform patient safety checks according to 0 0 1 N/A institution’s local operating procedure or within the required time frames? (13.102) * Overall percentage (MIT 13): 79.2% * The OIG clinicians considered these compliance tests along with their case review findings when determining the quality rating for this indicator. † CCHCS changed its policies and removed mandatory minimum rounding intervals for patients located in specialized medical housing. After April 2, 2019, MIT 13.003 only applied to CTCs that still have state-mandated rounding intervals. OIG case reviewers continued to test the clinical appropriateness of provider follow-ups within specialized medical housing units through case reviews. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: June 2021 – November 2021 Report Issued: November 2022 Cycle 6, Mule Creek State Prison | 76 Recommendations • Nursing leadership should determine the root cause of challenges to patients receiving all ordered medications within the required time frame and should implement remedial measures as appropriate. Office of the Inspector General, State of California Inspection Period: June 2021 – November 2021 Report Issued: November 2022 Cycle 6, Mule Creek State Prison | 77 Specialty Services In this indicator, OIG inspectors evaluated the quality of specialty services. The OIG clinicians focused on the institution’s performance in providing needed Overall specialty care. Our clinicians also examined specialty appointment scheduling, Rating providers’ specialty referrals, and medical staff’s retrieval, review, and Adequate implementation of any specialty recommendations. Case Review Results Overview Rating Adequate MCSP generally provided good specialty services for its patients. Both case Compliance review and compliance testing showed acceptable performance. However, we Score observed several instances wherein patients experienced delays in receiving Adequate specialty care. Some of these delays were attributed to circumstances beyond the (75.9%) institution’s control. As a result, we did not assign deficiencies in those few instances. The OIG rated this indicator adequate. Case Review and Compliance Testing Results We reviewed 125 events related to specialty services; 60 were specialty consultations and procedures. We found 11 deficiencies in this category, two of which were significant.61 Access to Specialty Services Performance in this area was mixed: case review found good access, but compliance scores were low. Case review clinicians reviewed 60 specialty services and procedures, identifying only two specialty follow-up delays which were not clinically significant. We also observed delays with access due to outside specialists’ availability. We did not include those delays in our rating of this indicator, as these delays were beyond the control of MCSP. In contrast, compliance testing showed poor access with routine-priority, medium-priority, and high-priority specialty access (MIT 14.007, 66.7%; MIT 14.004, 73.3%; and MIT 14.001, 73.3%, respectively). Continuity of specialty services upon transfer into the institution was also poor (MIT 14.010, 50.0%). Provider Performance Provider performance with specialty referrals was good. Out of the 60 specialty appointments in case review results, we found five deficiencies wherein specialists’ recommendations were not followed exactly and two minor deficiencies with provider follow-ups. While the deficiencies led to some delays, these deficiencies did not significantly increase the risk of harm to the patients. 61 Specialty deficiencies were found in cases 2, 11, 15, 22, 25, 27, 28, and 66. Significant deficiencies were found in cases 15 and 66. Office of the Inspector General, State of California Inspection Period: June 2021 – November 2021 Report Issued: November 2022 Cycle 6, Mule Creek State Prison | 78 In general, providers ordered appropriate specialty consultations within the proper time frames. Compliance testing also found good performance with provider follow-ups after high-priority specialty services were rendered (MIT 1.008, 78.6%). Nursing Performance Nursing performance with specialty services was acceptable. Nurses evaluated patients upon return from specialty appointments and generally performed complete assessments and necessary interventions. Case review clinicians found a few deficiencies in this area that offered opportunities for improvement. In two instances, the nurse assessing the patient upon return from off-site specialty appointments did not order the provider follow-up as the provider requested or as policy dictated. On three separate occasions, in the same case, the nurse did not assess the patient’s biopsy site. Health Information Management MCSP’s performance with specialty reports was good. Our case review found only two reports that were not endorsed by a provider within CCHCS policy