North Kern State Prison Medical Inspection Report Cycle 5

Roy W. Wesley Office of the Inspector General Inspector General North Kern State Prison Medical Inspection Results Cycle 5 October 2017 Office of the Inspector General State of California Office of the Inspector General NORTH KERN STATE PRISON Medical Inspection Results Cycle 5 Roy W. Wesley Inspector General Shaun R. Spillane Public Information Officer October 2017 T C ABLE OF ONTENTS Foreword .............................................................................................................................................. i Executive Summary ........................................................................................................................... iii Overall Rating: Inadequate ............................................................................................................. iii Clinical Case Review and OIG Clinician Inspection Results ................................................ v Compliance Testing Results.................................................................................................. vi Recommendations ......................................................................................................................... viii Population-Based Metrics ............................................................................................................. viii Introduction ......................................................................................................................................... 1 About the Institution ........................................................................................................................ 1 Objectives, Scope, and Methodology.................................................................................................. 3 Case Reviews ................................................................................................................................... 4 Patient Selection for Retrospective Case Reviews ................................................................. 4 Benefits and Limitations of Targeted Subpopulation Review ............................................... 5 Case Reviews Sampled .......................................................................................................... 5 Compliance Testing ......................................................................................................................... 7 Scoring of Compliance Testing Results ................................................................................. 7 Overall Quality Indicator Rating for Case Reviews and Compliance Testing ................................ 8 Population-Based Metrics ................................................................................................................ 8 Medical Inspection Results ................................................................................................................. 9 1 — Access to Care ................................................................................................................. 10 Case Review Results ............................................................................................................ 10 Compliance Testing Results................................................................................................. 13 2 — Diagnostic Services ......................................................................................................... 16 Case Review Results ............................................................................................................ 16 Compliance Testing Results................................................................................................. 17 3 — Emergency Services ........................................................................................................ 19 Case Review Results ............................................................................................................ 19 4 — Health Information Management .................................................................................... 21 Case Review Results ............................................................................................................ 21 Compliance Testing Results................................................................................................. 23 5 — Health Care Environment ............................................................................................... 25 Compliance Testing Results................................................................................................. 25 6 — Inter- and Intra-System Transfers ................................................................................... 28 Case Review Results ............................................................................................................ 28 Compliance Testing Results................................................................................................. 30 7 — Pharmacy and Medication Management ........................................................................ 31 Case Review Results ............................................................................................................ 31 Compliance Testing Results................................................................................................. 33 8 — Prenatal and Post-Delivery Services .............................................................................. 37 9 — Preventive Services ......................................................................................................... 38 Compliance Testing Results................................................................................................. 38 North Kern State Prison, Cycle 5 Medical Inspection Table of Contents Office of the Inspector General State of California 10 — Quality of Nursing Performance ................................................................................... 40 Case Review Results ............................................................................................................ 40 11 — Quality of Provider Performance .................................................................................. 44 Case Review Results ............................................................................................................ 44 12 — Reception Center Arrivals ............................................................................................. 50 Case Review Results ............................................................................................................ 50 Compliance Testing Results................................................................................................. 52 13 — Specialized Medical Housing ........................................................................................ 54 Case Review Results ............................................................................................................ 54 Compliance Testing Results................................................................................................. 56 14 — Specialty Services .......................................................................................................... 57 Case Review Results ............................................................................................................ 57 Compliance Testing Results................................................................................................. 60 15 — Administrative Operations (Secondary) ........................................................................ 61 Compliance Testing Results................................................................................................. 61 Recommendations ............................................................................................................................. 64 Population-Based Metrics ................................................................................................................. 65 Appendix A — Compliance Test Results ......................................................................................... 68 Appendix B — Clinical Data ............................................................................................................ 82 Appendix C — Compliance Sampling Methodology ....................................................................... 85 California Correctional Health Care Services’ Response ................................................................. 92 North Kern State Prison, Cycle 5 Medical Inspection Table of Contents Office of the Inspector General State of California L T F IST OF ABLES AND IGURES NKSP Executive Summary Table ...................................................................................................... iv NKSP Health Care Staffing Resources as of March 2017 ................................................................... 2 NKSP Master Registry Data as of March 27, 2017 ............................................................................. 2 NKSP Results Compared to State and National HEDIS Scores ........................................................ 67 Table B-1: NKSP Sample Sets .......................................................................................................... 82 Table B-2: NKSP Chronic Care Diagnoses ....................................................................................... 83 Table B-3: NKSP Event — Program ................................................................................................. 84 Table B-4: NKSP Review Sample Summary .................................................................................... 84 North Kern State Prison, Cycle 5 Medical Inspection List of Tables and Figures Office of the Inspector General State of California F OREWORD Pursuant to California Penal Code Section 6126 et seq., which assigns the Office of the Inspector General (OIG) responsibility for oversight of the California Department of Corrections and Rehabilitation (CDCR), the OIG conducts a comprehensive inspection program to evaluate the delivery of medical care at each of CDCR’s 35 adult prisons. The OIG explicitly makes no determination regarding the constitutionality of care in the prison setting. That determination is left to the Receiver and the federal court. The assessment of care by the OIG is just one factor in the court’s determination whether care in the prisons meets constitutional standards. The OIG’s inspections are mandated by the Penal Code and not aimed at specifically resolving the court’s questions on constitutional care. To the degree that they provide another factor for the court to consider, the OIG is pleased to provide added value to the taxpayers of California. In Cycle 5, for the first time, the OIG will be inspecting institutions delegated back to CDCR from the Receivership. There is no difference in the standards used for assessment of a delegated institution versus an institution not yet delegated. At the time of the Cycle 5 inspection of North Kern State Prison, the Receiver had not delegated this institution back to CDCR. This fifth cycle of inspections will continue evaluating the areas addressed in Cycle 4, which included clinical case review, compliance testing, and a population-based metric comparison of selected Healthcare Effectiveness Data Information Set (HEDIS) measures. In agreement with stakeholders, the OIG made changes to both the case review and compliance components. The OIG found that in every inspection in Cycle 4, larger samples were taken than were needed to assess the adequacy of medical care provided. As a result, the OIG reduced the number of case reviews and sample sizes for compliance testing. Also, in Cycle 4, compliance testing included two secondary (administrative) indicators (Internal Monitoring, Quality Improvement, and Administrative Operations; and Job Performance, Training, Licensing, and Certifications). For Cycle 5, these have been combined into one secondary indicator, Administrative Operations. North Kern State Prison, Cycle 5 Medical Inspection Page i Office of the Inspector General State of California This page intentionally left blank. North Kern State Prison, Cycle 5 Medical Inspection Page ii Office of the Inspector General State of California E S XECUTIVE UMMARY The OIG performed its Cycle 5 medical inspection at North Kern State Prison (NKSP) from April to June 2017. The inspection included in-depth reviews of 53 patient files conducted by clinicians, as well as reviews of documents from 455 patient files OVERALL RATING: covering 100 objectively scored tests of compliance with policies and procedures applicable to the delivery of medical care. The OIG Inadequate assessed the case review and compliance results at NKSP using 14 health care quality indicators applicable to the institution. To conduct clinical case reviews, the OIG employs a clinician team consisting of a physician and a registered nurse consultant, while compliance testing is done by a team of registered nurses trained in monitoring medical policy compliance. Of the indicators, eight were rated by both case review clinicians and compliance inspectors, three were rated by case review clinicians only, and three were rated by compliance inspectors only. The NKSP Executive Summary Table on the following page identifies the applicable individual indicators and scores for this institution. North Kern State Prison, Cycle 5 Medical Inspection Page iii Office of the Inspector General State of California NKSP Executive Summary Table Cycle 5 Cycle 4 Case Review Compliance Inspection Indicators Overall Overall Rating Rating Rating Rating 1—Access to Care Inadequate Inadequate Inadequate Adequate 2—Diagnostic Services Adequate Adequate Adequate Proficient 3—Emergency Services Adequate Not Applicable Adequate Adequate 4—Health Information Adequate Inadequate Adequate Inadequate Management 5—Health Care Environment Not Applicable Adequate Adequate Inadequate 6—Inter- and Intra-System Adequate Proficient Adequate Adequate Transfers 7—Pharmacy and Medication Inadequate Adequate Inadequate Inadequate Management 8—Prenatal and Post-Delivery Not Applicable Not Applicable Not Applicable Not Applicable Services 9—Preventive Services Not Applicable Adequate Adequate Adequate 10—Quality of Nursing Adequate Not Applicable Adequate Adequate Performance 11—Quality of Provider Inadequate Not Applicable Inadequate Inadequate Performance 12—Reception Center Arrivals Inadequate Inadequate Inadequate Adequate 13—Specialized Medical Housing Adequate Proficient Adequate Inadequate 14—Specialty Services Adequate Adequate Adequate Adequate 15—Administrative Operations Not Applicable Adequate Adequate Inadequate* (Secondary) *In Cycle 4, there were two secondary (administrative) indicators. This score reflects the average of those two scores. North Kern State Prison, Cycle 5 Medical Inspection Page iv Office of the Inspector General State of California Clinical Case Review and OIG Clinician Inspection Results The clinicians’ case reviews sampled patients with high medical needs and included a review of 1,273 patient care events.1 Of the 14 indicators applicable to NKSP, 11 were evaluated by clinician case review; four were inadequate, and seven were adequate. When determining the overall adequacy of care, the OIG paid particular attention to the clinical nursing and provider quality indicators, as adequate health care staff can sometimes overcome suboptimal processes and programs. However, the opposite is not true; inadequate health care staff cannot provide adequate care, even though the established processes and programs onsite may be adequate. The OIG clinicians identify inadequate medical care based on the risk of significant harm to the patient, not the actual outcome. The Quality of Provider Performance and Access to Care indicators showed the weaknesses of the institution. Providers did not properly assess patients, and requested follow-ups occurred late or not at all. Program Strengths — Clinical  NKSP had an excellent daily morning provider huddle. This allowed the administration to inform providers of any issues or concerns.  There was strong rapport between provider, nursing, and custody staff. With the exception of one clinic, team members worked cooperatively to ensure scheduled patient appointments were kept. Program Weaknesses — Clinical  Access to care was poor. Scheduling errors resulted in many provider appointments that did not occur or that were delayed. NKSP regularly scheduled an excessive number of patients for the sole provider in the D Yard clinic, which resulted in many dropped appointments. Since the OIG’s Cycle 4 inspection, several providers transferred to other institutions, which reduced the number of available provider appointments. NKSP lost six of its most seasoned providers and gained only four new providers. There were two vacancies open for over a year, contributing to poor access to care and poor provider performance.  Providers made poor assessments and decisions. In some cases, providers made decisions based on old information because they did not review recent diagnostic reports or medication lists. In other cases, providers did not follow CCHCS guidelines during chronic care visits. In some cases, providers simply exercised poor judgment. 1 Each OIG clinician team includes a board-certified physician and registered nurse consultant with experience in correctional and community medical settings. North Kern State Prison, Cycle 5 Medical Inspection Page v Office of the Inspector General State of California  NKSP did not cross-train nurses in specialty and telemedicine services. When nurses in those areas were absent from the institution, tracking of pending reports was poor.  NKSP nursing staff did not ensure that essential medications were administered as ordered. Compliance Testing Results Of the 14 health care indicators applicable to NKSP, 11 were evaluated by compliance inspectors.2 Two were proficient, six were adequate, and three were inadequate. There were 100 individual compliance questions within those 11 indicators, generating 1,350 data points, which tested NKSP’s compliance with California Correctional Health Care Services (CCHCS) policies and procedures.3 Those 100 questions are detailed in Appendix A — Compliance Test Results. Program Strengths — Compliance The following are some of NKSP’s strengths based on its compliance scores on individual questions in all the health care indicators:  The institution performed well in diagnostic services by providing radiology, laboratory, and pathology services timely.  The health care environment at NKSP was generally good; reusable invasive equipment was properly sterilized, clinics had adequate hygiene supplies available, and proper protocols were in place at clinic locations to mitigate exposure to blood-borne pathogens and contaminated waste.  Nursing staff properly completed the assessment and disposition sections of the Initial Health Screening form (CDCR form 7277) for patients who transferred into NKSP. Also, nursing staff properly identified pending specialty service appointments on transfer forms, and nursing staff included all required supporting documentation for patients transferring out of NKSP.  The institution’s main pharmacy followed general security, organization, and cleanliness management protocols, and properly stored and monitored both narcotic and non-narcotic medications.  The institution provided timely annual tuberculosis screenings. 2 The OIG’s compliance inspectors are trained registered nurses with expertise in CDCR policies regarding medical staff and processes. 3 The OIG used its own clinicians to provide clinical expert guidance for testing compliance in certain areas where CCHCS policies and procedures did not specifically address an issue. North Kern State Prison, Cycle 5 Medical Inspection Page vi Office of the Inspector General State of California  When patients were admitted to the CTC, nursing staff completed initial assessments, and providers completed initial encounters, within required time frames. Program Weaknesses — Compliance The following are some of the weaknesses identified by NKSP’s compliance scores on individual questions in all the health care indicators:  Patients with chronic conditions did not always receive timely provider appointments, and patients who recently transferred into NKSP did not receive their provider or nurse referral appointments within required time frames.  Inspectors found several mislabeled documents in patients’ electronic medical records, including documents scanned with incorrect dates.  Several clinic exam rooms did not have environments conducive to providers’ completion of comprehensive examinations, including exam rooms with inadequate space, no visual privacy, and furniture in disrepair.  NKSP did not always provide timely medication for patients that returned from a community hospital and patients received from a county jail.  The institution’s clinical staff did not properly monitor patients who were taking TB medications.  Patients who had recently arrived from a county jail did not receive a proper initial health screening upon arrival, and did not receive all required diagnostic tests. North Kern State Prison, Cycle 5 Medical Inspection Page vii Office of the Inspector General State of California RECOMMENDATIONS  The OIG recommends NKSP cross-train several nurses to work in the specialty clinic in the event that the regular specialty nurse is away from the institution.  The OIG recommends NKSP develop a system to ensure specialty reports are retrieved from the offsite specialist in a timely manner. POPULATION-BASED METRICS In general, NKSP performed well as measured by population-based metrics. In comprehensive diabetes care, NKSP performed comparably to other state and national entities, outscoring in most of the diabetic measures and scoring less well than other plans in a few measures. With regard to immunization measures, NKSP’s rates were also mixed, with the institution scoring poorly for influenza immunizations for young adults, but performed well in comparison to other health plans for influenza and pneumococcal immunizations for older adults. Patient refusals negatively affected immunizations for young adults. The institution’s rates for colorectal cancer screening were similar to other state and national health plans. The population-based metrics indicated that the chronic care program was functioning properly when compared to the other state and national health care plans, and the institution may further improve its comparable scores by educating patients on the benefits of immunizations. North Kern State Prison, Cycle 5 Medical Inspection Page viii Office of the Inspector General State of California I NTRODUCTION Pursuant to California Penal Code Section 6126 et seq., which assigns the Office of the Inspector General (OIG) responsibility for oversight of the California Department of Corrections and Rehabilitation (CDCR), and at the request of the federal Receiver, the OIG developed a comprehensive medical inspection program to evaluate the delivery of medical care at each of CDCR’s 35 adult prisons. The OIG conducts a clinical case review and a compliance inspection, ensuring a thorough, end-to-end assessment of medical care within CDCR. North Kern State Prison (NKSP) was the tenth medical inspection of Cycle 5. During the inspection process, the OIG assessed the delivery of medical care to patients using the primary clinical health care indicators applicable to the institution. The Administrative Operations indicator is secondary because it does not reflect the actual clinical care provided. This secondary indicator is not factored into the overall determination whether an institution provides adequate care. ABOUT THE INSTITUTION NKSP is a medium-security prison located in Delano in Kern County. As a reception center, its mission is to process and classify incoming inmates received from county jails by evaluating their medical and mental health needs, evaluating their security levels and program requirements, and determining appropriate institutional placement prior to their transfer to other state facilities. NKSP operates multiple clinics where staff members handle non-urgent requests for medical services. The institution also treats patients who need urgent or emergent care in its triage and treatment area (TTA) and provides inpatient care in its correctional treatment center (CTC). NKSP has been designated a “basic” health care institution by CDCR; basic facilities are typically located in rural areas, far away from tertiary care centers and specialty care providers whose services would likely be used frequently by patients with higher medical risk. Because of the institution’s remote location and its basic health care status, CDCR generally places healthier patients in this institution. NKSP received national accreditation from the Commission on Accreditation for Corrections on August 7, 2016. This accreditation program is a professional peer review process based on national standards set by the American Correctional Association. Based on staffing data the OIG obtained from the institution, NKSP’s vacancy rate among medical managers, primary care providers, supervisors, and rank-and-file nurses was 4 percent in March 2017. The highest vacancy percentage was among primary care providers at 27 percent, which equated to three vacant provider positions out of 11 authorized positions. Lastly, 14 percent of the staff was hired within the last 12 months. North Kern State Prison, Cycle 5 Medical Inspection Page 1 Office of the Inspector General State of California NKSP Health Care Staffing Resources as of March 2017 Primary Care Nursing Management Nursing Staff Totals Providers Supervisors