Pleasant Valley State Prison Medical Inspection Report Cycle 4

Robert A. Barton Office of the Inspector General Inspector General Pleasant Valley State Prison Medical Inspection Results Cycle 4 February 2017 Medical Inspection Unit Page 1 Office of the Inspector General State of California Office of the Inspector General PLEASANT VALLEY STATE PRISON Medical Inspection Results Cycle 4 Robert A. Barton Inspector General Roy W. Wesley Chief Deputy Inspector General Shaun R. Spillane Public Information Officer February 2017 TABLE OF CONTENTS Executive Summary ............................................................................................................................. i Overall Assessment: Proficient ............................................................................................. iii Clinical Case Review and OIG Clinician Inspection Results ............................................... iii Compliance Testing Results.................................................................................................. iv Population-Based Metrics ..................................................................................................... ix Introduction ......................................................................................................................................... 1 About the Institution ........................................................................................................................... 1 Objectives, Scope, and Methodology.................................................................................................. 5 Case Reviews ................................................................................................................................... 6 Patient Selection for Retrospective Case Reviews .................................................................... 6 Benefits and Limitations of Targeted Subpopulation Review .................................................. 7 Case Reviews Sampled ............................................................................................................. 8 Compliance Testing ......................................................................................................................... 9 Sampling Methods for Conducting Compliance Testing .......................................................... 9 Scoring of Compliance Testing Results .................................................................................... 9 Dashboard Comparisons ......................................................................................................... 10 Overall Quality Indicator Rating for Case Reviews and Compliance Testing .............................. 10 Population-Based Metrics .............................................................................................................. 11 Medical Inspection Results ............................................................................................................... 12 Primary (Clinical) Quality Indicators of Health Care .................................................................... 12 Access to Care ......................................................................................................................... 13 Case Review Results ............................................................................................................ 13 Compliance Testing Results................................................................................................. 15 Recommendations ................................................................................................................ 16 Diagnostic Services ................................................................................................................. 17 Case Review Results ............................................................................................................ 17 Compliance Testing Results................................................................................................. 18 Recommendations ................................................................................................................ 18 Emergency Services................................................................................................................. 19 Case Review Results ............................................................................................................ 19 Recommendations ................................................................................................................ 20 Health Information Management (Medical Records) ............................................................. 21 Case Review Results ............................................................................................................ 21 Compliance Testing Results................................................................................................. 22 Recommendations ................................................................................................................ 23 Health Care Environment ....................................................................................................... 24 Compliance Testing Results................................................................................................. 24 Recommendations ................................................................................................................ 25 Inter- and Intra-System Transfers ........................................................................................... 26 Case Review Results ............................................................................................................ 26 Compliance Testing Results................................................................................................. 28 Recommendations ................................................................................................................ 29 Pleasant Valley State Prison, Cycle 4 Medical Inspection Table of Contents Office of the Inspector General State of California Pharmacy and Medication Management ................................................................................ 30 Case Review Results ............................................................................................................ 30 Compliance Testing Results................................................................................................. 31 Recommendations ................................................................................................................ 33 Preventive Services ................................................................................................................. 34 Compliance Testing Results................................................................................................. 34 Recommendations ................................................................................................................ 35 Quality of Nursing Performance ............................................................................................. 36 Case Review Results ............................................................................................................ 36 Recommendations ................................................................................................................ 38 Quality of Provider Performance ............................................................................................ 39 Case Review Results ............................................................................................................ 39 Recommendations ................................................................................................................ 42 Specialized Medical Housing (OHU, CTC, SNF, Hospice) .................................................... 43 Case Review Results ............................................................................................................ 43 Compliance Testing Results................................................................................................. 44 Recommendations ................................................................................................................ 45 Specialty Services .................................................................................................................... 46 Case Review Results ............................................................................................................ 46 Compliance Testing Results................................................................................................. 47 Recommendations ................................................................................................................ 48 Secondary (Administrative) Quality Indicators of Health Care..................................................... 49 Internal Monitoring, Quality Improvement, and Administrative Operations ......................... 50 Compliance Testing Results................................................................................................. 50 Recommendations ................................................................................................................ 52 Job Performance, Training, Licensing, and Certifications ..................................................... 53 Compliance Testing Results................................................................................................. 53 Recommendations ................................................................................................................ 