guidelines. Compliance testing also showed good performance with provider reviews of routine-priority and medium-priority specialty reports, but borderline performance with high-priority reports (MIT 14.008, 86.7%; MIT 14.005, 80.0%; and MIT 14.002, 73.3%, respectively). In addition, MCSP scanned specialty reports into the electronic health records system in a timely manner (MIT 4.002, 93.3%). Clinician On-Site Inspection At our inspection, we discussed the identified deficiencies with the utilization management (UM) supervisor, health information management (HIM) supervisor, and providers. The UM supervisor reported limited specialist availability due to the COVID-19 pandemic as having been the main factor affecting specialty performance. The supervisors reported that one specialist delay was due to headquarters’ scheduling of telemedicine specialist. The HIM supervisor described the health information management process, whereby HIM staff retrieve documents from off-site reports and route them to providers for review. Providers described no significant concerns with obtaining medical records timely. Office of the Inspector General, State of California Inspection Period: June 2021 – November 2021 Report Issued: November 2022 Cycle 6, Mule Creek State Prison | 79 Compliance Testing Results Table 18. Specialty Services Table 18. Specialty Services Scored Answer Compliance Questions Yes No N/A Yes % Did the patient receive the high-priority specialty service within 14 calendar days of the primary care provider order or the Physician 11 4 0 73.3% Request for Service? (14.001) * Did the institution receive and did the primary care provider review the high-priority specialty service consultant report within the 11 4 0 73.3% required time frame? (14.002) * Did the patient receive the subsequent follow-up to the high-priority specialty service appointment as ordered by the primary care 7 4 4 63.6% provider? (14.003) * Did the patient receive the medium-priority specialty service within 15-45 calendar days of the primary care provider order or Physician 11 4 0 73.3% Request for Service? (14.004) * Did the institution receive and did the primary care provider review the medium-priority specialty service consultant report within the 12 3 0 80.0% required time frame? (14.005) * Did the patient receive the subsequent follow-up to the medium- priority specialty service appointment as ordered by the primary care 5 3 7 62.5% provider? (14.006) * Did the patient receive the routine-priority specialty service within 90 calendar days of the primary care provider order or Physician 10 5 0 66.7% Request for Service? (14.007) * Did the institution receive and did the primary care provider review the routine-priority specialty service consultant report within the 13 2 0 86.7% required time frame? (14.008) * Did the patient receive the subsequent follow-up to the routine- priority specialty service appointment as ordered by the primary care 7 0 8 100% provider? (14.009) * For endorsed patients received from another CDCR institution: If the patient was approved for a specialty services appointment at the 10 10 0 50.0% sending institution, was the appointment scheduled at the receiving institution within the required time frames? (14.010) * Did the institution deny the primary care provider’s request for 12 0 0 100% specialty services within required time frames? (14.011) Following the denial of a request for specialty services, was the patient informed of the denial within the required time frame? 9 2 1 81.8% (14.012) Overall percentage (MIT 14): 75.9% * The OIG clinicians considered these compliance tests along with their case review findings when determining the quality rating for this indicator. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: June 2021 – November 2021 Report Issued: November 2022 Cycle 6, Mule Creek State Prison | 80 Table 19. Other Tests Related to Specialty Services Table 19. Other Tests Related to Specialty Services Scored Answer Compliance Questions Yes No N/A Yes % Specialty service follow-up appointments: Did the clinician follow-up 22 6 17 78.6% visits occur within required time frames? (1.008) *, † Are specialty documents scanned into the patient’s electronic health 28 2 15 93.3% record within five calendar days of the encounter date? (4.002) * * The OIG clinicians considered these compliance tests along with their own case review findings when determining the quality rating for this indicator. † CCHCS changed its specialty policies in April 2019, removing the requirement for primary care physician follow-up visits following most specialty services. As a result, we test 1.008 only for high-priority specialty services or when the staff orders PCP or PC RN follow-ups. The OIG continues to test the clinical appropriateness of specialty follow-ups through its case review testing. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: June 2021 – November 2021 Report Issued: November 2022 Cycle 6, Mule Creek State Prison | 81 Recommendations • Medical leadership should ensure that patients receive their previously scheduled specialty appointments, when transferred, within the required timeframe. Office of the Inspector General, State of California Inspection Period: June 2021 – November 2021 Report Issued: November 2022 Cycle 6, Mule Creek State Prison | 82 Administrative Operations In this indicator, OIG compliance inspectors evaluated health care administrative processes. Our inspectors examined the timeliness of the medical Overall grievance process and checked whether the institution followed reporting Rating requirements for adverse or sentinel events and patient deaths. Inspectors Inadequate checked whether the Emergency Medical Response Review Committee (EMRRC) met and reviewed incident packages. We investigated and determined whether Case Review the institution conducted the required emergency response drills. Inspectors also Rating assessed whether the Quality Management Committee (QMC) met regularly and (N/A) addressed program performance adequately. In addition, our inspectors determined whether the institution provided training and job performance Compliance reviews for its employees. We checked whether staff possessed current, valid Score professional licenses, certifications, and credentials. The OIG rated this indicator Inadequate solely based on the compliance score, using the same scoring thresholds as in the (62.9%) Cycle 4 and Cycle 5 medical inspections. Our case review clinicians do not rate this indicator. Because none of the tests in this indicator affected clinical patient care directly (it is a secondary indicator), the OIG did not consider this indicator’s rating when determining the institution’s overall quality rating. Results Overview MCSP’s performance was mixed in this indicator, as the institution scored well in some applicable tests, but faltered in others. The Emergency Medical Response Review Committee (EMRRC) did not always complete the required checklists and review the cases within required time frames. In addition, the institution conducted medical emergency response drills with incomplete documentation. The local governing body either was not held or did not complete documentation timely. Physician managers did not always complete annual performance appraisals in a timely manner. Last, nursing managers did not ensure newly hired nurses received the required onboarding. These findings are set forth in the table on the next page. Overall, we rated this indicator inadequate. Nonscored Results At MCSP, the OIG did not have any applicable adverse sentinel events requiring root cause analysis during our inspection period (MIT 15.001). We obtained CCHCS Death Review Committee (DRC) reporting data. Four unexpected (Level 1) and four expected (Level 2) deaths occurred during our review period. The DRC did not complete seven death review reports promptly. The DRC finished six reports from 49 to 155 days late and submitted them to the institution’s chief executive officer from 42 to 148 days late. One death report was missing documentation of the notification date as the when the DRC notified the institution’s chief executive officer of the completed report. The remaining death report was overdue at the time of OIG’s inspection (MIT 15.998). Office of the Inspector General, State of California Inspection Period: June 2021 – November 2021 Report Issued: November 2022 Cycle 6, Mule Creek State Prison | 83 Compliance Testing Results Table 20. Administrative Operations Table 20. Administrative Operations Scored Answer Compliance Questions Yes No N/A Yes % For health care incidents requiring root cause analysis (RCA): Did the N/A N/A N/A N/A institution meet RCA reporting requirements? (15.001) * Did the institution’s Quality Management Committee (QMC) meet 6 0 0 100% monthly? (15.002) For Emergency Medical Response Review Committee (EMRRC) reviewed cases: Did the EMRRC review the cases timely, and did 1 11 0 8.3% the incident packages the committee reviewed include the required documents? (15.003) For institutions with licensed care facilities: Did the Local Governing Body (LGB) or its equivalent meet quarterly and discuss local 0 4 0 0 operating procedures and any applicable policies? (15.004) Did the institution conduct medical emergency response drills during each watch of the most recent quarter, and did health care and 0 3 0 0 custody staff participate in those drills? (15.101) Did the responses to medical grievances address all of the inmates’ 10 0 0 100% appealed issues? (15.102) Did the medical staff review and submit initial inmate death reports 9 1 0 90.0% to the CCHCS Death Review Unit on time? (15.103) Did nurse managers ensure the clinical competency of nurses who 10 0 0 100% administer