Description Number % Number % Number % Number % Number % Authorized 5 4% 11 9% 10.1 8% 102.1 80% 128.2 100% Positions Filled Positions 5 100% 8 73% 9.5 94% 100 98% 122.5 96% Vacancies 0 0% 3 27% 0.6 6% 2.1 2% 5.7 4% Recent Hires (within 12 0 0% 4 50% 1 11% 12 12% 17 14% months) Staff Utilized 0 0% 0 0% 0 0% 0 0% 0 0% from Registry Redirected Staff (to Non-Patient 0 0% 0 0% 0 0% 0 0% 0 0% Care Areas) Staff on Long-term 0 0% 0 0% 1 11% 1 1% 2 2% Medical Leave Note: NKSP Health Care Staffing Resources data was not validated by the OIG. As of March 27, 2017, the Master Registry for NKSP showed that the institution had a total population of 4,818. Within that total population, 1.0 percent was designated as high medical risk, Priority 1 (High 1), and 3.3 percent were designated as high medical risk, Priority 2 (High 2). Patients’ assigned risk levels are based on the complexity of their required medical care related to their specific diagnoses, frequency of higher levels of care, age, and abnormal laboratory results and procedures. High 1 has at least two high-risk conditions; High 2 has only one. Patients at high medical risk are more susceptible to poor health outcomes than those at medium or low medical risk. Patients at high medical risk also typically require more health care services than do patients with lower assigned risk levels. The chart below illustrates the breakdown of the institution’s medical risk levels at the start of the OIG medical inspection. NKSP Master Registry Data as of March 27, 2017 Medical Risk Level # of Patients Percentage High 1 47 0.98% High 2 157 3.26% Medium 1,622 33.67% Low 2,992 62.10% Total 4,818 100% North Kern State Prison, Cycle 5 Medical Inspection Page 2 Office of the Inspector General State of California O , S , M BJECTIVES COPE AND ETHODOLOGY In designing the medical inspection program, the OIG reviewed CCHCS policies and procedures, relevant court orders, and guidance developed by the American Correctional Association. The OIG also reviewed professional literature on correctional medical care; reviewed standardized performance measures used by the health care industry; consulted with clinical experts; and met with stakeholders from the court, the Receiver’s office, CDCR, the Office of the Attorney General, and the Prison Law Office to discuss the nature and scope of the OIG’s inspection program. With input from these stakeholders, the OIG developed a medical inspection program that evaluates medical care delivery by combining clinical case reviews of patient files, objective tests of compliance with policies and procedures, and an analysis of outcomes for certain population-based metrics. To maintain a metric-oriented inspection program that evaluates medical care delivery consistently at each State prison, the OIG identified 15 indicators (14 primary (clinical) indicators and one secondary (administrative) indicator) of health care to measure. The primary quality indicators cover clinical categories directly relating to the health care provided to patients, whereas the secondary quality indicator addresses the administrative functions that support a health care delivery system. These 15 indicators are identified in the NKSP Executive Summary Table on page iv. The OIG rates each of the quality indicators applicable to the institution under inspection based on case reviews conducted by OIG clinicians and compliance tests conducted by OIG registered nurses. The ratings may be derived from the case review results alone, the compliance test results alone, or a combination of both these information sources. For example, the ratings for the primary quality indicators Quality of Nursing Performance and Quality of Provider Performance are derived entirely from the case review done by clinicians, while the ratings for the primary quality indicators Health Care Environment and Preventive Services are derived entirely from compliance testing done by registered nurse inspectors. As another example, primary quality indicators such as Diagnostic Services and Specialty Services receive ratings derived from both sources. Consistent with the OIG’s agreement with the Receiver, this report only addresses the conditions found related to medical care criteria. The OIG does not review for efficiency and economy of operations. Moreover, if the OIG learns of a patient needing immediate care, the OIG notifies the chief executive officer of health care services and requests a status report. Additionally, if the OIG learns of significant departures from community standards, it may report such departures to the institution’s chief executive officer or to CCHCS. Because these matters involve confidential medical information protected by State and federal privacy laws, specific identifying details related to any such cases are not included in the OIG’s public report. In all areas, the OIG is alert for opportunities to make appropriate recommendations for improvement. Such opportunities may be present regardless of the score awarded to any particular North Kern State Prison, Cycle 5 Medical Inspection Page 3 Office of the Inspector General State of California quality indicator; therefore, recommendations for improvement should not necessarily be interpreted as indicative of deficient medical care delivery. CASE REVIEWS The OIG added case reviews to the Cycle 4 medical inspections at the recommendation of its stakeholders, which continues in Cycle 5 medical inspections. The OIG’s clinicians perform a retrospective chart review of selected patient files to evaluate the care given by an institution’s primary care providers and nurses. Retrospective chart review is a well-established review process used by health care organizations that perform peer reviews and patient death reviews. Currently, CCHCS uses retrospective chart review as part of its death review process and in its pattern-of-practice reviews. CCHCS also uses a more limited form of retrospective chart review when performing appraisals of individual primary care providers. Patient Selection for Retrospective Case Reviews Because retrospective chart review is time consuming and requires qualified health care professionals to perform it, OIG clinicians must carefully sample patient records. Accordingly, the group of patients the OIG targeted for chart review carried the highest clinical risk and utilized the majority of medical services. A majority of the patients selected for retrospective chart review were classified by CCHCS as high-risk patients. The reason the OIG targeted these patients for review is twofold: 1. The goal of retrospective chart review is to evaluate all aspects of the health care system. Statewide, high-risk and high-utilization patients consume medical services at a disproportionate rate; 11 percent of the total patient population are considered high-risk and account for more than half of the institution’s pharmaceutical, specialty, community hospital, and emergency costs. 2. Selecting this target group for chart review provides a significantly greater opportunity to evaluate all the various aspects of the health care delivery system at an institution. Underlying the choice of high-risk patients for detailed case review, the OIG clinical experts made the following three assumptions: 1. If the institution is able to provide adequate clinical care to the most challenging patients with multiple complex and interdependent medical problems, it will be providing adequate care to patients with less complicated health care issues. Because clinical expertise is required to determine whether the institution has provided adequate clinical care, the OIG utilizes experienced correctional physicians and registered nurses to perform this analysis. 2. The health of less complex patients is more likely to be affected by processes such as timely appointment scheduling, medication management, routine health screening, and North Kern State Prison, Cycle 5 Medical Inspection Page 4 Office of the Inspector General State of California immunizations. To review these processes, the OIG simultaneously performs a broad compliance review. 3. Patient charts generated during death reviews, sentinel events (unexpected occurrences involving death or serious injury, or risk thereof), and hospitalizations are mostly of high-risk patients. Benefits and Limitations of Targeted Subpopulation Review Because the selected patients utilize the broadest range of services offered by the health care system, the OIG’s retrospective chart review provides adequate data for a qualitative assessment of the most vital system processes (referred to as “primary quality indicators”). Retrospective chart review provides an accurate qualitative assessment of the relevant primary quality indicators as applied to the targeted subpopulation of high-risk and high-utilization patients. While this targeted subpopulation does not represent the prison population as a whole, the ability of the institution to provide adequate care to this subpopulation is a crucial and vital indicator of how the institution provides health care to its whole patient population. Simply put, if the institution’s medical system does not adequately care for those patients needing the most care, then it is not fulfilling its obligations, even if it takes good care of patients with less complex medical needs. Since the targeted subpopulation does not represent the institution’s general prison population, the OIG cautions against inappropriate extrapolation of conclusions from the retrospective chart reviews to the general population. For example, if the high-risk diabetic patients reviewed have poorly-controlled diabetes, one cannot conclude that the entire diabetic population is inadequately controlled. Similarly, if the high-risk diabetic patients under review have poor outcomes and require significant specialty interventions, one cannot conclude that the entire diabetic population is having similarly poor outcomes. Nonetheless, the health care system’s response to this subpopulation can be accurately evaluated and yields valuable systems information. In the above example, if the health care system is providing appropriate diabetic monitoring, medication therapy, and specialty referrals for the high-risk patients reviewed, then it can be reasonably inferred that the health care system is also providing appropriate diabetic services to the entire diabetic subpopulation. However, if these same high-risk patients needing monitoring, medications, and referrals are generally not getting those services, it is likely that the health care system is not providing appropriate diabetic services to the greater diabetic subpopulation. Case Reviews Sampled As indicated in Appendix B, Table B–1: NKSP Sample Sets, the OIG clinicians evaluated medical charts for 53 unique patients. Appendix B, Table B–4: NKSP Case Review Sample Summary clarifies that both nurses and physicians reviewed charts for 12 of those patients, for 65 reviews in total. Physicians performed detailed reviews of 20 charts, and nurses performed detailed reviews of North Kern State Prison, Cycle 5 Medical Inspection Page 5 Office of the Inspector General State of California 14 charts, totaling 34 detailed reviews. For detailed case reviews, physicians or nurses looked at all encounters occurring in approximately six months of medical care. Nurses also performed a limited or focused review of medical records for an additional 31 patients. These generated 1,273 clinical events for review (Appendix B, Table B–3: NKSP Event — Program). The inspection tool provides details on whether the encounter was adequate or had significant deficiencies, and identifies deficiencies by programs and processes to help the institution focus on improvement areas. While the sample method specifically pulled only 6 chronic care patient records, i.e., 3 diabetes patients and 3 anticoagulation patients (Appendix B, Table B–1: NKSP Sample Sets), the 53 unique patients sampled included patients with 141 chronic care diagnoses, including 15 additional patients with diabetes (for a total of 18) and 3 additional anticoagulation patients (for a total of 6) (Appendix B, Table B–2: NKSP Chronic Care Diagnoses). The OIG’s sample selection tool allowed evaluation of many chronic care programs because the complex and high-risk patients selected from the different categories often had multiple medical problems. While the OIG did not evaluate every chronic disease or health care staff member, the overall operation of the institution’s system and staff were assessed for adequacy. The OIG’s case review methodology and sample size matched other qualitative research. The empirical findings, supported by expert statistical consultants, showed adequate conclusions after 10 to 15 charts had undergone full clinician review. In qualitative statistics, this phenomenon is known as “saturation.” The OIG found the Cycle 4 medical inspection sample size of 30 for detailed physician reviews far exceeded the saturation point necessary for an adequate qualitative review. At the end of Cycle 4 inspections, the case review results were reanalyzed using 50 percent of the cases; there were no significant differences in the ratings. To improve inspection efficiency while preserving the quality of the inspection, the samples for Cycle 5 medical inspections were reduced in number. In Cycle 5, for basic institutions with small high-risk populations, case review will use a sample size of detailed physician-reviewed cases 67 percent as large as that used in Cycle 4. For intermediate institutions and basic institutions housing many high-risk patients, case review physicians will use a sample 83 percent as large as that in Cycle 4. Finally, for the most medically complex institution, California Health Care Facility (CHCF), the OIG will continue to use a sample size 100 percent as large as that used in Cycle 4. With regard to reviewing charts from different providers, the case review is not intended to be a focused search for poorly performing providers; rather, it is focused on how the system cares for those patients who need care the most. Nonetheless, while not sampling cases by each provider at the institution, the OIG inspections adequately review most providers. Providers would only escape OIG case review if institutional management successfully mitigated patient risk by having the more poorly performing providers care for the less complicated, low-utilizing, and lower-risk patients. The OIG’s clinicians concluded that the case review sample size was more than adequate to assess the quality of services provided. Based on the collective results of clinicians’ case reviews, the OIG rated each quality indicator as either proficient (excellent), adequate (passing), inadequate (failing), or not applicable. A separate North Kern State Prison, Cycle 5 Medical Inspection Page 6 Office of the Inspector General State of California confidential NKSP Supplemental Medical Inspection Results: Individual Case Review Summaries report details the case reviews OIG clinicians conducted and is available to specific stakeholders. For further details regarding the sampling methodologies and counts, see Appendix B — Clinical Data, Table B–1; Table B–2; Table B–3; and Table B–4. COMPLIANCE TESTING From April to June 2017, registered nurse inspectors attained answers to 100 objective medical inspection test (MIT) questions designed to assess the institution’s compliance with critical policies and procedures applicable to the delivery of medical care. To conduct most tests, inspectors randomly selected samples of patients for whom the testing objectives were applicable and reviewed their electronic unit health records. In some cases, inspectors used the same samples to conduct more than one test. In total, inspectors reviewed health records for 455 individual patients and analyzed specific transactions within their records for evidence that critical events occurred. Inspectors also reviewed management reports and meeting minutes to assess certain administrative operations. In addition, during the week of April 10, 2017, field registered nurse inspectors conducted a detailed onsite inspection of NKSP’s medical facilities and clinics; interviewed key institutional employees; and reviewed employee records, logs, medical appeals, death reports, and other documents. This generated 1,350 scored data points to assess care. In addition to the scored questions, the OIG obtained information from the institution that it did not score. This included, for example, information about NKSP’s plant infrastructure, protocols for tracking medical appeals and local operating procedures, and staffing resources. For Cycle 5 medical inspection testing, the OIG reduced the number of compliance samples tested for 18 indicator tests from a sample of 30 patients to a sample of 25 patients. The OIG also removed some inspection tests upon stakeholder agreement that either were duplicated in the case reviews or had limited value. Lastly, for Cycle 4 medical inspections, the OIG tested two secondary (administrative) indicators; Internal Monitoring, Quality Improvement, and Administrative Operations; and Job Performance, Training, Licensing, and Certifications, and have combined these tests into one Administrative Operations indicator for Cycle 5 inspections. For details of the compliance results, see Appendix A — Compliance Test Results. For details of the OIG’s compliance sampling methodology, see Appendix C — Compliance Sampling Methodology. Scoring of Compliance Testing Results After compiling the answers to the 100 questions for the 14 applicable indicators, the OIG derived a score for each quality indicator by calculating the percentage score of all Yes answers for each of the questions applicable to a particular indicator, then averaging those scores. Based on those results, the OIG assigned a rating to each quality indicator of proficient (greater than 85 percent), adequate (between 75 percent and 85 percent), or inadequate (less than 75 percent). North Kern State Prison, Cycle 5 Medical Inspection Page 7 Office of the Inspector General State of California OVERALL QUALITY INDICATOR RATING FOR CASE REVIEWS AND COMPLIANCE TESTING The OIG derived the final rating for each quality indicator by combining the ratings from the case reviews and from the compliance testing, as applicable. When combining these ratings, the case review evaluations and the compliance testing results usually agreed, but there were instances when the rating differed for a particular quality indicator. In those instances, the inspection team assessed the quality indicator based on the collective ratings from both components. Specifically, the OIG clinicians and registered nurse inspectors discussed the nature of individual exceptions found within that indicator category and considered the overall effect on the ability of patients to receive adequate medical care. To derive an overall assessment rating of the institution’s medical inspection, the OIG evaluated the various rating categories assigned to each of the quality indicators applicable to the institution, giving more weight to the rating results of the primary quality indicators, which directly relate to the health care provided to patients. Based on that analysis, OIG experts made a considered and measured overall opinion about the quality of health care observed. POPULATION-BASED METRICS The OIG identified a subset of Healthcare Effectiveness Data Information Set (HEDIS) measures applicable to the CDCR patient population. To identify outcomes for NKSP, the OIG reviewed some of the compliance testing results, randomly sampled additional patients’ records, and obtained NKSP data from the CCHCS Master Registry. The OIG compared those results to HEDIS metrics reported by other statewide and national health care organizations. North Kern State Prison, Cycle 5 Medical Inspection Page 8 Office of the Inspector General State of California M I R EDICAL NSPECTION ESULTS The quality indicators assess the clinical aspects of health care. As shown on the NKSP Executive Summary Table on page iv of this report, 14 of the OIG’s indicators were applicable to NKSP. Of those 14 indicators, 8 were rated by both the case review and compliance components of the inspection, 3 were rated by the case review component alone, and 3 were rated by the compliance component alone. The Administrative Operations indicator is a secondary indicator, and, therefore, does not affect the overall score for the institution. Summary of Case Review Results: The clinical case review component assessed 11 of the 14 indicators applicable to NKSP. Of these 11 indicators, OIG clinicians rated none proficient, 7 adequate, and 4 inadequate. The OIG physicians rated the overall adequacy of care for each of the 20 detailed case reviews they conducted. Of these 20 cases, 11 were adequate, and 9 were inadequate. In the 1,273 events reviewed, there were 271 deficiencies, of which 96 were significant and considered to be of such magnitude that, if left unaddressed, they would likely contribute to patient harm. Adverse Events Identified During Case Review: Adverse events are medical errors that are more likely than not to cause serious or grave patient harm. Medical care is a complex dynamic process with many moving parts, subject to human error even within the best health care organizations. Adverse events are identified and tracked typically by all major health care organizations for the purpose of quality improvement. They are not generally representative of medical care delivered by the organization. The OIG identifies adverse events for the dual purposes of quality improvement and the illustration of problematic patterns of practice found during the inspection. Because of the anecdotal nature of these events, the OIG cautions against drawing inappropriate conclusions regarding the institution based solely on adverse events. There were no adverse events identified in the case reviews at NKSP. Summary of Compliance Results: The compliance component assessed 11 of the 14 indicators applicable to NKSP. Of these 11 indicators, OIG inspectors rated two proficient, six adequate, and three inadequate. The results of those assessments are summarized within this section of the report. The test questions used to assess compliance for each indicator are detailed in Appendix A. North Kern State Prison, Cycle 5 Medical Inspection Page 9 Office of the Inspector General State of California 1 — ACCESS TO CARE This indicator evaluates the institution’s ability to provide patients Case Review Rating: with timely clinical appointments. Areas specific to patients’ access Inadequate to care are reviewed, such as initial assessments of newly arriving Compliance Score: patients, acute and chronic care follow-ups, face-to-face nurse Inadequate appointments when a patient requests to be seen, provider referrals (67.9%) from nursing lines, and follow-ups after hospitalization or specialty Overall Rating: care. Compliance testing for this indicator also evaluates whether Inadequate patients have Health Care Services Request forms (CDCR Form 7362) available in their housing units. Case Review Results The OIG clinicians reviewed 325 provider, nurse, specialty, and hospital events that required a follow-up appointment and identified 62 deficiencies relating to the Access to Care indicator¸ of which 41 were significant (more likely than not to cause patient harm if not rectified). Significant deficiencies were identified in cases 7, 9, 20, 24, 26, 27, 31, 34, 39, 40, 41, 43, 44, 48, and 49. They occurred twice in cases 8, 12, 14, 16, 18, 21, and 23. They occurred three times in cases 11 and 32, and six times in case 19. The OIG clinicians rated this indicator inadequate. Provider-to-Provider Follow-up Appointments NKSP did not satisfactorily provide patients timely appointments after providers ordered them. During the review period, 112 outpatient provider appointments were reviewed. The OIG identified six deficiencies in provider-ordered follow-up appointments, four of which were significant:  In case 7, the patient had lung cancer that had spread to multiple areas of his body. The provider determined the patient needed a short interval follow-up appointment of seven to ten days based on the physical exam and abnormal vital signs. However, the patient was not seen until he was transferred to the hospital over one month later.  In case 8, the provider ordered another provider appointment in five to seven days to ensure the patient was doing better with his dehydration and eczema. However, this did not occur, and the patient was not seen again by a provider until he was found unresponsive months later.  In case 11, the patient had blood clots requiring an anticoagulant medication to reduce risk of death. During a visit, the provider noted that the patient was not medicated appropriately and requested a follow-up appointment in three to four weeks, but the appointment never occurred. North Kern State Prison, Cycle 5 Medical Inspection Page 10 Office of the Inspector General State of California  In case 12, the patient with uncontrolled diabetes had his medication adjusted, and the provider requested a two-week follow-up. The visit occurred seven weeks later. Sick Call Access Nurses are required to review sick call requests on the same day they are received and identify if patients require same-day or next-business-day assessments. The OIG clinicians reviewed 54 sick call events. There were ten deficiencies, one of which was significant:  In case 19, the nurse failed to perform a face-to-face assessment on the same day the nurse reviewed the sick call request for a patient with shortness of breath. Nurse-to-Provider Referrals NKSP performed at a marginally sufficient level in nurse-to-provider referrals. A nurse who performs a sick call assessment is required to refer a patient to a provider if the nurse determines a higher level of care is needed. When nurses at NKSP referred patients for routine provider evaluations, the appointments should have occurred within 14 days. The OIG clinicians reviewed 54 sick call events and identified 10 deficiencies, all of which were significant. Significant deficiencies were identified in cases 34, 39, 41, 43, 44, and 48, and two times in cases 18 and 19. The following are examples of late appointments or those that did not occur:  In case 18, the nurse evaluated the patient for hearing loss and difficulty understanding, and requested a provider appointment in 14 days. The appointment did not occur. About one month later, the nurse evaluated the patient again for hearing loss, and the patient requested a hearing device. The nurse requested a provider appointment in 14 days, and that appointment did not occur.  