Pelican Bay State Prison Medical Inspection Report Cycle 5

Roy W. Wesley Office of the Inspector General Inspector General Pelican Bay State Prison Medical Inspection Results Cycle 5 January 2018 Office of the Inspector General PELICAN BAY STATE PRISON Medical Inspection Results Cycle 5 Roy W. Wesley Inspector General Bryan B. Beyer Chief Deputy Inspector General Shaun R. Spillane Public Information Officer January 2018 December 2017 T C ABLE OF ONTENTS Foreword .............................................................................................................................................. i Executive Summary ........................................................................................................................... iii Overall Rating: Proficient ............................................................................................................... iii Clinical Case Review and OIG Clinician Inspection Results ................................................ v Compliance Testing Results .................................................................................................. vi Recommendations ................................................................................................................ vii Population-Based Metrics .................................................................................................... vii 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 Sampling Methods for Conducting 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 Access to Care ................................................................................................................. 11 Case Review Results ............................................................................................................ 11 Compliance Testing Results ................................................................................................. 13 Diagnostic Services ......................................................................................................... 14 Case Review Results ............................................................................................................ 14 Compliance Testing Results ................................................................................................. 15 Emergency Services ......................................................................................................... 16 Case Review Results ............................................................................................................ 16 Health Information Management .................................................................................... 19 Case Review Results ............................................................................................................ 19 Compliance Testing Results ................................................................................................. 20 Health Care Environment ............................................................................................... 22 Compliance Testing Results ................................................................................................. 22 Inter- and Intra-System Transfers ................................................................................... 25 Case Review Results ............................................................................................................ 25 Compliance Testing Results ................................................................................................. 26 Pharmacy and Medication Management ........................................................................ 28 Case Review Results ............................................................................................................ 28 Compliance Testing Results ................................................................................................. 29 Prenatal and Post-Delivery Services .............................................................................. 32 Pelican Bay State Prison, Cycle 5 Medical Inspection Table of Contents Office of the Inspector General State of California Preventive Services .......................................................................................................... 33 Compliance Testing Results ................................................................................................. 33 Quality of Nursing Performance ................................................................................... 34 Case Review Results ............................................................................................................ 34 Quality of Provider Performance .................................................................................. 37 Case Review Results ............................................................................................................ 37 Reception Center Arrivals ............................................................................................. 40 Specialized Medical Housing ........................................................................................ 41 Case Review Results ............................................................................................................ 41 Compliance Testing Results ................................................................................................. 42 Specialty Services .......................................................................................................... 44 Case Review Results ............................................................................................................ 44 Compliance Testing Results ................................................................................................. 45 Administrative Operations (Secondary) ........................................................................ 47 Compliance Testing Results ................................................................................................. 47 Recommendations ............................................................................................................................. 50 Population-Based Metrics ................................................................................................................. 51 Appendix A — Compliance Test Results ......................................................................................... 54 Appendix B — Clinical Data ............................................................................................................ 67 Appendix C — Compliance Sampling Methodology ....................................................................... 71 California Correctional Health Care Services’ Response ................................................................. 78 Pelican Bay 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 PBSP Executive Summary Table ....................................................................................................... iv PBSP Health Care Staffing Resources as of June 2017 ...................................................................... 2 PBSP Master Registry Data as of June 5, 2017 .................................................................................. 2 PBSP Results Compared to State and National HEDIS Scores ........................................................ 53 Table B-1: PBSP Sample Sets ........................................................................................................... 67 Table B-2: PBSP Chronic Care Diagnoses ....................................................................................... 68 Table B-3: PBSP Event – Program ................................................................................................... 69 Table B-4: PBSP Review Sample Summary ..................................................................................... 70 Pelican Bay State Prison, Cycle 5 Medical Inspection List of Tables and Figures Office of the Inspector General State of California F OREWORD Pursuant to California Penal Code Section 6126 et seq., which assigns the Office of the Inspector General (OIG) responsibility for oversight of the California Department of Corrections and Rehabilitation (CDCR), the OIG conducts a comprehensive inspection program to evaluate the delivery of medical care at each of CDCR’s 35 adult prisons. The OIG explicitly makes no determination regarding the constitutionality of care in the prison setting. That determination is left to the Receiver and the federal court. The assessment of care by the OIG is just one factor in the court’s determination whether care in the prisons meets constitutional standards. The OIG’s inspections are mandated by the Penal Code and not aimed at specifically resolving the court’s questions on constitutional care. To the degree that they provide another factor for the court to consider, the OIG is pleased to provide added value to the taxpayers of California. In Cycle 5, for the first time, the OIG will be inspecting institutions delegated back to CDCR from the Receivership. There is no difference in the standards used for assessment of a delegated institution versus an institution not yet delegated. The Receiver delegated Pelican Bay State Prison back to CDCR in June 2016. 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. Pelican Bay State Prison, Cycle 5 Medical Inspection Page i Office of the Inspector General State of California This page intentionally left blank. Pelican Bay 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 Pelican Bay State Prison (PBSP) from June to August 2017. The inspection included in-depth reviews of 46 patient files conducted by OVERALL clinicians, as well as reviews of documents from 311 patient files, RATING: covering 83 objectively scored tests of compliance with policies and procedures applicable to the delivery of medical care. The OIG Proficient assessed the case review and compliance results at PBSP using 13 health care quality indicators applicable to the institution. To conduct clinical case reviews, the OIG employs a clinician team consisting of a physician and a registered nurse consultant, while compliance testing is done by a team of registered nurses trained in monitoring medical policy compliance. Of the indicators, seven were rated by both case review clinicians and compliance inspectors, three were rated by case review clinicians only, and three were rated by compliance inspectors only. The PBSP Executive Summary Table on the following page identifies the applicable individual indicators and scores for this institution. Pelican Bay State Prison, Cycle 5 Medical Inspection Page iii Office of the Inspector General State of California PBSP Executive Summary Table Cycle 5 Cycle 4 Case Review Compliance Inspection Indicators Overall Overall Rating Rating Rating Rating 1—Access to Care Proficient Proficient Proficient Proficient 2—Diagnostic Services Adequate Adequate Adequate Proficient 3—Emergency Services Adequate Not Applicable Adequate Adequate 4—Health Information Proficient Adequate Proficient Adequate Management 5—Health Care Environment Not Applicable Inadequate Inadequate Adequate 6—Inter- and Intra-System Proficient Inadequate Adequate Adequate Transfers 7—Pharmacy and Medication I Proficient Inadequate Adequate n Proficient Management a 8—Prenatal and Post-Delivery Not Applicable Not Applicable Not Applicable Not Applicable Services 9—Preventive Services Not Applicable Proficient Proficient Adequate 10—Quality of Nursing Proficient Not Applicable Proficient Adequate Performance 11—Quality of Provider Proficient Not Applicable Proficient Adequate Performance 12—Reception Center Arrivals Not Applicable Not Applicable Not Applicable Not Applicable 13—Specialized Medical Housing Proficient Proficient Proficient Proficient 14—Specialty Services Proficient Proficient Proficient Adequate 15—Administrative Operations Not Applicable Adequate Adequate Adequate* (Secondary) *In Cycle 4, there were two secondary (administrative) indicators. This score reflects the average of those two scores. Pelican Bay 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 624 patient care events.1 Of the 13 indicators applicable to PBSP, 10 were evaluated by clinician case review; 8 were proficient and 2 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. Program Strengths — Clinical • PBSP provided its patients with excellent access to care. • The institution adapted quickly and expertly to the new electronic health record system (EHRS). PBSP staff leveraged the built-in EHRS messaging capability to ensure that their patients received the necessary health care services. • For patients returning from an outside emergency department (ED) or hospital, PBSP implemented well-planned processes to ensure continuity of care. • Nursing care was excellent in all clinical areas. • The institution’s providers also excelled at delivering quality medical care. • CTC providers and nurses at PBSP also excelled at providing care for their infirmary patients. • PBSP was able to provide the needed specialty services for its patients, despite the institution’s remote locale. Program Weaknesses — Clinical • PBSP has had significant difficulty recruiting providers and has been unable to fill physician vacancies. According to PBSP medical leadership, future attrition of providers could degrade on-call provider performance, because there will be even fewer providers available. • On-call provider performance at the institution was occasionally unreliable. 1 Each OIG clinician team includes a board-certified physician and a registered nurse consultant with experience in correctional and community medical settings. Pelican Bay State Prison, Cycle 5 Medical Inspection Page v Office of the Inspector General State of California Compliance Testing Results Of the 13 health care indicators applicable to PBSP, 10 were evaluated by compliance inspectors.2 Of these, four were proficient, three were adequate, and three were inadequate. There were 83 individual compliance questions within those ten indicators, generating 898 data points that tested PBSP’s compliance with California Correctional Health Care Services (CCHCS) policies and procedures.3 Those 83 questions are detailed in Appendix A — Compliance Test Results. Program Strengths — Compliance The following are some of PBSP’s strengths based on its compliance scores on individual questions in all the health care indicators: • Patients with chronic care conditions received provider follow-up appointments within required time frames. In addition, nursing staff generally reviewed patient health care service requests the same day received, and nursing staff conducted face-to-face encounters with those patients within required time frames. • Patients received diagnostic services within ordered time frames, and providers timely reviewed the diagnostic service results. • PBSP staff scanned specialty service reports and hospital discharge documents into the electronic medical record within required time frames. • PBSP performed exceptionally well in providing preventive medical services to its patients, including administering medication to, and monitoring, patients receiving tuberculosis (TB) medications. In addition, the institution performed well in screening patients annually for TB, and offering influenza immunizations and colorectal cancer screenings. • The institution provided high-priority and routine specialty service appointments timely, and providers generally reviewed high-priority and routine specialty service reports within required time frames. Program Weaknesses — Compliance The following are some of the weaknesses identified by PBSP’s compliance scores on individual questions in all the health care indicators: • Inspectors observed clinician hand hygiene practices at several clinic locations at PBSP and found that some clinicians did not properly sanitize their hands before or after patient 2 The OIG’s compliance inspectors are 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 for which CCHCS policies and procedures did not specifically address an issue. Pelican Bay State Prison, Cycle 5 Medical Inspection Page vi Office of the Inspector General State of California contact. In addition, not all clinic examination rooms had adequate space to perform a comprehensive examination, and some examination tables had torn vinyl coverings. • Patients did not always receive their chronic care medication within required time frames, and several medication line locations at PBSP did not complete proper inventory counts of narcotic medications. Recommendations The OIG had no specific recommendations. Population-Based Metrics In general, PBSP performed well as measured by population-based metrics. In comprehensive diabetes care, PBSP outperformed statewide and national health care plans in most of the five diabetic measures, with blood pressure control as the only measure in which PBSP scored slightly lower compared to one health care plan. With regard to immunization measures, PBSP’s rates were lower or only matched the score of all other health care plans for influenza immunizations