medications? (15.104) Did physician managers complete provider clinical performance 3 12 0 20.0% appraisals timely? (15.105) Did the providers maintain valid state medical licenses? (15.106) 16 0 0 100% Did the staff maintain valid Cardiopulmonary Resuscitation (CPR), Basic Life Support (BLS), and Advanced Cardiac Life Support (ACLS) 2 0 1 100% certifications? (15.107) Did the nurses and the pharmacist-in-charge (PIC) maintain valid professional licenses and certifications, and did the pharmacy 6 0 1 100% maintain a valid correctional pharmacy license? (15.108) Did the pharmacy and the providers maintain valid Drug Enforcement 2 0 0 100% Agency (DEA) registration certificates? (15.109) Did nurse managers ensure their newly hired nurses received the 0 1 0 0 required onboarding and clinical competency training? (15.110) This is a nonscored test. Please Did the CCHCS Death Review Committee process death review refer to the discussion in this reports timely? (15.998) indicator. This is a nonscored test. Please What was the institution’s health care staffing at the time of the OIG refer to Table 4 for CCHCS- medical inspection? (15.999) provided staffing information. Overall percentage (MIT 15): 62.9% * Effective March 2021, this test was for informational purposes only. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: June 2021 – November 2021 Report Issued: November 2022 Cycle 6, Mule Creek State Prison | 84 Recommendations The OIG offers no recommendations for this indicator. Office of the Inspector General, State of California Inspection Period: June 2021 – November 2021 Report Issued: November 2022 Cycle 6, Mule Creek State Prison | 85 (This page left blank for reproduction purposes.) Office of the Inspector General, State of California Inspection Period: June 2021 – November 2021 Report Issued: November 2022 Cycle 6, Mule Creek State Prison | 86 Appendix A: Methodology In designing the medical inspection program, the OIG met with stakeholders to review CCHCS policies and procedures, relevant court orders, and guidance developed by the American Correctional Association. We 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, the department, the Office of the Attorney General, and the Prison Law Office to discuss the nature and scope of our inspection program. With input from these stakeholders, the OIG developed a medical inspection program that evaluates the delivery of medical care 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. We rate each of the quality indicators applicable to the institution under inspection based on case reviews conducted by our clinicians or compliance tests conducted by our registered nurses. Figure A–1 below depicts the intersection of case review and compliance. Figure A–1. Inspection Indicator Review Distribution for MCSP Office of the Inspector General, State of California Inspection Period: June 2021 – November 2021 Report Issued: November 2022 Cycle 6, Mule Creek State Prison | 87 Case Reviews The OIG added case reviews to the Cycle 4 medical inspections at the recommendation of its stakeholders, which continues in the Cycle 6 medical inspections. Below, Table A–1 provides important definitions that describe this process. Table A–1. Case Review Definitions Office of the Inspector General, State of California Inspection Period: June 2021 – November 2021 Report Issued: November 2022 Cycle 6, Mule Creek State Prison | 88 The OIG eliminates case review selection bias by sampling using a rigid methodology. No case reviewer selects the samples he or she reviews. Because the case reviewers are excluded from sample selection, there is no possibility of selection bias. Instead, nonclinical analysts use a standardized sampling methodology to select most of the case review samples. A randomizer is used when applicable. For most basic institutions, the OIG samples 20 comprehensive physician review cases. For institutions with larger high-risk populations, 25 cases are sampled. For the California Health Care Facility, 30 cases are sampled. Case Review Sampling Methodology We obtain a substantial amount of health care data from the inspected institution and from CCHCS. Our analysts then apply filters to identify clinically complex patients with the highest need for medical services. These filters include patients classified by CCHCS with high medical risk, patients requiring hospitalization or emergency medical services, patients arriving from a county jail, patients transferring to and from other departmental institutions, patients with uncontrolled diabetes or uncontrolled anticoagulation levels, patients requiring specialty services or who died or experienced a sentinel event (unexpected occurrences resulting in high risk of, or actual, death or serious injury), patients requiring specialized medical housing placement, patients requesting medical care through the sick