In case 19, the nurse evaluated the patient for swelling and numbness of the hands, legs, and feet. The nurse informed the patient that a provider appointment was already scheduled for him to be seen in two days. The appointment did not occur. Three months later, the nurse evaluated the patient for hand and foot pain, difficulty walking, and loss of balance. The nurse requested a provider appointment in 14 days, but the appointment did not occur until 41 days later.  In case 39, the nurse evaluated the patient for shoulder and collarbone pain. While the nurse requested a provider appointment in 14 days, the appointment occurred 46 days later instead. Nursing Follow-up Appointments NKSP did not perform satisfactorily with scheduling and completing follow-up nursing appointments that were generated by a provider or nurse. The OIG clinicians reviewed eight referrals for nurse follow-up and identified four deficiencies, two of which were significant: North Kern State Prison, Cycle 5 Medical Inspection Page 11 Office of the Inspector General State of California  In case 40, the provider evaluated the patient for skin abscesses and requested a nurse follow-up appointment in two to four days. The appointment did not occur.  In case 49, the provider evaluated the patient for an earache and hearing loss, and requested a nurse follow-up visit in four to five days. The appointment did not occur. Provider Follow-up After Specialty Services NKSP ensured that its providers saw their patients after specialty services. The OIG reviewed 108 specialty appointments and procedures that required provider follow-up. In only two instances (cases 11 and 23), follow-up appointments were late or did not occur. Intra-System Transfers & Reception Center NKSP satisfactorily ensured that patients who transferred in from other CDCR facilities were given timely provider appointments. The OIG clinicians reviewed 18 intra-system transfer-in events; appointments occurred significantly late in the following cases:  In case 26, the nurse referred the patient to the medical provider within two weeks, but he was not seen until nearly six weeks later.  In case 27, the nurse referred the patient to the medical provider within seven days, but he was not seen until nearly four weeks later. In contrast, NKSP performed poorly with patients arriving through the reception center. The seven significant deficiencies in access to care for reception center arrivals are discussed in the Reception Center Arrivals indicator. Follow-up After Hospitalization NKSP ensured that providers saw their patients after hospitalizations or outside emergency room visits. Among 27 of these events reviewed, clinicians found no deficiencies. Follow-up After Urgent/Emergent Care The institution effectively ensured that providers saw their patients after TTA visits. The OIG reviewed six cases in which the patient went to the TTA, returned to his housing, and required provider follow-up. There were no deficiencies. Specialized Medical Housing The institution sufficiently ensured that providers admitted their patients quickly to the CTC and saw them regularly. The OIG clinicians reviewed six CTC admissions and 102 CTC provider encounters, with only one minor deficiency. This is further discussed in the Specialized Medical Housing indicator. North Kern State Prison, Cycle 5 Medical Inspection Page 12 Office of the Inspector General State of California Specialty Access and Follow-up NKSP performed poorly with specialty access and specialty follow-up. Performance in this area is discussed further in the Specialty Services indicator. Diagnostic Results Follow-up Providers generally saw their patients appropriately after diagnostic studies. However, there were several instances in which the provider requested a follow-up to discuss abnormal laboratory results but the appointment was never scheduled. Performance in this area is discussed further in the Diagnostic Services indicator. Clinician Onsite Inspection The OIG clinicians interviewed NKSP staff regarding poor access to care in critical areas, such as provider follow-ups and nurse-to-provider referrals. According to staff, there were not enough appointments available to accommodate the need for provider visits. One provider interviewed stated that he was scheduled over 30 appointments per day. In order to manage his workload, he had to cancel or reschedule over half of them. This resulted in worsening patient backlogs, with many patients who were never seen at all. The medical leadership at NKSP stated that a few years ago, the institution was allocated 13.5 primary care provider positions, but those had been reduced to only 11 positions. Over the past year, NKSP had four vacancies and had filled two of those positions. There were no applicants for the physician and surgeon positions in the last few months. Several of the positions were converted to midlevel positions in an attempt to fill provider vacancies. Case Review Conclusion NKSP performed poorly with regard to Access to Care, and the indicator rating was inadequate. At the time of the onsite inspection, NKSP had 11 primary care provider positions allocated and had two positions vacant. The lack of availability of provider appointments severely affected access to care. Most of the patient appointment deficiencies were due to lack of provider availability. The additional workload from the transition to the new Electronic Health Record System (EHRS) was also expected to further reduce the number of provider appointments available. Compliance Testing Results The institution performed in the inadequate range in the Access to Care indicator, with a compliance score of 67.9 percent. The following tests showed areas for improvement:  Among 25 patients sampled who transferred into NKSP from other institutions and were referred to a provider based on nursing staff’s initial health care screening, only 2 (8 percent) were seen timely. Seven patients received their provider appointments from 7 to 14 days late; 14 patients received their appointments 15 to 41 days late. For two final North Kern State Prison, Cycle 5 Medical Inspection Page 13 Office of the Inspector General State of California patients, there was no medical record evidence found to indicate they were ever seen (MIT 1.002).4  Inspectors sampled 25 patients who suffered from one or more chronic care conditions; only 9 patients timely received their provider ordered follow-up appointments (36 percent). Sixteen other patients received their appointments late or not at all; one patient’s follow-up appointment occurred one day late; 5 patients’ appointments were between 8 and 27 days late; and 3 patients’ appointments were between 41 and 64 days late. Also, six patients’ visits had not yet occurred at the time of the OIG inspection and were between 29 and 122 days late as of the date of testing. Finally, one patient’s two separate appointments were late by 7 and 62 days (MIT 1.001).  Among 15 applicable Health Care Services Request forms (CDCR Form 7362) sampled on which nursing staff referred the patient for a provider appointment, only eight patients (53 percent) received a timely appointment. Two patients received their appointments one and four days late; two other patients received their appointments 13 and 16 days late; the final three patients did not receive a provider visit at all (MIT 1.005).  For 19 of the 30 patients sampled who submitted a health care service request, nursing staff completed a face-to-face encounter with the patient within one business day of reviewing the service request form (63 percent). For 9 of the 11 other patients, the nurse conducted the visit between two and seven days late. For the final two patients, there was no evidence found in the medical record that a face-to-face visit occurred (MIT 1.004). Five tests in this indicator earned proficient scores, as follows:  Patients had access to health care services request forms at all six housing units the OIG inspected (MIT 1.101).  Among 24 applicable sampled patients who were discharged from a community hospital, 22 (92 percent) received timely primary care provider follow-up appointments upon their return to NKSP. Two patients received their follow-up appointments one and 19 days late (MIT 1.007).  Inspectors sampled 30 health care services request forms and found that nursing staff reviewed 26 of them on the same day they were received (87 percent). Nursing staff reviewed four of the forms one day after the forms were received (MIT 1.003).  Of the seven applicable patients sampled who were referred to and seen by a provider and for whom the provider subsequently ordered a follow-up appointment, six (86 percent) 4 These compliance findings differed significantly from those of the case review clinicians because while compliance testing considered only CCHCS policy when determining compliance, the case review evaluated the actual quality of care patients received during transfers. North Kern State Prison, Cycle 5 Medical Inspection Page 14 Office of the Inspector General State of California received their follow-up appointments timely. One patient’s follow-up appointment was 21 days late (MIT 1.006).  Inspectors sampled 22 patients who were scheduled to receive a specialty service follow-up appointment with their primary care provider; 19 of them (86 percent) received a timely follow-up. Two patients each received their follow-up appointments four days late. For one final patient, there was no evidence found that his follow-up appointment ever occurred (MIT 1.008). North Kern State Prison, Cycle 5 Medical Inspection Page 15 Office of the Inspector General State of California 2 — DIAGNOSTIC SERVICES This indicator addresses several types of diagnostic services. Case Review Rating: Specifically, it addresses whether radiology and laboratory services Adequate were timely provided to patients, whether the primary care provider Compliance Score: timely reviewed the results, and whether the results were Adequate communicated to the patient within the required time frames. In (84.4%) addition, for pathology services, the OIG determines whether the Overall Rating: institution received a final pathology report and whether the Adequate provider timely reviewed and communicated the pathology results to the patient. The case reviews also factor in the appropriateness, accuracy, and quality of the diagnostic tests ordered and the clinical response to the results. Case Review Results The OIG clinicians reviewed 227 diagnostic events and found 12 deficiencies, 3 of which were significant. Among the 12 deficiencies, 9 related to health information management and 3 related to test completion. Test Completion NKSP performed diagnostic tests adequately. Out of 227 events, there were only three instances in which NKSP did not complete a test. Health Information Management NKSP performed adequately with relaying test results to providers and ensuring that providers reviewed, signed, and communicated the results to patients. There were occasional mislabeled reports, and radiology reports that were not signed off and were missing from the main electronic medical records. However, these minor deficiencies did not significantly increase the risk of harm to the patients involved.  In cases 2, 13, 21, and 33, there were mislabeled laboratory reports or dates of service.  In cases 19 and 24, there were radiology reports that were not signed off, missing from the eUHR, and not readily available for further review.  In case 24, NKSP scanned an abnormal colon cancer screening report into the medical record without a provider sign-off. Fortunately, the provider reviewed the report and acted on it promptly. These deficiencies are also mentioned in the Health Information Management indicator. North Kern State Prison, Cycle 5 Medical Inspection Page 16 Office of the Inspector General State of California Clinician Onsite Inspection During the onsite inspection, the OIG clinicians observed the dissemination of most diagnostic reports during the daily morning provider huddle. The providers reviewed the reports, signed off on them, and returned them to staff for scanning into the electronic medical record. The providers had a computer open to the radiology portal so they could view radiology reports and images during provider huddles. They explained that not scanning radiology reports in the main electronic medical record was per CCHCS policy. Instead, the providers viewed the radiology reports in the alternative record repository, RIS-PACS. This practice ensured that pertinent results were acted upon, at least initially. While reviewing the radiology reports in the alternative repository was a good initial practice, it did not ensure that the radiology reports were readily available for future medical staff caring for the patient. Nurses did not have access to the RIS-PACS system, and future medical providers would have little reason to search for radiology reports that were missing from the primary medical record. Despite these problems, the OIG expects the risk associated with missing radiology reports to diminish when all institutions transition to the Electronic Health Records System (EHRS). The radiology reports, or at least the existence of the reports, should be visible to all health care staff once each institution has switched to the EHRS. Case Review Conclusion NKSP performed well with regard to the Diagnostic Services indicator, and the indicator rating was thus adequate. The laboratory, radiology, and outside specialty reports were given to the providers in a systematic way. Radiology reports that were not signed off and were missing from the main electronic medical record posed barriers to future medical care since health care staff would be unaware of the existence of those missing reports. Compliance Testing Results The institution received an adequate compliance score of 84.4 percent in the Diagnostic Services indicator, which encompasses radiology, laboratory, and pathology services. For clarity, each type of diagnostic service is discussed separately below: Radiology Services  Radiology services were provided within the time frame specified by the ordering provider for all ten patients sampled (MIT 2.001). NKSP received a score of zero, however, because none of the corresponding diagnostic services reports had provider initials or a date, which were required per CCHCS policy (MIT 2.002). Providers did timely communicate the radiology results to all ten of the sampled patients (MIT 2.003). North Kern State Prison, Cycle 5 Medical Inspection Page 17 Office of the Inspector General State of California Laboratory Services  Laboratory services were completed within the time frame specified in the provider’s order for all ten patients sampled (MIT 2.004). In all ten instances, providers properly evidenced their timely review of the diagnostic reports and timely reported those results to the patients (MIT 2.005, 2.006). Pathology Services  NKSP timely received the final pathology reports for all ten patients sampled; in addition, providers properly evidenced their timely review of pathology results for the ten corresponding sampled reports (MIT 2.007, 2.008). Providers timely communicated the final pathology results to only six of the ten patients sampled (60 percent). Four report results were communicated between one and five days late (MIT 2.009). North Kern State Prison, Cycle 5 Medical Inspection Page 18 Office of the Inspector General State of California 3 — EMERGENCY SERVICES An emergency medical response system is essential to providing Case Review Rating: effective and timely emergency medical response, assessment, Adequate treatment, and transportation 24 hours per day. Provision of Compliance Score: urgent/emergent care is based on a patient’s emergency situation, Not Applicable clinical condition, and need for a higher level of care. The OIG Overall Rating: reviews emergency response services including first aid, basic life Adequate support (BLS), and advanced cardiac life support (ACLS) consistent with the American Heart Association guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiovascular care, and the provision of services by knowledgeable staff appropriate to each individual’s training, certification, and authorized scope of practice. The OIG evaluates this quality indicator entirely through clinicians’ reviews of case files and conducts no separate compliance testing element. Case Review Results The OIG clinicians reviewed 24 urgent or emergent events and found 22 deficiencies with various aspects of emergency care, 2 of which were significant (cases 20 and 42). The OIG clinicians rated this indicator adequate. Provider Performance In general, provider performance in the emergency setting was good. In the vast majority of TTA encounters, providers performed adequate assessments and displayed good decision-making in urgent or emergent situations. On-call providers usually documented their telephone calls with nurses via progress notes. There was one significant deficiency:  In case 20, the provider saw a patient in the TTA with fever, nausea, and flank pain, who had undergone recent surgery of his urinary tract. The provider sent the patient back to housing without a full evaluation, progress note, laboratory orders, or follow-up orders. The next day, the patient was admitted to the community hospital with a severe kidney infection. Nursing Performance In general, nurses at NKSP provided appropriate care during emergency medical response incidents. Although the majority of the nursing deficiencies were not significant and did not affect the patient’s outcome, one case displayed a significant deficiency related to nursing assessment and interventions:  In case 42, the patient had severe chest pain radiating to the right shoulder. The nurse administered nitroglycerin (heart blood flow medication). Five minutes later, the patient’s North Kern State Prison, Cycle 5 Medical Inspection Page 19 Office of the Inspector General State of California pain level decreased slightly but remained severe. The nurse did not reassess the patient’s pain level for 40 minutes, and the patient continued to experience severe pain. The nurse should have administered a second dose of nitroglycerin, notified the provider, and reassessed the patient’s pain level. Additionally, the nurse called 9-1-1 but not until two hours after the provider gave the order for transfer because the patient may have had a heart attack. Nursing Documentation The OIG clinicians identified nursing deficiencies in the form of incomplete or missing documentation of medical emergencies. Although they did not affect patients’ outcomes, they indicated areas for improvement. First medical responders did not provide documentation about the interventions provided to patients during medical emergencies. Additionally, nurses often did not document the time CPR was initiated or the amount of oxygen administered. Some nurses did not document assessments such as chest exams or details for interventions such as insertion of intravenous lines for fluids and medication administration. Contacting Local EMS Nurses responded timely to emergency medical events, and there were no significant deficiencies found. However, there was a pattern of delays in calling EMS in some of the cases reviewed, which may be appropriate for quality improvement strategies. For example, in cases 19 and 20, the nurses did not contact local EMS services for nearly two hours after receiving the order for priority but non-emergent medical transfer to the hospital. Emergency Medical Response Review Committee The emergency medical response review committee (EMRRC) met regularly and discussed emergency events. Most deficiencies were captured, and education and training was provided to the nursing staff. Clinician Onsite Inspection During the onsite visit, the OIG clinicians found the patient care environment in the TTA to be good for health care staff to perform patient care. Custody, medical, and nursing staff had good rapport and worked well together. Case Review Conclusion Nurses and providers at NKSP administered appropriate care with regard to the Emergency Services indicator, and the rating was adequate. NKSP had made improvements since the OIG’s Cycle 4 inspection in provider emergency care. North Kern State Prison, Cycle 5 Medical Inspection Page 20 Office of the Inspector General State of California 4 — HEALTH INFORMATION MANAGEMENT Health information management is a crucial link in the delivery of Case Review Rating: medical care. Medical personnel require accurate information in Adequate order to make sound judgments and decisions. This indicator Compliance Score: examines whether the institution adequately manages its health care Inadequate information. This includes determining whether the information is (74.1%) correctly labeled and organized and available in the electronic Overall Rating: health record; whether the various medical records (internal and Adequate external, e.g., hospital and specialty reports and progress notes) are obtained and scanned timely into the patient’s electronic health record; whether records routed to clinicians include legible signatures or stamps; and whether hospital discharge reports include key elements and are timely reviewed by providers. In this indicator, the OIG’s case review and compliance review process yielded different results with the compliance testing resulting in an inadequate score, and the case review resulting in an adequate rating. The compliance deficiencies did not have negative effects on patient care, and the compliance score was nearly adequate. The OIG’s internal review process considered all aspects of information management and its accessibility to medical personnel and concluded the overall indicator rating was adequate. During the OIG’s testing period, NKSP had not converted to the new Electronic Health Record System (EHRS); therefore, all testing occurred in the electronic Unit Health Record (eUHR) system. Case Review Results The OIG clinicians reviewed 1,273 events and found 52 deficiencies related to health information management, 6 of which were significant. Significant deficiencies were identified twice each in cases 9, 23, and 53. The OIG clinicians rated this indicator adequate. Inter-Departmental Transmission NKSP performed well in inter-departmental transmission. There were no deficiencies identified. Hospital Records NKSP did well with retrieving emergency department and hospitalization reports. The OIG reviewed 27 outside ED and community hospital events. There were no deficiencies identified. Specialty Services The OIG clinicians reviewed 104 specialty appointments and procedures. There were 16 deficiencies, 3 of which were severe: one in case 23 and two in case 9. The deficiencies involved North Kern State Prison, Cycle 5 Medical Inspection Page 21 Office of the Inspector General State of California missing specialty reports in the electronic health record. Performance in this area is also discussed in the Specialty Services indicator.  In case 9, NKSP failed to obtain the oncologist’s and radiation oncologist’s reports. This prevented an accurate assessment of the patient’s health when primary care providers managed the patient. Diagnostic Reports NKSP performed adequately with diagnostic reports. Performance in this area is further discussed in the Diagnostic Services indicator. Urgent/Emergent Records NKSP performed adequately with urgent or emergent records. There were only occasional mislabeled and duplicate documents. Scanning Performance NKSP did not do well with scanning performance. They had mislabeled, misfiled, or duplicated documents in 48 events. Some reports were missing, some were not scanned with the date of service, and some were mislabeled as other documents, as illustrated by the following examples:  In case 9, a radiation oncology report was never scanned and, therefore, was missing from the electronic medical record.  