54 Population-Based Metrics .............................................................................................................. 55 Appendix A — Compliance Test Results ......................................................................................... 58 Appendix B — Clinical Data ............................................................................................................ 72 Appendix C — Compliance Sampling Methodology ....................................................................... 75 California Correctional Health Care Services’ Response ................................................................. 82 Pleasant Valley State Prison, Cycle 4 Medical Inspection Table of Contents Office of the Inspector General State of California LIST OF TABLES AND FIGURES Health Care Quality Indicators ........................................................................................................... ii PVSP Executive Summary Table .................................................................................................... viii PVSP Health Care Staffing Resources as of March 2016 ................................................................... 2 PVSP Master Registry Data as of March 28, 2016 .............................................................................. 3 Commonly Used Abbreviations .......................................................................................................... 4 PVSP Results Compared to State and National HEDIS Scores ........................................................ 57 Pleasant Valley State Prison, Cycle 4 Medical Inspection List of Tables and Figures Office of the Inspector General State of California EXECUTIVE SUMMARY Pursuant to California Penal Code Section 6126, 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 court may find that an institution the OIG found to be providing adequate care still did not meet constitutional standards, depending on the analysis of the underlying data provided by the OIG. Likewise, an institution that has been rated inadequate by the OIG could still be found to pass constitutional muster with the implementation of remedial measures if the underlying data were to reveal easily mitigated deficiencies. 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. For this fourth cycle of inspections, the OIG added a clinical case review component and significantly enhanced the compliance portion of the inspection process from that used in prior cycles. In addition, the OIG added a population-based metric comparison of selected Healthcare Effectiveness Data Information Set (HEDIS) measures from other State and national health care organizations and compared that data to similar results for Pleasant Valley State Prison (PVSP). The OIG performed its Cycle 4 medical inspection at PVSP from April to June 2016. The inspection included in-depth reviews of 76 inmate-patient files conducted by clinicians, as well as reviews of documents from 380 inmate-patient files, covering 95 objectively scored tests of compliance with policies and procedures applicable to the delivery of medical care. The OIG assessed the case review and compliance results at PVSP using 14 health care quality indicators applicable to the institution, made up of 12 primary clinical indicators and 2 secondary administrative indicators. 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 deputy inspectors general and registered nurses trained in monitoring medical policy compliance. Of the 12 primary indicators, 7 were rated by both case review clinicians and compliance inspectors, 3 were rated by case review clinicians only, and 2 were rated by compliance inspectors only; both secondary indicators were rated by compliance inspectors only. See the Health Care Quality Indicators table on page ii. Based on that analysis, OIG experts made a considered and measured overall opinion that the quality of health care at PVSP was proficient. Pleasant Valley State Prison, Cycle 4 Medical Inspection Page i Office of the Inspector General State of California Health Care Quality Indicators All Institutions– PVSP Fourteen Primary Indicators (Clinical) Applicability Applicability Both case review 1–Access to Care All institutions and compliance Both case review 2–Diagnostic Services All institutions and compliance 3–Emergency Services All institutions Case review only 4–Health Information Management Both case review All institutions (Medical Records) and compliance 5–Health Care Environment All institutions Compliance only Both case review 6–Inter- and Intra-System Transfers All institutions and compliance Both case review 7–Pharmacy and Medication Management All institutions and compliance Female institutions 8–Prenatal and Post-Delivery Services Not Applicable only 9–Preventive Services All institutions Compliance only 10–Quality of Nursing Performance All institutions Case review only 11–Quality of Provider Performance All institutions Case review only Institutions with 12–Reception Center Arrivals Not Applicable reception centers All institutions with 13–Specialized Medical Housing Both case review an OHU, CTC, SNF, (OHU, CTC, SNF, Hospice) and compliance or Hospice Both case review 14–Specialty Services All institutions and compliance Two Secondary Indicators All Institutions– PVSP (Administrative) Applicability Applicability 15–Internal Monitoring, Quality All institutions Compliance only Improvement, and Administrative Operations 16–Job Performance, Training, Licensing, All institutions Compliance only and Certifications Pleasant Valley State Prison, Cycle 4 Medical Inspection Page ii Office of the Inspector General State of California Overall Assessment: Proficient Based on the clinical case reviews and compliance testing, the OIG’s overall assessment rating for PVSP was proficient. Of the Overall Assessment 12 primary (clinical) quality indicators applicable to PVSP, the Rating: OIG found seven proficient and five adequate. Of the two secondary (administrative) quality indicators, the OIG found one Proficient proficient and one inadequate. To determine the overall assessment for PVSP, the OIG considered individual clinical ratings and individual compliance question scores within each of the indicator categories, putting emphasis on the primary indicators. Based on that analysis, OIG experts made a considered and measured overall opinion about the quality of health care observed at PVSP. Clinical Case Review and OIG Clinician Inspection Results The clinicians’ case reviews sampled patients with high medical needs and included a review of 1,062 patient care events.1 Of the 12 primary indicators applicable to PVSP, 10 were evaluated by clinician case review; 5 were proficient, 5 were adequate, and none was inadequate. When determining the overall adequacy of care, the OIG paid particular attention to the clinical nursing and provider quality indicators, as adequate health care staff can sometimes overcome suboptimal processes and programs. However, the opposite is not true; inadequate health care staff cannot provide adequate care, even though the established processes and programs onsite may be adequate. The OIG clinicians identify inadequate medical care based on the risk of significant harm to the patient, not the actual outcome. Program Strengths — Clinical  With a nearly full staff of medical providers and a mostly low-complexity patient population, the majority of patients at PVSP received adequate care.  Most providers were experienced with the care of patients in a correctional environment.  The chief medical executive, who also had administrative responsibility at a neighboring institution, shared proven processes from the other institution. This led to an overall improvement in health care delivery.  With an enforced policy that all scheduled patients should be seen on the same day, there was no clinic backlog. 1 Each OIG clinician team includes a board-certified physician and registered nurse consultant with experience in correctional and community medical settings. Pleasant Valley State Prison, Cycle 4 Medical Inspection Page iii Office of the Inspector General State of California  PVSP had many proficient health care systems: specialty services, diagnostic services, emergency services, and pharmacy services.  The morale among the providers was high, and all reported that the chief physician and surgeon and the chief medical executive were very supportive. PVSP had helpful clinic staff and a good working relationship with custody staff. Program Weaknesses — Clinical  One of the PVSP mid-level providers demonstrated many significant deficiencies when providing care to medically complex patients. This may have indicated suboptimal supervision.  Health information management was deficient in the scanning process with missing or mislabeled documents.  There was a lack of coordination to ensure continuity of care when patients returned to PVSP from higher levels of care. In a few cases, this led to a delay in the implementation of discharge instructions.  