call process, and patients requiring prenatal or postpartum care. After applying filters, analysts follow a predetermined protocol and select samples for clinicians to review. Our physician and nurse reviewers test the samples by performing comprehensive or focused case reviews. Case Review Testing Methodology An OIG physician, a nurse consultant, or both review each case. As the clinicians review medical records, they record pertinent interactions between the patient and the health care system. We refer to these interactions as case review events. Our clinicians also record medical errors, which we refer to as case review deficiencies. Deficiencies can be minor or significant, depending on the severity of the deficiency. If a deficiency caused serious patient harm, we classify the error as an adverse event. On the next page, Figure A–2 depicts the possibilities that can lead to these different events. After the clinician inspectors review all the cases, they analyze the deficiencies, then summarize their findings in one or more of the health care indicators in this report. Office of the Inspector General, State of California Inspection Period: June 2021 – November 2021 Report Issued: November 2022 Cycle 6, Mule Creek State Prison | 89 Figure A–2. Case Review Testing Office of the Inspector General, State of California Inspection Period: June 2021 – November 2021 Report Issued: November 2022 Cycle 6, Mule Creek State Prison | 90 Compliance Testing Compliance Sampling Methodology Our analysts identify samples for both our case review inspectors and compliance inspectors. Analysts follow a detailed selection methodology. For most compliance questions, we use sample sizes of approximately 25 to 30. Figure A–3 below depicts the relationships and activities of this process. Figure A–3. Compliance Sampling Methodology Compliance Testing Methodology Our inspectors answer a set of predefined medical inspection tool (MIT) questions to determine the institution’s compliance with CCHCS policies and procedures. Our nurse inspectors assign a Yes or a No answer to each scored question. OIG headquarters nurse inspectors review medical records to obtain information, allowing them to answer most of the MIT questions. Our regional nurses visit and inspect each institution. They interview health care staff, observe medical processes, test the facilities and clinics, review employee records, logs, medical grievances, death reports, and other documents, and obtain information regarding plant infrastructure and local operating procedures. Office of the Inspector General, State of California Inspection Period: June 2021 – November 2021 Report Issued: November 2022 Cycle 6, Mule Creek State Prison | 91 Scoring Methodology Our compliance team calculates the percentage of all Yes answers for each of the questions applicable to a particular indicator, then averages the scores. The OIG continues to rate these indicators based on the average compliance score using the following descriptors: proficient (85.0 percent or greater), adequate (between 84.9 percent and 75.0 percent), or inadequate (less than 75.0 percent). Indicator Ratings and the Overall Medical Quality Rating To reach an overall quality rating, our inspectors collaborate and examine all the inspection findings. We consider the case review and the compliance testing results for each indicator. After considering all the findings, our inspectors reach consensus on an overall rating for the institution. Office of the Inspector General, State of California Inspection Period: June 2021 – November 2021 Report Issued: November 2022 Cycle 6, Mule Creek State Prison | 92 Appendix B. Case Review Data Table B–1. MCSP Case Review Sample Sets Sample Set Total Anticoagulation 3 CTC/OHU 4 Death Review / Sentinel Events 3 Diabetes 3 Emergency Services – CPR 3 Emergency Services – Non-CPR 3 High Risk 5 Hospitalization 4 Intra-system Transfers In 3 Intra-system Transfers Out 3 RN Sick Call 29 Specialty Services 4 67 Office of the Inspector General, State of California Inspection Period: June 2021 – November 2021 Report Issued: November 2022 Cycle 6, Mule Creek State Prison | 93 Table B–2. MCSP Case Review Chronic Care Diagnoses Diagnosis Total Anemia 2 Anticoagulation 3 Asthma 8 COPD 8 COVID-19 6 Cardiovascular Disease 8 Chronic Kidney Disease 8 Chronic Pain 25 Cirrhosis/End-Stage Liver Disease 4 Coccidioidomycosis 1 Deep Venous Thrombosis/Pulmonary Embolism 1 Diabetes 18 Gastroesophageal Reflux Disease 10 Hepatitis C 12 HIV 2 Hyperlipidemia 26 Hypertension 31 Mental Health 23 Seizure Disorder 7 Sleep Apnea 5 Substance Abuse 21 Thyroid Disease 10 242 Office of the Inspector General, State of California Inspection Period: June 2021 – November 2021 Report Issued: November 2022 Cycle 6, Mule Creek State Prison | 94 Table B–3. MCSP Case Review Events by Program Diagnosis Total Diagnostic Services 273 