In case 53, another patient’s health care transfer document was erroneously scanned into this patient’s electronic medical record. Legibility Legibility of progress notes was generally not an issue; however, inspectors did find illegible provider signatures in some cases. Clinician Onsite Inspection The OIG clinicians observed clinical information distribution during the daily provider huddles; laboratory and radiology reports, discharge paperwork, and overnight events were disseminated to the appropriate primary care providers. Signed-off reports were then submitted to support staff to send to the medical record unit for scanning. Each yard then had its own morning huddle in which each primary care team discussed its patients. Clinicians followed a standardized huddle guide to ensure important changes to the assigned patients were reviewed. This included discussion of high-risk patients recently transferred into the institution, and patients with potentially unstable medical conditions. North Kern State Prison, Cycle 5 Medical Inspection Page 22 Office of the Inspector General State of California The OIG discussed the missing outside specialty reports with medical records staff, and they explained that some of the reports were not scanned into the electronic medical records, and some other reports were not obtained from the offsite specialist by specialty services. Case Review Conclusion NKSP did well with the retrieval of outside ED reports and hospital discharge summaries. Scanning time frames were acceptable, but scanning accuracy was poor. Missing, misfiled, or mislabeled documents were common in some cases. NKSP had difficulty obtaining outside specialty reports and scanning them into the electronic medical record. The institution followed the OIG’s recommendations made in Cycle 4 and improved legibility by having providers type or dictate their progress notes and time-stamp reports from offsite visits. The retrieval of outside ED reports and hospital discharge summaries improved in comparison to the last cycle. However, there was an ongoing issue with mislabeled and misfiled records. There was also difficulty obtaining outside specialty reports. NKSP improved in this cycle with regard to Health Information Management, and the indicator rating was adequate. Compliance Testing Results With a compliance score of 74.1 percent, NKSP performed in the inadequate range in the Health Information Management indicator. The following tests showed areas for improvement:  The institution scored zero in its labeling and filing of documents scanned into patients’ electronic medical records. Sixteen scanning errors were mislabeled and misfiled documents. There were also four missing records and four records filed under the wrong date. For this test, once the OIG identifies 24 mislabeled or misfiled documents, the maximum points are lost and the resulting score is zero (MIT 4.006).  The institution timely scanned five of ten applicable sampled non-dictated progress notes into the electronic medical record (50 percent). Five forms were each scanned between one and eight days late (MIT 4.001).  NKSP staff scanned 13 of 19 applicable specialty service consultant reports into the patient’s health record file within five calendar days (68 percent). Six documents were scanned between 3 and 30 days late (MIT 4.003). The institution did earn proficient scores in four tests in this indicator:  NKSP timely scanned all 20 sampled dictated or transcribed provider progress notes into patients’ electronic medical record files within five days of the PCP visit with the patient (MIT 4.002). North Kern State Prison, Cycle 5 Medical Inspection Page 23 Office of the Inspector General State of California  The OIG tested 20 patients’ discharge records to determine if staff timely scanned the records into each patient’s electronic medical record. All 20 samples were timely scanned (MIT 4.004).  NKSP timely scanned all 18 sampled medication administration records into patients’ electronic medical records (MIT 4.005).  Inspectors reviewed electronic medical record files for 25 patients who were admitted to a community hospital and then returned to NKSP; providers reviewed all the hospital discharge reports within three calendar days of discharge (MIT 4.007). North Kern State Prison, Cycle 5 Medical Inspection Page 24 Office of the Inspector General State of California 5 — HEALTH CARE ENVIRONMENT This indicator addresses the general operational aspects of the Case Review Rating: institution’s clinics, including certain elements of infection control Not Applicable and sanitation, medical supplies and equipment management, the Compliance Score: availability of both auditory and visual privacy for patient visits, Adequate (80.7%) and the sufficiency of facility infrastructure to conduct comprehensive medical examinations. Rating of this component is Overall Rating: based entirely on the compliance testing results from the visual Adequate observations inspectors make at the institution during their onsite visit. This indicator is evaluated entirely by compliance testing and does not include a case review portion. Compliance Testing Results The institution received an adequate compliance score of 80.7 percent in the Health Care Environment indicator, with proficient scores in six tests, as follows:  Inspectors examined NKSP’s 11 clinics to verify that adequate hygiene supplies were available and sinks were operable; all clinics were compliant (MIT 5.103).  The non-clinic bulk medical supply storage areas met the supply management process and support needs of the medical health care program, earning NKSP a score of 100 percent on this test (MIT 5.106).  All 11 clinics followed adequate protocols for managing and storing bulk medical supplies (MIT 5.107).  Clinical health care staff at 10 of 11 applicable clinics ensured that reusable invasive and non-invasive medical equipment was properly sterilized or disinfected (91 percent). In one clinic, inspectors observed staff fail to replace exam table paper between patient encounters (MIT 5.102).  When inspecting for proper protocols to mitigate exposure to blood-borne pathogens and contaminated waste, OIG inspectors found 10 of the 11 clinics (91 percent) compliant. In one clinic, an exam room did not have a puncture-resistant container for expended needles and sharps (MIT 5.105). North Kern State Prison, Cycle 5 Medical Inspection Page 25 Office of the Inspector General State of California  Inspectors examined emergency response bags to determine if institution staff inspected the bags daily and inventoried them monthly, and whether the bags contained all essential items. Emergency response bags were compliant at seven of the eight applicable clinical locations (88 percent). At one location, the portable oxygen tank was less than fully charged (MIT 5.111).  Among the 11 clinics examined, 9 (82 percent) were appropriately disinfected, cleaned, and sanitized; in two clinics, cleaning logs were not maintained (MIT 5.101).  Only 5 of 11 clinic exam rooms observed (46 percent) had appropriate space, configuration, supplies, and equipment to allow clinicians to perform a proper clinical examination. The remaining six clinics had one or more of the following deficiencies: exam rooms lacked portable screens for visual privacy; and furniture was in disrepair with torn vinyl covers on exam tables (Figure 1); exam rooms did not have space adequate to perform patient examinations. Typically, exam rooms Figure 1: Torn vinyl on exam table. should measure at least 100 square feet in area; four exam rooms throughout the institution measured from 46 to 94 square feet (Figure 2) (MIT 5.110).  Only 6 of 11 clinic locations (55 percent) met compliance requirements for essential core medical equipment and supplies. The remaining five clinics were missing one or more functional pieces of properly calibrated core equipment or other medical supplies necessary to conduct a comprehensive exam, including an exam table, a nebulization unit, a peak flow meter with disposable tips, and tongue depressors. In addition, a nebulization unit was missing a calibration sticker (MIT 5.108). Figure 2: Clinic Exam room in Facility D  Clinic common areas at 7 of 11 clinics measuring 46 square feet in area. (64 percent) had an environment conducive North Kern State Prison, Cycle 5 Medical Inspection Page 26 Office of the Inspector General State of California to providing medical services. The location of vital signs stations in four clinics compromised patients’ auditory privacy (MIT 5.109).  OIG inspectors observed clinician encounters with patients in 11 clinics. Clinicians followed good hand hygiene practices in eight clinics (73 percent). At three clinic locations, clinicians failed to wash their hands after patient contact (MIT 5.104). Non-Scored Results  The OIG gathered information to determine if the institution’s physical infrastructure was maintained in a manner that supported health care management’s ability to provide timely or adequate health care. The OIG did not score this question. When OIG inspectors interviewed health care managers, they did not identify any significant concerns. At the time of the OIG’s medical inspection, NKSP had several significant infrastructure projects underway, which included increasing clinic space at four yards, expanding medication distribution areas, and remodeling the TTA. These projects started in the fall of 2013, and the institution estimated that they would be completed by the end of fall 2017 (MIT 5.999). North Kern State Prison, Cycle 5 Medical Inspection Page 27 Office of the Inspector General State of California 6 — INTER- AND INTRA-SYSTEM TRANSFERS This indicator focuses on the management of patients’ medical Case Review Rating: needs and continuity of patient care during the inter- and Adequate intra-system transfer process. The patients reviewed for this Compliance Score: indicator include those received from, as well as those transferring Proficient (91.7%) out to, other CDCR institutions. The OIG review includes evaluation of the institution’s ability to provide and document Overall Rating: health screening assessments, initiation of relevant referrals based Adequate on patient needs, and the continuity of medication delivery to patients arriving from other institutions. For those patients, the OIG clinicians also review the timely completion of pending appointments, tests, and requests for specialty services. For patients who transfer out of the institution, the OIG evaluates the ability of the institution to document transfer information that includes pre-existing health conditions, pending appointments, tests and requests for specialty services, medication transfer packages, and medication administration prior to transfer. The OIG clinicians also evaluate the care provided to patients returning to the institution from outside hospitals and check to ensure appropriate implementation of hospital assessments and treatment plans. In this indicator, the OIG’s case review and compliance review processes yielded different results, with the case review giving an adequate rating and the compliance review resulting in a proficient score. The OIG’s internal review process considered those factors that led to both scores and ultimately rated this indicator adequate. Case review revealed some lengthy delays in referrals for medical and mental health evaluations and breaks in continuity of medication administration for patients transferring into NKSP. Case Review Results The OIG clinicians reviewed 67 inter- and intra-system transfer events, including information from both the sending and receiving institutions. These included 38 hospitalization and outside emergency room events, each of which resulted in a transfer back to the institution. There were 16 deficiencies, 6 of which were significant. Significant deficiencies occurred once each in cases 20 and 23 and twice each in cases 26 and 27. The OIG rated this indicator adequate. Transfers In The transfer-in process was poor. NKSP did not properly maintain medication continuity for patients that transferred into the institution without their prescribed medications. Nursing staff in the receiving area did not temporarily administer patients’ current medication doses from available stock medication in the Omnicell unit (automated dispensing cabinet), and newly arrived patients missed their medication doses until the pharmacy was able to dispense the medications. Additionally, the transfer-in appointment referrals did not always occur timely. North Kern State Prison, Cycle 5 Medical Inspection Page 28 Office of the Inspector General State of California  In case 26, the patient’s medications did not arrive with him, and the nurse did not administer the patient’s evening diabetes medication. Additionally, the nurse referred the newly arrived patient to the medical provider for an evaluation within 14 days and to the mental health provider for an evaluation within five days, but both appointments occurred six weeks later.  In case 27, the patient’s medications did not arrive with him, and the nurses did not administer the patient’s blood pressure medication for two days. Additionally, the nurse referred the newly arrived patient to the medical provider for an evaluation within seven days, but the appointment occurred one month later. Transfers Out The transfer out process at NKSP was generally acceptable. However, there was one significant deficiency:  In case 23, the health care transfer form from a different patient had been scanned into the transferring out patient’s electronic medical record. This placed the patient at risk of harm because the receiving institution did not receive his correct medical information. Hospitalizations Patients returning from hospitalizations are some of the highest-risk encounters due to two factors. First, these patients are generally hospitalized for a severe illness or injury. Second, they are at risk due to potential lapses in care that can occur during any transfer.  In case 20, the nurses did not administer the patient’s full course of antibiotics. The patient received only two of seven doses. This was a critical lapse in medication continuity that contributed to the patient’s second hospitalization for an infection of his urinary tract. After the second hospital discharge, the hospital recommended additional antibiotics to continue upon discharge. However, the nurse did not administer the antibiotic until two days later. This was a critical delay for a patient who had multiple admissions to the hospital for infections of his urinary tract. This case is also discussed in the Pharmacy and Medication Management indicator. Hospital discharge summaries were timely received, reviewed by a provider, and scanned into the electronic medical record, as discussed in the Health Information Management indicator. The primary care providers followed up with patients in a timely manner. Clinician Onsite Inspection The OIG clinicians discussed transfer deficiencies with medical management, and there was agreement that NKSP needed to implement improvement strategies to ensure better medication continuity. North Kern State Prison, Cycle 5 Medical Inspection Page 29 Office of the Inspector General State of California Case Review Conclusion The clinicians rated the Inter- and Intra-System Transfers indicator NKSP adequate, the same rating as in Cycle 4. As in Cycle 4, the nurses failed to provide some medications when patients arrived at NKSP. Compliance Testing Results The institution obtained a proficient compliance score of 91.7 percent in the Inter- and Intra-System Transfers indicator, with scores of 100 percent on three tests, as follows:  For all 23 of the applicable sampled patients who transferred into NKSP, nursing staff timely completed the assessment and disposition sections of the Initial Health Screening form (CDCR Form 7277) on the same day that they performed the patient’s initial health screening (MIT 6.002).  Inspectors sampled 20 patients who transferred from NKSP to other CDCR institutions to determine whether nurses identified scheduled specialty service appointments on the patients’ health care transfer forms. Nursing staff correctly listed the pending specialty service appointments for all 20 patients (MIT 6.004).  The OIG inspected the transfer packages of ten patients who were transferring out of the institution to determine whether the packages included required medications and support documentation. All ten transfer packages were compliant (MIT 6.101). Two tests earned adequate scores:  The OIG tested 25 patients who transferred into NKSP from other CDCR institutions to determine whether they received a complete initial health screening assessment from nursing staff on their day of arrival. Nursing staff timely and properly prepared the screening forms for 20 of the 25 sampled patients (80 percent). For one patient, a complete set of vital signs was not documented; for three patients, answers were not provided to one or more of the screening questions; and for one final patient, there was no evidence of an initial health screening found in the electronic medical record (MIT 6.001).  Inspectors sampled 14 applicable patients who transferred into NKSP with an existing medication order that required nursing staff to issue or administer medications upon arrival; 11 patients (79 percent) received their medications timely. Three patients incurred medication interruptions of one or more dosing periods (MIT 6.003). North Kern State Prison, Cycle 5 Medical Inspection Page 30 Office of the Inspector General State of California 7 — PHARMACY AND MEDICATION MANAGEMENT This indicator is an evaluation of the institution’s ability to provide Case Review Rating: appropriate pharmaceutical administration and security Inadequate management, encompassing the process from the written Compliance Score: prescription to the administration of the medication. By combining Adequate (79.1%) both a quantitative compliance test with case review analysis, this assessment identifies issues in various stages of the medication Overall Rating: management process, including ordering and prescribing, Inadequate transcribing and verifying, dispensing and delivering, administering, and documenting and reporting. Because effective medication management is affected by numerous entities across various departments, this assessment considers internal review and approval processes, pharmacy, nursing, health information systems, custody processes, and actions taken by the prescriber, staff, and patient. In this indicator, the OIG’s case review and compliance review process yielded different results with the compliance review giving an adequate rating, and the case review resulting in an inadequate score. The OIG’s internal review process considered the factors that led to both scores and ultimately rated this indicator inadequate because the deficiencies identified during the case review directly led to several preventable hospitalizations. Case Review Results The OIG clinicians evaluate the pharmacy and medication management as secondary processes as they relate to the quality of clinical care provided. Compliance testing is a more targeted approach and is generally relied on for the overall rating of this indicator. Despite this, the deficiencies identified by case review strongly affected the overall indicator rating. The OIG clinicians evaluated 85 events related to medications and found 32 deficiencies, 11 of which were significant (once each in cases 18, 19, 26, 27, 32, 33, and 52, and four times in case 20).The OIG clinicians rated this indicator inadequate. Medication Continuity NKSP maintained medication continuity in the majority of transfer and reception cases reviewed, but there were several severe deficiencies. When patients transferred into the institution without their medications, the patient rarely got their evening medications.  In case 18, the provider ordered acetaminophen to start on the same day as it was ordered, but the patient did not receive it until six days later.  In case 19, the nurse stopped administering the patient’s furosemide (diuretic) morning dose without a discontinue order. The provider was unaware the medication had been discontinued. North Kern State Prison, Cycle 5 Medical Inspection Page 31 Office of the Inspector General State of California  In case 26, the patient arrived from another CDCR institution without his glipizide (diabetes medication), and the nurse failed to administer it the evening that he arrived.  In case 27, the patient arrived from another CDCR institution with no medication, and the nurses failed to administer his lisinopril (blood pressure medication) until two days later.  In case 32, the patient arrived from another CDCR institution without his medications, and the nurse failed to administer the evening doses of ten different medications consisting of those for hypertension, seizure control, glaucoma, and high cholesterol.  In case 33, the patient had a topical steroid prescribed and dispensed by the pharmacy, but there was no evidence the patient received it. Medication Administration Case reviews revealed several severe deficiencies in medication administration, the most severe of which involved incomplete administration of antibiotics on two separate occasions for the same patient. This led to worsening infection and the patient requiring hospitalization several times. More medication administration deficiencies are discussed in Quality of Nursing Performance indicator.  In case 20, the nurse failed to administer the patient’s antibiotics for five days of the seven-day course. This was a critical break in medication continuity that led to the patient’s second hospitalization for urinary tract infection. On another occasion, the patient was prescribed antibiotics upon returning from the hospital, but the nurse failed to administer the medication until two days later. The nurse also failed to document the patient’s blood sugar and insulin administration on one day. Finally in this case, the nurse failed to administer the patient’s evening medications of sulfamethoxazole & trimethoprim (antibiotic), amitriptyline (nerve pain medication), and ferrous sulfate (iron deficiency anemia medication).  In case 52, the nurse administered propranolol (blood pressure medication) against orders to hold (not give) the medication if the patient’s blood pressure or heart dropped below certain thresholds. The nurse also did not administer spironolactone (diuretic) for one dose. Pharmacy Errors Pharmacy documents typically reside in a different record system with only limited information present in the electronic medical record. The NKSP pharmacy generally processed and dispensed medication orders without problems. Case reviews did not reveal any deficiencies regarding the pharmacy. North Kern State Prison, Cycle 5 Medical Inspection Page 32 Office of the Inspector General State of California Clinician Onsite Inspection The OIG clinicians met with nursing and pharmacy staff to discuss the cases reviewed regarding patients arriving at the institution without their medications and nurse staff that failed to administer stock medications from the Omnicell to patients. The NSKP clinical administrators agreed that strategies would be implemented to ensure that nursing staff temporarily administered medications to transferred new arrivals until the pharmacy dispensed the medication. Case Review Conclusion While NKSP performed better in comparison with Cycle 4 in the Pharmacy and Medication Management indicator, the institution continued to have issues with medication continuity such as missed antibiotics doses that increased the risk of harm to patients, which resulted in poor outcomes for patients. The severity and number of these deficiencies contributed to the inadequate rating for this indicator. Compliance Testing Results The institution received an adequate compliance score of 79.1 percent in the Pharmacy and Medication Management indicator. For discussion purposes below, this indicator is divided into three sub-indicators: medication administration, observed medication practices and storage controls, and pharmacy protocols. Medication Administration In this sub-indicator, the institution received an inadequate average score of 63.3 percent, with areas needing improvement displayed by the following tests:  Nursing staff administered medications without interruption to only two of ten patients who were en route from one institution to another and had a temporary layover at NKSP (20 percent). For eight patients, there was no electronic medical record evidence that ordered medications were administered as ordered (MIT 7.006).  NKSP timely provided ordered hospital discharge medications to 13 of 24 applicable patients sampled (54 percent). For ten patients, nursing staff failed to administer between one and six doses of hospital discharge medications. One final patient missed 17 doses of a discharge medication (MIT 7.003).  Inspectors reviewed files of seven applicable sampled patients who recently arrived at NKSP from a county jail for whom a NKSP provider had ordered medications upon their arrival. Inspectors found that only four of those patients (57 percent) received their ordered medications within required time frames. For three patients, the medications were late by either one day or by one dosage interval (MIT 7.004). North Kern State Prison, Cycle 5 Medical Inspection Page 33 Office of the Inspector General State of California  Among 19 applicable sampled patients, 13 (68 percent) timely received ordered chronic care medications. For four patients, no evidence of medication delivery was found for one or more dosage intervals; for one patient, there were medication dosages refused with no evidence of required refusal forms; and for one final patient, there was an ordered keep-on-person (KOP) medication that was not timely made available (MIT 7.001). One test in this sub-indicator earned an adequate score:  Twenty of the 25 sampled patients (80 percent) at NKSP who had transferred from one housing unit to another received their prescribed medications without interruption. Five patients did not receive one or more doses of their medications at the next dosing interval after the transfer occurred (MIT 7.005). Lastly, NKSP earned a proficient score on one test in this sub-indicator:  Inspectors found that all 25 patients sampled received their newly ordered medications in a timely manner (MIT 7.002). Observed Medication Practices and Storage Controls In this sub-indicator, the institution received an adequate score of 78.0 percent. Two tests earned scores in the proficient range:  At all seven of the inspected medication line locations, nursing staff were compliant with proper hand hygiene protocols (MIT 7.104).  