for both younger and older patients, and for pneumococcal immunizations. For colorectal cancer screenings, PBSP scored lower than all but one health care plan. However, for both immunizations and colorectal cancer screenings, patient refusals negatively affected the institution’s score. Overall, PBSP has a good chronic care program compared to the other state and national health care plans reviewed. The institution could improve its scores for immunizations and colorectal cancer screenings by increasing patient education concerning the benefits of these preventive services. Pelican Bay State Prison, Cycle 5 Medical Inspection Page vii 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. Pelican Bay State Prison (PBSP) was the 17th medical inspection of Cycle 5. During the inspection process, the OIG assessed the delivery of medical care to patients using the primary clinical health care indicators applicable to the institution. The Administrative Operations indicator is secondary because it does not reflect the actual clinical care provided. ABOUT THE INSTITUTION PBSP is located in Crescent City in Del Norte County. The institution is designed to house California’s most serious criminal offenders in a secure, safe, and disciplined institutional setting. PBSP has one Level I minimum-security yard, one facility housing Level II patients, and two Level IV yards housing maximum-security patients in a general population setting. In addition, PBSP has a security housing unit (SHU) facility, which is designed for individuals who present serious management concerns, including prison gang members and violent maximum-security patients. The institution operates multiple clinics where medical staff handle non-urgent requests for medical services. It also provides inpatient care at its correctional treatment center (CTC) and treats patients needing urgent or emergent care in its triage and treatment area (TTA). PBSP has been designated by CDCR as a “basic care prison,” secondary to its location in a rural area away from tertiary care centers and specialty care providers whose services would likely be frequently used by higher-risk patients. On August 8, 2016, PBSP received national accreditation from the Commission on Accreditation for Corrections. This accreditation program is a professional peer review process based on national standards set by the American Correctional Association. Based on staffing data the OIG obtained from the institution, PBSP’s vacancy rate among medical managers, primary care providers, supervisors, and rank-and-file nurses was 21 percent in June 2017. The highest vacancy percentage was among primary care providers at 45 percent. Finally, four staff were on long-term medical leave. Pelican Bay State Prison, Cycle 5 Medical Inspection Page 1 Office of the Inspector General State of California PBSP Health Care Staffing Resources as of June 2017 Primary Care Nursing Management Nursing Staff Totals Providers Supervisors Description Number % Number % Number % Number % Number % Authorized 5 6% 5.5 6% 9.5 10% 70.9 78% 90.9 100% Positions Filled Positions 4 80% 3 55% 6 63% 59 83% 72 79% Vacancies 1 20% 2.5 45% 3.5 37% 11.9 17% 18.9 21% Recent Hires (within 12 1 25% 0 0% 3 50% 15 25% 19 26% 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% 0 0% 4 7% 4 6% Medical Leave Note: PBSP Health Care Staffing Resources data was not validated by the OIG. As of June 5, 2017, the Master Registry for PBSP showed that the institution had a total population of 2,039. Within that total population, 0.2 percent was designated as high medical risk, Priority 1 (High 1), and 1.7 percent was 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 are those at medium or low medical risk. Patients at high medical risk also typically require more health care services than patients do at 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. PBSP Master Registry Data as of June 5, 2017 Medical Risk Level Number of Patients Percentage High 1 4 0.2% High 2 34 1.7% Medium 352 17.3% Low 1,649 80.9% Total 2,039 100.0% Pelican Bay 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 PBSP Executive Summary Table on page iv of this report. The OIG rates each of the quality indicators applicable to the institution under inspection based on case reviews conducted by OIG clinicians and compliance tests conducted by OIG registered nurses. The ratings may be derived from the case review results alone, the compliance test results alone, or a combination of both these information sources. For example, the ratings for the primary quality indicators Quality of Nursing Performance and Quality of Provider Performance are derived entirely from the case review done by clinicians, while the ratings for the primary quality indicators Health Care Environment and Preventive Services are derived entirely from compliance testing done by registered nurse inspectors. As another example, primary quality indicators such as Diagnostic Services and Specialty Services receive ratings derived from both sources. Consistent with the OIG’s agreement with the Receiver, this report only addresses the conditions found related to medical care criteria. The OIG does not review for efficiency and economy of operations. Moreover, if the OIG learns of a patient needing immediate care, the OIG notifies the chief executive officer of health care services and requests a status report. Additionally, if the OIG learns of significant departures from community standards, it may report such departures to the institution’s chief executive officer or to CCHCS. Because these matters involve confidential medical information protected by state and federal privacy laws, specific identifying details related to any such cases are not included in the OIG’s public report. In all areas, the OIG is alert for opportunities to make appropriate recommendations for improvement. Such opportunities may be present regardless of the score awarded to any particular Pelican Bay 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. As there were only 38 patients at PBSP classified by CCHCS as High 1 or High 2, the majority of patients selected for retrospective chart review were high-utilizing patients with chronic care illnesses who were classified as high or medium risk. 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 Pelican Bay 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 it 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: PBSP Sample Sets, the OIG clinicians evaluated medical charts for 46 unique patients. Appendix B, Table B-4: PBSP Case Review Sample Summary clarifies that both nurses and physicians reviewed charts for 14 of those patients, for 60 reviews in total. Physicians performed detailed reviews of 20 charts, and nurses performed detailed reviews of Pelican Bay State Prison, Cycle 5 Medical Inspection Page 5 Office of the Inspector General State of California 15 charts, totaling 35 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 25 patients. These generated 624 clinical events for review (Appendix B, Table B–3: PBSP 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 3 chronic care patient records, i.e., 3 diabetes patients (Appendix B, Table B-1: PBSP Sample Sets), the 46 unique patients sampled included patients with 109 chronic care diagnoses, including 4 additional patients with diabetes (for a total of 7) (Appendix B, Table B-2: PBSP 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 was 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 re-analyzed 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. PBSP is a basic facility, and the physician sample was 67 percent of the Cycle 4 sample. With regard to reviewing charts from different providers, the case review is not intended to be a focused search for poorly performing providers; rather, it is focused on how the system cares for those patients who need care the most. Nonetheless, while not sampling cases by each provider at the institution, the OIG inspections adequately review most providers. Providers would only escape OIG case review if institutional management successfully mitigated patient risk by having the more poorly performing providers care for the less complicated, low-utilizing, and lower-risk patients. 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 proficient (excellent), adequate (passing), inadequate (failing), or not applicable. A separate Pelican Bay State Prison, Cycle 5 Medical Inspection Page 6 Office of the Inspector General State of California confidential PBSP Supplemental Medical Inspection Results: Individual Case Review Summaries report details the case reviews OIG clinicians conducted and is available to specific stakeholders. For further details regarding the sampling methodologies and counts, see Appendix B — Clinical Data, Table B-1; Table B-2; Table B-3; and Table B-4. COMPLIANCE TESTING Sampling Methods for Conducting Compliance Testing From June to August 2017, registered nurse inspectors obtained answers to 83 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 311 individual patients and analyzed specific transactions within their records for evidence that critical events occurred. Inspectors also reviewed management reports and meeting minutes to assess certain administrative operations. In addition, during the week of June 19, 2017, registered nurse field inspectors conducted a detailed onsite inspection of PBSP’s medical facilities and clinics; interviewed key institutional employees; and reviewed employee records, logs, medical appeals, death reports, and other documents. This generated 898 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 PBSP’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 offered 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 it has 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 83 questions for the ten 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 Pelican Bay State Prison, Cycle 5 Medical Inspection Page 7 Office of the Inspector General State of California results, the OIG assigned a rating to each quality indicator of proficient (greater than 85 percent), adequate (between 75 percent and 85 percent), or inadequate (less than 75 percent). OVERALL QUALITY INDICATOR RATING FOR CASE REVIEWS AND COMPLIANCE TESTING The OIG derived the final rating for each quality indicator by combining the ratings from the case reviews and from the compliance testing, as applicable. When combining these ratings, the case review evaluations and the compliance testing results usually agreed, but there were instances when the rating differed for a particular quality indicator. In those instances, the inspection team assessed the quality indicator based on the collective ratings from both components. Specifically, the OIG clinicians and registered nurse inspectors discussed the nature of individual exceptions found within that indicator category and considered the overall effect on the ability of patients to receive adequate medical care. To derive an overall assessment rating of the institution’s medical inspection, the OIG evaluated the various rating categories assigned to each of the quality indicators applicable to the institution, giving more weight to the rating results of the primary quality indicators, which directly relate to the health care provided to patients. Based on that analysis, OIG experts made a considered and measured overall opinion about the quality of health care observed. POPULATION-BASED METRICS The OIG identified a subset of Healthcare Effectiveness Data Information Set (HEDIS) measures applicable to the CDCR patient population. To identify outcomes for PBSP, the OIG reviewed some of the compliance testing results, randomly sampled additional patients’ records, and obtained PBSP data from the CCHCS Master Registry. The OIG compared those results to HEDIS metrics reported by other statewide and national health care organizations. Pelican Bay 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 PBSP Executive Summary Table on page iv of this report, 13 of the OIG’s indicators were applicable to PBSP. Of those 13 indicators, 7 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, was not relied upon for the overall score for the institution. Based on the analysis and results in all the primary indicators, the OIG experts made a considered and measured opinion that the quality of health care at PBSP was proficient. Summary of Case Review Results: The clinical case review component assessed 10 of the 13 primary (clinical) indicators applicable to PBSP. Of these 10 indicators, OIG clinicians rated eight proficient and two adequate. The OIG physicians rated the overall adequacy of care for each of the 20 detailed case reviews they conducted. Of these 20 cases, 10 were proficient, 8 were adequate, and 2 were inadequate. In the 624 events reviewed, there were 64 deficiencies, of which 14 were considered to be of such magnitude that, if left unaddressed, they would likely contribute to patient harm. Adverse Events Identified During Case Review: Adverse events are medical errors that cause serious patient harm. Medical care is a complex and dynamic process with many moving parts, subject to human error even within the best health care organizations. Adverse events are typically identified and tracked by all major health care organizations for the purpose of quality improvement. They are not generally representative of medical care delivered by the organization. The OIG identified adverse events for the dual purposes of quality improvement and the illustration of problematic patterns of practice found during the inspection. Because of the anecdotal nature of these events, the OIG cautions against drawing inappropriate conclusions regarding the institution based solely on adverse events. One adverse event was identified in the case reviews at PBSP. This event is duplicated in the Emergency Services indicator and is detailed below: • In case 21, the patient had recently undergone surgery for severe hemorrhoids. The following errors resulted in the OIG classifying this case as an adverse event: o After the surgery, the patient complained that he had an increase in rectal bleeding and was feeling weak and shaky. The patient required a wheelchair. Orthostatic vital signs (vital signs obtained in the reclining, sitting, and standing positions) were unstable, which suggested that the patient was severely dehydrated and could have lost a large amount of blood. The provider ignored these unstable vital signs, did not order intravenous fluid rehydration, and did not obtain any laboratory tests. Instead, the provider released the patient back to his regular housing. Pelican Bay State Prison, Cycle 5 Medical Inspection Page 9 Office of the Inspector General State of California o Three days later, the patient went to the triage and treatment area (TTA) for continued rectal bleeding. This time, the nurse did not perform any orthostatic vital signs, and the provider again sent the patient back to housing without performing an evaluation. Less than three hours later, the patient developed severe weakness and confusion. The patient was barely conscious and developed severely unstable breathing. His oxygen levels dropped to dangerously low levels, despite supplemental oxygen administration. The patient was sent emergently to a community hospital, where he was found to have lost an extremely large amount of blood. After receiving a blood transfusion in the emergency room, he was sent back to the institution. o A provider accepted the patient back to the institution prematurely from the emergency room. The provider should have insisted on post-transfusion blood tests to ensure that the patient’s bleeding had stopped, but instead allowed the patient’s return to the institution without obtaining sufficient information for proper decision-making. o When the patient returned from the emergency room, providers did not order appropriate monitoring for him. The next test should have been performed immediately to determine whether the single earlier blood transfusion had been enough for the patient’s anemia. When the test was eventually performed, the provider did not interpret the test results correctly. The results showed that the patient had already lost most of the blood transfused in the emergency room and may have still been bleeding. Fortunately, the bleeding stopped spontaneously, and the patient did not require further intervention. Summary of Compliance Results: The compliance component assessed 10 of the 13 indicators applicable to PBSP. Of these ten indicators, OIG inspectors rated four proficient, three 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. Pelican Bay State Prison, Cycle 5 Medical Inspection Page 10 Office of the Inspector General State of California ACCESS TO CARE This indicator evaluates the institution’s ability to provide patients Case Review Rating: with timely clinical appointments. Areas specific to patients’ access Proficient to care are reviewed, such as initial assessments of newly arriving Compliance Score: patients, acute and chronic care follow-ups, face-to-face nurse Proficient appointments when a patient requests to be seen, provider referrals (86.5%) from