Emergency Care 45 Hospitalization 31 Intrasystem Transfers In 11 Intrasystem Transfers Out 8 Not Specified 6 Outpatient Care 477 Specialized Medical Housing 105 Specialty Services 125 1,081 Table B–4. MCSP Case Review Sample Summary Total MD Reviews Detailed 25 MD Reviews Focused 0 RN Reviews Detailed 18 RN Reviews Focused 37 Total Reviews 80 Total Unique Cases 67 Overlapping Reviews (MD & RN) 13 Office of the Inspector General, State of California Inspection Period: June 2021 – November 2021 Report Issued: November 2022 Cycle 6, Mule Creek State Prison | 95 (This page left blank for reproduction purposes.) Office of the Inspector General, State of California Inspection Period: June 2021 – November 2021 Report Issued: November 2022 Cycle 6, Mule Creek State Prison | 96 Appendix C. Compliance Sampling Methodology Mule Creek State Prison Quality No. of Indicator Sample Category Samples Data Source Filters Access to Care MIT 1.001 Chronic Care 25 Master Registry • Chronic care conditions (at least Patients one condition per patient—any risk level) • Randomize MIT 1.002 Nursing Referrals 25 OIG Q: 6.001 • See Transfers MITs 1.003–006 Nursing Sick Call 35 Clinic Appointment • Clinic (each clinic tested) (6 per clinic) List • Appointment date (2–9 months) • Randomize MIT 1.007 Returns From 24 OIG Q: 4.005 • See Health Information Community Management (Medical Records) Hospital (returns from community hospital) MIT 1.008 Specialty Services 45 OIG Q: 14.001, • See Specialty Services Follow-Up 14.004 & 14.007 MIT 1.101 Availability of 6 OIG on-site review • Randomly select one housing unit Health Care from each yard Services Request Forms Diagnostic Services MITs 2.001–003 Radiology 10 Radiology Logs • Appointment date (90 days–9 months) • Randomize • Abnormal MITs 2.004–006 Laboratory 10 Quest • Appt. date (90 days–9 months) • Order name (CBC or CMPs only) • Randomize • Abnormal MITs 2.007–009 Laboratory STAT 10 Quest • Appt. date (90 days–9 months) • Order name (CBC or CMPs only) • Randomize • Abnormal MITs 2.010–012 Pathology 10 InterQual • Appt. date (90 days–9 months) • Service (pathology related) • Randomize Office of the Inspector General, State of California Inspection Period: June 2021 – November 2021 Report Issued: November 2022 Cycle 6, Mule Creek State Prison | 97 Quality No. of Indicator Sample Category Samples Data Source Filters Health Information Management (Medical Records) MIT 4.001 Health Care Services 35 OIG Qs: 1.004 • Nondictated documents Request Forms • First 20 Ips for MIT 1.004 MIT 4.002 Specialty Documents 45 OIG Qs: 14.002, • Specialty documents 14.005 & 14.008 • First 10 Ips for each question MIT 4.003 Hospital Discharge 24 OIG Q: 4.005 • Community hospital discharge Documents documents • First 20 Ips selected MIT 4.004 Scanning Accuracy 24 Documents for any • Any misfiled or mislabeled tested inmate document identified during OIG compliance review (24 or more = No) MIT 4.005 Returns From 24 CADDIS Off-site • Date (2–8 months) Community Hospital Admissions • Most recent 6 months provided (within date range) • Rx count • Discharge date • Randomize Health Care Environment MITs 5.101–105 Clinical Areas 14 OIG inspector • Identify and inspect all on-site MITs 5.107–111 on-site review clinical areas. Transfers MITs 6.001–003 Intrasystem Transfers 25 SOMS • Arrival date (3–9 months) • Arrived from (another departmental facility) • Rx count • Randomize MIT 6.101 Transfers Out 0 OIG inspector • R&R IP transfers with medication on-site review Office of the Inspector General, State of California Inspection Period: June 2021 – November 2021 Report Issued: November 2022 Cycle 6, Mule Creek State Prison | 98 Quality No. of Indicator Sample Category Samples Data Source Filters Pharmacy and Medication Management MIT 7.001 Chronic Care 25 OIG Q: 1.001 See Access to Care Medication • At least one condition per patient—any risk level • Randomize MIT 7.002 New Medication 25 Master Registry • Rx count Orders • Randomize • Ensure no duplication of Ips tested in MIT 7.001 MIT 7.003 Returns From 24 OIG Q: 4.005 • See Health Information Community Hospital Management (Medical Records) (returns from community hospital) MIT 7.004 RC Arrivals— N/A at this OIG Q: 12.001 • See Reception Center Medication Orders institution MIT 7.005 Intrafacility Moves 25 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) • Randomize MIT 7.006 En Route 10 SOMS • Date of transfer (2–8 months) • Sending institution (another departmental facility) • Randomize • NA/DOT meds MITs 7.101–103 Medication Storage Varies OIG inspector • Identify and inspect clinical Areas by test on-site review & med line areas that store medications MITs 7.104–107 Medication Varies OIG inspector • Identify and inspect on-site Preparation and by test on-site review clinical areas that prepare and Administration Areas administer medications MITs 7.108–111 Pharmacy 