NKSP nursing staff at six of the seven sampled locations (86 percent) employed appropriate administrative controls and protocols when preparing patients’ medications. At one medication line location, medications were found not stored in their original labeled packaging (MIT 7.105). The institution scored in the adequate range on one test in this sub-indicator:  Non-narcotic refrigerated medications were properly stored in seven of nine clinics and medication line storage locations (78 percent). In two locations, one or more of the following deficiencies were observed: the medication area lacked a designated area for return-to-pharmacy medications; previously opened multi-dose medication was missing an opened date label; and the medication room and refrigerator were found unlocked at the time of the inspection (MIT 7.103). North Kern State Prison, Cycle 5 Medical Inspection Page 34 Office of the Inspector General State of California Three tests in this sub-indicator showed areas for needed improvement with inadequate scores:  The institution employed adequate security controls over narcotic medications in six of the nine applicable clinic and medication line locations where narcotics were stored (67 percent). At three clinics, the narcotics log book lacked evidence on multiple dates that a controlled substance inventory was performed by two licensed nursing staff (MIT 7.101).  NKSP properly stored non-narcotic medications not requiring refrigeration in six of the nine applicable clinic and medication line storage locations (67 percent). In three locations, one or more of the following deficiencies were observed: the medication area lacked a designated area for return-to-pharmacy medications, and external and internal medications were not properly separated when stored (MIT 7.102).  Five of the seven inspected medication preparation and administration areas demonstrated appropriate administrative controls and protocols (71 percent). At two medication line locations, patients waiting to receive their medications did not have sufficient outdoor cover to protect them from heat or Figure 3: Facility A clinic medication inclement weather (Figure 3) (MIT 7.106). line area providing no shade or protection from inclement weather. Pharmacy Protocols In this sub-indicator, the institution received a proficient average score of 99.2 percent, comprised of scores received at the institution’s main pharmacy. Every test in this indicator earned a proficient score, as follows:  In its main pharmacy, the institution followed general security, organization, and cleanliness management protocols; properly stored and monitored non-narcotic medications that required refrigeration and those that did not; and maintained adequate controls over and properly accounted for narcotic medications (MIT 7.107, 7.108, 7.109, 7.110).  The institution’s pharmacist in charge (PIC) followed required protocols for 24 of the 25 medication error reports and monthly statistical reports reviewed (96 percent). One monthly medication error statistic report was submitted to the chief of pharmacy services six days late (MIT 7.111). North Kern State Prison, Cycle 5 Medical Inspection Page 35 Office of the Inspector General State of California Non-Scored Tests  In addition to the OIG’s testing of reported medication errors, inspectors follow up on any significant medication errors found during compliance testing to determine whether the errors were properly identified and reported. The OIG provides those results for information purposes only. At NKSP, the OIG did not find any applicable medication errors (MIT 7.998).  The OIG interviewed patients in isolation units to determine if they had immediate access to their prescribed KOP rescue inhalers or nitroglycerin medications. All ten of the sampled patients had access to their rescue medications (MIT 7.999). North Kern State Prison, Cycle 5 Medical Inspection Page 36 Office of the Inspector General State of California 8 — PRENATAL AND POST-DELIVERY SERVICES This indicator evaluates the institution’s capacity to provide timely Case Review Rating: and appropriate prenatal, delivery, and postnatal services to Not Applicable pregnant patients. This includes the ordering and monitoring of Compliance Score: indicated screening tests, follow-up visits, referrals to higher levels Not Applicable of care, e.g., high-risk obstetrics clinic, when necessary, and Overall Rating: postnatal follow-up. Not Applicable As NKSP is a male-only institution, this indicator did not apply. North Kern State Prison, Cycle 5 Medical Inspection Page 37 Office of the Inspector General State of California 9 — PREVENTIVE SERVICES This indicator assesses whether various preventive medical services Case Review Rating: are offered or provided to patients. These include cancer Not Applicable screenings, tuberculosis (TB) screenings, and influenza and chronic Compliance Score: care immunizations. This indicator also assesses whether certain Adequate institutions take preventive actions to relocate patients identified as (79.1%) being at higher risk for contracting coccidioidomycosis Overall Rating: (valley fever). Adequate The OIG rates this indicator entirely through the compliance testing component; the case review process does not include a separate qualitative analysis for this indicator. Compliance Testing Results The institution performed in the adequate range in the Preventive Services indicator, with a compliance score of 79.1 percent. Four tests earned proficient scores:  All 25 sampled patients timely received or were offered influenza vaccinations during the most recent influenza season (MIT 9.004).  The OIG tested 20 patients at high risk for contracting coccidioidomycosis (valley fever), identified as medically restricted and ineligible to reside at NKSP, to determine if they were transferred out of the institution within 60 days from the time they were deemed ineligible. Inspectors found that NKSP timely transferred all 20 patients (MIT 9.009).  NKSP scored 97 percent for the required annual screening of patients for TB; 29 of the 30 sampled patients were properly screened. For one patient, the TB screening form was incomplete (MIT 9.003).  NKSP timely offered colorectal cancer screenings to 23 of 25 sampled patients subject to the annual screening requirement (92 percent). For one patient, the most recent fecal occult blood test had been completed more than 12 months prior to the date of OIG testing. For one other patient, there was no medical record evidence either that health care staff offered a colorectal cancer screening within the previous 12 months or that the patient had a normal colonoscopy within the last ten years (MIT 9.005). One test earned an adequate compliance score:  NKSP timely administered TB medications to 21 of 25 patients (84 percent). One patient’s medication was not initiated on the date ordered, resulting in one missed dosage. For three other patients, there were dosages missed for which the patients did not receive provider counseling as required by CCHCS policy (MIT 9.001). North Kern State Prison, Cycle 5 Medical Inspection Page 38 Office of the Inspector General State of California The institution showed room for improvement in two areas, with inadequate scores, as follows:  The OIG tested whether NKSP offered required influenza, pneumonia, and hepatitis vaccinations to patients who suffered from chronic conditions; 11 of the 15 applicable patients sampled (73 percent) received them. For four patients, there was no evidence found that they were either administered or offered one or more required vaccinations (MIT 9.008).  The institution scored poorly for monitoring of patients on TB medications, with only 2 of 25 patients that received proper TB monitoring (8 percent). For 23 patients sampled, the institution either failed to complete monitoring at all required intervals or failed to scan the monitoring form into the patient’s medical record in a timely manner (MIT 9.002). North Kern State Prison, Cycle 5 Medical Inspection Page 39 Office of the Inspector General State of California 10 — QUALITY OF NURSING PERFORMANCE The Quality of Nursing Performance indicator is a qualitative Case Review Rating: evaluation of the institution’s nursing services. The evaluation is Adequate completed entirely by OIG nursing clinicians within the case review Compliance Score: process, and does not have a score under the OIG compliance Not Applicable testing component. Case reviews include face-to-face encounters Overall Rating: and indirect activities performed by nursing staff on behalf of the Adequate patient. Review of nursing performance includes all nursing services performed on site, such outpatient, inpatient, urgent/emergent, patient transfers, care coordination, and medication management. The key focus areas for evaluation of nursing care include appropriateness and timeliness of patient triage and assessment, identification and prioritization of health care needs, use of the nursing process to implement interventions, and accurate, thorough, and legible documentation. Although nursing services provided in the OHU, CTC, or other inpatient units are reported in the Specialized Medical Housing indicator and nursing services provided in the TTA or related to emergency medical responses are reported in the Emergency Services indicator, all areas of nursing services are summarized in this Quality of Nursing Performance indicator. Case Review Results The OIG clinicians reviewed 193 nursing encounters, of which 79 were outpatient nursing encounters. Most outpatient nursing encounters were for sick call requests, walk-in visits, and RN follow-up visits. In all, there were 82 deficiencies identified related to nursing care performance, 11 of which were significant. One significant deficiency occurred in each of seven cases (cases 18, 20, 26, 40, 41, 46, and 53), and two significant deficiencies occurred in each of two cases (cases 21 and 42). The OIG clinicians rated this indicator adequate. Nursing Assessment Adequate nursing care involves the quality of nursing assessments, which includes both subjective (patient interview) and objective (evaluation and observation) components. The majority of nurses at NKSP included both subjective and objective nursing assessments when assessing patients. However, a review of cases demonstrated areas to target for staff education and other quality improvement strategies, as illustrated by the following significant deficiencies:  In case 18, the nurse failed to assess a patient who submitted a second complaint of left ear hearing loss and instead referred him to the provider. The nurse should have examined the patient’s ear. Additionally, the appointment with the provider did not occur.  In case 46, the nurse did not assess a patient with continuing ankle pain. Nurses are required to assess all patients who submit health care requests for physical complaints or symptoms. North Kern State Prison, Cycle 5 Medical Inspection Page 40 Office of the Inspector General State of California Nursing Interventions Nurses generally provided appropriate and timely nursing interventions. However, in some of the cases reviewed, the nurses did not timely implement interventions, and some interventions ordered by a provider were not implemented at all:  In case 26, the provider ordered daily blood pressure and blood sugar checks. The first blood pressure check occurred four days after the provider wrote the order, and the nurses did not implement the blood sugar checks for one week.  In case 40, the nurses failed to perform daily wound care as ordered for a patient with skin abscesses. Nursing Documentation Nursing documentation was sufficient. Complete and accurate nursing documentation is an essential component of patient care. Without proper documentation, changes in patient health are often missed or delayed, and health care staff have challenges in assessing the ongoing status of a patient’s condition. Nursing Sick Call The sick call process at NKSP was not always triaged timely, and interventions were not always appropriate. The following deficiencies show areas to target for quality improvement strategies:  In case 41, the sick call nurse did not make an urgent provider referral for a patient with recent onset of multiple genital lesions indicating potential sexually transmitted infection. The appointment with the provider did not occur until two months after the nurse assessed the patient’s lesions.  In case 42, the sick call nurse allowed a patient with severe chest pain and an elevated blood pressure to walk to the TTA for a higher level of care. The potentially unstable patient should have been transported on a gurney. Urgent/Emergent Nurses in the TTA and first medical responders provided appropriate care to patients during emergency medical responses. Deficiencies identified in this area are discussed in the Emergency Services indicator. Care Management Care managers generally provided sufficient care to the patients. The role of the care manager included assessing patients, initiating appropriate interventions to support goals with patients’ treatment plans, and monitoring patients with chronic health needs and those at increased risk for North Kern State Prison, Cycle 5 Medical Inspection Page 41 Office of the Inspector General State of California developing serious health complications. In most cases reviewed, care managers provided timely monitoring and follow-up for their patients. After Hospital Returns Patients returning to NKSP after hospital discharges were appropriately assessed by the TTA nurse and received relevant follow-up care as needed. This is further discussed in the Inter- and Intra-System Transfers indicator. Specialized Medical Housing Nurses in the CTC provided timely and appropriate nursing care services. The majority of nurses routinely assessed patients periodically throughout their shifts and documented patient-specific interventions. One significant CTC nursing deficiency occurred in case 53, which is discussed in the Specialized Medical Housing indicator. Inter- and Intra-System Transfers Nurses provided sufficient nursing care for transferring patients. Nurses utilized translators as needed for incoming patients and documented pertinent patient information for inmates transferring out of NKSP. This is further discussed in the Inter- and Intra-System Transfers indicator. Reception Center The reception center patients who transferred into NKSP received poor continuity of health care services. For example, nurses failed to administer medications from stock supplies to patients who arrived at NKSP without their medications, and they read TB skin test results before the required 48-to-72-hour time frame established by the Centers for Disease Control and Prevention. A significant nursing deficiency regarding a reception center patient occurred in case 20, in which the nurse did not notify the provider about the kidney tube removal scheduled on the same day as the patient’s arrival at NKSP, which is further discussed in the Reception Center Arrivals indicator. Offsite Specialty Services Returns Patients returning from offsite specialty appointments were assessed by nurses upon their return to NKSP. Follow-up recommendations from specialty consultants were communicated to the provider without delays. One significant deficiency occurred in case 21, in which nurses did not implement orders to administer blood pressure medications and recheck the patient’s blood pressure prior to a cardiology consultation, which is discussed in the Specialty Services indicator. Clinician Onsite Inspection The OIG clinicians visited several clinical areas and spoke with the acting chief nurse executive, supervising registered nurses, and various nursing staff, including nurses in the reception center, outpatient clinics, specialty services, telemedicine, medication lines, TTA, and CTC. The huddles were well organized and attended by various members of the multidisciplinary team. The majority North Kern State Prison, Cycle 5 Medical Inspection Page 42 Office of the Inspector General State of California of the nurses stated that morale was good and that nursing supervisors and managers were receptive and approachable. Case Review Conclusion Nurses provided appropriate nursing care services to NKSP patients. All nursing staff members interviewed were very familiar with their patient populations, responsibilities, and duties. Nursing areas were well staffed. The Quality of Nursing Performance indicator at NKSP was adequate. North Kern State Prison, Cycle 5 Medical Inspection Page 43 Office of the Inspector General State of California 11 — QUALITY OF PROVIDER PERFORMANCE In this indicator, the OIG physicians provide a qualitative Case Review Rating: evaluation of the adequacy of provider care at the institution. Inadequate Appropriate evaluation, diagnosis, and management plans are Compliance Score: reviewed for programs including, but not limited to, nursing sick Not Applicable call, chronic care programs, TTA, specialized medical housing, and Overall Rating: specialty services. The assessment of provider care is performed Inadequate entirely by OIG physicians. There is no compliance testing component associated with this quality indicator. Case Review Results The OIG clinicians reviewed 284 medical provider encounters and identified 46 deficiencies related to provider performance, 27 of which were significant. The OIG clinicians rated this indicator inadequate. Assessment and Decision-Making Providers performed unsatisfactorily with assessments and decision-making because of either poor judgment or lack of attention to detail. Many follow-up appointments were requested with inappropriate time frames. For example, providers requested appointments in one to two months for diabetes medication adjustments when CCHCS guidelines suggest a few days. Cloned notes were used in a number of cases, which typically had old patient information with only changes to vital signs, and very little or no change to the physical exam or assessment and plan portion of the document. Because of cloned notes, providers often were not aware of changes in the patients’ health, which resulted in providers failing to make appropriate changes to the patients’ plan of care, or patients missing or not receiving critical medications.  In case 8, the patient had a chronic skin condition that was treated with topical steroids, but the provider ordered a one-time intramuscular injection of steroids. This was an inappropriate treatment for a chronic skin condition; furthermore, there was no treatment plan after this one-time dose.  In case 10, the patient had diabetes and other strong risk factors that predisposed him to a heart attack. The American Diabetes Association guidelines recommended a high-dose cholesterol medication to reduce the risk of a heart attack. While the provider noted that the patient was on the high-dose cholesterol medication, the patient, in fact, was not on such a dose. The provider was unaware that the patient was not at the recommended dose because of the use of cloned notes.  In case 13, the provider saw the patient for chronic neuropathy (nerve pain), but the provider did not address the underlying cause of his neuropathy. North Kern State Prison, Cycle 5 Medical Inspection Page 44 Office of the Inspector General State of California  In case 19, the patient requested an appointment to review his medications and of worsening nerve pain. The provider did not consider isoniazid (antibiotic for TB) as a potential cause for the patient’s nerve pain. The provider did not review medications appropriately to discover that the patient was already on a higher dose of the nerve medication than what the provider intended to order for the patient. He did not consider other possible causes for the patient’s nerve damage. In addition, the provider noted uncontrolled blood sugar levels, but did not change the patient’s medication to increase glucose control.  In case 23, the patient was receiving chemotherapy known to damage the kidneys if the patient was not properly hydrated. The provider noted dehydration and abnormal laboratory results, but failed to intervene timely. This delay resulted in a temporary loss of kidney function. Review of Records NKSP providers failed to recognize abnormal values in laboratory reports due to poor review, as illustrated by the following examples:  In case 9, the patient had blood work that indicated a severely inflamed liver, and the provider appropriately ordered a follow-up with the patient to further manage the problem. However, the same provider at the follow-up appointment failed to review the abnormal laboratory results or order further testing.  In case 11, the patient had a history of life-threatening blood clots in the lungs. The provider inappropriately requested a follow-up in one to two weeks after reviewing abnormal laboratory reports. The provider should have scheduled a more urgent follow-up.  In case 12, the provider reviewed a diabetes blood test that showed diabetes was out of control. The provider did not request an appointment to occur within two weeks. The patient was seen two months later.  In case 17, the specialist recommended laboratory tests to diagnose lung nodules. The provider did not realize that one of the tests was not ordered and a different test was ordered in its place. The provider did not reorder the appropriate test to help with the diagnosis. Emergency Care NKSP providers performed well in emergency care. In general, the providers triaged and appropriately managed patients during the urgent care process, with the following exception, which is further discussed in the Emergency Services indicator:  In case 20, the patient had a recent hospitalization for an infected kidney stone. He presented to the TTA with fever, fast heart rate, back pain, and nausea. An infection of the kidney should have been considered a possible cause, and a urine culture should have been ordered. North Kern State Prison, Cycle 5 Medical Inspection Page 45 Office of the Inspector General State of California The provider should have considered hospitalization and intravenous antibiotics. The provider sent the patient back to his housing unit with an oral antibiotic without ordering laboratory tests and follow-up appointment. The patient was sent to the hospital the next day after he saw a different provider. Chronic Care Out of 114 outpatient provider encounters, there were 33 deficiencies, 21 of which were significant. The deficiencies involved non-adherence to CCHCS guidelines of chronic conditions (high blood pressure, diabetes, and asthma), inattention to specialist recommendations, and superficial reviews of laboratory results and medications. One provider in the D Yard clinic was responsible for half of the significant deficiencies. However, because NKSP scheduled the provider an excessive caseload, the provider had to repeatedly triage patients that could not reasonably be seen. This led to multiple errors as well as dropped appointments.  In case 10, the patient had uncontrolled diabetes with associated complications. His blood tests showed that his diabetes was worsening. The provider made a miniscule adjustment in the insulin dosage and requested an inappropriately long follow-up, placing the patient at high risk for continued uncontrolled diabetes.  In case 12, the patient stated that his inhaler was not controlling his asthma. The provider reduced the dose and strength of the inhaler. The provider’s decision to lower the dose level of therapy when the patient was symptomatic was inappropriate. The provider should have determined if the patient was using the medication appropriately.  In case 13, the patient had diabetes with many elevated blood sugar tests. The provider reduced insulin in this patient without a face-to-face visit and without describing the thought process or informing the patient. Meanwhile, the patient was complaining of additional diabetic complications, but the provider did not address them.  In case 14, the provider failed to recheck the blood test that assessed the average blood sugar over the past three months in a patient with poorly controlled diabetes.  Also in case 14, the provider counseled the noncompliant patient and convinced him to restart his diabetes medications. As long as he was taking his medications, the patient’s diabetes was well controlled. Only a few days later, a blood test showed that the patient had not actually resumed his medications. The provider should have promptly ordered an appointment instead of waiting two to three months for the next scheduled appointment.  In case 16, the provider relied on a cloned note and repeated that the patient’s blood pressure was not under control. The provider documented an increase to the patient’s blood pressure medication, but failed to identify that he had already increased the patient’s dose of the medication several months before. The provider also documented the wrong insulin dose that the patient was on at the time. North Kern State Prison, Cycle 5 Medical Inspection Page 46 Office of the Inspector General State of California  In case 19, the provider documented conflicting information (weight decreased by 2 pounds and increased 3 pounds since the patient’s last visit), which made it unclear if the patient’s diuretic medication was at the appropriate dose.  Also in case 19, the provider did not recheck the patient’s severely elevated blood pressure before allowing the patient to leave the clinic. Specialty Services Providers generally referred patients appropriately, reviewed specialty reports timely, and followed specialty recommendations. This is discussed in the Specialty Services indicator. However, the following deficiencies occurred:  In case 17, the patient had several lung nodules and was seen by the pulmonologist (lung specialist). The specialist recommended obtaining blood tests to rule out several possible diagnoses and requested a follow-up in three months with a repeat imaging test to evaluate any changes to the lung nodules. However, the provider did not order a follow-up appointment with the specialist.  