In accordance with PVSP institutional policy, only patients with a history of hypertension or diabetes, or those with acute symptoms, had their vital signs recorded upon arrival at the institution. However, CCHCS policy requires that all new arrivals have their vital signs checked upon arrival. Compliance Testing Results Of the 14 health care indicators applicable to PVSP, 11 were evaluated by compliance inspectors. There were 95 individual compliance questions within those 11 indicators, generating 1,205 data points, that tested PVSP’s compliance with California Correctional Health Care Services (CCHCS) policies and procedures. Those 95 questions are detailed in Appendix A — Compliance Test Results. The institution’s inspection scores in the 11 applicable indicators ranged from 68.5 percent to 98.0 percent, with the secondary (administrative) indicator Internal Monitoring, Quality Improvement and Administrative Operations receiving the lowest score, and the primary (clinical) indicator Health Care Environment receiving the highest. Of the nine primary indicators applicable to compliance testing, the OIG rated six proficient, three adequate, and none inadequate. Of the two secondary indicators, which involve administrative health care functions, one was rated proficient and the other, inadequate. Program Strengths — Compliance As the PVSP Executive Summary Table on page viii indicates, the institution’s compliance ratings were proficient, scoring above 85 percent, in the following six primary indicators: Access to Care, Diagnostic Services, Health Care Environment, Pharmacy and Medication Management, Pleasant Valley State Prison, Cycle 4 Medical Inspection Page iv Office of the Inspector General State of California Specialized Medical Housing, and Specialty Services. The institution also received a proficient score in the secondary indicator Job Performance, Training, Licensing, and Certifications. The following are some of PVSP’s strengths based on its compliance scores on individual questions in all the primary health care indicators:  Providers conducted timely appointments with patients who required a follow-up visit for chronic care conditions, patients who were released from a community hospital, and patients who were referred by nursing staff after requesting a service or who required a follow-up visit.  Patients had a standardized process to obtain and submit request forms for health care services, and nursing staff timely reviewed patients’ requests and timely completed face-to-face visits with patients.  PVSP provided patients with timely radiology and laboratory services, and providers timely reviewed the related diagnostic studies and communicated the results to patients.  Clinical health care areas were appropriately disinfected, cleaned, and sanitized. They contained operable sinks and sufficient quantities of hygiene supplies, and clinical staff adhered to universal hand hygiene precautions and properly controlled exposure to blood-borne pathogens and contaminated waste.  Clinical staff followed adequate protocols for managing and storing bulk medical supplies; clinic exam rooms and common areas had environments conducive to providing medical services.  The institution’s emergency medical response bags were appropriately inspected and inventoried, and they contained all essential items.  Nursing staff timely administered or delivered patients’ chronic care medications, newly ordered medications, and tuberculosis medications; and ensured that those patients who transferred from one housing unit to another received their medications without interruption.  Nursing staff employed appropriate administrative controls and hand hygiene protocols during medication preparation and administration processes.  In its main pharmacy, PVSP followed general security, organization, and cleanliness management protocols; properly stored medications; properly accounted for narcotic medications; and followed key medication error reporting protocols.  Patients were timely offered colorectal cancer screenings and annual influenza vaccinations. Pleasant Valley State Prison, Cycle 4 Medical Inspection Page v Office of the Inspector General State of California  Patients timely received their high-priority specialty services and providers timely reviewed the related consultant reports. When PVSP denied a provider’s request for a patient’s specialty service, the denial was timely processed and timely communicated to the patient. The following are some of the strengths identified within the two secondary administrative indicators:  The institution promptly processed all inmate-patient medical appeals during the 12 months preceding the OIG’s inspection.  The Quality Management Committee (QMC) met monthly, evaluated program performance and took action when improvement opportunities were identified. The committee also took adequate steps to ensure the accuracy of its Dashboard data reporting.  Nursing staff received periodic reviews from their supervisors, and nursing staff who administered medications were current on their clinical competency validations. Program Weaknesses — Compliance The institution did not receive ratings of inadequate, scoring below 75 percent, in any of the primary (clinical) indicators. The institution received one inadequate score in the secondary (administrative) indicator Internal Monitoring, Quality Improvement, and Administrative Operations. The following are some of the weaknesses identified by PVSP’s compliance scores on individual questions in all the primary health care indicators:  Providers did not always conduct timely appointments with patients who had been referred to them by nursing staff after transferring to PVSP from another institution.  Health care staff did not always properly label or file documents into patients’ electronic health records.  For patients who transferred to PVSP from other CDCR institutions, nursing staff did not always properly complete the Initial Health Screening form (CDCR Form 7277) including answering all required screening questions.  For patients who transferred out of PVSP, scheduled specialty service appointments were not always identified on the Health Care Transfer Information form (CDCR Form 7371).  PVSP did not timely transfer those patients deemed to be at high risk for contracting coccidioidomycosis (valley fever) to other CDCR institutions. Pleasant Valley State Prison, Cycle 4 Medical Inspection Page vi Office of the Inspector General State of California The following are some of the weaknesses identified within the two secondary administrative indicators:  PVSP did not follow adverse/sentinel event reporting requirements which included the completion of required monthly status reports.  Medical staff did not timely review and submit the required death report form to CCHCS’s Death Review Unit for one death that occurred during the review period. The PVSP Executive Summary Table on the following page lists the quality indicators the OIG inspected and assessed during the clinical case reviews and objective compliance tests, and provides the institution’s rating in each area. The overall indicator ratings were based on a consensus decision by the OIG’s clinicians and non-clinical inspectors. Pleasant Valley State Prison, Cycle 4 Medical Inspection Page vii Office of the Inspector General State of California PVSP Executive Summary Table Case Compliance Overall Indicator Primary Indicators (Clinical) Review Rating Rating Rating Access to Care Adequate Proficient Proficient Diagnostic Services Proficient Proficient Proficient Emergency Services Proficient Not Applicable Proficient Health Information Management Adequate Adequate Adequate (Medical Records) Health Care Environment Not Applicable Proficient Proficient Inter- and Intra-System Transfers Adequate Adequate Adequate Pharmacy and Medication Management Proficient Proficient Proficient Preventive Services Not Applicable Adequate Adequate Quality of Nursing Performance Adequate Not Applicable Adequate Quality of Provider Performance Adequate Not Applicable Adequate Specialized Medical Housing Proficient Proficient Proficient (OHU, CTC, SNF, Hospice) Specialty Services Proficient Proficient Proficient The Prenatal and Post-Delivery Services and Reception Center Arrivals indicators did not apply to this institution. Case Compliance Overall Indicator Secondary Indicators (Administrative) Review Rating Rating Rating Internal Monitoring, Quality Improvement, Not Applicable Inadequate Inadequate and Administrative Operations Job Performance, Training, Licensing, and Not Applicable Proficient Proficient Certifications Compliance results for quality indicators are proficient (greater than 85.0 percent), adequate (75.0 percent to 85.0 percent), or inadequate (below 75.0 percent). Pleasant Valley State Prison, Cycle 4 Medical Inspection Page viii Office of the Inspector General State of California Population-Based Metrics The institution performed well as measured by population-based metrics. In all five diabetes care measures, PVSP outperformed or closely matched both Medi-Cal and Kaiser Permanente, typically one of the highest scoring health organizations in California. Nationally, PVSP outperformed Medicaid, Medicare, and commercial health plans in all five diabetic care measures, but scored slightly lower than the U.S. Department of Veterans Affairs (VA) in one measure, dilated eye exams for diabetic patients. With regard to influenza immunizations for younger adults, PVSP outperformed all state and national health care organizations. For colorectal cancer screenings, the institution scored higher than commercial entities, the same as Medicare, and lower than Kaiser and the VA. For both these measures, the institution offered the preventive services to all patients sampled, but many refused the offers, adversely affecting PVSP’s scores. Overall, with the exception of colorectal cancer screenings, PVSP’s HEDIS performance reflected a well-performing chronic care program. With regard to PVSP’s scores in the immunization and colorectal cancer screening measures, the institution could further improve their scores by taking interventions to lower the refusal rates. Pleasant Valley State Prison, Cycle 4 Medical