2 OIG inspector • Identify & inspect all on-site on-site review pharmacies MIT 7.112 Medication Error 13 Medication error • All medication error reports with Reporting reports Level 4 or higher • Select total of 25 medication error reports (recent 12 months) MIT 7.999 Restricted Unit 10 On-site active • KOP rescue inhalers & KOP Medications medication listing nitroglycerin medications for Ips housed in restricted units Office of the Inspector General, State of California Inspection Period: June 2021 – November 2021 Report Issued: November 2022 Cycle 6, Mule Creek State Prison | 99 Quality No. of Indicator Sample Category Samples Data Source Filters Prenatal and Postpartum Care MITs 8.001–007 Recent Deliveries N/A at this OB Roster • Delivery date (2–12 months) institution • Most recent deliveries (within date range) Pregnant Arrivals N/A at this OB Roster • Arrival date (2–12 months) institution • Earliest arrivals (within date range) Preventive Services MITs 9.001–002 TB Medications 18 Maxor • Dispense date (past 9 months) • Time period on TB meds (3 months or 12 weeks) • Randomize MIT 9.003 TB Evaluation, 25 SOMS • Arrival date (at least 1 year prior Annual Screening to inspection) • Birth month • Randomize MIT 9.004 Influenza 25 SOMS • Arrival date (at least 1 year prior Vaccinations to inspection) • Randomize • Filter out Ips tested in MIT 9.008 MIT 9.005 Colorectal Cancer 25 SOMS • Arrival date (at least 1 year prior Screening to inspection) • Date of birth (45 or older) • Randomize MIT 9.006 Mammogram N/A at this SOMS • Arrival date (at least 2 yrs. Prior institution to inspection) • Date of birth (age 52–74) • Randomize MIT 9.007 Pap Smear N/A at this SOMS • Arrival date (at least three yrs. institution Prior to inspection) • Date of birth (age 24–53) • Randomize MIT 9.008 Chronic Care 25 OIG Q: 1.001 • Chronic care conditions (at least Vaccinations 1 condition per IP—any risk level) • Randomize • Condition must require vaccination(s) MIT 9.009 Valley Fever N/A at this Cocci transfer • Reports from past 2–8 months institution status report • Institution • Ineligibility date (60 days prior to inspection date) • All Office of the Inspector General, State of California Inspection Period: June 2021 – November 2021 Report Issued: November 2022 Cycle 6, Mule Creek State Prison | 100 Quality No. of Indicator Sample Category Samples Data Source Filters Reception Center MITs 12.001–008 Reception Center N/A at this SOMS • Arrival date (2–8 months) institution • Arrived from (county jail, return from parole, etc.) • Randomize Specialized Medical Housing MITs 13.001–004 Specialized Health 6 CADDIS • Admit date (2–8 months) Care Housing Unit • Type of stay (no MH beds) • Length of stay (minimum of 5 days) • Rx count • Randomize MITs 13.101–102 Call Buttons All OIG inspector • Specialized Health Care Housing on-site review • Review by location Specialty Services MITs 14.001–003 High-Priority 15 Specialty Services • Approval date (3–9 months) Initial and Follow-Up Appointments • Remove consult to audiology, RFS chemotherapy, dietary, Hep C, HIV, orthotics, gynecology, consult to public health/Specialty RN, dialysis, ECG 12-Lead (EKG), mammogram, occupational therapy, ophthalmology, optometry, oral surgery, physical therapy, physiatry, podiatry, and radiology services • Randomize MITs 14.004–006 Medium-Priority 15 Specialty Services • Approval date (3–9 months) Initial and Follow-Up Appointments • Remove consult to audiology, RFS chemotherapy, dietary, Hep C, HIV, orthotics, gynecology, consult to public health/Specialty RN, dialysis, ECG 12-Lead (EKG), mammogram, occupational therapy, ophthalmology, optometry, oral surgery, physical therapy, physiatry, podiatry, and radiology services • Randomize MITs 14.007–009 Routine-Priority 15 Specialty Services • Approval date (3–9 months) Initial and Follow-Up Appointments • Remove consult to audiology, RFS chemotherapy, dietary, Hep C, HIV, orthotics, gynecology, consult to public health/Specialty RN, dialysis, ECG 12-Lead (EKG), mammogram, occupational therapy, ophthalmology, optometry, oral surgery, physical Office of the Inspector General, State of California Inspection Period: June 2021 – November 2021 Report Issued: November 2022 Cycle 6, Mule Creek State Prison | 101 therapy, physiatry, podiatry, and radiology services • Randomize MIT 14.010 Specialty Services 20 Specialty Services • Arrived from (other departmental Arrivals Arrivals institution) • Date of transfer (3–9 months) • Randomize MITs 14.011–012 Denials 12 InterQual • Review date (3–9 months) • Randomize N/A IUMC/MAR • Meeting date (9 months) Meeting Minutes • Denial upheld • Randomize Office of the Inspector General, State of California Inspection Period: June 2021 – November 2021 Report Issued: November 2022 Cycle 6, Mule Creek State Prison | 102 Quality No. of Indicator Sample Category Samples Data Source