nursing lines, and follow-ups after hospitalization or specialty Overall Rating: care. Compliance testing for this indicator also evaluates whether Proficient patients have Health Care Services Request forms (CDCR Form 7362) available in their housing units. Case Review Results The OIG clinicians reviewed 165 provider, nurse, specialty, and hospital events requiring follow-up appointments. Six deficiencies were identified relating to Access to Care, two of which were significant. Provider-to-Provider Follow-up Appointments PBSP performed extremely well with provider ordered follow-up appointments. All appointments were scheduled, and delays were rare. RN Sick Call Access RN sick call access was very good. Patients were seen within appropriate time frames. RN-to-Provider Referrals Nurse-to-provider referral appointments were also scheduled appropriately, and no significant errors were observed. RN Follow-up Appointments PBSP performed well in follow-up appointments with its registered nurses (RNs). No patterns of errors were found in this area, but one deficiency resulting from an oversight was noted in the following: • In case 34, the nurse planned to refer the patient with back pain for RN follow-up in 14 days, but neglected to make the referral. Provider Follow-up After Specialty Services PBSP consistently arranged timely patient appointment follow-ups with providers after the patients returned from specialty services. No significant problems were identified in this area. Pelican Bay State Prison, Cycle 5 Medical Inspection Page 11 Office of the Inspector General State of California Intra-System Transfers / Reception Center PBSP performed effectively with ensuring provider and nurse follow-up appointments after patients transferred into the institution. The OIG clinicians identified no significant problems. Follow-up After Hospitalization PBSP excelled in ensuring consistent provider follow-ups after hospitalization. Follow-up After Urgent/Emergent Care PBSP reliably ensured that patients who were seen in the TTA received their follow-up appointments. Only one error was found in this area, detailed below: • In case 5, the RN emergency medical responder assessed the patient for chest pain and scheduled an RN follow-up in the morning. The RN follow-up occurred a day late due to institution-wide tuberculosis (TB) testing. Specialized Medical Housing When patients were admitted to the CTC at PBSP, providers evaluated them promptly. Providers also performed their rounds within the appropriate time frames. No deficiencies were identified in this area. Specialty Access and Follow-up PBSP dependably scheduled appointments with specialists for needed consultations and procedures. Performance in this area is also discussed in the Specialty Services indicator. Diagnostic Results Follow-up PBSP providers appropriately ordered follow-up appointments whenever they reviewed abnormal diagnostic results. Such appointments were scheduled timely and occurred reliably. Clinician Onsite Inspection PBSP managers explained that the majority of the deficiencies identified either were due to initial unfamiliarity with the new electronic health record system (EHRS) or were isolated performance errors. When the EHRS was first implemented, PBSP staff identified various flaws with the scheduling processes and quickly moved to correct those concerns. PBSP managers believed that they had adequately identified and corrected the scheduling process deficiencies shortly after the EHRS was implemented. Case Review Conclusion PBSP performed extremely well with regard to Access to Care, with this indicator rated proficient. Pelican Bay State Prison, Cycle 5 Medical Inspection Page 12 Office of the Inspector General State of California Compliance Testing Results The institution performed in the proficient range in the Access to Care indicator, with a compliance score of 86.5 percent; performing well on the following tests: • For 27 of the 30 sampled patients who submitted health care services request forms (90 percent), nursing staff completed face-to-face encounters with them within one business day of reviewing the service request form. For one patient, the nurse conducted the face-to-face visit two days late. For two other patients, their face-to-face visits never occurred (MIT 1.004). • OIG inspectors reviewed recent appointments for 25 patients with chronic care conditions and found that 22 of them (88 percent) received timely routine appointments. Three patients received chronic care appointments from 2 to 87 days late (MIT 1.001). • OIG inspectors sampled 30 health care services request forms and found that nursing staff reviewed the forms on the same day received for 26 of them (87 percent). For four sampled patients, nursing staff reviewed the services request forms one day after the forms were received (MIT 1.003). • Of the seven sampled health care services request forms that resulted in nursing staff referring the patient for a provider appointment, six such appointments (86 percent) were timely received by patients. For one patient, no evidence was found that the appointment occurred (MIT 1.005). Two tests received adequate scores: • Primary care provider visits occurred timely for 21 of the 25 sampled patients (84 percent) who either transferred into PBSP with a pre-existing chronic care primary-care provider visit need or who, upon arrival, received a new provider referral from the PBSP screening nurse. Three patients received their appointments from 7 to 19 days late, and one other patient received his appointment 175 days late (MIT 1.002). • Patients had access to health care services request forms at five of the six housing units inspected (83 percent). One inspected housing unit, however, had no supply of the forms available for patients to complete, nor did it have a secure, locking box for patients to use when confidentially submitting their requests (MIT 1.101). One test showed room for improvement: • OIG inspectors sampled 27 patients who received a high-priority or routine specialty service; 20 of them (74 percent) received a timely follow-up appointment with a provider. Six patients received follow-up appointments from one to 47 days late, and one other patient never received an appointment at all (MIT 1.008). Pelican Bay State Prison, Cycle 5 Medical Inspection Page 13 Office of the Inspector General State of California DIAGNOSTIC SERVICES This indicator addresses several types of diagnostic services. Case Review Rating: Specifically, it addresses whether radiology and laboratory services 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 (75.2%) addition, for pathology services, the OIG determines whether the Overall Rating: institution received a final pathology report and whether the provider Adequate timely reviewed and communicated the pathology results to the patient. The case reviews also factor in the appropriateness, accuracy, and quality of the diagnostic test(s) ordered and the clinical response to the results. Case Review Results The OIG clinicians reviewed 92 diagnostic events, noting 11 deficiencies of which only one was significant. None concerned the completion of ordered tests. All deficiencies noted pertained to health information management. Test Completion PBSP performed superbly in completing ordered diagnostic tests. No deficiencies were identified in this area. Health Information Management Most diagnostic test results were reviewed by a provider, who signed off on them in a timely manner. The OIG clinicians identified one significant deviation with respect to report handling: • In case 11, an X-ray of the spine was not reviewed or signed by a provider. Patterns of minor deficiencies were also identified in the case reviews. In several cases, providers did not notify their patients of laboratory or X-ray test results, or inform their patients of their electrocardiogram (EKG) test results. In two cases, laboratory results ordered by a mental health provider that were supposed to be reviewed within two business days were not reviewed until two and three weeks later, respectively. Clinician Onsite Inspection PBSP managers expressed the belief that some of the deficiencies identified could be explained by their providers’ initial unfamiliarity with the new EHRS. The managers also informed the OIG clinicians that the institution’s providers were trained to notify all their patients of diagnostic results, a requirement PBSP managers planned to re-emphasize. Pelican Bay State Prison, Cycle 5 Medical Inspection Page 14 Office of the Inspector General State of California Case Review Conclusion PBSP performed flawlessly with regard to diagnostic test completion. However, the institution’s providers did not consistently notify their patients of their diagnostic test results. The OIG clinicians rated the Diagnostic Services indicator adequate. Compliance Testing Results The institution received an adequate compliance score of 75.2 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 • In all ten sampled radiology services, the services were timely performed and the ordering provider timely reviewed the diagnostic report results (MIT 2.001, 2.002). PBSP providers timely communicated the test results to only six of the ten patients (60 percent). For three patients, providers communicated the results from 5 to 99 days late. For one additional patient, the provider issued a letter, but did not reference the specific test results in the letter (MIT 2.003). Laboratory Services • Nine of the ten sampled patients (90 percent) received their provider-ordered laboratory services timely; one of the ten services was provided two days late (MIT 2.004). The institution’s providers timely reviewed all of the resulting laboratory services report results within required time frames (MIT 2.005). Providers timely communicated results to only one of the ten sampled patients (10 percent). For eight patients, letters were issued, but did not indicate which test results were being referenced. For one other patient, the OIG inspectors found no evidence in the patient’s medical record that he had received notification of the test result (MIT 2.006). Pathology Services • PBSP received the final pathology reports timely for all six sampled patients, and providers properly evidenced their review of the corresponding final pathology results for all of those sampled reports (MIT 2.007, 2.008). However, providers timely communicated the final pathology results to only one of the six sampled patients (17 percent). For the other five patients, providers communicated the results between 3 and 17 days late (MIT 2.009). Pelican Bay State Prison, Cycle 5 Medical Inspection Page 15 Office of the Inspector General State of California EMERGENCY SERVICES An emergency medical response system is essential to providing effective and timely emergency medical response, assessment, Case Review Rating: treatment, and transportation 24 hours per day. Provision of Adequate urgent/emergent care is based on a patient’s emergency situation, Compliance Score: Not Applicable clinical condition, and need for a higher level of care. The OIG reviews emergency response services including first aid, basic life Overall Rating: support (BLS), and advanced cardiac life support (ACLS) consistent Adequate 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/emergent events and found ten deficiencies with various aspects of emergency care. Of these ten, five were considered significant. CPR Response and Emergency Preparedness PBSP performed well with emergency response times, emergency interventions (including CPR), and 9-1-1 activation. However, PBSP demonstrated that the institution was ill prepared for an emergency response when an emergency medication was not readily available at the scene, as noted in the following example: • In case 4, the intranasal naloxone (a medication used to treat a drug overdose) was not available during the emergency medical response for a patient with a possible drug overdose. PBSP explained that at the time of the incident, statewide policy prevented the institution from placing the medication in the emergency medical response bags. However, by the time of the onsite inspection, the institution had corrected this flawed policy and had put the critical medications into the emergency medical response bags. Provider Performance PBSP providers performed satisfactorily for most patients in urgent or emergent situations. However, on a few occasions, providers’ performance could be improved, as noted in the following: • In case 7, nurses notified on-call providers of the patient’s dangerously high blood sugar levels on multiple occasions. The on-call providers repeatedly did not refer the patient back to the primary care provider for review of the patient’s poor diabetic control. Pelican Bay State Prison, Cycle 5 Medical Inspection Page 16 Office of the Inspector General State of California • In case 8, the nurse notified the on-call provider of a severely elevated blood sugar level. As in the preceding case, the on-call provider did not refer the patient back to the primary care provider for review of the patient’s poor diabetic control. • In case 21, the patient had recently undergone surgery for severe hemorrhoids. The following errors resulted in the OIG classifying this case as an adverse event as discussed in the Medical Inspection Results section of this report: o After the surgery, the patient was sitting in a wheelchair and complained that he had an increase in rectal bleeding, and was feeling weak and shaky during the nurse’s assessment. Orthostatic vital signs (vital signs obtained in the reclining, sitting, and standing positions) were unstable, which suggested that the patient was severely dehydrated and could have lost a large amount of blood. The provider ignored these unstable vital signs, did not order intravenous fluid rehydration, and did not obtain any laboratory tests. Instead, the provider released the patient back to his regular housing. o Three days later, the patient went to the TTA for continued rectal bleeding. This time, the nurse did not perform any orthostatic vital signs, and the provider again sent the patient back to housing without performing an evaluation. Less than three hours later, the patient developed severe weakness and confusion. The patient was barely conscious and developed severely unstable breathing. His oxygen levels dropped to dangerously low levels, despite supplemental oxygen administration. The patient was sent emergently to a community hospital, where he was found to have lost an extremely large amount of blood. After receiving a blood transfusion in the emergency room, he was sent back to the institution. o A provider accepted the patient prematurely from the emergency room. That provider should have insisted on post-transfusion blood tests to ensure that the patient’s bleeding had stopped, but instead allowed the patient’s return to the institution without obtaining sufficient information for proper decision-making. o When the patient returned from the emergency room, providers did not order appropriate monitoring for him. The next test should have been performed immediately to determine whether the single earlier blood transfusion had been enough for the patient’s anemia. When the test was eventually performed, the provider did not interpret the test results correctly. The results showed that the patient had already lost most of the blood transfused in the emergency room and may have still been bleeding. Fortunately, the bleeding eventually stopped spontaneously, and the patient did not require further intervention. Pelican Bay State Prison, Cycle 5 Medical Inspection Page 17 Office of the Inspector General State of California Nursing Performance PBSP nurses performed well during emergency responses. The nurses responded quickly, made good assessments, and provided appropriate care. The OIG clinicians identified minor nursing deficiencies related to inadequate assessment and documentation in only two cases, which did not affect the quality of care. Emergency Medical Response Review Committee (EMRRC) The OIG clinicians reviewed the committee’s meeting minutes for the cases reviewed. The EMRRC promptly reviewed emergency medical responses and successfully identified various problems with emergency procedures such as inadequate intervention, incomplete documentation, communication issues, and the death notification process. Clinician Onsite Inspection The OIG clinicians toured the TTA and interviewed TTA staff. The TTA was adequately equipped, and its staff were prepared to handle any emergent event. A serious altercation between multiple prisoners occurred while the OIG clinicians were inspecting the institution. The PBSP emergency response was prompt, organized, and appropriate. Case Review Conclusion PBSP was well prepared for emergencies, demonstrating good performance in most of the cases reviewed. On-call provider performance was generally satisfactory, but occasionally unreliable. There was one adverse event in case 21, in which providers made multiple significant errors, but this case was not representative of the institution’s normally good performance. With regard