Inspection Page ix Office of the Inspector General State of California INTRODUCTION Pursuant to California Penal Code Section 6126, 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. For this fourth cycle of inspections, the OIG augmented the breadth and quality of its inspection program used in prior cycles, adding a clinical case review component and significantly enhancing the compliance component of the program. Pleasant Valley State Prison (PVSP) was the 27th medical inspection of Cycle 4. During the inspection process, the OIG assessed the delivery of medical care to patients for 12 primary clinical health care indicators and two secondary administrative health care indicators applicable to the institution. It is important to note that while the primary quality indicators represent the clinical care being provided by the institution at the time of the inspection, the secondary quality indicators are purely administrative and are not reflective of the actual clinical care provided. The OIG is committed to reporting on each institution’s delivery of medical care to assist in identifying areas for improvement, but the federal court will ultimately determine whether any institution’s medical care meets constitutional standards. ABOUT THE INSTITUTION Pleasant Valley State Prison (PVSP) is located in Coalinga and houses general population, minimum to maximum custody level inmates. PVSP operates six medical clinics where staff members handle non-urgent requests for medical services. PVSP also conducts screenings in its receiving and release clinical area (R&R); treats patients needing urgent or emergency care in its triage and treatment area (TTA); and treats those requiring inpatient health services in its correctional treatment center (CTC). The institution primarily provides medical care for patients designated as low to medium medical risk; however, it does have a very small population of patients classified as high medical risk. California Correctional Health Care Services (CCHCS) has designated PVSP a “basic” care institution. Basic institutions are located in rural areas away from tertiary care centers and specialty care providers whose services would likely be used frequently by higher-risk patients. PVSP’s geographical location is in the Western San Joaquin Valley, and the institution is one of two California prisons designated as a restricted area for patients who are at high risk for contracting coccidioidomycosis (“valley fever”). On August 8, 2016, the institution 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. Pleasant Valley State Prison, Cycle 4 Medical Inspection Page 1 Office of the Inspector General State of California Based on March 2016 staffing data obtained from the institution, PVSP’s average vacancy rate among medical managers, primary care providers, supervisors, and non-supervisory nurses was 13 percent. Nursing supervisors had the highest vacancy rate, at 24 percent; however, nursing staff had the most vacant positions with 10.5 vacancies (12 percent). In addition, three nurses were redirected to non-patient care areas while six other nurses were on long-term medical leave. In total, only 78 percent of the institution’s nursing work force was actively contributing to patient care. The institution also reported that one management staff member, and two nursing supervisors were on long-term medical leave. In a related area, PVSP’s chief executive officer reported that during the last 12 months, there were five health care managers or employees who were under CDCR disciplinary review; however, all five were still working in a clinical setting. PVSP Health Care Staffing Resources as of March 2016 Primary Care Nursing Management Nursing Staff Totals Providers Supervisors Description Number % Number % Number % Number % Number % Authorized 5 4% 7 6% 10.5 10% 87.5 80% 110 100% Positions Filled Positions 5 100% 6 86% 8 76% 77 88% 96 87% Vacancies 0 0% 1 14% 2.5 24% 10.5 12% 14 13% Recent Hires (within 12 1 20% 1 17% 2 25% 18 23% 22 23% 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% 3 4% 3 3% Care Areas) Staff on Long-term 1 20% 0 0% 2 25% 6 8% 9 9% Medical Leave Note: PVSP Health Care Staffing Resources data was not validated by the OIG. Pleasant Valley State Prison, Cycle 4 Medical Inspection Page 2 Office of the Inspector General State of California As of March 28, 2016, the Master Registry for PVSP showed that the institution had a total population of 3,217. Within that total population, none were designated as high medical risk, Priority 1 (High 1), and 0.3 percent were designated as high medical risk, Priority 2 (High 2). Patients’ assigned risk levels are based on the complexity of their required medical care related to their specific diagnoses, frequency of higher levels of care, age, and abnormal labs and procedures. High 1 has at least two high-risk conditions; High 2 has only one. Patients at high medical risk are more susceptible to poor health outcomes than those at medium or low medical risk. Patients at high medical risk also typically require more health care services than do patients with lower assigned risk levels. The chart below illustrates the breakdown of the institution’s medical risk levels at the start of the OIG medical inspection. PVSP Master Registry Data as of March 28, 2016 Medical Risk Level # of Inmate-Patients Percentage High 1 0 0.0% High 2 10 0.3% Medium 1,256 39.0% Low 1,951 60.7% Total 3,217 100.0% Pleasant Valley State Prison, Cycle 4 Medical Inspection Page 3 Office of the Inspector General State of California Commonly Used Abbreviations ACLS Advanced Cardiovascular Life Support HIV Human Immunodeficiency Virus AHA American Heart Association HTN Hypertension ASU Administrative Segregation Unit INH Isoniazid (anti-tuberculosis medication) BLS Basic Life Support IV Intravenous CBC Complete Blood Count KOP Keep-on-Person (in taking medications) CC Chief Complaint LPT Licensed Psychiatric Technician CCHCS California Correctional Health Care Services LVN Licensed Vocational Nurse CCP Chronic Care Program MAR Medication Administration Record California Department of Corrections and CDCR MRI Magnetic Resonance Imaging Rehabilitation CEO Chief Executive Officer MD Medical Doctor CHF Congestive Heart Failure NA Nurse Administered (in taking medications) CME Chief Medical Executive N/A Not Applicable CMP Comprehensive Metabolic (Chemistry) Panel NP Nurse Practitioner CNA Certified Nursing Assistant OB Obstetrician CNE Chief Nurse Executive OHU Outpatient Housing Unit C/O Complains of OIG Office of the Inspector General COPD Chronic Obstructive Pulmonary Disease P&P Policies and Procedures (CCHCS) CP&S Chief Physician and Surgeon PA Physician Assistant CPR Cardio-Pulmonary Resuscitation PCP Primary Care Provider CSE Chief Support Executive POC Point of Contact CT Computerized Tomography PPD Purified Protein Derivative CTC Correctional Treatment Center PRN As Needed (in taking medications) DM Diabetes Mellitus RN Registered Nurse Directly Observed Therapy (in taking DOT Rx Prescription medications) Dx Diagnosis SNF Skilled Nursing Facility Subjective, Objective, Assessment, Plan, EKG Electrocardiogram SOAPE Education ENT Ear, Nose and Throat SOMS Strategic Offender Management System ER Emergency Room S/P Status Post eUHR electronic Unit Health Record TB Tuberculosis FTF Face-to-Face TTA Triage and Treatment Area History and Physical (reception center H&P UA Urinalysis examination) HIM Health Information Management UM Utilization Management Pleasant Valley State Prison, Cycle 4 Medical Inspection Page 4 Office of the Inspector General State of California OBJECTIVES, SCOPE, AND METHODOLOGY 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 14 primary (clinical) and 2 secondary (administrative) quality indicators 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 indicators address the administrative functions that support a health care delivery system. The 14 primary quality indicators are Access to Care, Diagnostic Services, Emergency Services, Health Information Management (Medical Records), Health Care Environment, Inter- and Intra-System Transfers, Pharmacy and Medication Management, Prenatal and Post-Delivery Services, Preventive Services, Quality of Nursing Performance, Quality of Provider Performance, Reception Center Arrivals, Specialized Medical Housing (OHU, CTC, SNF, Hospice), and Specialty Services. The two secondary quality indicators are Internal Monitoring, Quality Improvement, and Administrative Operations; and Job Performance, Training, Licensing, and Certifications. 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 deputy inspectors general and 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 results, while the ratings for the primary quality indicators Health Care Environment and Preventive Services are derived entirely from compliance test results. As another example, primary quality indicators such as Diagnostic Services and Specialty Services receive ratings derived from both sources. At PVSP, 14 of the quality indicators were applicable, consisting of 12 primary clinical indicators and two secondary administrative indicators. Of the 12 primary indicators, 7 were rated by both case review clinicians and compliance inspectors, 3 were rated by case review clinicians only, and 2 were rated by compliance inspectors only; both secondary indicators were rated by compliance inspectors only. 