In case 23, the patient had chemotherapy that increased the risk of kidney injury if the patient were not well hydrated. The specialist recommended a slow increase of tube feeding (nutrition administration via a tube directly inserted into the stomach), but the provider ordered a low rate, did not make any adjustments, and did not ensure the patient took in enough fluids-- either by tube feeding or by intravenous line). This contributed to the patient’s decreasing kidney function. NKSP started an anticoagulation clinic (a specialty clinic headed by the chief physician and surgeon that standardized the monitoring, ordering, and administration of medications to prevent blood clotting) upon the OIG’s recommendations from the inspection in Cycle 4. This improved the anticoagulation care. There were two significant deficiencies pertaining to anticoagulation:  In case 9, the patient was on anticoagulation to reduce risk of recurrent stroke caused by a blood clot. Before the patient’s anticoagulation levels had reached a therapeutic range, the provider inappropriately stopped one of the blood thinners. The patient was seen weekly but did not achieve therapeutic levels. On a subsequent visit, the provider planned to order a laboratory test to determine if the provider needed to restart anticoagulants, but the provider did not order the test.  In case 11, a high-risk patient needed a blood-thinner due to a history of blood clots in his legs and lungs. The provider reviewed a laboratory result that showed the patient’s anticoagulation levels were low, but the provider failed to schedule an urgent appointment. When the patient was seen more than a month later, the provider did not intervene for the low anticoagulation level and requested an inappropriately lengthy follow-up. These errors North Kern State Prison, Cycle 5 Medical Inspection Page 47 Office of the Inspector General State of California placed the patient at significant risk of developing more blood clots or developing complications. Pharmacy and Medication Management On several occasions, NKSP providers failed to carefully check their patients’ exact medications as well as their dosages.  In case 19, the provider failed to carefully review the patient’s medications and, relying on cloned progress notes, did not see a previous encounter’s change when a diuretic medication had been removed from the patient’s medication list. This contributed to the patient requiring a visit to the emergency department to receive intravenous fluids.  In case 20, the patient had a severe infection of his kidneys, and the hospital recommended an additional seven days of antibiotic medications. When the patient returned to NKSP, he only received the first two days’ of antibiotics. The provider failed to carefully check on the patient’s medications, and was not aware of this the lapse in medication delivery, which contributed to the patient’s worsening kidney infection and a second hospitalization. Health Information Management NKSP providers generally documented outpatient and TTA encounters the same day. Notes were either dictated or typed. As a result, there were no illegible provider notes, which was an improvement in comparison to Cycle 4. This is further discussed in the Health Information Management indicator. Clinician Onsite Inspection As a reception center, NKSP processed patients from county jails and determined their security and health care needs prior to placing patients in appropriate housing. There were 11 medical provider positions approved at NKSP with two vacancies. The providers rotated through the different clinics, TTA, and CTC every six months. The providers worked ten hours per day, four days per week, and saw between 12 and 14 patients per day. Most providers expressed good morale despite having lost one provider to retirement and five other providers to other institutions, while having only gained four new, inexperienced providers. Some providers expressed low morale due to the loss of the providers. Discussions with leadership revealed that despite advertised vacancies, the institution was unable to interview any outside physicians. The institution had converted several of the physician and surgeon positions to mid-level positions to obtain the number of providers they had on staff at the time of the OIG’s inspection. North Kern State Prison, Cycle 5 Medical Inspection Page 48 Office of the Inspector General State of California Case Review Conclusion Of the 20 cases reviewed, 9 were rated inadequate. Since the Cycle 4 inspection, NKSP had implemented some changes that had marginally improved provider care. The creation of an anticoagulation clinic reduced the significant deficiencies related to treating and preventing clots. Regarding medication reconciliation, there were fewer deficiencies found in Cycle 5, but there was still significant room for improvement. There were no illegible documents, in contrast to the findings in Cycle 4. In Cycle 5, providers still had major problems with assessment and decision-making, and demonstrated worsened chronic care management since Cycle 4. The providers did not review medications and diagnostic reports adequately, which affected their decision-making abilities. The providers did not follow established CCHCS guidelines for diabetes management. Provider oversight errors resulted in several patients being lost to follow-up. After taking all factors into consideration, the OIG rated the Quality of Provider Performance indicator inadequate. North Kern State Prison, Cycle 5 Medical Inspection Page 49 Office of the Inspector General State of California 12 — RECEPTION CENTER ARRIVALS This indicator focuses on the management of medical needs and Case Review Rating: continuity of care for patients arriving from outside the CDCR Inadequate system. The OIG review includes evaluation of the ability of the Compliance Score: institution to provide and document initial health screenings, initial Inadequate health assessments, continuity of medications, and completion of (63.1%) required screening tests; address and provide significant Overall Rating: accommodations for disabilities and health care appliance needs; Inadequate and identify health care conditions needing treatment and monitoring. The patients reviewed for reception center cases are those received from non-CDCR facilities, such as county jails. Case Review Results The OIG clinicians reviewed 12 reception center arrivals and 68 events. There were 21 deficiencies, 12 of which were significant. Significant deficiencies were identified once each in cases 19, 24, 31, and 33, two times in cases 8 and 20, and four times in case 32. The OIG rated this indicator inadequate. Access to Care NKSP had problems with timely referral appointments to providers and obtaining initial baseline assessments for chronic conditions after patients arrived at the institution. The following cases are examples of significant delays or dropped provider appointments and incomplete initial assessments:  In case 8, the nurse informed the patient that he would follow up with the provider for his eczema in one week, but the appointment did not occur.  In case 19, the provider ordered three monthly follow-up visits for treatment of the patient’s latent TB infection and one chronic care follow-up in two to four weeks. The patient did not receive any of these four follow-up appointments with his provider.  In case 24, the initial history and physical occurred more than 75 days after the patient arrived at the reception center, instead of within 7 days per CCHCS policy. This was a severe delay for a patient with possible liver cancer.  In case 31, the provider ordered daily blood pressure checks for one week. The nurses initiated the daily blood pressure checks five days after the order was written, and checked the blood pressure only once during the one-week period.  In case 32, the provider ordered daily blood pressure and blood sugar checks for one week for a reception center patient with hypertension and diabetes. The patient’s blood pressure North Kern State Prison, Cycle 5 Medical Inspection Page 50 Office of the Inspector General State of California was checked once, but his blood sugar was never checked. Furthermore, the nurse care manager did not assess this patient with numerous chronic conditions within 30 days of the patient’s arrival at the institution. Medication Continuity NKSP staff did not adequately maintain medication continuity for reception center arrivals. For example, nursing staff did not administer medications that were due upon patients’ arrival at NKSP, even though the medications were available from the Omnicell. Patients repeatedly missed their medication doses until the pharmacy was able to dispense the medications. The following cases demonstrated breaks in medication continuity patients experienced upon arriving at NKSP:  In case 20, the patient’s medications did not arrive with him from the county jail. Nurses still should have obtained and administered his evening antibiotic and pain medications, but did not.  In case 32, the patient’s medications did not arrive with him from the county jail. The nurse did not administer his evening medications for his seizure disorder, diabetes, and hypertension.  In case 33, the provider ordered a steroid cream for a skin lesion for the patient, but the patient did not receive it. Two days later, the provider ordered the steroid cream again, and again, the patient did not receive it. Specialty Services Continuity The following case was an isolated incident, but it demonstrated a significant deficiency regarding the lack of nurse-to-provider notification for a patient arriving with a pending specialty appointment:  In case 20, the nurse did not notify the provider that the patient was scheduled to have his kidney drainage tube removed the same day he arrived. The provider was unaware of the scheduled procedure, and the patient did not have the drainage tube removed until five weeks later, which increased the patient’s risk of infection, bleeding, dislodgement, and damage to surrounding organs. Clinician Onsite Inspection The OIG clinicians discussed these reception center deficiencies with medical management, and there was agreement that NKSP needed to implement improvement strategies to ensure better medication continuity. North Kern State Prison, Cycle 5 Medical Inspection Page 51 Office of the Inspector General State of California Case Review Conclusion The Reception Center Arrivals indicator was rated inadequate primarily due to lapses in medication continuity and poor access to care. Patients did not receive their medications or needed specialty follow-up appointments timely. Compliance Testing Results The institution received an inadequate compliance score of 63.1 percent in the Reception Center Arrivals indicator. The following tests showed areas for needed improvement:  Inspectors sampled 20 reception center patients to ensure that they received timely and complete health screenings upon arriving at the institution. Nursing staff timely conducted the screenings, but all 20 were missing at least the required pain assessment; some screenings also lacked explanations for affirmative screening question answers. The institution scored zero on this test (MIT 12.001).  None of the 20 sampled reception center patients received all of the required intake tests; all 20 did not receive hepatitis C testing, for a score of zero (MIT 12.005).  Among 20 sampled patients who arrived at NKSP from county jails, nurses referred ten to see a provider. Of the ten referred patients, six patients were timely seen (60 percent). One patient was seen one day late; three other patients were seen from 13 to 25 days late (MIT 12.003). The institution scored in the adequate range on three tests in this indicator:  The OIG sampled 20 reception center arrivals to ensure that each patient had a timely completed and properly documented TB skin test. Seventeen of the 20 patients (85 percent) had their TB tests timely and properly administered, read, and documented. One patient’s TB test was not timely read; another patient’s testing form was incomplete, missing information in the history section; and, for one final patient, there was no evidence found that a TB screening occurred (MIT 12.007).  Providers timely completed reception center history and physical examinations within seven calendar days of the patient’s arrival for 16 of 20 sampled patients (80 percent). For four patients, the history and physical was completed from one to 25 days late (MIT 12.004).  The institution timely offered or administered a coccidioidomycosis skin test to 16 of the 20 sampled reception center patients (80 percent). Two patients were offered or administered the test 6 and 25 days late; for two final patients, there was no evidence that a coccidioidomycosis test occurred (MIT 12.008). North Kern State Prison, Cycle 5 Medical Inspection Page 52 Office of the Inspector General State of California Two tests earned the institution proficient scores:  For the 20 sampled patients who arrived at the NKSP reception center, 11 of their screenings required that an RN complete an assessment and disposition of the results on the same day staff completed the health screening. Based on the OIG’s review, the RN timely completed the assessment and disposition section of the screening form for all 11 of the sampled patients (MIT 12.002).  Providers timely reviewed and communicated the results of the intake tests performed for all 20 of the reception center patients who arrived at NKSP during the sample period (MIT 12.006). North Kern State Prison, Cycle 5 Medical Inspection Page 53 Office of the Inspector General State of California 13 — SPECIALIZED MEDICAL HOUSING This indicator addresses whether the institution follows appropriate Case Review Rating: policies and procedures when admitting patients to onsite inpatient Adequate facilities, including completion of timely nursing and provider Compliance Score: assessments. The chart review assesses all aspects of medical care Proficient related to these housing units, including quality of provider and (92.5%) nursing care. NKSP’s only specialized medical housing unit was a Overall Rating: CTC. Adequate In this indicator, the OIG’s case review and compliance review processed yielded different results, with the case review giving an adequate rating and the compliance testing resulting in a proficient score. While each area’s results are discussed in detail below, the result variance is due to the testing approaches. Because the case review process contained a more detailed review, the OIG inspection team determined the final overall rating was adequate. Case Review Results The institution had six medical CTC beds and ten mental health CTC beds. There were two designated negative pressure rooms to minimize the spread of airborne infection. The OIG clinicians reviewed eight CTC admissions, including 102 provider and 44 nursing encounters. A total of 32 deficiencies were identified, 6 of which were significant. One significant deficiency was identified in case 52, two in case 23, and three in case 53. The OIG clinicians rated this indicator adequate. Provider Performance NKSP providers generally provided good care. One provider, who worked four days a week, was assigned to both the TTA and the CTC. Other providers covered the other three days. Poor continuity of care by different providers contributed to poor care in one case:  In case 23, the patient received chemotherapy that required careful monitoring and replacement of fluids to protect his kidneys from damage. While blood tests to monitor kidney function were ordered, the covering provider failed to act when the tests showed declining kidney function. In addition, another provider on another visit noted low blood pressure, low fluid intake, and dehydration, but also failed to act and did not increase fluids. Fortunately, the patient’s kidney function was not permanently damaged by the provider’s oversight. Nursing Performance Overall, the nursing staff at NKSP provided appropriate care to the patients in the CTC. Nurses conducted daily patient assessments that included physical examinations, and monitored patient North Kern State Prison, Cycle 5 Medical Inspection Page 54 Office of the Inspector General State of California status for activities of daily living. However, one problem was cloned documentation by one CTC nurse who repeatedly documented the exact same complaints, interventions, and observations, which always occurring at the same time of day. Health Information Management There were six deficiencies identified, two of which were significant, in health information management within the CTC. The minor deficiencies involved mislabeled, misdated, and duplicated records scanned into the electronic medical record. The two significant deficiencies occurred in the same case:  In case 53, another patient’s orders and records were erroneously scanned into the electronic medical record. Additionally, the provider’s progress note was mislabeled as a psychiatrist progress note in the electronic medical record. Pharmacy and Medication Management Generally, CTC staff ensured that patients received proper medications at proper times, which was challenging with complex patients with frequent changes in medications, dosages, and time administrations. The following was an example of a rare significant lapse:  In case 52, the CTC nurse administered propranolol to lower blood pressure and heart rate when the patient already had a low blood pressure and heart rate. Administering this medication was against the provider’s orders. Additionally, CTC nurses failed to administer spironolactone (diuretic) for one dose. Clinician Onsite Inspection The OIG clinicians visited the CTC unit and interviewed nursing staff. One nurse was assigned to the medical patients and the other nurse was assigned to the mental health patients. They worked well together as a team and helped each other as needed. The nurses interviewed demonstrated knowledge of the CTC’s admission and discharge process. Case Review Conclusion In comparison to that in the OIG’s Cycle 4 inspection, NKSP’s performance in the Specialized Medical Housing indicator in this cycle was better. Provider performance was improved with fewer significant deficiencies. The OIG clinicians continued to find patterns of nursing deficiencies related to incomplete nursing assessments and documentation. However, most of these deficiencies were minor and unlikely to contribute to patient harm. In general, NKSP nurses and providers gave appropriate care to patients. The OIG clinicians rated the Specialized Medical Housing indicator adequate. North Kern State Prison, Cycle 5 Medical Inspection Page 55 Office of the Inspector General State of California Compliance Testing Results NKSP earned a proficient compliance score of 92.5 percent in the Specialized Medical Housing indicator, with high scores in three of the four tests, as follows:  OIG inspectors sampled ten patients who were admitted to the CTC. Providers completed a written history and physical examination within the required time frame for all ten (MIT 13.002).  When inspectors observed the working order of sampled call buttons in CTC patient rooms, all were working properly. In addition, according to staff members interviewed, custody officers and clinicians were able to expeditiously access patients’ locked rooms when emergent events occurred. NKSP earned a score of 100 percent on this test (MIT 13.101).  For nine of ten sampled patients (90 percent), nursing staff completed an initial assessment on the day the patient was admitted to the CTC. For one CTC admission, there was no evidence found that the nurse completed an initial assessment at all (MIT 13.001). One test earned an adequate score:  Providers completed Subjective, Objective, Assessment, Plan, and Education (SOAPE) notes at required three-day intervals for eight of ten sampled patients (80 percent). One patient’s notes were two days late, and another patient’s notes did not include all required elements (MIT 13.003). North Kern State Prison, Cycle 5 Medical Inspection Page 56 Office of the Inspector General State of California 14 — SPECIALTY SERVICES This indicator focuses on specialist care from the time a request for Case Review Rating: services or physician’s order for specialist care is completed to the Adequate time of receipt of related recommendations from specialists. This Compliance Score: indicator also evaluates the providers’ timely review of specialist Adequate records and documentation reflecting the patients’ care plans, (80.2%) including course of care when specialist recommendations were not Overall Rating: ordered, and whether the results of specialists’ reports are Adequate communicated to the patients. For specialty services denied by the institution, the OIG determines whether the denials are timely and appropriate, and whether the patient is updated on the plan of care. Case Review Results The OIG clinicians reviewed 154 events related to specialty services (26 procedures, 78 consultations, 41 anticoagulation clinic visits, and 9 nursing encounters). Of the 33 deficiencies, 9 were significant. Access to Specialty Services NKSP performed adequately providing access to specialty services. Of 154 specialty consultations and procedures, the OIG clinicians identified 6 deficiencies in scheduling. Significant deficiencies were identified once in cases 9 and 20, twice in case 21, and twice in case 23. Analysis of these deficiencies revealed that NKSP had problems obtaining appointments for urgent request for services as well as urgent follow-ups after hospitalizations.  In case 9, the provider requested an urgent biopsy of lung nodules, but it was not performed until over two months later. At the onsite inspection, NKSP staff claimed that the delay for the CT guided biopsy of lung nodules was due to NKSP having trouble getting the previous CT scan to the offsite specialist.  In case 20, the on-call physician ordered a follow-up with urology in one week to remove a drainage tube. This appointment never occurred, and the patient returned to the hospital due to a kidney infection. The delay in removing the tube likely caused the infection and need for hospitalization.  In case 21, the provider ordered a follow-up with cardiology in two weeks for management of an irregular heart rhythm. This follow-up occurred four weeks later.  Also in case 21, the provider ordered a chest surgery follow-up in two weeks after an aortic aneurysm repair. This follow-up did not occur until 81 days later. When the OIG clinicians discussed this case onsite, NKSP staff reviewed the follow-up requests for the chest surgeon North Kern State Prison, Cycle 5 Medical Inspection Page 57 Office of the Inspector General State of California and the cardiologist. The specialty nurse was unaware that the appointments were not booked.  In case 23, the patient had increasing difficulty with swallowing, and an MRI revealed a possible mass. The provider requested an urgent referral to see an ear, nose, and throat (ENT) surgeon, but the patient was not scheduled to be seen until five weeks later. At the onsite inspection, NKSP staff explained that they had difficulty obtaining an appointment for the ENT surgeon because the provider was outside NKSP’s contracted providers.  Also in case 23, after a recommendation from a telemedicine ENT specialist to refer the patient to tertiary care center, an urgent request for services was submitted. Unfortunately, the patient was scheduled with another telemedicine ENT specialist, who then requested, again, the same tertiary care referral. This led to a delay in the diagnosis and treatment of the patient’s laryngeal cancer. Nursing Performance In general, NKSP nurses performed appropriately for patients returning from offsite specialty appointments. Nurses generally assessed patients, reviewed specialty recommendations, and scheduled provider follow-ups to review and discuss with patients specialty report recommendations. There was one minor deficiency in which the nurse did not reassess the patient’s low pulse rate upon return from an offsite lung and sleep disorder consultation. One significant deficiency involved nursing performance:  In case 21, the patient had an elevated blood pressure upon his return from an offsite consultation with a cardiologist. The nurse did not implement the provider’s order to administer the patient’s morning blood pressure medications “now” and to recheck his blood pressure in two hours. Provider Performance NKSP providers performed adequately when making referrals to see specialists. Providers recognized the need for referral and ordered the correct referrals with appropriate priority. One deficiency occurred, as follows:  In case 23, the patient had worsening kidney function and the provider requested a routine consultation by the nephrologist and an ultrasound of his kidneys. The requests should have been urgent instead of routine because his kidney injury could have become permanent if not addressed in a timely fashion. NKSP providers performed adequately when reviewing specialty reports. Providers reviewed the reports and made appropriate decisions based on the specialty recommendations. North Kern State Prison, Cycle 5 Medical Inspection Page 58 Office of the Inspector General State of California For anticoagulation management, NKSP’s chief physician and surgeon regularly tracked, monitored, and assessed patients. The OIG case reviewers found minor deficiencies related to cloned notes but found care to be generally good. There was one significant anticoagulation deficiency:  In case 9, the anticoagulation provider discontinued enoxaparin sodium (injectable blood thinner to immediately reduce clotting ability) before warfarin could successfully reduce the blood’s clotting ability into the desired range. Given the patient’s history of stroke from a blood clot, the provider should have waited until the warfarin level was therapeutic to stop the enoxaparin sodium. Health Information Management NKSP did not adequately retrieve or scan specialty reports. The OIG clinicians found a pattern of failure to obtain, review, and scan outside specialty consultation notes.  