to Emergency Services, the indicator rating was thus adequate. Pelican Bay State Prison, Cycle 5 Medical Inspection Page 18 Office of the Inspector General State of California HEALTH INFORMATION MANAGEMENT Health information management is a crucial link in the delivery of Case Review Rating: medical care. Medical personnel require accurate information in Proficient order to make sound judgments and decisions. This indicator Compliance Score: examines whether the institution adequately manages its health care Adequate information. This includes determining whether the information is (83.1%) correctly labeled and organized and available in the electronic health Overall Rating: record; whether the various medical records (internal and external, Proficient 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. For this indicator, the OIG’s case review and compliance review processes yielded different results, with the case review giving a proficient rating and the compliance testing resulting in an adequate score. For PBSP, the case review findings were more reflective of the care provided at the institution due to a larger sample size available for review. Compliance testing had a significantly smaller sample size for certain tests, and the institution also performed sufficiently in those available tests. The OIG’s internal review process considered those factors that led to both scores and ultimately rated this indicator proficient. PBSP converted to the new electronic health record system (EHRS) in September 2016; therefore, most testing occurred in the EHRS, with a minor portion of the review occurring in the electronic unit health record (eUHR). Case Review Results The OIG clinicians reviewed 624 events and found 18 deficiencies related to health information management, only 3 of which were significant. Inter-Departmental Transmission PBSP demonstrated excellent inter-departmental transmission processes. Providers, nurses, and pharmacists ably communicated their patients’ needs and concerns via the EHRS messaging system and shared message pools. There were no concerns in this area. Hospital Records The institution performed extremely well with retrieving hospital and emergency room records. In the vast majority of cases, the proper documentation was promptly retrieved, reviewed by a provider, and scanned into the medical record. Only one minor delay was identified in this area. Pelican Bay State Prison, Cycle 5 Medical Inspection Page 19 Office of the Inspector General State of California Specialty Services Specialty report handling was usually good. Performance in this area is also discussed in the Specialty Services indicator. Diagnostic Reports Diagnostic report handling was sufficient. A pattern was observed whereby PBSP providers did not always notify patients of their test results. Performance in this area is also discussed in the Diagnostic Services indicator. Urgent/Emergent Records No problems were found with the handling of urgent or emergent records. These records were properly completed and filed in the EHRS. Scanning Performance Most records no longer required scanning with the institution’s conversion to the EHRS. However, for those documents that still required scanning, the OIG clinicians identified no concerns. Legibility Legibility was good because most documents were typed or dictated into the EHRS. Clinician Onsite Inspection The OIG clinicians met with PBSP supervisors to discuss their health information management performance. PBSP has leveraged its extensive experience with a different electronic medical record system and applied its institutional knowledge to the EHRS. When PBSP made the transition to the EHRS, several new challenges arose, yet the institution quickly identified and corrected any related issues. Case Review Conclusion PBSP performed superbly with regard to Health Information Management, and the indicator rating was thus proficient. Compliance Testing Results The indicator received an adequate score of 83.1 percent, with the following test receiving a proficient score: • For 18 of 20 sampled specialty service consultant reports (90 percent), PBSP staff scanned the reports into the patient’s health record file within five calendar days. Two documents were both scanned one day late (MIT 4.003). Pelican Bay State Prison, Cycle 5 Medical Inspection Page 20 Office of the Inspector General State of California Two tests received scores in the adequate range: • PBSP’s health information staff timely scanned four of the five sampled requests for health care services (80 percent). One health care services request form was scanned two days late (MIT 4.001). • The institution scored 79 percent in its labeling and filing of documents scanned into patients’ electronic unit health records. For this test, the OIG bases its score on an allowable maximum of 24 mislabeled or misfiled documents. For the PBSP medical inspection, inspectors identified five mislabeled or misfiled documents (MIT 4.006). Pelican Bay State Prison, Cycle 5 Medical Inspection Page 21 Office of the Inspector General State of California HEALTH CARE ENVIRONMENT This indicator addresses the general operational aspects of the Case Review Rating: institution’s clinics, including certain elements of infection control Not Applicable and sanitation, medical supplies and equipment management, the Compliance Score: availability of both auditory and visual privacy for patient visits, and Inadequate (71.5%) the sufficiency of facility infrastructure to conduct comprehensive medical examinations. Rating of this component is based entirely on Overall Rating: the compliance testing results from the visual observations inspectors Inadequate make at the institution during their onsite visit. This indicator is evaluated entirely by compliance testing. There is no case review portion. Compliance Testing Results The institution received an inadequate compliance score of 71.5 percent in the Health Care Environment indicator, showing room for improvement in the following test areas: • Inspectors examined emergency medical response bags (EMRBs) and crash carts to determine whether they were inspected daily, inventoried monthly, and contained all essential items. EMRBs and crash carts were compliant in only three of the eight clinical locations where they were stored (38 percent). One or more of the following deficiencies were found at five locations: EMRB logs were missing entries evidencing staff had verified the bag’s compartments were sealed and intact; one EMRB was missing a large blood pressure cuff; and emergency crash carts were found storing medical supplies beyond manufacturers’ guidelines (MIT 5.111). • Only four of nine clinic examination rooms observed (44 percent) had appropriate space, configuration, supplies, and equipment to allow clinicians to perform proper clinical examinations. Five clinics had one or more of the following deficiencies identified: examination room tables had torn vinyl covers; and one examination room did not have adequate space to perform patient examinations (Figure 1) (MIT 5.110). • PBSP appropriately disinfected, cleaned, and sanitized five of nine clinic locations inspected (56 percent). At three different locations, cleaning logs were not maintained regularly by the cleaning crew. At one Figure 1: Examination room with insufficient space clinic, the examination room’s floor had extensive dirt (measures 63 sq. ft.) and built-up dust (MIT 5.101). Pelican Bay State Prison, Cycle 5 Medical Inspection Page 22 Office of the Inspector General State of California • When inspectors examined PBSP’s nine clinics to verify that adequate hygiene supplies were available and sinks were operable, only five of nine clinics (56 percent) were in compliance. Specifically, four separate clinics’ patient restrooms had insufficient quantities of hygiene supplies such as antiseptic soap and disposable hand towels (MIT 5.103). • Only six of ten clinic locations (60 percent) met compliance requirements for essential core medical equipment and supplies. The remaining four clinics were missing one or more functional pieces of properly calibrated core equipment or other medical supplies necessary to conduct a comprehensive examination. The missing items included an examination table, tips for an otoscope device, hemoccult cards, and developer. In addition, one nebulization unit had an expired calibration sticker (MIT 5.108). • OIG inspectors observed that PBSP clinicians in six of nine clinics adhered to universal hand hygiene precautions. In three clinics, however, providers did not sanitize or wash their hands prior to putting on gloves or after physically examining patients. As a result, PBSP scored 67 percent in this test (MIT 5.104). • OIG inspectors found that six of the nine clinics (67 percent) followed adequate medical supply storage and management protocols. Three clinics’ storage rooms did not have a system in place to ensure that medical supplies in clinics were stocked or re-stocked on a regular basis (MIT 5.107). Several other areas, however, received perfect scores, which fell in the proficient range: • At all seven applicable clinics, clinical health care staff made sure that reusable invasive and non-invasive medical equipment was either properly sterilized or disinfected (MIT 5.102). • Health care staff at all nine clinics followed proper protocols to mitigate exposure to blood-borne pathogens and contaminated waste (MIT 5.105). • The non-clinic bulk medical supply storage areas met the supply management process and support needs of the medical health care program, earning PBSP a score of 100 percent in this test (MIT 5.106). • All nine clinics had an environment adequately conducive to providing medical services (MIT 5.109). Pelican Bay State Prison, Cycle 5 Medical Inspection Page 23 Office of the Inspector General State of California Non-Scored Results • The OIG gathered information to determine whether the institution’s physical infrastructure was maintained in a manner that supported health care management’s ability to provide timely or adequate health care. The OIG does not score this question. The OIG inspectors interviewed health care managers, who did not identify any significant concerns. At the time of the OIG’s medical inspection, PBSP had several significant infrastructure projects underway, which included increasing clinic space at four yards. These projects were started in the winter of 2017, and the institution estimated they would be completed by the summer of 2018 (MIT 5.999). Pelican Bay State Prison, Cycle 5 Medical Inspection Page 24 Office of the Inspector General State of California INTER- AND INTRA-SYSTEM TRANSFERS This indicator focuses on the management of patients’ medical needs Case Review Rating: and continuity of patient care during the inter- and intra-system Proficient transfer process. The patients reviewed for this indicator include Compliance Score: those received from, as well as those transferring out to, other CDCR Inadequate (56.0%) institutions. The OIG review includes evaluation of the institution’s ability to provide and document health screening assessments, Overall Rating: initiation of relevant referrals based on patient needs, and the Adequate continuity of medication delivery to patients arriving from another institution. For those patients, the OIG clinicians also review the timely completion of pending health appointments, tests, and requests for specialty services. For patients who transfer out of the institution, the OIG evaluates the ability of the institution to document transfer information that includes pre-existing health conditions, pending appointments, tests and requests for specialty services, medication transfer packages, and medication administration prior to transfer. The OIG clinicians also evaluate the care provided to patients returning to the institution from an outside hospital and check to ensure appropriate implementation of the hospital assessment and treatment plans. For this indicator, the OIG’s case review and compliance review processes yielded different results, with the case review giving a proficient rating and the compliance testing resulting in an inadequate score. For PBSP, the case review findings were more reflective of the care provided at the institution, while smaller sample sizes may have resulted in less accurate compliance findings. The OIG’s internal review process considered those factors that led to both scores and ultimately rated this indicator adequate. Case Review Results The OIG clinicians reviewed 30 inter- and intra-system transfer events, including information from both the sending and receiving institutions. There were four deficiencies, none of which were significant. Transfers In PBSP performed well with the transferring-in process. The OIG clinicians reviewed nine patients who transferred from another CDCR institution and found only two minor deficiencies in this area. R&R nurses at PBSP performed adequate initial health screenings. Patients also received their medications timely, and providers evaluated patients within appropriate time frames. Transfers Out PBSP excelled with patients transferring out to other CDCR institutions. The OIG clinicians reviewed records for seven of these patients. PBSP nurses performed satisfactory face-to-face evaluations prior to patient transfers. In all cases, PBSP sent health care transfer information, medications, and health care equipment with the patient to the receiving institution. Pelican Bay State Prison, Cycle 5 Medical Inspection Page 25 Office of the Inspector General State of California 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. PBSP performed effectively when ensuring that its patients at an outside hospital did not suffer lapses in care when they transferred back to the institution. The OIG reviewed nine hospitalization and outside emergency room events. There were two minor deficiencies, and the OIG inspectors did not identify any pattern of deficiencies. Clinician Onsite Inspection PBSP leadership explained they had an effective quality improvement process that monitored, and continuously identified and corrected problems in the institution’s health systems. The transfer process was one of many health care processes that were continually monitored. When the EHRS was implemented, PBSP staff quickly identified several concerns, including outpatient orders that were automatically discontinued for patients who were hospitalized for more than 48 hours. When necessary, PBSP quickly identified problems and implemented alternative processes that successfully addressed such occurrences. Case Review Conclusion PBSP performed well with regard to Inter- and Intra-System Transfers, and the indicator was thus rated proficient. Compliance Testing Results The institution received an inadequate score of 56.0 percent in the Inter- and Intra-System Transfers indicator, with the following tests showing room for improvement: • The institution scored zero when the OIG inspectors tested three patients who transferred out of PBSP during the onsite inspection to determine whether the patients’ transfer packages included required medications and related documentation. Three packages were missing transfer checklists and medication administration records (MIT 6.101). • The OIG tested 25 patients who transferred into PBSP from another CDCR institution to determine whether they received a complete initial health screening assessment from nursing staff on the day of their arrival. PBSP received a score of 60 percent in this test because nursing staff timely completed this assessment for only 15 of the 25 sampled patients. For the ten exceptions, nurses neglected to answer one or more of the screening form questions (MIT 6.001). Pelican Bay State Prison, Cycle 5 Medical Inspection Page 26 Office of the Inspector General State of California • Of the 25 sampled patients who transferred into PBSP, 10 of them had existing medication orders upon arrival, but only 6 received their medications without interruption (60 percent). Four patients incurred medication interruptions of one or more dosing periods after arrival (MIT 6.003). • Records for five applicable patients who transferred out of PBSP to another CDCR institution were tested to determine whether PBSP identified previously scheduled specialty service appointments on the patients’ health care transfer forms. Nursing staff correctly listed the pending specialty service appointments for three of those five patients (60 percent). Staff failed to list pending specialty service appointments for two patients (MIT 6.004). In the following test, however, the institution scored within the proficient range: • Nursing staff timely completed the assessment and disposition sections of the screening forms for all 25 sampled patients (MIT 6.002). Pelican Bay State Prison, Cycle 5 Medical Inspection Page 27 Office of the Inspector General State of California PHARMACY AND MEDICATION MANAGEMENT This indicator is an evaluation of the institution’s ability to provide Case Review Rating: appropriate pharmaceutical administration and security Proficient management, encompassing the process from the written Compliance Score: prescription to the administration of the medication. By combining Inadequate (72.2%) 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, Adequate 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. For this indicator, the OIG’s case review and compliance review processes yielded different results, with the case review giving a proficient rating and the compliance testing resulting in an inadequate score. Although compliance scores showed poor results in the areas of chronic care medications and return-from-hospital medications, the case review had a considerably larger and more meaningful sample size, and found that the patients received their return-from-hospital medications appropriately and timely. Furthermore, at the onsite inspection, nearly all administration deficiencies were determined to be due to documentation errors, and there was no problem with actual medication continuity. The OIG’s internal review process considered those factors that led to both scores and ultimately rated this indicator adequate. Case Review Results The OIG clinicians evaluated 37 events related to medications and found four deficiencies, none of which were significant. These deficiencies stemmed from the recent transition to the EHRS, as PBSP nursing staff made errors while learning the new process of documenting medication administration in this system. Medication Continuity PBSP did well with medication continuity. No deficiencies were found in this area. Medication Administration PBSP nurses performed satisfactorily in medication administration. The OIG clinicians identified only minor documentation deficiencies, which are noted in the cases below: • In case 2, the nurses on two occasions incorrectly documented that medications were not administered and were not available. At the onsite inspection, however, PBSP showed evidence that the patient received his medications timely and accurately. Pelican Bay State Prison, Cycle 5 Medical Inspection Page 28 Office of the Inspector General State of California • In case 15, the nurse did not document the medication’s administration. However, at the onsite inspection, PBSP showed evidence that it had been administered. • In case 11, it appeared that the nurse administered the same medication twice, but PBSP showed evidence that the patient was not given an extra dose of the medication. Pharmacy Errors The OIG clinicians did not find any deficiencies in this area. Clinician Onsite Inspection The OIG clinicians inquired about the initial apparent medication errors in the case reviews. PBSP successfully demonstrated the medications were administered correctly, offering credible explanations and evidence that these errors resulted from nurses not documenting their medication administration correctly in the EHRS. Case Review Conclusion PBSP continued to perform well with regard to Pharmacy and Medication Management, and the indicator was thus rated proficient. Compliance Testing Results The institution received a compliance score of 72.2 percent in the Pharmacy and Medication Management indicator. For discussion purposes below, this indicator is divided into three sub-indicators: medication administration, observed medication practices and storage controls, and pharmacy protocols. Medication Administration In this sub-indicator, the institution received an average score of 84.8 percent, scoring well in the following tests: • PBSP ensured that all eight sampled patients who transferred from one housing unit to another received their ordered medications without interruption (MIT 7.005). • Inspectors found that 23 of 25 sampled patients (92 percent) received their newly ordered medications in a timely manner. Two patients both received their medications one day late (MIT 7.002). However, the following test received an inadequate score: • Among 16 sampled patients, 10 (63 percent) timely received their ordered chronic care medications. For five patients, no evidence was found that they received all their medications. For one other patient, nursing staff noted on his chart that he refused his KOP Pelican Bay State Prison, Cycle 5 Medical Inspection Page 29 Office of the Inspector General State of California monthly medication replenishment, but no evidence was found that a refusal form was signed (MIT 7.001). Observed Medication Practices and Storage Controls In this sub-indicator, the institution received an average score of 65.4 percent. The following areas showed room for improvement: • The institution employed adequate security controls over narcotic medications in four of the nine applicable clinic and medication line locations where narcotics were stored (44 percent). At five clinics, the narcotics logbook lacked evidence on multiple dates that a controlled substance inventory had been performed by two licensed nursing staff (MIT 7.101). • Inspectors observed the medication preparation and administration processes at six applicable medication line locations. Nursing staff were compliant regarding proper hand hygiene and contamination control protocols at three locations (50 percent). At three locations, not all nursing staff washed or sanitized their hands when required, such as before putting on gloves, or before each subsequent re-gloving (MIT 7.104). • Only three of six inspected medication preparation and administration areas demonstrated appropriate administrative controls and protocols (50 percent). At one location, OIG inspectors observed that PBSP nurses did not follow manufacturer’s guidelines related to properly administering insulin to diabetic patients. The guidelines state that nurses must disinfect previously opened insulin vials before withdrawing and administering the medication, a practice that nurses whom the OIG inspectors observed did not employ. At another medication line location, patients waiting to receive their medications did not have sufficient outdoor cover to protect them from heat or inclement weather. At a third location, the medication nurse did not always ensure whether the patient swallowed direct observation therapy (DOT) medication (MIT 7.106). • PBSP properly stored non-narcotic medications not requiring refrigeration in seven of the ten applicable clinic and medication line storage locations (70 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 multi-use medications were not labeled with the date they were opened (MIT 7.102). One test received an adequate score: • Non-narcotic refrigerated medications were properly stored in seven of the nine clinics and medication line storage locations (78 percent). At two locations, medication refrigerators were left unlocked when not in active use (MIT 7.103). Pelican Bay State Prison, Cycle 5 Medical Inspection Page 30 Office of the Inspector General State of California One test received a proficient score: • Nursing staff at all six of the inspected medication line locations employed appropriate administrative controls and followed appropriate protocols when preparing medications (MIT 7.105). Pharmacy Protocols In this sub-indicator, the institution received an average score of 72.8 percent, composed of scores received at the institution’s main pharmacy. The following two tests showed room for improvement: • The institution’s pharmacist-in-charge (PIC) properly accounted for narcotic medications stored in PBSP’s main pharmacy. OIG inspectors also reviewed monthly inventories of controlled substances in the institution’s clinical and medication line storage locations. However, OIG inspectors found several Medication Area Inspection Checklist forms (CDCR Form 7477) that were missing the name, signature, and date of the PIC responsible for completing each inventory record. As a result, the institution scored zero in this test (MIT 7.110). • OIG inspectors examined 25 Medication Error Follow-up Reports and found 16 were timely or correctly processed (64 percent). Of the remainder, three reports were completed 13 days late, and for one, the OIG inspectors found no evidence the PIC had completed a Medication Error Follow-up Review form (CDCR Form 7541). In addition, OIG inspectors examined five monthly Medication Error Statistical Reports and found the report for June 2016 was submitted to the chief of pharmacy services four days late (MIT 7.111). Three tests received scores in the proficient range: • PBSP’s main pharmacy followed general security, organization, and cleanliness management protocols. In addition, the institution, properly stored non-refrigerated and refrigerated medications (MIT 7.107, 7.108, 7.109). Non-Scored Tests • In addition to the OIG’s testing of reported medication errors, inspectors follow up on any significant medication errors that were found during the compliance testing to determine whether the errors were properly identified and reported. The OIG provides those results for information purposes only. At PBSP, the OIG did not find any applicable medication errors (MIT 7.998). • The OIG interviewed patients in isolation units to determine whether they had immediate access to their prescribed KOP rescue medications. All 11 of the sampled patients had access to their rescue medications (MIT 7.999). Pelican Bay State Prison, Cycle 5 Medical Inspection Page 31 Office of the Inspector General State of California PRENATAL AND POST-DELIVERY SERVICES This indicator evaluates the institution’s capacity to provide timely Case Review Rating: and appropriate prenatal, delivery, and postnatal services to pregnant Not Applicable patients. This includes the ordering and monitoring of indicated Compliance Score: screening tests, follow-up visits, referrals to higher levels of care, e.g., Not Applicable high-risk obstetrics clinic, when necessary, and postnatal follow-up. Overall Rating: Because PBSP is a male-only institution, this indicator did not apply. Not Applicable Pelican Bay State Prison, Cycle 5 Medical Inspection Page 32 Office of the Inspector General State of California PREVENTIVE SERVICES This indicator assesses whether various preventive medical Case Review Rating: services are offered or provided to patients. These include cancer Not Applicable screenings, tuberculosis screenings, and influenza and chronic Compliance Score: care immunizations. This indicator also assesses whether certain Proficient institutions take preventive actions to relocate patients identified (95.5%) as being at higher risk for contracting coccidioidomycosis Overall Rating: (valley fever). Proficient The OIG rates this indicator entirely through the compliance-testing component; the case review process does not include a separate qualitative analysis for this indicator. Compliance Testing Results The institution performed in the proficient range in the Preventive Services indicator, with a compliance score of 95.5 percent. Several tests received scores of proficient: • The OIG examined the health care records of the two patients at PBSP who were on TB medications during the inspection period; both patients received their required medications (MIT 9.001). • For the two patients on TB medications, the institution complied with policy by monitoring both of them at all required intervals (MIT 9.002). • All 25 sampled patients timely received or were timely offered influenza vaccinations during the most recent influenza season (MIT 9.004). • PBSP timely offered colorectal cancer screenings to all 25 sampled patients subject to the annual screening requirement (MIT 9.005). • The institution scored 97 percent for the required annual TB screening of patients. Of the 30 sampled patients, 29 of them were properly screened. For the one exception, the patient’s TB screening form was found to be incomplete (MIT 9.003). One test received an adequate score: • Inspectors tested whether PBSP offered required influenza, pneumonia, and hepatitis vaccinations to patients who suffered from a chronic condition; 13 of the 17 applicable sampled patients (76 percent) received all recommended vaccinations at required intervals. For four patients, no evidence was found that the vaccinations were administered or that the patients were offered one or more of the required vaccinations (MIT 9.008). Pelican Bay State Prison, Cycle 5 Medical Inspection Page 33 Office of the Inspector General State of California QUALITY OF NURSING PERFORMANCE The Quality of Nursing Performance indicator is a qualitative Case Review Rating: evaluation of the institution’s nursing services. The evaluation is Proficient completed entirely by OIG nursing clinicians within the case review Compliance Score: process and does not have a score under the OIG compliance-testing Not Applicable component. Case reviews include face-to-face encounters and Overall Rating: indirect activities performed by nursing staff on behalf of the Proficient patient. Review of nursing performance includes all nursing services performed onsite, such as outpatient, inpatient, urgent/emergent, inmate transfers, care coordination, and medication management. The key focus areas for evaluation of nursing care include appropriateness and timeliness of patient triage and assessment, identification and prioritization of health care needs, use of the nursing process to implement interventions, and accurate, thorough, and legible documentation. Although nursing services provided in specialized medical housing units are reported in the Specialized Medical Housing indicator, and those provided in the TTA or related to emergency medical responses are reported in the Emergency Services indicator, all areas of nursing services are summarized in this Quality of Nursing Performance indicator. Case Review Results The OIG clinicians reviewed 248 nursing encounters, 133 of which were outpatient nursing encounters. Most outpatient nursing encounters were for sick call requests and RN follow-up appointments. In all, there were 14 nursing deficiencies, with none significant enough to affect patient outcomes. The OIG clinicians rated this indicator proficient. Nursing Assessment, Intervention, and Documentation Nurses provided excellent nursing care in all clinical areas. The nurses performed thorough assessments and provided appropriate interventions. Nursing progress notes included pertinent information about the care provided. The nurses were diligent, and they understood their patients’ health care needs. They demonstrated competency in providing necessary nursing care, and communicated well with their peers and other health care providers. While the OIG clinicians did identify various minor nursing deficiencies related to inadequate assessments, lack of appropriate intervention, and incomplete documentation, these deficiencies were unlikely to contribute to patient harm. Nursing Sick Call The OIG clinicians reviewed 77 nursing sick call visits. Each clinic usually received an average of 15 sick call requests per day. PBSP nurses reviewed sick call requests on the same day to identify patients with symptoms needing a same-day urgent evaluation. All other patients with medical symptoms were scheduled for RN assessment on the next business day. Each main clinic had a primary care RN who saw about ten patients daily for episodic care and RN follow-ups. The nurses recognized potentially urgent conditions, performed adequate assessments, and made appropriate Pelican Bay State Prison, Cycle 5 Medical Inspection Page 34 Office of the Inspector General State of California interventions and dispositions. The OIG clinicians identified ten minor nursing deficiencies, none of which affected patient outcomes. The nursing sick call process at PBSP was an impressive institutional strength. Care Management PBSP had a licensed vocational nurse (LVN) care coordinator assigned to each clinic, whose main responsibilities were to assess the health care needs of newly arrived patients, communicate findings to the health care team, and coordinate delivery of care. The LVNs conducted preventive health and TB screenings, provided patient counseling and education, facilitated delivery of durable medical equipment and supplies, and implemented provider orders such as blood pressure checks, immunizations, and wound care. The primary care provider managed the patient’s chronic care conditions and provided directions to other members of the care team to manage patients’ health care needs. Although PBSP had a shortage of LVN care coordinators, other members of the care team usually assisted to ensure that patients received necessary health care services. The care management process at PBSP was efficient in managing and coordinating patient care. Urgent/Emergent Care PBSP nurses were timely and well organized during emergency medical responses. The OIG clinicians reviewed 24 urgent/emergent events and found only two minor nursing deficiencies. These findings are described in the Emergency Services indicator. Specialized Medical Housing PBSP provided competent nursing care in the CTC. The OIG clinicians did not find any nursing deficiencies. These findings are described in the Specialized Medical Housing indicator. Transfers and Reception Centers PBSP nurses were very thorough in assessing and ensuring continuity of care for both newly arrived patients and patients returning from the hospital. The nurses also