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 Pleasant Valley State Prison, Cycle 4 Medical Inspection Page 5 Office of the Inspector General State of California operations. Moreover, if the OIG learns of an inmate-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 quality indicator; therefore, recommendations for improvement should not necessarily be interpreted as indicative of deficient medical care delivery. CASE REVIEWS The OIG has added case reviews to the Cycle 4 medical inspections at the recommendation of its stakeholders. At the conclusion of Cycle 3, the federal Receiver and the Inspector General determined that the health care provided at the institutions was not fully evaluated by the compliance tool alone, and that the compliance tool was not designed to provide comprehensive qualitative assessments. Accordingly, the OIG added case reviews in which OIG physicians and nurses evaluate selected cases in detail to determine the overall quality of health care provided to the inmate-patients. 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 PVSP had only six high risk patients, additional case review samples included chronic care illnesses such as diabetes mellitus. 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. Pleasant Valley State Prison, Cycle 4 Medical Inspection Page 6 Office of the Inspector General State of California 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 immunizations. To review these processes, the OIG simultaneously performs a broad compliance review. 3. Patient charts generated during death reviews, sentinel events (unexpected occurrences involving death or serious injury, or risk thereof), and hospitalizations are mostly of high-risk patients. BENEFITS AND LIMITATIONS OF TARGETED SUBPOPULATION REVIEW Because the selected patients utilize the broadest range of services offered by the health care system, the OIG’s retrospective chart review provides adequate data for a qualitative assessment of the most vital system processes (referred to as “primary quality indicators”). Retrospective chart review provides an accurate qualitative assessment of the relevant primary quality indicators as applied to the targeted subpopulation of high-risk and high-utilization patients. While this targeted subpopulation does not represent the prison population as a whole, the ability of the institution to provide adequate care to this subpopulation is a crucial and vital indicator of how the institution provides health care to its whole patient population. Simply put, if the institution’s medical system does not adequately care for those patients needing the most care, then it is not fulfilling its obligations, even if it takes good care of patients with less complex medical needs. Since the targeted subpopulation does not represent the institution’s general prison population, the OIG cautions against inappropriate extrapolation of conclusions from the retrospective chart reviews to the general population. For example, if the high-risk diabetic patients reviewed have poorly-controlled diabetes, one cannot conclude that the entire diabetic population is inadequately controlled. Similarly, if the high-risk diabetic patients under review have poor outcomes and require significant specialty interventions, one cannot conclude that the entire diabetic population is having similarly poor outcomes. Nonetheless, the health care system’s response to this subpopulation can be accurately evaluated and yields valuable systems information. In the above example, if the health care system is Pleasant Valley State Prison, Cycle 4 Medical Inspection Page 7 Office of the Inspector General State of California 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, PVSP Sample Sets, the OIG clinicians evaluated medical charts for 76 unique inmate-patients. Appendix B, Table B–4, PVSP Case Review Sample Summary, clarifies that both nurses and physicians reviewed charts for 25 of those patients, for 101 reviews in total. Physicians performed detailed reviews of 31 charts, and nurses performed detailed reviews of 16 charts, totaling 47 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 47 patients, while physicians reviewed an additional 7. These generated 1,062 clinical events for review (Appendix B, Table B-3, PVSP Event-Program). The reporting format 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 10 chronic care patient (all diabetic) records, the 76 unique patients sampled included patients with 156 chronic care diagnoses. The OIG’s sample selection tool allowed evaluation of many chronic care programs even with the limited number of high risk patients at PVSP. All six high risk patients were used in the samples. While the OIG did not evaluate every chronic disease or health care staff member, the overall operation of the institution’s system and staff were assessed for adequacy. The OIG’s case review methodology and sample size matched other qualitative research. The empirical findings, supported by expert statistical consultants, showed adequate conclusions after 10 to 15 charts had undergone full clinician review. In qualitative statistics, this phenomenon is known as “saturation.” The OIG asserts that the physician sample size of over 30 detailed reviews certainly far exceeds the saturation point necessary for an adequate qualitative review. With regard to reviewing charts from different providers, the case review is not intended to be a focused search for poorly performing providers; rather, it is focused on how the system cares for those patients who need care the most. Nonetheless, while not sampling cases by each provider at the institution, the OIG inspections adequately review most providers. Providers would only escape OIG case review if institutional management successfully mitigated patient risk by having the more poorly performing providers care for the less complicated, low-utilizing, and lower-risk patients. The OIG’s clinicians concluded that the case review sample size was more than adequate to assess the quality of services provided. Based on the collective results of clinicians’ case reviews, the OIG rated each quality indicator as either proficient (excellent), adequate (passing), inadequate (failing), or not applicable. A separate Pleasant Valley State Prison, Cycle 4 Medical Inspection Page 8 Office of the Inspector General State of California confidential PVSP 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 April to June 2016, deputy inspectors general and registered nurses attained answers to 95 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 inmate-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 380 individual inmate-patients and analyzed specific transactions within their records for evidence that critical events occurred. Inspectors also reviewed management reports and meeting minutes to assess certain administrative operations. In addition, during the week of April 11, 2016, field inspectors conducted a detailed onsite inspection of PVSP’s medical facilities and clinics; interviewed key institutional employees; and reviewed employee records, logs, medical appeals, death reports, and other documents. This generated 1,205 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 PVSP’s plant infrastructure, protocols for tracking medical appeals and local operating procedures, and staffing resources. 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 The OIG rated the institution in the following nine primary (clinical) and two secondary (administrative) quality indicators applicable to the institution for compliance testing: Primary indicators: Access to Care, Diagnostic Services, Health Information Management (Medical Records), Health Care Environment, Inter-Intra-System Transfers, Pharmacy and Medical Management, Preventive Services, Specialized Medical Housing (OHU, CTC, SNF, Hospice), and Specialty Services. Secondary indicators: Internal Monitoring, Quality Improvement, and Administrative Operations; and Job Performance, Training, Licensing, and Certifications. Pleasant Valley State Prison, Cycle 4 Medical Inspection Page 9 Office of the Inspector General State of California After compiling the answers to the 95 questions, the OIG derived a score for each primary and secondary quality indicator identified above by calculating the percentage score of all Yes answers for each of the questions applicable to a particular indicator, then averaging those scores. Based on those results, the OIG assigned a rating to each quality indicator of proficient (greater than 85 percent), adequate (between 75 percent and 85 percent), or inadequate (less than 75 percent). DASHBOARD COMPARISONS In the first ten medical inspection reports of Cycle 4, the OIG identified where similar metrics for some of the individual compliance questions were available within the CCHCS Dashboard, which is a monthly report that consolidates key health care performance measures statewide and by institution. However, there was not complete parity between the metrics due to differing time frames for data collecting and differences in sampling methods, rendering the metrics unable to be compared. The OIG has removed the Dashboard comparisons to eliminate confusion. Dashboard data is available on CCHCS’s website, www.cphcs.ca.gov. 