In case 9, staff failed to obtain oncology, surgery, and radiation oncology consultation reports and scan them into the electronic medical record.  In case 19, staff erroneously scanned a kidney specialist report with the wrong date, and failed to obtain an ultrasound report.  In case 23, staff failed to obtain specialist reports from ENT, oncology, and radiation oncology and scan them into the electronic medical record.  In case 24, staff failed to obtain a dictated radiology report and outside specialty reports from interventional radiology, cardiothoracic surgery, and ophthalmology, and to scan them into the electronic medical record. Clinician Onsite Inspection The OIG inspectors inquired about why some specialty reports were not scanned into the electronic medical record. The offsite specialty nurse explained that she was the only individual who was tracking all of the offsite visits and pending reports on a log. She also explained that when she was not working, other inexperienced nurses were covering her duties and may not have known about specialty report tracking system. Case Review Conclusion The OIG clinicians rated the Specialty Services indicator adequate. North Kern State Prison, Cycle 5 Medical Inspection Page 59 Office of the Inspector General State of California Compliance Testing Results The institution received an adequate compliance score of 80.2 percent in the Specialty Services indicator. Two tests received proficient scores, as follows:  For all 15 patients sampled, routine specialty service appointments occurred within 90 days of the provider’s order (MIT 14.003).  The institution’s health care management timely denied providers’ specialty service requests for 19 of 20 patients sampled (95 percent). One of the specialty service requests was denied three days late (MIT 14.006). The institution performed in the adequate range on the following tests:  When a patient is scheduled for a specialty service appointment and is then transferred to another institution, policy requires that the receiving institution ensure that the appointment occurs timely. At NKSP, 14 of the 17 applicable sampled transfer-in patients received their specialty services appointment within the required time frame (82 percent). Two patients received their appointments 21 and 23 days late, and there was no evidence found in the electronic medical record that one patient received an appointment at all (MIT 14.005).  Of the 15 patients sampled, 12 (80 percent) received their high-priority specialty service appointment within 14 calendar days of the provider’s order. Three patients received their appointments one, 6, and 21 days late (MIT 14.001).  NKSP providers timely received and reviewed the routine priority specialists’ reports for 9 of the 12 applicable patients sampled (75 percent). For three patients, there was no evidence of timely provider review of the reports (MIT 14.004). The institution showed room for improvement in the following areas:  Providers at NKSP timely received and reviewed the high-priority specialists’ reports for only 9 of the 15 sampled patients (60 percent). For three patients, the institution received the reports late; for one patient, the report was reviewed late; for two final patients, the reports were both received and reviewed late. All the untimely receipts and reviews were from one to 14 days late (MIT 14.002).  Of the 16 patients sampled for whom NKSP’s management denied a specialty service, only 11 (69 percent) received a timely notification of the denied service, including a provider meeting with them within 30 days to discuss alternate treatment strategies. For three patients, the follow-up visit occurred 4, 5, and 13 days late; one patient’s appointment was 10 days overdue when he transferred out to another institution; and for one final patient, there was no evidence found of provider follow-up to discuss the denial at all (MIT 14.007). North Kern State Prison, Cycle 5 Medical Inspection Page 60 Office of the Inspector General State of California 15 — ADMINISTRATIVE OPERATIONS (SECONDARY) This indicator focuses on the institution’s administrative health care Case Review Rating: oversight functions. The OIG evaluates whether the institution Not Applicable promptly processes patient medical appeals and addresses all Compliance Score: appealed issues. Inspectors also verify that the institution follows Adequate reporting requirements for adverse/sentinel events and patient (80.4%) deaths. The OIG verifies that the Emergency Medical Response Overall Rating: Review Committee (EMRRC) performs required reviews and that Adequate staff perform required emergency response drills. Inspectors also assess whether the Quality Management Committee (QMC) meets regularly and adequately addresses program performance. For those institutions with licensed facilities, inspectors also verify that required committee meetings are held. In addition, OIG examines whether the institution adequately manages its health care staffing resources by evaluating whether job performance reviews are completed as required; specified staff possess current, valid credentials and professional licenses or certifications; nursing staff receive new employee orientation training and annual competency testing; and clinical and custody staff have current medical emergency response certifications. The Administrative Operations indicator is a secondary indicator, and, therefore, was not relied on for the overall score for the institution. Compliance Testing Results The institution earned an adequate compliance score of 80.4 percent in the Administrative Operations indicator. The majority of tests in this indicator scored in the proficient range, as follows:  The OIG reviewed data received from the institution to determine if NKSP timely processed at least 95 percent of its monthly patient medical appeals during the most recent 12-month period. NKSP timely processed all 12 months’ appeals reviewed (MIT 15.001).  Inspectors reviewed the last 12 months of NKSP’s local governing body (LGB) meeting minutes and determined that the LGB met at least quarterly and exercised responsibility for the quality management of patient heath care each quarter, as documented in the meeting minutes. As a result, NKSP scored 100 percent on this test (MIT 15.006).  Based on a sample of ten second-level medical appeals, the institution’s responses addressed all of the patients’ appealed issues (MIT 15.102).  Medical staff promptly submitted the initial Inmate Death Report (CDCR Form 7229A) to CCHCS’s Death Review Unit for all ten applicable deaths that occurred at NKSP in the prior 12-month period (MIT 15.103). North Kern State Prison, Cycle 5 Medical Inspection Page 61 Office of the Inspector General State of California  All ten nurses sampled were current with their clinical competency validations (MIT 15.105).  All providers at the institution were current with their professional licenses. Similarly, all nursing staff and the pharmacist in charge were current with their professional licenses and certification requirements (MIT 15.107, 15.109).  All active duty providers, nurses, and custody staff were current with their emergency response certifications (MIT 15.108).  All pharmacy staff and providers who prescribed controlled substances had current Drug Enforcement Agency registrations (MIT 15.110).  All nursing staff hired within the most recent year timely received new employee orientation training (MIT 15.111).  The OIG inspected incident package documentation for 12 emergency medical responses reviewed by NKSP’s EMRRC during the prior six-month period; 11 of 12 sampled packages (92 percent) complied with policy. One did not include the required EMRRC checklist (MIT 15.005). Two tests earned adequate scores:  NKSP’s QMC met monthly, evaluated program performance, and took action when management identified areas for improvement opportunities in five of the six months reviewed (83 percent) (MIT 15.003).  Seven of nine NKSP providers had a proper clinical performance appraisal completed by their supervisor (78 percent). One provider had not received a performance appraisal or a 360 Degree Evaluation, and one other provider also did not receive a 360 Degree Evaluation (MIT 15.106). The institution showed room for improvement with inadequate scores in the following tests:  Based on a review of QMC meeting minutes sampled, there was no evidence of the following discussions. On this test, NKSP received a score of zero (MIT 15.004): o Discussion of the methodologies used to conduct periodic data validation of the institution’s Dashboard data. o Discussion of the results of that data validation testing. o Discussion of methodologies used to train the staff who collected Dashboard data. North Kern State Prison, Cycle 5 Medical Inspection Page 62 Office of the Inspector General State of California  The OIG inspected records for five nurses from February 2017 to determine if their nursing supervisors properly completed monthly performance reviews. Inspectors identified the following deficiencies among all five of the nurses’ monthly nursing reviews, resulting in a score of zero (MIT 15.104): o The supervisor did not complete the required number of reviews for one nurse; o The supervisor’s review did not summarize aspects that were well done and needing improvement for all nurses.  The institution did not meet the emergency response drill requirements for the most recent quarter for two of its three watches, resulting in a score of 33 percent. More specifically, the institution’s second-watch drill package was missing documentation of the time frame of the event, and the third-watch drill package did not contain a Triage and Treatment Services Flow sheet (CDCR Form 7464) (MIT 15.101). Non-Scored Results  The OIG gathered non-scored data regarding the completion of death review reports by CCHCS’s Death Review Committee (DRC). Ten deaths occurred at NKSP during the OIG’s review period, seven unexpected (Level 1) deaths and three expected (Level 2) deaths. The DRC was required to complete its death review summary report within 60 days from the date of death for the Level 1 deaths and within 30 days from the date of death for the Level 2 deaths; the reports should then have been submitted to the institution’s chief executive officer (CEO) within seven days thereafter. However, for the seven Level 1 deaths, the DRC completed its reports from one to 175 days late (61 to 235 days after death) and submitted them to NKSP’s CEO from 3 to 188 days late; for the three Level 2 deaths, the DRC completed its report 19 to 108 days late (49 to 138 days after death) and submitted it to the CEO from 21 to 123 days late (MIT 15.998).  The OIG discusses the institution’s health care staffing resources in the About the Institution section of this report (MIT 15.999). North Kern State Prison, Cycle 5 Medical Inspection Page 63 Office of the Inspector General State of California R ECOMMENDATIONS  The OIG recommends NKSP cross-train several nurses to work in the specialty clinic in the event that the regular specialty nurse is away from the institution.  The OIG recommends NKSP develop a system to ensure specialty reports are retrieved from the offsite specialist in a timely manner. North Kern State Prison, Cycle 5 Medical Inspection Page 64 Office of the Inspector General State of California P -B M OPULATION ASED ETRICS The compliance testing and the case reviews give an accurate assessment of how the institution’s health care systems are functioning with regard to the patients with the highest risk and utilization. This information is vital to assess the capacity of the institution to provide sustainable, adequate care. However, one significant limitation of the case review methodology is that it does not give a clear assessment of how the institution performs for the entire population. For better insight into this performance, the OIG has turned to population-based metrics. For comparative purposes, the OIG has selected several Healthcare Effectiveness Data and Information Set (HEDIS) measures for disease management to gauge the institution’s effectiveness in outpatient health care, especially chronic disease management. The Healthcare Effectiveness Data and Information Set is a set of standardized performance measures developed by the National Committee for Quality Assurance with input from over 300 organizations representing every sector of the nation’s health care industry. It is used by over 90 percent of the nation’s health plans as well as many leading employers and regulators. It was designed to ensure that the public (including employers, the Centers for Medicare and Medicaid Services, and researchers) has the information it needs to accurately compare the performance of health care plans. Healthcare Effectiveness Data and Information Set data is often used to produce health plan report cards, analyze quality improvement activities, and create performance benchmarks. Methodology For population-based metrics, the OIG used a subset of HEDIS measures applicable to the CDCR inmate-patient population. Selection of the measures was based on the availability, reliability, and feasibility of the data required for performing the measurement. The OIG collected data utilizing various information sources, including the eUHR, the Master Registry (maintained by CCHCS), as well as a random sample of patient records analyzed and abstracted by trained personnel. Data obtained from the CCHCS Master Registry and Diabetic Registry was not independently validated by the OIG and is presumed to be accurate. For some measures, the OIG used the entire population rather than statistically random samples. While the OIG is not a certified HEDIS compliance auditor, the OIG uses similar methods to ensure that measures are comparable to those published by other organizations. Comparison of Population-Based Metrics For North Kern State Prison, nine HEDIS measures were selected and are listed in the following NKSP Results Compared to State and National HEDIS Scores table. Multiple health plans publish their HEDIS performance measures at the State and national levels. The OIG has provided selected results for several health plans in both categories for comparative purposes. North Kern State Prison, Cycle 5 Medical Inspection Page 65 Office of the Inspector General State of California Results of Population-Based Metric Comparison Comprehensive Diabetes Care For chronic care management, the OIG chose measures related to the management of diabetes. Diabetes is the most complex common chronic disease requiring a high level of intervention on the part of the health care system in order to produce optimal results. NKSP performed well with its management of diabetes. When compared statewide, NKSP outperformed all plans in three out of five diabetic measures tested. Kaiser Permanente (Northern and Southern California regions) scored higher with regard to diabetic blood pressure control, while Kaiser Permanente (Southern California) also outscored NKSP in completing diabetic eye exams. When compared nationally, NKSP outperformed three plans in all five measures, with the U.S. Department of Veterans Affairs (VA) outscoring NKSP in two measures (diabetic monitoring and performing diabetic eye exams). Immunizations Comparative data for immunizations was only fully available for the VA and partially available for Kaiser, commercial plans, Medicaid, and Medicare. With respect to administering influenza vaccinations to younger adults, NKSP scored lower than all statewide and national plans, but the high patient refusal rate of 65 percent negatively affected the institutions score. When administering influenza vaccinations to older adults, NKSP outperformed both Medicare and the VA. With regard to immunizations for pneumococcal infection, NKSP performed better than Medicare, but performed less well than the VA. Cancer Screening With respect to colorectal cancer screening, NKSP outscored three out of five comparative plans, while scoring only slightly below Kaiser Permanente (Southern California) and the VA. If not for the 16 percent refusal rate, NKSP would have scored higher than all health plans. Summary NKSP’s population-based metrics performance reflected an adequate chronic care program in comparison to the other six health care plans reporting data. NKSP may improve its scores for influenza immunizations for younger adults by educating patients of the benefits of these preventive services. North Kern State Prison, Cycle 5 Medical Inspection Page 66 Office of the Inspector General State of California NKSP Results Compared to State and National HEDIS Scores California National NKSP HEDIS HEDIS HEDIS Clinical Measures HEDIS Kaiser Kaiser HEDIS Com- HEDIS VA Cycle 5 Medi-Cal (No.CA) (So.CA) Medicaid mercial Medicare Average Results1 20152 20163 20163 20164 20164 20164 20155 Comprehensive Diabetes Care HbA1c Testing (Monitoring) 97% 86% 94% 94% 86% 90% 93% 98% Poor HbA1c Control (>9.0%)6, 7 16% 39% 20% 23% 45% 34% 27% 19% HbA1c Control (<8.0%)6 73% 49% 70% 63% 46% 55% 63% - Blood Pressure Control (<140/90) 75% 63% 83% 83% 59% 60% 62% 74% Eye Exams 79% 53% 68% 81% 53% 54% 69% 89% Immunizations Influenza Shots–Adults (18–64) 35% - 56% 57% 39% 48% - 55% Influenza Shots–Adults (65+)6 83% - - - - - 72% 76% Immunizations: Pneumococcal6 92% - - - - - 71% 93% Cancer Screening Colorectal Cancer Screening 81% - 79% 82% - 63% 67% 82% 1. Unless otherwise stated, data was collected in April 2017 by reviewing medical records from a sample of NKSP’s population of applicable inmate-patients. These random statistical sample sizes were based on a 95 percent confidence level with a 15 percent maximum margin of error. 2. HEDIS Medi-Cal data was obtained from the California Department of Health Care Services 2015 HEDIS Aggregate Report for Medi-Cal Managed Care. 3. Data was obtained from Kaiser Permanente November 2016 reports for the Northern and Southern California regions. 4. National HEDIS data for Medicaid, commercial plans, and Medicare was obtained from the 2016 State of Health Care Quality Report, available on the NCQA website: www.ncqa.org. The results for commercial plans were based on data received from various health maintenance organizations. 5. The Department of Veterans Affairs (VA) data was obtained from the VA’s website, www.va.gov. For the Immunizations: Pneumococcal measure only, the data was obtained from the VHA Facility Quality and Safety Report - Fiscal Year 2012 Data. 6. For this indicator, the entire applicable NKSP population was tested. 7. For this measure only, a lower score is better. For Kaiser, the OIG derived the Poor HbA1c Control indicator using the reported data for the <9.0% HbA1c control indicator. North Kern State Prison, Cycle 5 Medical Inspection Page 67 Office of the Inspector General State of California A A — C T R PPENDIX OMPLIANCE EST ESULTS North Kern State Prison (NKSP) Range of Summary Scores: 63.13%–92.50% Indicator Compliance Score (Yes %) 1–Access to Care 67.90% 2–Diagnostic Services 84.44% 3–Emergency Services Not Applicable 4–Health Information Management (Medical Records) 74.10% 5–Health Care Environment 80.68% 6–Inter- and Intra-System Transfers 91.71% 7–Pharmacy and Medication Management 79.06% 8–Prenatal and Post-Delivery Services Not Applicable 9–Preventive Services 79.14% 10–Quality of Nursing Performance Not Applicable 11–Quality of Provider Performance Not Applicable 12–Reception Center Arrivals 63.13% 13–Specialized Medical Housing (OHU, CTC, SNF, Hospice) 92.50% 14–Specialty Services 80.16% 15–Administrative Operations 80.38% North Kern State Prison, Cycle 5 Medical Inspection Page 68 Office of the Inspector General State of California Scored Answers Yes Reference + 1–Access to Care Number Yes No No Yes % N/A Chronic care follow-up appointments: Was the patient’s most recent chronic care visit within the health care guideline’s 1.001 9 16 25 36.00% 0 maximum allowable interval or within the ordered time frame, whichever is shorter? For endorsed patients received from another CDCR institution: If 1.002 the nurse referred the patient to a provider during the initial health 2 23 25 8.00% 0 screening, was the patient seen within the required time frame? Clinical appointments: Did a registered nurse review the patient’s 1.003 26 4 30 86.67% 0 request for service the same day it was received? Clinical appointments: Did the registered nurse complete a 1.004 face-to-face visit within one business day after the CDCR Form 19 11 30 63.33% 0 7362 was reviewed? Clinical appointments: If the registered nurse determined a referral to a primary care provider was necessary, was the patient 1.005 8 7 15 53.33% 15 seen within the maximum allowable time or the ordered time frame, whichever is the shorter? Sick call follow-up appointments: If the primary care provider 1.006 ordered a follow-up sick call appointment, did it take place within 6 1 7 85.71% 23 the time frame specified? Upon the patient’s discharge from the community hospital: Did 1.007 the patient receive a follow-up appointment within the required 22 2 24 91.67% 1 time frame? Specialty service follow-up appointments: Do specialty service 1.008 primary care physician follow-up visits occur within required time 19 3 22 86.36% 8 frames? Clinical appointments: Do patients have a standardized process to 1.101 6 0 6 100% 0 obtain and submit health care services request forms? Overall percentage: 67.90% North Kern State Prison, Cycle 5 Medical Inspection Page 69 Office of the Inspector General State of California Scored Answers Yes Reference + 2–Diagnostic Services Number Yes No No Yes % N/A Radiology: Was the radiology service provided within the time 2.001 10 0 10 100% 0 frame specified in the provider’s order? Radiology: Did the primary care provider review and initial the 2.002 0 10 10 0.00% 0 diagnostic report within specified time frames? Radiology: Did the primary care provider communicate the results 2.003 10 0 10 100% 0 of the diagnostic study to the patient within specified time frames? Laboratory: Was the laboratory service provided within the time 2.004 10 0 10 100% 0 frame specified in the provider’s order? Laboratory: Did the primary care provider review and initial the 2.005 10 0 10 100% 0 diagnostic report within specified time frames? Laboratory: Did the primary care provider communicate the 2.006 results of the diagnostic study to the patient within specified time 10 0 10 100% 0 frames? Pathology: Did the institution receive the final diagnostic report 2.007 10 0 10 100% 0 within the required time frames? Pathology: Did the primary care provider review and initial the 2.008 10 0 10 100% 0 diagnostic report within specified time frames? Pathology: Did the primary care provider communicate the results 2.009 6 4 10 60.00% 0 of the diagnostic study to the patient within specified time frames? Overall percentage: 84.44% 3–Emergency Services This indicator is evaluated only by case review clinicians. There is no compliance testing component. North Kern State Prison, Cycle 5 Medical Inspection Page 70 Office of the Inspector General State of California Scored Answers Yes Reference + 4–Health Information Management Number Yes No No Yes % N/A Are non-dictated health care documents (provider progress notes) 4.001 5 5 10 50.00% 0 scanned within 3 calendar days of the patient encounter date? Are dictated/transcribed documents scanned into the patient’s 4.002 electronic health record within five calendar days of the encounter 20 0 20 100% 0 date? Are High-Priority specialty notes (either a Form 7243 or other 4.003 scanned consulting report) scanned within the required time 13 6 19 68.42% 0 frame? Are community hospital discharge documents scanned into the 4.004 patient’s electronic health record within three calendar days of 20 0 20 100% 0 hospital discharge? Are medication administration records (MARs) scanned into the 4.005 18 0 18 100% 0 patient’s electronic health record within the required time frames? During the inspection, were medical records properly scanned, 4.006 0 24 24 0.00% 0 labeled, and included in the correct patients’ files? For patients discharged from a community hospital: Did the preliminary hospital discharge report include key elements and 4.007 25 0 25 100% 0 did a primary care provider review the report within three calendar days of discharge? Overall percentage: 74.10% North Kern State Prison, Cycle 5 Medical Inspection Page 71 Office of the Inspector General State of California Scored Answers Yes Reference + 5–Health Care Environment Number Yes No No Yes % N/A Are clinical health care areas appropriately disinfected, cleaned, 5.101 9 2 11 81.82% 0 and sanitary? Do clinical health care areas ensure that reusable invasive and 5.102 non-invasive medical equipment is properly sterilized or 10 1 11 90.91% .0 disinfected as warranted? Do clinical health care areas contain operable sinks and sufficient 5.103 11 0 11 100% 0 quantities of hygiene supplies? Does clinical health care staff adhere to universal hand hygiene 5.104 8 3 11 72.73% 0 precautions? Do clinical health care areas control exposure to blood-borne 5.105 10 1 11 90.91% 0 pathogens and contaminated waste? Warehouse, Conex and other non-clinic storage areas: Does the 5.106 medical supply management process adequately support the needs 1 0 1 100% 0 of the medical health care program? Does each clinic follow adequate protocols for managing and 5.107 11 0 11 100% 0 storing bulk medical supplies? Do clinic common areas and exam rooms have essential core 5.108 6 5 11 54.55% 0 medical equipment