ensured that relevant health care information, medications, and durable medical equipment accompanied patients transferring to other institutions. These findings are discussed in the Inter- and Intra-System Transfers indicator. Out-to-Medical Return and Specialty Service The PBSP nurses were efficient in providing care for patients returning from specialty services. The OIG clinicians reviewed 16 nursing encounters when patients returned from their specialty appointments and did not find any nursing deficiencies. These findings are discussed in the Specialty Services indicator. Pelican Bay State Prison, Cycle 5 Medical Inspection Page 35 Office of the Inspector General State of California Medication Administration PBSP nurses were proficient with medication administration and always ensured patients received the correct medications and in a timely manner as prescribed. These findings were discussed in the Pharmacy and Medication Management indicator. Clinician Onsite Inspection The OIG clinicians attended the morning huddles on both days in the outpatient clinics. The huddles were well attended by members of the primary care team, including nursing supervisors and custody staff. Huddle discussions were substantial and informative. The provider and primary care RN also discussed the patients on their appointment schedules for the day and coordinated the delivery of necessary health care services. The OIG clinicians visited the various clinic areas and interviewed the staff. Nursing staff were very knowledgeable concerning their responsibilities and generally expressed job satisfaction. They identified no communication barriers with providers, supervisors, or custody staff that concerned meeting patient care needs. The nurses were actively involved in nursing projects such as medication administration matters and other EHRS training issues. Training records also showed evidence that extensive training was provided to new and current nursing staff. Case Review Conclusion Despite significant turnover of nursing staff since the previous inspection cycle, nursing performance at PBSP had greatly improved. This improvement was attributed to a supportive health care executive team, strong nursing leadership, and a well-managed staff development unit. The OIG clinicians found very few nursing deficiencies in all the clinic areas and thus rated the Quality of Nursing Performance indicator proficient. Pelican Bay State Prison, Cycle 5 Medical Inspection Page 36 Office of the Inspector General State of California QUALITY OF PROVIDER PERFORMANCE In this indicator, the OIG physicians provide a qualitative evaluation Case Review Rating: of the adequacy of provider care at the institution. Appropriate Proficient evaluation, diagnosis, and management plans are reviewed for Compliance Score: programs including, but not limited to, nursing sick call, chronic Not Applicable care programs, TTA, specialized medical housing, and specialty Overall Rating: services. The assessment of provider care is performed entirely by Proficient OIG physicians. No compliance-testing component is associated with this quality indicator. Case Review Results The OIG clinicians reviewed 135 medical provider encounters and identified 21 deficiencies related to provider performance, 8 of which were significant. Of the 20 cases reviewed, 10 were proficient 8 were adequate, and 2 were inadequate. Provider performance was rated proficient overall. Assessment and Decision-Making In most cases, PBSP providers regularly excelled with their assessments and decision-making. The providers reacted quickly to changes in their patients’ medical conditions. They implemented appropriate tests and interventions, and monitored the results of those interventions properly. • In case 2, the patient’s diabetes started to worsen. PBSP providers reacted promptly by increasing his diabetic medications and ordering closer monitoring. When the patient was unable to tolerate his medications, providers reassessed the patient quickly and offered alternative treatment strategies. When the patient developed worrisome symptoms that could have represented a stroke, he was sent to an outside ED appropriately. Fortunately, all the tests returned with normal results. • In case 13, the patient was prescribed a highly effective hepatitis C treatment. The provider regularly followed the patient by monitoring laboratory tests and appointments. The provider also made correct decisions to increase blood pressure medications when the patient’s blood pressure readings were not consistently within the target range. • In case 16, the patient developed a new problem with a chronic cough and at times coughed up blood. The provider thoroughly reviewed the medical record and found that prior physicians had diagnosed the condition as acid reflux. The provider carefully considered the alternative diagnostic possibilities and prescribed medications directed at the two most likely causes. The provider also ordered appropriate diagnostic laboratory and radiology imaging studies to exclude any dangerous possibilities. The provider saw the patient frequently over several months, and after medication adjustments, the patient improved once the provider made the correct diagnosis of chronic bronchitis. Pelican Bay State Prison, Cycle 5 Medical Inspection Page 37 Office of the Inspector General State of California Errors in assessment and decision-making were uncommon. Deficiencies of this type were identified in four cases, but most of them were related to provider oversight and did not reflect the underlying skills of the providers. Review of Records PBSP providers demonstrated exceptional skill with their thorough review of medical records. These thorough reviews helped contribute to the proficient ratings of 10 of the 20 detailed physician case reviews. Problems in review were rare, typically occurring when the provider was on call. Chronic Care Providers at PBSP demonstrated good skill with managing chronic conditions, including diabetes, hypertension, high cholesterol levels, asthma, liver disease, and hepatitis C. The OIG clinicians did not identify any patterns of problems in this area. Specialty Services The institution’s providers performed superbly with regard to specialty services. This finding is also discussed in the Specialty Services indicator. Emergency Care The PBSP providers performed satisfactorily for most patients in urgent or emergent situations. The OIG clinicians identified some concerns with PBSP on-call provider performance. These findings are further discussed in the Emergency Services indicator. Specialized Medical Housing PBSP providers performed well for nearly all of their CTC patients. These findings are further discussed in the Specialized Medical Housing indicator. Clinician Onsite Inspection Providers at PBSP reported that they were pleased with their work as well as their working conditions. Their morale was good, and they enjoyed working with each other. They felt supported by their medical leadership and believed that the PBSP health care processes were running smoothly. They believed that they were delivering an excellent quality of care to their patients. They felt that their chief medical executive (CME) was fair and actively involved with their day-to-day work. They reported that their encounters were appropriately monitored, and they believed they could always turn to their CME for assistance whenever it was needed. They believed, however, that they were understaffed because they were unable to replace physicians who had left the institution over the past few years. The physicians were concerned about the sustainability of their program because they were anticipating the retirement of another physician within the coming year. They were also concerned about the future sustainability of the on-call duties because of the relatively few providers available. Pelican Bay State Prison, Cycle 5 Medical Inspection Page 38 Office of the Inspector General State of California The PBSP CME had no concerns with the quality of the existing providers. The CME reported that provider performance was monitored in a variety of ways, including chart review, specialty request reviews, huddles, and population management, as well as via the day-to-day consultation requests from the mid-level providers. The CME did express the belief that PBSP was chronically understaffed. At the time of the onsite inspection, the CME reported that there was one vacant Chief Physician position as well as 1.5 vacant provider positions. Recruitment had been a problem for years, and there were no viable candidates. The CME attributed the institution’s recruitment difficulty to PBSP’s remote location. Case Review Conclusion PBSP providers demonstrated excellent skill with most areas of medical care, with half of the detailed physician reviews rated as proficient. While the case reviews did identify isolated examples of inadequate care, such cases were uncommon and did not reflect the typical case. The OIG clinicians thus rated this indicator proficient. Pelican Bay State Prison, Cycle 5 Medical Inspection Page 39 Office of the Inspector General State of California RECEPTION CENTER ARRIVALS This indicator focuses on the management of medical needs and continuity of care for patients arriving from outside the CDCR Case Review Rating: system. The OIG review includes evaluation of the ability of the Not Applicable Compliance Score: institution to provide and document initial health screenings, Not Applicable initial health assessments, continuity of medications, and completion of required screening tests; address and provide Overall Rating: Not Applicable significant accommodations for disabilities and health care appliance needs; and identify health care conditions needing treatment and monitoring. The patients reviewed for reception center cases are those received from non-CDCR facilities, such as county jails. Because PBSP did not have a reception center, this indicator did not apply. Pelican Bay State Prison, Cycle 5 Medical Inspection Page 40 Office of the Inspector General State of California SPECIALIZED MEDICAL HOUSING This indicator addresses whether the institution follows appropriate Case Review Rating: policies and procedures when admitting patients to onsite inpatient Proficient facilities, including completion of timely nursing and provider Compliance Score: assessments. The chart review assesses all aspects of medical care Proficient related to these housing units, including quality of provider and (95.0%) nursing care. PBSP’s only specialized medical housing unit is the Overall Rating: correctional treatment center (CTC). Proficient Case Review Results The institution had 20 CTC beds, 10 of which were designated for medical patients and 10 for mental health patients. There were two designated negative pressure rooms, designed to minimize the spread of airborne infection. The OIG clinicians reviewed nine CTC admissions, which included 21 provider encounters and 48 nursing encounters. Each provider and nurse encounter included up to one month of provider rounds and several consecutive days of nursing care. Only two deficiencies related to provider performance were identified. There were no deficiencies for nursing found in the cases reviewed. Provider Performance The CTC providers performed very well. They performed in-depth histories and physicals, and ensured that their patients received their needed health services. Providers performed in-depth chart review, rarely overlooking important information. They completed rounds on their patients at medically appropriate intervals and composed sufficiently detailed discharge summaries when their patients were ready for release from the CTC. Only two deficiencies were identified, both of which occurred in the same case: • In case 21, the patient had been prematurely released from an outside emergency department (ED) after losing a large amount of blood resulting from his recent hemorrhoid surgery. He had received two units of blood in the ED and was returned to the institution and admitted to the CTC. However, on his return to PBSP, the CTC provider did not timely review the available ED records. • Also in case 21, when the provider did eventually review the ED records, the provider did not recognize the patient’s blood counts had not risen to the expected range after the blood transfusion and that the patient could still have been bleeding. Consequently, the provider did not order the blood monitoring tests within an appropriate time frame. Fortunately, the patient did eventually stop bleeding and suffered no harm from this oversight. Pelican Bay State Prison, Cycle 5 Medical Inspection Page 41 Office of the Inspector General State of California Nursing Performance PBSP nurses continued to provide excellent nursing care to CTC patients as they had during the Cycle 4 inspection. Nurses assessed patients and reviewed care plans at least once per watch. Nurses also documented thorough progress notes of relevant care provided to the patient. When patients were discharged from the CTC, the CTC nurses provided discharge instructions and education to the patient and gave a report to the primary care team to ensure continuity of care. Clinician Onsite Inspection During the onsite inspection, one of the medical beds and two of the mental health beds were filled. There were three RNs, including a shift lead RN, assigned during all watches. A licensed psychiatric technician was assigned during the second and third watches. The LVN positions were currently vacant, and the CNA positions were filled intermittently. Adequate custody staff were present to assist and provide access to the patients. The nurses interviewed demonstrated knowledge of both CTC procedures and their responsibilities. Case Review Conclusion In the majority of cases reviewed, PBSP providers and nurses demonstrated excellent care for their CTC patients. The OIG clinicians rated this indicator proficient. Compliance Testing Results The institution received a proficient compliance score of 95.0 percent in the Specialized Medical Housing indicator, with the following test areas receiving high scores: • For all ten sampled patients, nursing staff timely completed an initial health assessment on the day the patient was admitted to the CTC (MIT 13.001). • OIG inspectors sampled ten patients who were admitted to the CTC and found that PBSP providers completed written history and physical examinations within the required time frame for all of them (MIT 13.002). • When inspectors observed the working order of sampled call buttons in CTC patient rooms, inspectors found all 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 (MIT 13.101). Pelican Bay State Prison, Cycle 5 Medical Inspection Page 42 Office of the Inspector General State of California One test received an adequate score: • When the OIG tested whether providers completed their Subjective, Objective, Assessment, Plan, and Education (SOAPE) notes at the required three-day intervals, it was noted that providers timely completed SOAPE notes for eight of the ten sampled patients (80 percent). For one patient, one note exceeded the policy limit by two days. For one other patient, one note did not include all required elements, and other notes were late by one or two days (MIT 13.003). Pelican Bay State Prison, Cycle 5 Medical Inspection Page 43 Office of the Inspector General State of California SPECIALTY SERVICES This indicator focuses on specialist care from the time a request for Case Review Rating: services or physician’s order for specialist care is completed to the Proficient time of receipt of related recommendations from specialists. This Compliance Score: indicator also evaluates the providers’ timely review of specialist Proficient records and documentation reflecting the patients’ care plans, (91.0%) including course of care when specialist recommendations were not Overall Rating: ordered, and whether the results of specialists’ reports are Proficient 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 49 events related to Specialty Services, 27 of which were specialty consultations and procedures. Five deficiencies were found in this category, two of which were significant. Access to Specialty Services PBSP performed well in this area. Specialty procedures and consultations occurred accurately and within medically appropriate time frames in the cases reviewed. The OIG clinicians found no deficiencies in this area. Nursing Performance Nurses performed well for patients returning from an offsite specialty appointment. They assessed patients and reviewed specialty reports. Nurses would also inform the provider of the specialty findings and recommendations, obtain orders, and schedule provider follow-ups. The OIG clinicians did not identify any nursing deficiencies in this area. Provider Performance PBSP providers performed well for patients requiring specialty services. Providers appropriately referred their patients to specialists when needed, and within medically correct time frames. The OIG clinicians did not identify any deficiencies in provider performance with regard to specialty services. Health Information Management