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 deputy inspectors general 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 inmate-patients. Based on that analysis, OIG experts made a considered and measured overall opinion about the quality of health care observed. Pleasant Valley State Prison, Cycle 4 Medical Inspection Page 10 Office of the Inspector General State of California POPULATION-BASED METRICS The OIG identified a subset of Healthcare Effectiveness Data Information Set (HEDIS) measures applicable to the CDCR inmate-patient population. To identify outcomes for PVSP, the OIG reviewed some of the compliance testing results, randomly sampled additional inmate-patients’ records, and obtained PVSP data from the CCHCS Master Registry. The OIG compared those results to HEDIS metrics reported by other statewide and national health care organizations. Pleasant Valley State Prison, Cycle 4 Medical Inspection Page 11 Office of the Inspector General State of California MEDICAL INSPECTION RESULTS PRIMARY (CLINICAL) QUALITY INDICATORS OF HEALTH CARE The primary quality indicators assess the clinical aspects of health care. As shown on the Health Care Quality Indicators table on page ii of this report, 12 of the OIG’s primary indicators were applicable to PVSP. Of those 12 indicators, seven were rated by both the case review and compliance components of the inspection, three were rated by the case review component alone, and two were rated by the compliance component alone. The PVSP Executive Summary Table on page viii shows the case review compliance ratings for each applicable indicator. Summary of Case Review Results: The clinical case review component assessed 10 of the 12 primary (clinical) indicators applicable to PVSP. Of these 10 indicators, OIG clinicians rated 5 proficient, 5 adequate, and none inadequate. The OIG physicians rated the overall adequacy of care for each of the 31 detailed case reviews they conducted. Of these 31 cases, 29 were adequate, and 2 were inadequate. In the 1,062 events reviewed, there were 191 deficiencies, of which 22 were considered to be of such magnitude that, if left unaddressed, they would likely contribute to patient harm. Adverse Events Identified During Case Review: Medical care is a complex dynamic process with many moving parts, subject to human error even within the best health care organizations. Adverse events are typically identified and tracked by all major health care organizations for the purpose of quality improvement. They are not generally representative of medical care delivered by the organization. The OIG identified adverse events for the dual purposes of quality improvement and the illustration of problematic patterns of practice found during the inspection. Because of the anecdotal description of these events, the OIG cautions against drawing inappropriate conclusions regarding the institution based solely on adverse events. There were no adverse events identified in the case reviews at PVSP. However, as discussed in the Internal Monitoring, Quality Improvement, and Administrative Operations indicator, compliance review identified where the institution did not complete required status reports for a previously reported sentinel event. Summary of Compliance Results: The compliance component assessed 9 of the 12 primary (clinical) indicators applicable to PVSP. Of these nine indicators, OIG inspectors rated six proficient, three adequate, and none 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. Pleasant Valley State Prison, Cycle 4 Medical Inspection Page 12 Office of the Inspector General State of California ACCESS TO CARE This indicator evaluates the institution’s ability to provide Case Review Rating: inmate-patients with timely clinical appointments. Areas specific to Adequate inmate-patients’ access to care are reviewed, such as initial Compliance Score: assessments of newly arriving inmates, acute and chronic care Proficient follow-ups, face-to-face nurse appointments when an inmate-patient (93.3%) requests to be seen, provider referrals from nursing lines, and Overall Rating: follow-ups after hospitalization or specialty care. Compliance Proficient testing for this indicator also evaluates whether inmate-patients have Health Care Services Request forms (CDCR Form 7362) available in their housing units. In this indicator, the OIG case review and compliance review processes yielded different results, with the case review giving an adequate rating and the compliance review resulting in a proficient score. The OIG’s internal review process considered those factors that led to both scores and ultimately rated this indicator proficient because case review had relatively few deficiencies related to the number of events reviewed and the institution scored well in many of the compliance review’s test areas. Case Review Results The OIG clinicians reviewed 783 nursing, medical provider, specialty care, and hospital discharge encounters and identified 22 deficiencies relating to Access to Care. Five of these were significant (cases 9, 11, 39, 41, and 76) and placed the patient at risk of harm. However, patients at PVSP generally had adequate access to address their health care needs. As a result, the OIG clinicians rated this indicator adequate. RN Sick Call Access Nursing staff at PVSP generally collected and reviewed health care services request forms in a timely manner, and most patients with non-urgent medical conditions were appropriately scheduled for nurse clinic visits on the next business day. Cases 9 and 18 had minor deficiencies related to timely nurse clinic visits. RN-to-Provider Referrals In two cases (18 and 48), triage nurses made referrals for their patients to see a provider; however, the visits did not occur within the requested time frame. In the case below, the requested provider appointment was never made:  In case 39, a routine provider appointment was never scheduled after the nurse referred the patient who had a metal rod in his leg and complained of pain and swelling in his ankle. This was a significant deficiency. Pleasant Valley State Prison, Cycle 4 Medical Inspection Page 13 Office of the Inspector General State of California Provider Follow-up Appointments After discharge from the correctional treatment center (CTC), timely follow-up with a provider was not ordered in case 78. In addition, in case 76, a patient with a fractured jaw did not receive a timely follow-up appointment. This was a significant deficiency. Providers’ ordered follow-up visits did not occur as intended in the following two cases:  In case 9, appointments for follow-up in the hepatitis C clinic and a chronic care visit were not scheduled as ordered. This was a significant deficiency.  In case 11, the five-day follow-up appointment for seizure disorder after CTC discharge did not occur for four weeks. This was a significant deficiency. Access to Specialty Services Delays in return visits to specialty providers are discussed in the Specialty Services indicator. Follow-up After Specialty Consultation Patients were timely seen by their providers following specialty consultations with the exception of case 41. In this case, the provider did not see the patient for a follow-up visit until a month after an ophthalmology consultation. This was a significant deficiency. Follow-up After TTA Evaluation Patients seen in the TTA for emergent or urgent problems received timely follow-up appointments with their primary care providers. Follow-up After Hospitalization Following discharge from a higher level of care, providers timely saw their patients. Specialized Medical Housing Deficiencies with access to care in the CTC are discussed in the Specialized Medical Housing indicator. Onsite Inspection Findings The OIG clinicians noted that health care team members had a good working relationship and that meaningful interactions occurred during the morning huddle. None of the clinics had backlogs. Implementation of the LVN care management program was reported to have optimized management of chronic conditions, immunizations, and cancer screenings. The executive leadership opined that having more onsite specialty consultants would further improve access to health care. Pleasant Valley State Prison, Cycle 4 Medical Inspection Page 14 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 93.3 percent. PVSP scored in the proficient range in the following test areas:  Inspectors sampled 30 health care services request forms submitted by patients across all facility clinics. Nursing staff reviewed all patients’ request forms on the same day they were received (MIT 1.003). Nursing staff also completed a timely face-to-face triage encounter for all of those 30 patients (MIT 1.004).  Of the 12 patients sampled who were referred to and seen by a provider and for whom the provider subsequently ordered a follow-up appointment, all 12 received their follow-up appointments timely (MIT 1.006).  PVSP offered all ten sampled patients a follow-up appointment with a provider within five days of discharge from a community hospital (MIT 1.007).  Inmates had access to health care services request forms at all six housing units the OIG inspected (MIT 1.101).  Inspectors reviewed recent appointments for 30 patients with chronic care conditions and found that 29 (97 percent) received timely routine appointments. One patient’s appointment was 26 days late (MIT 1.001).  Among 15 health care services request forms sampled on which nursing staff referred the patient for a provider appointment, 14 patients (93 percent) received a timely appointment. The one exception was a patient who received a routine appointment 35 days late (MIT 1.005).  