and supplies? Do clinic common areas have an adequate environment conducive 5.109 7 4 11 63.64% 0 to providing medical services? Do clinic exam rooms have an adequate environment conducive 5.110 5 6 11 45.45% 0 to providing medical services? Emergency response bags: Are TTA and clinic emergency 5.111 medical response bags inspected daily and inventoried monthly, 7 1 8 87.50% 3 and do they contain essential items? Overall percentage: 80.68% North Kern State Prison, Cycle 5 Medical Inspection Page 72 Office of the Inspector General State of California Scored Answers Yes Reference + 6–Inter- and Intra-System Transfers Number Yes No No Yes % N/A For endorsed patients received from another CDCR institution or COCF: Did nursing staff complete the initial health screening and 6.001 20 5 25 80.00% 0 answer all screening questions on the same day the patient arrived at the institution? For endorsed patients received from another CDCR institution or COCF: When required, did the RN complete the assessment and disposition section of the health screening form; refer the patient 6.002 23 0 23 100% 2 to the TTA, if TB signs and symptoms were present; and sign and date the form on the same day staff completed the health screening? For endorsed patients received from another CDCR institution or COCF: If the patient had an existing medication order upon 6.003 11 3 14 78.57% 11 arrival, were medications administered or delivered without interruption? For patients transferred out of the facility: Were scheduled 6.004 specialty service appointments identified on the patient’s health 20 0 20 100% 0 care transfer information form? For patients transferred out of the facility: Do medication transfer 6.101 packages include required medications along with the 10 0 10 100% 0 corresponding transfer packet required documents? Overall percentage: 91.71% North Kern State Prison, Cycle 5 Medical Inspection Page 73 Office of the Inspector General State of California Scored Answers 7–Pharmacy and Medication Yes Reference + Management Number Yes No No Yes % N/A Did the patient receive all chronic care medications within the 7.001 required time frames or did the institution follow departmental 13 6 19 68.42% 6 policy for refusals or no-shows? Did health care staff administer, make available, or deliver new 7.002 order prescription medications to the patient within the required 25 0 25 100% 0 time frames? Upon the patient’s discharge from a community hospital: Were all 7.003 ordered medications administered, made available, or delivered to 13 11 24 54.17% 1 the patient within required time frames? For patients received from a county jail: Were all medications ordered by the institution’s reception center provider 7.004 4 3 7 57.14% 13 administered, made available, or delivered to the patient within the required time frames? Upon the patient’s transfer from one housing unit to another: 7.005 20 5 25 80.00% 0 Were medications continued without interruption? For patients en route who lay over at the institution: If the 7.006 temporarily housed patient had an existing medication order, were 2 8 10 20.00% 0 medications administered or delivered without interruption? All clinical and medication line storage areas for narcotic 7.101 medications: Does the Institution employ strong medication 6 3 9 66.67% 0 security over narcotic medications assigned to its clinical areas? All clinical and medication line storage areas for non-narcotic medications: Does the Institution properly store non-narcotic 7.102 6 3 9 66.67% 0 medications that do not require refrigeration in assigned clinical areas? All clinical and medication line storage areas for non-narcotic 7.103 medications: Does the institution properly store non-narcotic 7 2 9 77.78% 0 medications that require refrigeration in assigned clinical areas? Medication preparation and administration areas: Do nursing staff employ and follow hand hygiene contamination control protocols 7.104 7 0 7 100% 2 during medication preparation and medication administration processes? Medication preparation and administration areas: Does the 7.105 institution employ appropriate administrative controls and 6 1 7 85.71% 2 protocols when preparing medications for patients? Medication preparation and administration areas: Does the 7.106 Institution employ appropriate administrative controls and 5 2 7 71.43% 2 protocols when distributing medications to patients? Pharmacy: Does the institution employ and follow general 7.107 security, organization, and cleanliness management protocols in 1 0 1 100% 0 its main and satellite pharmacies? North Kern State Prison, Cycle 5 Medical Inspection Page 74 Office of the Inspector General State of California Scored Answers 7–Pharmacy and Medication Yes Reference + Management Number Yes No No Yes % N/A Pharmacy: Does the institution’s pharmacy properly store 7.108 1 0 1 100% 0 non-refrigerated medications? Pharmacy: Does the institution’s pharmacy properly store 7.109 1 0 1 100% 0 refrigerated or frozen medications? Pharmacy: Does the institution’s pharmacy properly account for 7.110 1 0 1 100% 0 narcotic medications? Does the institution follow key medication error reporting 7.111 24 1 25 96.00% 0 protocols? Overall percentage: 79.06% 8–Prenatal and Post-Delivery Services The institution has no female patients, so this indicator is not applicable. North Kern State Prison, Cycle 5 Medical Inspection Page 75 Office of the Inspector General State of California Scored Answers Yes Reference + 9–Preventive Services Number Yes No No Yes % N/A Patients prescribed TB medication: Did the institution administer 9.001 21 4 25 84.00% 0 the medication to the patient as prescribed? Patients prescribed TB medication: Did the institution monitor the 9.002 patient monthly for the most recent three months he or she was on 2 23 25 8.00% 0 the medication? Annual TB Screening: Was the patient screened for TB within the 9.003 29 1 30 96.67% 0 last year? Were all patients offered an influenza vaccination for the most 9.004 25 0 25 100% 0 recent influenza season? All patients from the age of 50 - 75: Was the patient offered 9.005 23 2 25 92.00% 0 colorectal cancer screening? Female patients from the age of 50 through the age of 74: Was the 9.006 Not Applicable patient offered a mammogram in compliance with policy? Female patients from the age of 21 through the age of 65: Was 9.007 Not Applicable patient offered a pap smear in compliance with policy? Are required immunizations being offered for chronic care 9.008 11 4 15 73.33% 10 patients? Are patients at the highest risk of coccidioidomycosis (valley 9.009 20 0 20 100% 0 fever) infection transferred out of the facility in a timely manner? Overall percentage: 79.14% 10–Quality of Nursing Performance This indicator is evaluated only by case review clinicians. There is no compliance testing component. 11–Quality of Provider Performance This indicator is evaluated only by case review clinicians. There is no compliance testing component. North Kern State Prison, Cycle 5 Medical Inspection Page 76 Office of the Inspector General State of California Scored Answers Yes Reference + 12–Reception Center Arrivals Number Yes No No Yes % N/A For patients received from a county jail: Did nursing staff complete the initial health screening and answer all screening 12.001 0 20 20 0.00% 0 questions on the same day the patient arrived at the institution? For patients received from a county jail: When required, did the RN complete the assessment and disposition section of the health 12.002 11 0 11 100% 9 screening form, and sign and date the form on the same day staff completed the health screening? For patients received from a county jail: If, during the assessment, 12.003 the nurse referred the patient to a provider, was the patient seen 6 4 10 60.00% 10 within the required time frame? For patients received from a county jail: Did the patient receive a 12.004 history and physical by a primary care provider within seven 16 4 20 80.00% 0 calendar days? For patients received from a county jail: Were all required intake 12.005 0 20 20 0.00% 0 tests completed within specified timelines? For patients received from a county jail: Did the primary care 12.006 provider review and communicate the intake test results to the 20 0 20 100% 0 patient within specified timelines? For patients received from a county jail: Was a tuberculin test 12.007 17 3 20 85.00% 0 both administered and read timely? For patients received from a county jail: Was a 12.008 Coccidioidomycosis (Valley Fever) skin test offered, 16 4 20 80.00 0 administered, read, or refused timely? Overall percentage: 63.13% North Kern State Prison, Cycle 5 Medical Inspection Page 77 Office of the Inspector General State of California Scored Answers Yes Reference + 13–Specialized Medical Housing Number Yes No No Yes % N/A For OHU, CTC, and SNF: Did the registered nurse complete an 13.001 initial assessment of the patient on the day of admission, or within 9 1 10 90.00% 0 eight hours of admission to CMF’s Hospice? For CTC and SNF only: Was a written history and physical 13.002 10 0 10 100% 0 examination completed within the required time frame? For OHU, CTC, SNF, and Hospice: Did the primary care provider complete the Subjective, Objective, Assessment, Plan, and 13.003 8 2 10 80.00% 0 Education (SOAPE) notes on the patient at the minimum intervals required for the type of facility where the patient was treated? For OHU and CTC Only: Do inpatient areas either have properly working call systems in its OHU & CTC or are 30-minute patient 13.101 1 0 1 100% 0 welfare checks performed; and do medical staff have reasonably unimpeded access to enter patient’s cells? Overall percentage: 92.50% North Kern State Prison, Cycle 5 Medical Inspection Page 78 Office of the Inspector General State of California Scored Answers Yes Reference + 14–Specialty Services Number Yes No No Yes % N/A Did the patient receive the high-priority specialty service within 14.001 14 calendar days of the primary care provider order or the 12 3 15 80.00% 0 Physician Request for Service? Did the primary care provider review the high-priority specialty 14.002 9 6 15 60.00% 0 service consultant report within the required time frame? Did the patient receive the routine specialty service within 90 14.003 calendar days of the primary care provider order or Physician 15 0 15 100% 0 Request for Service? Did the primary care provider review the routine specialty service 14.004 9 3 12 75.00% 3 consultant report within the required time frame? For endorsed patients received from another CDCR institution: If the patient was approved for a specialty services appointment at 14.005 14 3 17 82.35% 0 the sending institution, was the appointment scheduled at the receiving institution within the required time frames? Did the institution deny the primary care provider request for 14.006 19 1 20 95.00% 0 specialty services within required time frames? Following the denial of a request for specialty services, was the 14.007 11 5 16 68.75% 4 patient informed of the denial within the required time frame? Overall percentage: 80.16% North Kern State Prison, Cycle 5 Medical Inspection Page 79 Office of the Inspector General State of California Scored Answers Yes Reference 15–Administrative Operations + Number Yes No No Yes % N/A Did the institution promptly process inmate medical appeals 15.001 12 0 12 100% 0 during the most recent 12 months? Does the institution follow adverse / sentinel event reporting 15.002 Not Applicable requirements? Did the institution Quality Management Committee (QMC) meet at least monthly to evaluate program performance, and did the 15.003 5 1 6 83.33% 0 QMC take action when improvement opportunities were identified? Did the institution’s Quality Management Committee (QMC) or 15.004 other forum take steps to ensure the accuracy of its Dashboard 0 1 1 0.00% 0 data reporting? Does the Emergency Medical Response Review Committee 15.005 perform timely incident package reviews that include the use of 11 1 12 91.67% 0 required review documents? For institutions with licensed care facilities: Does the Local Governing Body (LGB), or its equivalent, meet quarterly and 15.006 4 0 4 100% 0 exercise its overall responsibilities for the quality management of patient health care? Did the institution complete a medical emergency response drill 15.101 for each watch and include participation of health care and 1 2 3 33.33% 0 custody staff during the most recent full quarter? Did the institution’s second level medical appeal response address 15.102 10 0 10 100% 0 all of the patient’s appealed issues? Did the institution’s medical staff review and submit the initial 15.103 10 0 10 100% 0 inmate death report to the Death Review Unit in a timely manner? Does the institution’s Supervising Registered Nurse conduct 15.104 0 5 5 0.00% 0 periodic reviews of nursing staff? Are nursing staff who administer medications current on their 15.105 10 0 10 100% 0 clinical competency validation? 15.106 Are structured clinical performance appraisals completed timely? 7 2 9 77.78% 0 15.107 Do all providers maintain a current medical license? 15 0 15 100% 0 Are staff current with required medical emergency response 15.108 2 0 2 100% 1 certifications? Are nursing staff and the Pharmacist-in-Charge current with their professional licenses and certifications, and is the pharmacy licensed as a correctional pharmacy by the California State Board 15.109 5 0 5 100% 0 of Pharmacy? North Kern State Prison, Cycle 5 Medical Inspection Page 80 Office of the Inspector General State of California Scored Answers Yes Reference 15–Administrative Operations + Number Yes No No Yes % N/A Do the institution’s pharmacy and authorized providers who 15.110 prescribe controlled substances maintain current Drug 1 0 1 100% 0 Enforcement Agency (DEA) registrations? 15.111 Are nursing staff current with required new employee orientation? 1 0 1 100% 0 Overall percentage: 80.38% North Kern State Prison, Cycle 5 Medical Inspection Page 81 Office of the Inspector General State of California A B — C D PPENDIX LINICAL ATA Table B-1: NKSP Sample Sets Sample Set Total Anticoagulation 3 CTC/OHU 2 Death Review/Sentinel Events 2 Diabetes 3 Emergency Services – CPR 4 Emergency Services – Non-CPR 2 High Risk 4 Hospitalization 4 Intra-System Transfers In 3 Intra-System Transfers Out 3 RN Sick Call 18 Reception Center Transfers 3 Specialty Services 2 53 North Kern State Prison, Cycle 5 Medical Inspection Page 82 Office of the Inspector General State of California Table B-2: NKSP Chronic Care Diagnoses Diagnosis Total Anemia 3 Anticoagulation 6 Arthritis/Degenerative Joint Disease 3 Asthma 11 COPD 6 Cancer 4 Cardiovascular Disease 5 Chronic Kidney Disease 1 Chronic Pain 8 Cirrhosis/End Stage Liver Disease 2 Deep Venous Thrombosis/Pulmonary Embolism 3 Diabetes 18 Gastroesophageal Reflux Disease 12 Hepatitis C 10 Hyperlipidemia 14 Hypertension 25 Mental Health 3 Seizure Disorder 4 Sleep Apnea 2 Thyroid Disease 1 141 North Kern State Prison, Cycle 5 Medical Inspection Page 83 Office of the Inspector General State of California Table B-3: NKSP Event — Program Program Total Diagnostic Services 228 Emergency Care 40 Hospitalization 38 Intra-System Transfers In 21 Intra-System Transfers Out 7 Not Specified 7 Outpatient Care 392 Reception Center Care 64 Specialized Medical Housing 306 Specialty Services 170 1,273 Table B-4: NKSP Review Sample Summary Total MD Reviews Detailed 20 MD Reviews Focused 0 RN Reviews Detailed 14 RN Reviews Focused 31 Total Reviews 65 Total Unique Cases 53 Overlapping Reviews (MD & RN) 12 North Kern State Prison, Cycle 5 Medical Inspection Page 84 Office of the Inspector General State of California A C — C S M PPENDIX OMPLIANCE AMPLING ETHODOLOGY North Kern State Prison (NKSP) Sample Category Quality (number of Indicator samples) Data Source Filters Access to Care MIT 1.001 Chronic Care Patients Master Registry  Chronic care conditions (at least one condition per patient—any risk level) (25)  Randomize MIT 1.002 Nursing Referrals OIG Q: 6.001  See Intra-system Transfers (25) MITs 1.003-006 Nursing Sick Call MedSATS  Clinic (each clinic tested) (5 per clinic)  Appointment date (2–9 months) (30)  Randomize MIT 1.007 Returns from OIG Q: 4.007  See Health Information Management (Medical Community Hospital Records) (returns from community hospital) (25) MIT 1.008 Specialty Services OIG Q: 14.001 &  See Specialty Services Follow-up 14.003 (30) MIT 1.101 Availability of Health OIG onsite  Randomly select one housing unit from each yard Care Services review Request Forms (6) Diagnostic Services MITs 2.001–003 Radiology Radiology Logs  Appointment date (90 days–9 months)  Randomize (10)  Abnormal MITs 2.004–006 Laboratory Quest  Appt. date (90 days–9 months)  Order name (CBC or CMPs only)  Randomize (10)  Abnormal MITs 2.007–009 Pathology InterQual  Appt. date (90 days–9 months)  Service (pathology related) (10)  Randomize North Kern State Prison, Cycle 5 Medical Inspection Page 85 Office of the Inspector General State of California Sample Category Quality (number of Indicator samples) Data Source Filters Health Information Management (Medical Records) MIT 4.001 Timely Scanning OIG Qs: 1.001,  Non-dictated documents (10) 1.002, & 1.004  1st 10 IPs MIT 1.001, 1st 5 IPs MITs 1.002, 1.004 MIT 4.002 OIG Q: 1.001  Dictated documents (20)  First 20 IPs selected MIT 4.003 OIG Qs: 14.002  Specialty documents (19) & 14.004  First 10 IPs for each question MIT 4.004 OIG Q: 4.007  Community hospital discharge documents (20)  First 20 IPs selected MIT 4.005 OIG Q: 7.001  MARs (18)  First 20 IPs selected MIT 4.006 Documents for  Any misfiled or mislabeled document identified (24) any tested inmate during OIG compliance review (24 or more = No) MIT 4.007 Returns From Inpatient claims  Date (2–8 months) Community Hospital data  Most recent 6 months provided (within date range)  Rx count  Discharge date  Randomize (each month individually)  First 5 patients from each of the 6 months (if not 5 in a month, supplement from another, as needed) (25) Health Care Environment MIT 5.101–105 Clinical Areas OIG inspector  Identify and inspect all onsite clinical areas. MIT 5.107–111 (11) onsite review Inter- and Intra-System Transfers MIT 6.001–003 Intra-System SOMS  Arrival date (3–9 months) Transfers  Arrived from (another CDCR facility)  Rx count  Randomize (25) MIT 6.004 Specialty Services MedSATS  Date of transfer (3–9 months) Send-Outs  Randomize (20) MIT 6.101 Transfers Out OIG inspector  R&R IP transfers with medication (10) onsite review North Kern State Prison, Cycle 5 Medical Inspection Page 86 Office of the Inspector General State of California Sample Category Quality (number of Indicator samples) Data Source Filters Pharmacy and Medication Management MIT 7.001 Chronic Care OIG Q: 1.001 See Access to Care Medication  At least one condition per patient—any risk level  Randomize (25) MIT 7.002 New Medication Master Registry  Rx count Orders  Randomize (25)  Ensure no duplication of IPs tested in MIT 7.001 MIT 7.003 Returns from OIG Q: 4.007  See Health Information Management (Medical Community Hospital Records) (returns from community hospital) (25) MIT 7.004 RC Arrivals – OIG Q: 12.001  See Reception Center Arrivals Medication Orders (20) MIT 7.005 Intra-Facility Moves MAPIP transfer  Date of transfer (2–8 months) data  To location/from location (yard to yard and to/from ASU)  Remove any to/from MHCB  NA/DOT meds (and risk level) (25)  Randomize MIT 7.006 En Route SOMS  Date of transfer (2–8 months)  Sending institution (another CDCR facility)  Randomize (10)  NA/DOT meds MITs 7.101–103 Medication Storage OIG inspector  Identify and inspect clinical & med line areas that Areas onsite review store medications (varies by test) MITs 7.104–106 Medication OIG inspector  Identify and inspect onsite clinical areas that Preparation and onsite review prepare and administer medications Administration Areas (varies by test) MITs 7.107-110 Pharmacy OIG inspector  Identify & inspect all onsite pharmacies (1) onsite review MIT 7.111 Medication Error Monthly  All monthly statistic reports with Level 4 or higher Reporting medication error  Select a total of 5 months (25) reports MIT 7.999 Isolation Unit KOP Onsite active  KOP rescue inhalers & nitroglycerin medications Medications medication for IPs housed in isolation units (10) listing Prenatal and Post-Delivery Services MIT 8.001–007 Recent Deliveries OB Roster  Delivery date (2–12 months) (N/A at this  Most recent deliveries (within date range) institution) Pregnant Arrivals OB Roster  Arrival date (2–12 months) (N/A at this  Earliest arrivals (within date range) institution) North Kern State Prison, Cycle 5 Medical Inspection Page 87 Office of the Inspector General State of California Sample Category Quality (number of Indicator samples) Data Source Filters Preventive Services MITs 9.001–002 TB Medications Maxor  Dispense date (past 9 months)  Time period on TB meds (3 months or 12 weeks) (25)  Randomize MIT 9.003 TB Evaluation, SOMS  Arrival date (at least 1 year prior to inspection) Annual Screening  Birth Month (30)  Randomize MIT 9.004 Influenza SOMS  Arrival date (at least 1 year prior to inspection) Vaccinations  Randomize (25)  Filter out IPs tested in MIT 9.008 MIT 9.005 Colorectal Cancer SOMS  Arrival date (at least 1 year prior to inspection) Screening  Date of birth (51 or older) (25)  Randomize MIT 9.006 Mammogram SOMS  Arrival date (at least 2 yrs prior to inspection) (N/A at this  Date of birth (age 52–74) institution)  Randomize MIT 9.007 Pap Smear SOMS  Arrival date (at least three yrs prior to inspection) (N/A at this  Date of birth (age 24–53) institution)  Randomize MIT 9.008 Chronic Care OIG Q: 1.001  Chronic care conditions (at least 1 condition per Vaccinations IP—any risk level)  Randomize (25)  Condition must require vaccination(s) MIT 9.009 Valley Fever Cocci transfer  Reports from past 2–8 months (number will vary) status report  Institution  Ineligibility date (60 days prior to inspection date) (20)  All North Kern State Prison, Cycle 5 Medical Inspection Page 88 Office of the Inspector General State of California Sample Category Quality (number of Indicator samples) Data Source Filters Reception Center Arrivals MITs 12.001–008 RC SOMS  Arrival date (2–8 months)  Arrived from (county jail, return from parole, etc.) (20)  Randomize Specialized Medical Housing MITs 13.001–003 CTC CADDIS  Admit date (1–6 months)  Type of stay (no MH beds)  Length of stay (minimum of 5 days) (10)  Randomize MIT 13.101 Call Buttons OIG inspector  Review by location CTC onsite review (all) Specialty Services MITs 14.001–002 High-Priority MedSATS  Approval date (3–9 months) (15)  Randomize MITs 14.003–004 Routine MedSATS  Approval date (3–9 months)  Remove optometry, physical therapy or podiatry (15)  Randomize MIT 14.005 Specialty Services MedSATS  Arrived from (other CDCR institution) Arrivals  Date of transfer (3–9 months) (17)  Randomize MIT 14.006–007 Denials InterQual  Review date (3–9 months) (20)  Randomize IUMC/MAR  Meeting date (9 months) Meeting Minutes  Denial upheld (0)  Randomize North Kern State Prison, Cycle 5 Medical Inspection Page 89 Office of the Inspector General State of California Sample Category Quality (number of Indicator samples) Data Source Filters Administrative Operations MIT 15.001 Medical Appeals Monthly medical  Medical appeals (12 months) (all) appeals reports MIT 15.002 Adverse/Sentinel Adverse/sentinel  Adverse/sentinel events (2–8 months) Events events report (0) MITs 15.003–004 QMC Meetings Quality  Meeting minutes (12 months) Management Committee (6) meeting minutes MIT 15.005 EMRRC EMRRC meeting  Monthly meeting minutes (6 months) (12) minutes MIT 15.006 LGB LGB meeting  Quarterly meeting minutes (12 months) (4) minutes MIT 15.101 Medical Emergency Onsite summary  Most recent full quarter Response Drills reports &  Each watch documentation (3) for ER drills MIT 15.102 2nd Level Medical Onsite list of  Medical appeals denied (6 months) Appeals appeals/closed (10) appeals files MIT 15.103 Death Reports Institution-list of  Most recent 10 deaths deaths in prior 12  Initial death reports (10) months MIT 15.104 RN Review Onsite supervisor  RNs who worked in clinic or emergency setting Evaluations periodic RN six or more days in sampled month reviews  Randomize (5) MIT 15.105 Nursing Staff Onsite nursing  On duty one or more years Validations education files  Nurse administers medications (10)  Randomize MIT 15.106 Provider Annual Onsite  All required performance evaluation documents Evaluation Packets provider (9) evaluation files MIT 15.107 Provider licenses Current provider  Review all listing (at start of (15) inspection) MIT 15.108 Medical Emergency Onsite  All staff Response certification o Providers (ACLS) Certifications tracking logs o Nursing (BLS/CPR) (all)  Custody (CPR/BLS) MIT 15.109 Nursing staff and Onsite tracking  All required licenses and certifications Pharmacist in system, logs, or Charge Professional employee files Licenses and Certifications (all) North Kern State Prison, Cycle 5 Medical Inspection Page 90 Office of the Inspector General State of California Sample Category Quality (number of Indicator samples) Data Source Filters Administrative Operations MIT 15.110 Pharmacy and Onsite listing of  All DEA registrations Providers’ Drug provider DEA Enforcement Agency registration #s & (DEA) Registrations pharmacy registration (all) document MIT 15.111 Nursing Staff New Nursing staff  New employees (hired within last 12 months) Employee training logs  Orientations (all) MIT 15.998 Death Review OIG summary  Between 35 business days & 12 months prior Committee log - deaths  CCHCS death reviews (10) North Kern State Prison, Cycle 5 Medical Inspection Page 91 Office of the Inspector General State of California C C ALIFORNIA ORRECTIONAL H C S ’ EALTH ARE ERVICES R ESPONSE North Kern State Prison, Cycle 5 Medical Inspection Page 92 Office of the Inspector General State of California