PBSP performed satisfactorily concerning specialty report management. Most specialty records were properly retrieved, reviewed by the provider, and scanned into the medical record. However, five deficiencies were identified in this area, two of which were significant: Pelican Bay State Prison, Cycle 5 Medical Inspection Page 44 Office of the Inspector General State of California • In case 21, a specialty report was not scanned into the medical record until more than three weeks after the consultation. At the onsite inspection, PBSP explained that the delay was due to the offsite surgeon falling behind in completing his charts. • In case 22, the patient underwent eye surgery. The surgeon’s initial surgical report was not retrieved, scanned, or reviewed. This error was of little consequence because the patient saw the surgeon for follow-up the very next day. The follow-up report was properly retrieved, reviewed, and scanned into the medical record. Clinician Onsite Inspection PBSP explained that its staff had successfully merged the EHRS processes into the institution’s existing specialty referral processes. PBSP leadership was not aware of any outstanding problems that would compromise their ability to provide specialty services to the institution’s patients. Case Review Conclusion The institution performed very well in the Specialty Services indicator, and the case review rating is proficient. Compliance Testing Results The institution received a proficient compliance score of 91.0 percent in the Specialty Services indicator. The following tests received scores in the proficient range: • For all 13 sampled patients, high-priority specialty services appointments occurred within 14 calendar days of the provider’s order (MIT 14.001). • For all 15 sampled patients, routine specialty services appointments occurred within 90 calendar days of the provider’s order. In addition, providers also timely received and reviewed the routine specialists’ reports for all 15 of these patients (MIT 14.003, 14.004). • The institution’s administration timely denied providers’ specialty services requests for 19 of 20 sampled patients (95 percent). One specialty services request was denied six days late (MIT 14.006). • Providers timely received and reviewed the high-priority specialists’ reports for 12 of the 13 sampled patients (92 percent). For one patient, PBSP received the specialist’s report one day late (MIT 14.002). Two tests received scores in the adequate range: • When patients were approved or scheduled for specialty services at one institution and then transferred to another, CCHCS policy requires that the receiving institution reschedule and provide the patient’s appointment within the required time frame. For 15 of the 20 sampled Pelican Bay State Prison, Cycle 5 Medical Inspection Page 45 Office of the Inspector General State of California patients (75 percent) who transferred to PBSP with approved specialty services, they received their appointments within the required time frame. For five patients, however, no evidence was found that they ever received their appointments at PBSP (MIT 14.005). • For 20 sampled patients who had a specialty services request denied by PBSP’s health care management, 15 patients (75 percent) received a timely notification of the denied service, including the provider meeting with the patient within 30 days to discuss alternative treatment strategies. For four patients, the providers’ follow-up visits occurred two or three days late. For one other patient, no evidence was found of a provider’s follow-up appointment to discuss the denial (MIT 14.007). Pelican Bay State Prison, Cycle 5 Medical Inspection Page 46 Office of the Inspector General State of California ADMINISTRATIVE OPERATIONS (SECONDARY) This indicator focuses on the institution’s administrative health care Case Review Rating: oversight functions. The OIG evaluates whether the institution Not Applicable promptly processes patient medical appeals and addresses all Compliance Score: appealed issues. Inspectors also verify that the institution follows Adequate reporting requirements for adverse/sentinel events and inmate (84.3%) 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, the 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, it was not relied on for the overall score for the institution. Compliance Testing Results The institution received a score of adequate in the Administrative Operations indicator, with a compliance score of 84.3 percent. The following tests received high scores: • PBSP’s Quality Management Committee (QMC) met monthly, evaluated program performance, and took action when management identified areas for improvement. Also, PBSP took adequate steps to ensure the accuracy of its Dashboard data reporting (MIT 15.003, 15.004). • Inspectors reviewed drill packages for three emergency medical response drills conducted in the prior quarter, and each one contained all required summary reports and related documentation. In addition, the drills included participation by both health care and custody staff (MIT 15.101). • Based on a sample of ten second-level medical appeals, the institution’s responses addressed all of the patients’ appealed issues (MIT 15.102). • All ten sampled nurses were current with their clinical competency validations (MIT 15.105). • The OIG reviewed performance evaluation packets for PBSP’s four providers; PBSP met all performance review requirements for its providers (MIT 15.106). Pelican Bay State Prison, Cycle 5 Medical Inspection Page 47 Office of the Inspector General State of California • All providers at the institution were current with their professional licenses. Similarly, all nursing staff and the PIC were current with their professional licenses and certification requirements (MIT 15.107, 15.109). • All active duty providers and nurses were current with their emergency response certifications (MIT 15.108). • All pharmacy staff and providers who prescribed controlled substances had current Drug Enforcement Agency registrations (MIT 15.110). • All nursing staff hired within the past year had received new employee orientation training on a timely basis (MIT 15.111). One test received an adequate score: • The OIG reviewed documentation for 12 emergency medical response incidents addressed by the institution’s Emergency Medical Response Review Committee (EMRRC) during the prior six-month period; only 9 of the 12 sampled packages (75 percent) complied with policy. Three EMRRC event packages had checklist forms that were incomplete (MIT 15.005). A few tests revealed room for improvement: • The OIG inspected records from April 2017 for five nurses to determine whether their nursing supervisors properly completed monthly performance reviews. Inspectors identified the following deficiencies for three of the nurses’ monthly nursing reviews (MIT 15.104): o For two nurses, the supervisor did not complete the required number of reviews. o For one nurse, the supervisor’s review did not summarize aspects needing improvement. • PBSP’s local governing body met quarterly during the four-quarter period ending March 2017, but none of the meeting minutes evidenced discussion of general management and planning consistent with CCHCS policies and other directives. These deficiencies resulted in a score of zero (MIT 15.006). • The OIG reviewed data received from the institution to determine whether PBSP timely processed at least 95 percent of its monthly patient medical appeals during the most recent 12-month period. PBSP timely processed appeals in 8 of the 12 months reviewed (67 percent). Of the four months with more than 5 percent of medical appeals in overdue status, the percentages ranged from 6 to 10 percent (MIT 15.001). Pelican Bay State Prison, Cycle 5 Medical Inspection Page 48 Office of the Inspector General State of California • Medical staff reviewed and timely submitted the Initial Inmate Death Report (CDCR Form 7229A) to CCHCS’ Death Review Unit for four of six cases tested, resulting in a score of 67 percent. The institution did not timely notify CCHCS’ Death Review Unit of a death that occurred. Policy required that death notification be made by noon on the next business day following the date of death. PBSP made the notification three minutes late. In addition, the Initial Inmate Death Report (CDCR Form 7229A) for one of the death packets reviewed was missing the required physician’s signature (MIT 15.103). Non-Scored Results • The OIG gathered non-scored data regarding the completion of death review reports by CCHCS’ Death Review Committee (DRC). Six deaths occurred at PBSP during the OIG’s review period, all unexpected (Level 1) deaths. The DRC was required to complete its death review summary report within 60 calendar days from the date of death; the reports were then to be submitted to the institution’s CEO within seven calendar days thereafter. The DRC completed one report timely; however, three reports ranged from 30 to 63 days late (90 to 123 days after the death); all four final reports were submitted to the CEO from 23 to 72 days late. In addition, as of June 19, 2017, two death reports had not been completed and were overdue (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). Pelican Bay State Prison, Cycle 5 Medical Inspection Page 49 Office of the Inspector General State of California R ECOMMENDATIONS The OIG had no specific recommendations. Pelican Bay State Prison, Cycle 5 Medical Inspection Page 50 Office of the Inspector General State of California P -B M OPULATION ASED ETRICS The compliance testing and the case reviews give an accurate assessment of how the institution’s health care systems are functioning with regard to the patients with the highest risk and utilization. This information is vital to assess the capacity of the institution to provide sustainable, adequate care. However, one significant limitation of the case review methodology is that it does not give a clear assessment of how the institution performs for the entire population. For better insight into this performance, the OIG has turned to population-based metrics. For comparative purposes, the OIG has selected several Healthcare Effectiveness Data and Information Set (HEDIS) measures for disease management to gauge the institution’s effectiveness in outpatient health care, especially chronic disease management. The Healthcare Effectiveness Data and Information Set is a set of standardized performance measures developed by the National Committee for Quality Assurance with input from over 300 organizations representing every sector of the nation’s health care industry. It is used by over 90 percent of the nation’s health plans as well as many leading employers and regulators. It was designed to ensure that the public (including employers, the Centers for Medicare and Medicaid Services, and researchers) has the information it needs to accurately compare the performance of health care plans. Healthcare Effectiveness Data and Information Set data is often used to produce health plan report cards, analyze quality improvement activities, and create performance benchmarks. Methodology For population-based metrics, the OIG used a subset of HEDIS measures applicable to the CDCR patient population. Selection of the measures was based on the availability, reliability, and feasibility of the data required for performing the measurement. The OIG collected data utilizing various information sources, including the 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 Pelican Bay State Prison, nine HEDIS measures were selected and are listed in the following PBSP 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. Pelican Bay State Prison, Cycle 5 Medical Inspection Page 51 Office of the Inspector General State of California Results of Population-Based Metrics 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. PBSP performed well with its management of diabetes. When compared statewide, PBSP outperformed most other reporting entities in all five diabetic measures. However, the institution scored lower than did Kaiser, North and South regions, for diabetic blood pressure control monitoring. When compared to nationwide health care providers, PBSP also performed well in comprehensive diabetes care. PBSP outperformed Medicaid, Medicare, and commercial health care plans in all five diabetic measures, and outperformed or matched the United States Department of Veterans Affairs (VA) in four applicable measures. 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 both younger and older adults, PBSP scored lower than all other health care plans did. The patient refusal rate for younger adults was 62 percent and 43 percent for older adults, with these percentages negatively affecting the institution’s score for these measures. With regard to administering pneumococcal vaccines to older adults, PBSP matched Medicare, but scored lower than the VA. Cancer Screening With respect to colorectal cancer screening, PBSP scored lower than all health care plans, except commercial health plans and Medicare. As they had with immunization measures, patient refusals (32 percent) negatively affected the institution’s score. Summary The population-based metrics performance of PBSP reflects an adequate chronic care program compared to the other statewide and national health care plans. The institution can improve scores for immunizations and colorectal cancer screening by educating patients concerning the benefits of these preventive services. Pelican Bay State Prison, Cycle 5 Medical Inspection Page 52 Office of the Inspector General State of California PBSP Results Compared to State and National HEDIS Scores California National PBSP HEDIS HEDIS HEDIS HEDIS HEDIS HEDIS VA Clinical Measures Kaiser Kaiser Com- Medi-Cal Medicaid Medicare Average Cycle 5 20152 (No. CA) (So. CA) 20164 mercial 20164 20155 Results1 20163 20163 20164 Comprehensive Diabetes Care HbA1c Testing (Monitoring) 100% 86% 94% 94% 86% 90% 93% 98% Poor HbA1c Control (>9.0%)6, 7 9% 39% 20% 23% 45% 34% 27% 19% HbA1c Control (<8.0%)6 82% 49% 70% 63% 46% 55% 63% - Blood Pressure Control (<140/90)6 77% 63% 83% 83% 59% 60% 62% 74% Eye Exams 89% 53% 68% 81% 53% 54% 69% 89% Immunizations Influenza Shots - Adults (18–64) 38% - 56% 57% 39% 48% - 55% Influenza Shots - Adults (65+) 57% - - - - - 72% 76% Immunizations: Pneumococcal 71% - - - - - 71% 93% Cancer Screening Colorectal Cancer Screening 68% - 79% 82% - 63% 67% 82% 1. Unless otherwise stated, data was collected in June 2017 by reviewing medical records from a sample of PBSP’s population of applicable patients. These random statistical sample sizes were based on a 95 percent confidence level with a 15 percent maximum margin of error. 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.ncqu.