Filters Administrative Operations MIT 15.001 Adverse/sentinel 0 Adverse/sentinel • Adverse/Sentinel events events (ASE) events report (2–8 months) MIT 15.002 QMC Meetings 6 Quality • Meeting minutes (12 months) Management Committee meeting minutes MIT 15.003 EMRRC 12 EMRRC meeting • Monthly meeting minutes minutes (6 months) MIT 15.004 LGB 4 LGB meeting • Quarterly meeting minutes minutes (12 months) MIT 15.101 Medical Emergency 3 On-site summary • Most recent full quarter Response Drills reports & • Each watch documentation for ER drills MIT 15.102 Institutional Level 10 On-site list of • Medical grievances closed Medical Grievances grievances/closed (6 months) grievance files MIT 15.103 Death Reports 10 Institution-list of • Most recent 10 deaths deaths in prior • Initial death reports 12 months MIT 15.104 Nursing Staff 10 On-site nursing • On duty one or more years Validations education files • Nurse administers medications • Randomize MIT 15.105 Provider Annual 15 On-site • All required performance Evaluation Packets provider evaluation documents evaluation files MIT 15.106 Provider Licenses 16 Current provider • Review all listing (at start of inspection) MIT 15.107 Medical Emergency All On-site • All staff Response certification ◦ Providers (ACLS) Certifications tracking logs ◦ Nursing (BLS/CPR) • Custody (CPR/BLS) MIT 15.108 Nursing Staff and All On-site tracking • All required licenses and Pharmacist in Charge system, logs, or certifications Professional Licenses employee files and Certifications Office of the Inspector General, State of California Inspection Period: June 2021 – November 2021 Report Issued: November 2022 Cycle 6, Mule Creek State Prison | 103 Quality No. of Indicator Sample Category Samples Data Source Filters Administrative Operations MIT 15.109 Pharmacy and All On-site listing • All DEA registrations Providers’ Drug of provider DEA Enforcement Agency registration #s (DEA) Registrations & pharmacy registration document MIT 15.110 Nursing Staff New All Nursing staff • New employees (hired within last Employee training logs 12 months) Orientations MIT 15.998 Death Review 8 OIG summary log: • Between 35 business days & Committee deaths 12 months prior • California Correctional Health Care Services death reviews Office of the Inspector General, State of California Inspection Period: June 2021 – November 2021 Report Issued: November 2022 Cycle 6, Mule Creek State Prison | 104 California Correctional Health Care Services’ Response (cid:14)(cid:25)(cid:19)(cid:27)(cid:18)(cid:22)(cid:21)(cid:24)(cid:1)(cid:15)(cid:24)(cid:28)(cid:20)(cid:23)(cid:25)(cid:26)(cid:20)(cid:1)(cid:17)(cid:14)(cid:11)(cid:1)(cid:6)(cid:16)(cid:6)(cid:10)(cid:16)(cid:16)(cid:3)(cid:15)(cid:2)(cid:4)(cid:7)(cid:8)(cid:6)(cid:2)(cid:7)(cid:10)(cid:9)(cid:12)(cid:2)(cid:13)(cid:15)(cid:10)(cid:3)(cid:2)(cid:5)(cid:16)(cid:9)(cid:5)(cid:12)(cid:10)(cid:16)(cid:3)(cid:13)(cid:3)(cid:8)(cid:13) October 24, 2022 Amarik Singh, Inspector General Office of the Inspector General 10111 Old Placerville Road, Suite 110 Sacramento, CA 95827 Dear Ms. Singh: The Office of the Receiver has reviewed the draft Medical Inspection Report for Mule Creek State Prison (MCSP) conducted by the Office of the Inspector General (OIG) from June to November 2021. California Correctional Health Care Services (CCHCS) acknowledges the OIG findings. Thank you for preparing the report. Your efforts have advanced our mutual objective of ensuring transparency and accountability in CCHCS operations. If you have any questions or concerns, please contact me at (916) 896-6780. Sincerely, Robin Hart Associate Director Risk Management Branch California Correctional Health Care Services cc: Clark Kelso, Receiver Diana Toche, D.D.S., Undersecretary, Health Care Services, CDCR Directors, CCHCS Roscoe Barrow, Chief Counsel, CCHCS Office of Legal Affairs Jackie Clark, Deputy Director, Institution Operations, CCHCS DeAnna Gouldy, Deputy Director, Policy and Risk Management Services, CCHCS Renee Kanan, M.D., Deputy Director, Medical Services, CCHCS Barbara Barney-Knox, R.N., Deputy Director, Nursing Services, CCHCS Annette Lambert, Deputy Director, Quality Management, CCHCS Regional Health Care Executive, Region I, CCHCS Regional Deputy Medical Executive, Region I, CCHCS Regional Nursing Executive, Region I, CCHCS Chief Executive Officer, MCSP Katherine Tebrock, Chief Assistant Inspector General, OIG Doreen Pagaran, R.N., Nurse Consultant Program Review, OIG Misty Polasik, Staff Services Manager I, OIG P.O. Box 588500 Elk Grove, CA 95758 Office of the Inspector General, State of California Inspection Period: June 2021 – November 2021 Report Issued: November 2022 Cycle 6 Medical Inspection Report for Mule Creek State Prison OFFICE of the INSPECTOR GENERAL Amarik K. Singh Inspector General Neil Robertson Chief Deputy Inspector General STATE of CALIFORNIA November 2022 OIG