The OIG examined the timeliness of specialty services provided to 15 patients who needed their service as a high-priority urgency and another 15 patients who required a service on a routine urgency basis. Of the 30 sampled patients who received a high-priority or routine specialty service, 26 (87 percent) received a timely follow-up appointment with a provider. Two patients’ high-priority specialty service follow-up appointments were seven and nine days late. Two patients’ routine specialty service follow-up appointments were 25 and 111 days late (MIT 1.008). PVSP performed in the inadequate range in the following test:  Among 30 patients sampled who transferred into PVSP from other institutions and were referred to a provider based on nursing staff’s initial health care screening, only 19 (63 percent) were seen timely. Eight patients received their provider appointment from 6 to Pleasant Valley State Prison, Cycle 4 Medical Inspection Page 15 Office of the Inspector General State of California 23 days late, but for three other patients, there was no eUHR evidence found to indicate they were ever seen (MIT 1.002). Recommendations No specific recommendations. Pleasant Valley State Prison, Cycle 4 Medical Inspection Page 16 Office of the Inspector General State of California DIAGNOSTIC SERVICES This indicator addresses several types of diagnostic services. Case Review Rating: Specifically, it addresses whether radiology and laboratory services Proficient were timely provided to inmate-patients, whether the primary care Compliance Score: provider timely reviewed the results, and whether the results were Proficient communicated to the inmate-patient within the required time (91.1%) frames. In addition, for pathology services, the OIG determines Overall Rating: whether the institution received a final pathology report and Proficient whether the provider timely reviewed and communicated the pathology results to the patient. The case reviews also factor in the appropriateness, accuracy, and quality of the diagnostic test(s) ordered and the clinical response to the results. Case Review Results The OIG clinicians reviewed 83 diagnostic events and found 13 deficiencies, two of which were significant. Of those deficiencies, eight were related to health information management, three regarded the quality of provider performance, and two were a result of access to care deficiencies. PVSP performed well with regard to diagnostic services, and the indicator rating was thus proficient. Health Information Management There were eight minor deficiencies due to health information management. These included delays in review of diagnostic reports (cases 7 and 26), failures of the providers to review reports (cases 22, 26, and 31), and errors in the document scanning process (cases 13 and 31). These deficiencies are also noted in the Health Information Management and Quality of Provider Performance indicators. Quality of Provider Performance There were three deficiencies due to Quality of Provider Performance. Two deficiencies were significant (both in case 31). As these are discussed in and contributed to the rating of the Quality of Provider Performance indicator, they did not contribute to the rating of the Diagnostic Services indicator. Access to Care Laboratory tests were not performed as ordered in cases 43 and 75. Clinician Onsite Inspection PVSP had an efficient system for performing urgent laboratory tests and obtaining the results in a timely manner. The providers reported adequate onsite radiology support. Pleasant Valley State Prison, Cycle 4 Medical Inspection Page 17 Office of the Inspector General State of California Compliance Testing Results The institution received a proficient compliance score of 91.1 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 of the radiology services sampled, the services were timely performed, the ordering provider timely reviewed the diagnostic report results, and the test results were timely communicated to the patients (MIT 2.001, 2.002, 2.003). Laboratory Services  In all ten of the laboratory services sampled, the services were timely performed (MIT 2.004). For nine of those ten (90 percent) sampled services, the provider timely reviewed the diagnostic report and timely reported the results to the patient. In one case, the provider did not initial and date the laboratory diagnostic report and communicated the results 77 days late (MIT 2.005, 2.006). Pathology Services  Clinicians at PVSP timely received the final pathology report for eight of ten patients sampled (80 percent). The two untimely reports were received 12 and 27 days late (MIT 2.007). Providers timely reviewed the pathology results for nine of ten patients (90 percent). In the one exception, the provider documented evidence of review 55 days late (MIT 2.008). Additionally, providers timely communicated the final pathology results to seven of the ten patients sampled (70 percent). Results were communicated 14 to 55 days late for three patients (MIT 2.009). Recommendations No specific recommendations. Pleasant Valley State Prison, Cycle 4 Medical Inspection Page 18 Office of the Inspector General State of California EMERGENCY SERVICES An emergency medical response system is essential to providing Case Review Rating: effective and timely emergency medical response, assessment, Proficient treatment, and transportation 24 hours per day. Provision of Compliance Score: urgent/emergent care is based on a patient’s emergency situation, Not Applicable clinical condition, and need for a higher level of care. The OIG reviews emergency response services including first aid, basic life Overall Rating: support (BLS), and advanced cardiac life support (ACLS) Proficient consistent with the American Heart Association guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiovascular care, and the provision of services by knowledgeable staff appropriate to each individual’s training, certification, and authorized scope of practice. The OIG evaluates this quality indicator entirely through clinicians’ reviews of case files and conducts no separate compliance testing element. Case Review Results The OIG clinicians reviewed 43 urgent/emergent events and found 28 minor deficiencies. PVSP generally provided appropriate and timely response for basic life support care during medical emergencies, so this indicator was, therefore, rated proficient. Provider Performance Consistent with its designation as a basic institution, very few medical emergencies occurred during the case review period. Most encounters were managed by telephone consultation with the TTA RN. Nonetheless, the care provided was complete. One example of good management for a patient with poorly controlled diabetes is described below:  In case 23, the patient was sent to the TTA after arrival from another institution with a dangerously high blood glucose level (higher than 500 mg/dL). The provider ordered intravenous hydration, regular insulin, repeat blood sugar checks after treatment, pre-meal and fasting blood glucose levels, laboratory tests to be performed the following morning, and evaluation by the patient’s primary provider in three to five days. Nursing Performance Nursing staff generally responded timely to emergency alarms and activation of 9-1-1 calls, made appropriate assessments, and implemented effective interventions. The patients in cases 4 and 6 both received excellent care. In addition, both cases had unresponsive patients with decreased breathing and absent pulses. Emergency measures, including CPR and Narcan (antidote for narcotic over dosage), successfully restored consciousness and vital signs. After a brief community hospital evaluation, they returned to the institution. Pleasant Valley State Prison, Cycle 4 Medical Inspection Page 19 Office of the Inspector General State of California Recommendations No specific recommendations. Pleasant Valley State Prison, Cycle 4 Medical Inspection Page 20 Office of the Inspector General State of California HEALTH INFORMATION MANAGEMENT (MEDICAL RECORDS) Health information management is a crucial link in the delivery of Case Review Rating: medical care. Medical personnel require accurate information in Adequate order to make sound judgments and decisions. This indicator Compliance Score: examines whether the institution adequately manages its health care Adequate information. This includes determining whether the information is (75.4%) correctly labeled and organized and available in the electronic unit Overall Rating: health record (eUHR); whether the various medical records (internal Adequate and external, e.g., hospital and specialty reports and progress notes) are obtained and scanned timely into the inmate-patient’s eUHR; whether records routed to clinicians include legible signatures or stamps; and whether hospital discharge reports include key elements and are timely reviewed by providers. Case Review Results After completing all case reviews, the OIG clinicians evaluated 1,062 health information management related events and identified only 36 deficiencies in this area. Only two of these deficiencies were deemed significant (cases 9 and 37), neither of which resulted in adverse patient outcomes. As a result, the OIG clinicians rated this indicator as adequate. Hospital Records PVSP performed adequately with retrieval and scanning of hospital and emergency room (ER) records. The OIG clinicians reviewed nine separate encounters and noted one deficiency:  In case 9, a delay in receiving and reviewing the discharge summary led to recommendations not being implemented upon the patient’s return to the institution. This was a significant deficiency. PVSP providers routinely did not initial and date the hospital and ER records to evidence their reviews. However, discharge recommendations were routinely implemented, suggesting that the providers had reviewed the records. Specialty Services PVSP had two different processes of obtaining consultation records. The telemedicine RN scanned consultant notes and sent them to the medical providers via e-mail. The office technician had responsibility for obtaining and sending offsite consultation notes to the health records administrative staff or scanning into the electronic health record.  