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, http://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 PBSP 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. Pelican Bay State Prison, Cycle 5 Medical Inspection Page 53 Office of the Inspector General State of California A A — C T R PPENDIX OMPLIANCE EST ESULTS Pelican Bay State Prison Range of Summary Scores: 56.00% – 95.52% Indicator Compliance Score (Yes %) 1–Access to Care 86.47% 2–Diagnostic Services 75.19% 3–Emergency Services Not Applicable 4–Health Information Management (Medical Records) 83.06% 5–Health Care Environment 71.49% 6–Inter- and Intra-System Transfers 56.00% 7–Pharmacy and Medication Management 72.19% 8–Prenatal and Post-Delivery Services Not Applicable 9–Preventive Services 95.52% 10–Quality of Nursing Performance Not Applicable 11–Quality of Provider Performance Not Applicable 12–Reception Center Arrivals Not Applicable 13–Specialized Medical Housing (OHU, CTC, SNF, Hospice) 95.00% 14–Specialty Services 91.04% 15–Administrative Operations 84.27% Pelican Bay State Prison, Cycle 5 Medical Inspection Page 54 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 22 3 25 88.00% 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 21 4 25 84.00% 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 27 3 30 90.00% 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 6 1 7 85.71% 23 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 3 0 3 100% 27 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 Not Applicable time frame? Specialty service follow-up appointments: Do specialty service 1.008 primary care physician follow-up visits occur within required time 20 7 27 74.07% 1 frames? Clinical appointments: Do patients have a standardized process to 1.101 5 1 6 83.33% 0 obtain and submit health care services request forms? Overall percentage: 86.47% Pelican Bay State Prison, Cycle 5 Medical Inspection Page 55 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 10 0 10 100% 0 diagnostic report within specified time frames? Radiology: Did the primary care provider communicate the results 2.003 6 4 10 60.00% 0 of the diagnostic study to the patient within specified time frames? Laboratory: Was the laboratory service provided within the time 2.004 9 1 10 90.00% 0 frame specified in the provider's order? Laboratory: Did the primary care provider review and initial the 2.005 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 1 9 10 10.00% 0 frames? Pathology: Did the institution receive the final diagnostic report 2.007 6 0 6 100% 0 within the required time frames? Pathology: Did the primary care provider review and initial the 2.008 6 0 6 100% 0 diagnostic report within specified time frames? Pathology: Did the primary care provider communicate the results 2.009 1 5 6 16.67% 0 of the diagnostic study to the patient within specified time frames? Overall percentage: 75.19% 3–Emergency Services This indicator is evaluated only by case review clinicians. There is no compliance-testing component. Pelican Bay State Prison, Cycle 5 Medical Inspection Page 56 Office of the Inspector General State of California Scored Answers Yes Reference + 4–Health Information Management Number Yes No No Yes % N/A Are non-dictated healthcare documents (provider progress notes) 4.001 4 1 5 80.00% 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 Not Applicable date? Are High-Priority specialty notes (either a Form 7243 or other 4.003 scanned consulting report) scanned within the required time 18 2 20 90.00% 0 frame? Are community hospital discharge documents scanned into the 4.004 patient’s electronic health record within three calendar days of Not Applicable hospital discharge? Are medication administration records (MARs) scanned into the 4.005 Not Applicable patient’s electronic health record within the required time frames? During the inspection, were medical records properly scanned, 4.006 19 5 24 79.17% 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 Not Applicable did a primary care provider review the report within three calendar days of discharge? Overall percentage: 83.06% Pelican Bay State Prison, Cycle 5 Medical Inspection Page 57 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 5 4 9 55.56% 1 and sanitary? Do clinical health care areas ensure that reusable invasive and 5.102 non-invasive medical equipment is properly sterilized or 7 0 7 100% 3 disinfected as warranted? Do clinical health care areas contain operable sinks and sufficient 5.103 5 4 9 55.56% 1 quantities of hygiene supplies? Does clinical health care staff adhere to universal hand hygiene 5.104 6 3 9 66.67% 1 precautions? Do clinical health care areas control exposure to blood-borne 5.105 9 0 9 100% 1 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 6 3 9 66.67% 1 storing bulk medical supplies? Do clinic common areas and exam rooms have essential core 5.108 6 4 10 60.00% 0 medical equipment and supplies? Do clinic common areas have an adequate environment conducive 5.109 9 0 9 100% 1 to providing medical services? Do clinic exam rooms have an adequate environment conducive 5.110 4 5 9 44.44% 1 to providing medical services? Emergency response bags: Are TTA and clinic emergency 5.111 medical response bags inspected daily and inventoried monthly, 3 5 8 37.50% 2 and do they contain essential items? Overall percentage: 71.49% Pelican Bay State Prison, Cycle 5 Medical Inspection Page 58 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 15 10 25 60.00% 0 answer all screening questions on the same day the patient arrived at the institution? For endorsed patients received from another CDCR institution or COCF: When required, did the RN complete the assessment and disposition section of the health screening form; refer the patient 6.002 25 0 25 100% 0 to the TTA, if TB signs and symptoms were present; and sign and date the form on the same day staff completed the health screening? For endorsed patients received from another CDCR institution or COCF: If the patient had an existing medication order upon 6.003 6 4 10 60.00% 15 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 3 2 5 60.00% 0 care transfer information form? For patients transferred out of the facility: Do medication transfer 6.101 packages include required medications along with the 0 3 3 0.00% 0 corresponding transfer packet required documents? Overall percentage: 56.00% Pelican Bay State Prison, Cycle 5 Medical Inspection Page 59 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 10 6 16 62.50% 9 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 23 2 25 92.00% 0 time frames? Upon the patient’s discharge from a community hospital: Were all 7.003 ordered medications administered, made available, or delivered to Not Applicable the patient within required time frames? For patients received from a county jail: Were all medications ordered by the institution’s reception center provider 7.004 Not Applicable administered, made available, or delivered to the patient within the required time frames? Upon the patient’s transfer from one housing unit to another: 7.005 8 0 8 100% 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 Not Applicable medications administered or delivered without interruption? All clinical and medication line storage areas for narcotic 7.101 medications: Does the Institution employ strong medication 4 5 9 44.44% 2 security over narcotic medications assigned to its clinical areas? All clinical and medication line storage areas for non-narcotic medications: Does the Institution properly store non-narcotic 7.102 7 3 10 70.00% 1 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% 2 medications that require refrigeration in assigned clinical areas? Medication preparation and administration areas: Do nursing staff employ and follow hand hygiene contamination control protocols 7.104 3 3 6 50.00% 5 during medication preparation and medication administration processes? Medication preparation and administration areas: Does the 7.105 institution employ appropriate administrative controls and 6 0 6 100% 5 protocols when preparing medications for patients? Medication preparation and administration areas: Does the 7.106 Institution employ appropriate administrative controls and 3 3 6 50.00% 5 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? Pelican Bay State Prison, Cycle 5 Medical Inspection Page 60 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 0 1 1 0.00% 0 narcotic medications? Does the institution follow key medication error reporting 7.111 16 9 25 64.00% 0 protocols? Overall percentage: 72.19% 8–Prenatal and Post-Delivery Services The institution has no female patients, so this indicator is not applicable. Pelican Bay State Prison, Cycle 5 Medical Inspection Page 61 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 2 0 2 100% 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 0 2 100% 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 25 0 25 100% 0 colorectal cancer screening? Female patients from the age of 50 through the age of 74: Was the 9.006 Not Applicable patient offered a mammogram in compliance with policy? Female patients from the age of 21 through the age of 65: Was 9.007 Not Applicable patient offered a pap smear in compliance with policy? Are required immunizations being offered for chronic care 9.008 13 4 17 76.47% 8 patients? Are patients at the highest risk of coccidioidomycosis (valley 9.009 Not Applicable fever) infection transferred out of the facility in a timely manner? Overall percentage: 95.52% 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. Pelican Bay State Prison, Cycle 5 Medical Inspection Page 62 Office of the Inspector General State of California 12–Reception Center Arrivals The institution has no reception center, so this indicator is not applicable. Scored Answers Yes Reference + 13–Specialized Medical Housing Number Yes No No Yes % N/A For OHU, CTC, and SNF: Did the registered nurse complete an 13.001 initial assessment of the patient on the day of admission, or within 10 0 10 100% 0 eight hours of admission to CMF’s Hospice? For CTC and SNF only: Was a written history and physical 13.002 10 0 10 100% 0 examination completed within the required time frame? For OHU, CTC, SNF, and Hospice: Did the primary care provider complete the Subjective, Objective, Assessment, Plan, and 13.003 8 2 10 80.00% 0 Education (SOAPE) notes on the patient at the minimum intervals required for the type of facility where the patient was treated? For OHU and CTC Only: Do inpatient areas either have properly working call systems in its OHU & CTC or are 30-minute patient 13.101 1 0 1 100% 0 welfare checks performed; and do medical staff have reasonably unimpeded access to enter patient’s cells? Overall percentage: 95.00% Pelican Bay State Prison, Cycle 5 Medical Inspection Page 63 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 13 0 13 100% 0 Physician Request for Service? Did the primary care provider review the high priority specialty 14.002 12 1 13 92.31% 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 15 0 15 100% 0 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 15 5 20 75.00% 0 the sending institution, was the appointment scheduled at the receiving institution within the required time frames? Did the institution deny the primary care provider request for 14.006 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 15 5 20 75.00% 0 patient informed of the denial within the required time frame? Overall percentage: 91.04% Pelican Bay State Prison, Cycle 5 Medical Inspection Page 64 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 8 4 12 66.67% 0 during the most recent 12 months? Does the institution follow adverse / sentinel event reporting 15.002 Not Applicable requirements? Did the institution Quality Management Committee (QMC) meet at least monthly to evaluate program performance, and did the 15.003 6 0 6 100% 0 QMC take action when improvement opportunities were identified? Did the institution’s Quality Management Committee (QMC) or 15.004 other forum take steps to ensure the accuracy of its Dashboard 1 0 1 100% 0 data reporting? Does the Emergency Medical Response Review Committee 15.005 perform timely incident package reviews that include the use of 9 3 12 75.00% 0 required review documents? For institutions with licensed care facilities: Does the Local Governing Body (LGB), or its equivalent, meet quarterly and 15.006 0 4 4 0.00% 0 exercise its overall responsibilities for the quality management of patient health care? Did the institution complete a medical emergency response drill 15.101 for each watch and include participation of health care and 3 0 3 100% 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 4 2 6 66.67% 0 inmate death report to the Death Review Unit in a timely manner? Does the institution's Supervising Registered Nurse conduct 15.104 2 3 5 40.00% 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? 4 0 4 100% 0 15.107 Do all providers maintain a current medical license? 6 0 6 100% 0 Are staff current with required medical emergency response 15.108 2 0 2 100% 0 certifications? Are nursing staff and the Pharmacist-in-Charge current with their professional licenses and certifications, and is the pharmacy licensed as a correctional pharmacy by the California State Board 15.109 6 0 6 100% 0 of Pharmacy? Pelican Bay State Prison, Cycle 5 Medical Inspection Page 65 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: 84.27% Pelican Bay State Prison, Cycle 5 Medical Inspection Page 66 Office of the Inspector General State of California A B — C D PPENDIX LINICAL ATA Table B-1: PBSP Sample Sets Sample Set Total CTC/OHU 3 Death Review/Sentinel Events 2 Diabetes 3 Emergency Services – CPR 2 Emergency Services – Non-CPR 2 High Risk 7 Hospitalization 4 Intra-System Transfers In 3 Intra-System Transfers Out 3 RN Sick Call 15 Specialty Services 2 46 Pelican Bay State Prison, Cycle 5 Medical Inspection Page 67 Office of the Inspector General State of California Table B-2: PBSP Chronic Care Diagnoses Diagnosis Total Anemia 3 Arthritis/Degenerative Joint Disease 9 Asthma 5 COPD 1 Cancer 1 Cardiovascular Disease 3 Chronic Kidney Disease 2 Chronic Pain 5 Cirrhosis/End-Stage Liver Disease 4 Coccidioidomycosis 1 Diabetes 7 Gastroesophageal Reflux Disease 6 Hepatitis C 15 Hyperlipidemia 10 Hypertension 22 Mental Health 11 Migraine Headaches 1 Seizure Disorder 2 Sleep Apnea 1 109 Pelican Bay State Prison, Cycle 5 Medical Inspection Page 68 Office of the Inspector General State of California Table B-3: PBSP Event – Program Program Total Diagnostic Services 98 Emergency Care 36 Hospitalization 14 Intra-System Transfers In 9 Intra-System Transfers Out 7 Outpatient Care 329 Specialized Medical Housing 82 Specialty Services 49 624 Pelican Bay State Prison, Cycle 5 Medical Inspection Page 69 Office of the Inspector General State of California Table B-4: PBSP Review Sample Summary Total MD Reviews Detailed 20 MD Reviews Focused 0 RN Reviews Detailed 15 RN Reviews Focused 25 Total Reviews 60 Total Unique Cases 46 Overlapping Reviews (MD & RN) 14 Pelican Bay State Prison, Cycle 5 Medical Inspection Page 70 Office of the Inspector General State of California A C — C S M PPENDIX OMPLIANCE AMPLING ETHODOLOGY Pelican Bay State Prison (PBSP) 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) N/A at this institution MIT 1.008 Specialty Services OIG Q: 14.001 & • See Specialty Services Follow-up 14.003 (28) 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) (6) • Randomize Pelican Bay State Prison, Cycle 5 Medical Inspection Page 71 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 (5) 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 N/A at this institution • First 20 IPs selected MIT 4.003 OIG Qs: 14.002 • Specialty documents (20) & 14.004 • First 10 IPs for each question MIT 4.004 OIG Q: 4.007 • Community hospital discharge documents N/A at this institution • First 20 IPs selected MIT 4.005 OIG Q: 7.001 • MARs (0) • First 20 IPs selected MIT 4.006 Documents for • Any misfiled or mislabeled document identified (5) 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) N/A at this institution Health Care Environment MITs 5.101–105 Clinical Areas OIG inspector • Identify and inspect all onsite clinical areas. MITs 5.107–111 (10) onsite review Inter- and Intra-System Transfers MITs 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 (5) MIT 6.101 Transfers Out OIG inspector • R&R IP transfers with medication (3) onsite review Pelican Bay State Prison, Cycle 5 Medical Inspection Page 72 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) N/A at this institution MIT 7.004 RC Arrivals – OIG Q: 12.001 • See Reception Center Arrivals Medication Orders N/A at this institution 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) (8) • Randomize MIT 7.006 En Route SOMS • Date of transfer (2–8 months) • Sending institution (another CDCR facility) • Randomize (0) • 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 (20) listing Prenatal and Post-Delivery Services MITs 8.001–007 Recent Deliveries OB Roster • Delivery date (2–12 months) N/A at this institution • Most recent deliveries (within date range) Pregnant Arrivals OB Roster • Arrival date (2–12 months) N/A at this institution • Earliest arrivals (within date range) Pelican Bay State Prison, Cycle 5 Medical Inspection Page 73 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) (2) • 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) • Date of birth (age 52–74) N/A at this institution • Randomize MIT 9.007 Pap Smear SOMS • Arrival date (at least three yrs prior to inspection) • Date of birth (age 24–53) N/A at this 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) N/A at this institution • All Pelican Bay State Prison, Cycle 5 Medical Inspection Page 74 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.) N/A at this institution • Randomize Specialized Medical Housing MITs 13.001–004 CTC CADDIS • Admit date (1–6 months) • Type of stay (no MH beds) • Length of stay (minimum of 5 days) (10) • Randomize MIT 13.101 Call Buttons OIG inspector • Review by location CTC (all) onsite review Specialty Services MITs 14.001–002 High-Priority MedSATS • Approval date (3–9 months) (13) • Randomize MITs 14.003–004 Routine MedSATS • Approval date (3–9 months) (15) • Remove optometry, physical therapy or podiatry • Randomize MIT 14.005 Specialty Services MedSATS • Arrived from (other CDCR institution) Arrivals • Date of transfer (3–9 months) (20) • Randomize MITs 14.006–007 Denials InterQual • Review date (3–9 months) (10) • Randomize IUMC/MAR • Meeting date (9 months) Meeting Minutes • Denial upheld (10) • Randomize Pelican Bay State Prison, Cycle 5 Medical Inspection Page 75 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 (6) 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 OIG Q:16.001 • All required performance evaluation documents Evaluation Packets (4) MIT 15.107 Provider licenses Current provider • Review all listing (at start of (6) 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) Pelican Bay State Prison, Cycle 5 Medical Inspection Page 76 Office of the Inspector General State of California Sample Category Quality (number of Indicator samples) Data Source Filters 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 (6) Pelican Bay State Prison, Cycle 5 Medical Inspection Page 77 Office of the Inspector General State of California C C ALIFORNIA ORRECTIONAL H C S ’ EALTH ARE ERVICES R ESPONSE Pelican Bay State Prison, Cycle 5 Medical Inspection Page 78 Office of the Inspector General State of California Pelican Bay State Prison, Cycle 5 Medical Inspection Page 79 Office of the Inspector General State of California