In case 75, records pertaining to an offsite orthopedic procedure were not found in the eUHR. Pleasant Valley State Prison, Cycle 4 Medical Inspection Page 21 Office of the Inspector General State of California  In case 37, also described below, a diagnostic report was not obtained in a timely manner. Diagnostic Reports The following deficiencies were noted in retrieving and reviewing diagnostic reports:  In case 34, the sleep study report was not found in the eUHR.  In case 37, the electroencephalogram (brain wave tracing) report was not retrieved and scanned until more than a month after it was reported. The report was not available for the provider’s review when he met with the patient during an appointment intended to discuss the study result. This was a significant deficiency.  In cases 7 and 26, a provider did not review diagnostic reports in a timely manner.  In cases 22, 26, and 31, a provider did not review diagnostic reports at all. Scanning Performance There were numerous errors in the document scanning process. The most common were missing or mislabeled documents. One or more missing documents were noted for cases 3, 7, 8, 15, 64, and 75. In addition, one or more mislabeled documents were noted for cases 9, 13, 15, 18, 20, 26, 31, 37, and 74.  In case 64, the patient was seen by his provider, but no progress note was found in the eUHR. Legibility The OIG inspectors found sporadic instances of illegible notes, initials, signatures, or names. Onsite Inspection In response to a question regarding measures in place to ensure accurate scanning of documents, the OIG clinicians were informed that documents were audited for labeling accuracy both by a health record technician and an office assistant. The institution performed monthly audits. This was in addition to random audits by the Health Records Center in Sacramento. Compliance Testing Results The institution received an adequate compliance score of 75.4 percent in the Health Information Management (Medical Records) indicator and performed well in the following three areas:  PVSP timely scanned all 20 sampled specialty service consultant reports, all ten sampled community hospital discharge reports, and all 15 sampled medication administration records Pleasant Valley State Prison, Cycle 4 Medical Inspection Page 22 Office of the Inspector General State of California into the eUHR. As a result, PVSP scored 100 percent on these three test areas (MIT 4.003, 4.004, 4.005).  Inspectors reviewed eUHR files for ten patients who were admitted to a community hospital and then returned to PVSP; providers reviewed all the hospital discharge reports within three calendar days of discharge (MIT 4.008).  The institution timely scanned 18 of 20 sampled non-dictated progress notes, patients’ initial health screening forms, and requests for health care services into the eUHR (90 percent). Two health service request forms were each scanned one day late (MIT 4.001). PVSP displayed room for improvement in the following three areas:  The institution scored zero in its labeling and filing of documents scanned into patients’ electronic unit health records. Most errors included mislabeled and misfiled documents. However, there was also a missing transcribed physician’s progress note and one instance of a medication reconciliation order scanned into the incorrect patient’s file. For this test, once the OIG identifies 12 mislabeled or misfiled documents, the maximum points are lost and the resulting score is zero. For the PVSP medical inspection, inspectors identified a total of 17 documents with some sort of scanning error, five more than the maximum allowable errors (MIT 4.006).  The institution scored 50 percent for the timely scanning of dictated or transcribed provider progress notes into patients’ electronic health records. Only five of ten sampled progress notes were timely scanned within five calendar days of the patient encounter. Five other sampled progress notes were scanned between one and 11 days late (MIT 4.002).  When inspectors reviewed various medical documents such as hospital discharge reports, initial health screening forms, certain medication records, and specialty service reports to ensure that clinical staff legibly documented their names on the forms, 26 of 41 samples (63 percent) showed compliance. Fifteen of the sampled documents contained either illegible or missing signatures (MIT 4.007). Recommendations No specific recommendations. Pleasant Valley State Prison, Cycle 4 Medical Inspection Page 23 Office of the Inspector General State of California HEALTH CARE ENVIRONMENT This indicator addresses the general operational aspects of the Case Review Rating: institution’s clinics, including certain elements of infection control Not Applicable and sanitation, medical supplies and equipment management, the Compliance Score: Proficient availability of both auditory and visual privacy for inmate-patient (98.0%) visits, and the sufficiency of facility infrastructure to conduct comprehensive medical examinations. Rating of this component is Overall Rating: based entirely on the compliance testing results from the visual Proficient observations inspectors make at the institution during their onsite visit. Compliance Testing Results The institution received a proficient compliance score of 98.0 percent in the Health Care Environment indicator, scoring well in all test areas, as described below:  The institution appropriately disinfected, cleaned, and sanitized all nine clinical health care areas inspected and properly followed protocols to mitigate exposure to blood-borne pathogens and contaminated waste. Also, those nine clinical health care areas contained operable sinks with sufficient quantities of hygiene supplies, and all clinicians adhered to universal hand hygiene practices during inmate patient encounters (MIT 5.101, 5.103, 5.104, 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 PVSP a score of 100 percent on this test (MIT 5.106).  All nine clinics inspected followed adequate medical supply storage and management protocols in their clinical areas (MIT 5.107).  All nine clinics where medical services were provided, including common areas and patient exam rooms, had environments conducive to providing medical services (MIT 5.109, 5.110).  Inspectors examined emergency response bags at nine clinical areas to determine if the bags were inspected daily and inventoried monthly, and whether they contained all essential items. In all inspected locations, the bags sampled were in compliance (MIT 5.111). Pleasant Valley State Prison, Cycle 4 Medical Inspection Page 24 Office of the Inspector General State of California  Clinical health care staff at eight of nine applicable clinics (89 percent) ensured that reusable invasive and non-invasive medical equipment was properly sterilized or disinfected. The only exception was one clinic in which six pieces of reusable invasive medical equipment were stored in unsterile packaging (MIT 5.102).  Inspectors visited all nine clinics where medical services were provided to ensure that clinic common areas and exam rooms had essential core medical equipment and supplies. Of the nine clinics, eight were properly equipped and adequately stocked (89 percent). One clinic was missing a nebulizer unit and had a weight scale with a calibration sticker that was over a year old (MIT 5.108). Other Information Obtained from Non-Scored Results The OIG gathered information to determine if the institution’s physical infrastructure was maintained in a manner that supported health care management’s ability to provide timely or adequate health care. This question was not scored. When OIG inspectors interviewed health care managers, they did not have concerns about the facility’s infrastructure or its effect on the staff’s ability to provide adequate health care. However, as noted below, the institution had three master infrastructure projects underway, which management staff felt would improve the delivery of care at PVSP (5.999).  Project A: The Healthcare Facility Improvement Plan (HCFIP) funded project to replace the roofs of the program buildings, which house the health care clinics in B, C, and D yards. The project began in April 2016, with an anticipated completion date of February 2017.  Project B: The installation of a new roof on the program building in A yard, which includes health care clinics. This will be completed with special repair project funding from CDCR headquarters. The start date for this project was unknown.  Project C: The HCFIP funded project to construct two new buildings for health care clinics with short-term, restricted housing for patients, a pharmacy, and laboratory. Groundbreaking occurred in August 2016 with an expected completion date of March 2018. Recommendations No specific recommendations. Pleasant Valley State Prison, Cycle 4 Medical Inspection Page 25 Office of the Inspector General State of California INTER- AND INTRA-SYSTEM TRANSFERS This indicator focuses on the management of inmate-patients’ Case Review Rating: medical needs and continuity of patient care during the inter- and Adequate intra-facility transfer process. The patients reviewed for Inter- and Compliance Score: Intra-System Transfers include inmates received from other CDCR Adequate facilities and inmates transferring out of PVSP to another CDCR (75.8%) facility. The OIG review includes evaluation of the institution’s Overall Rating: ability to provide and document health screening assessments, Adequate initiation of relevant referrals based on patient needs, and the 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 inmate-patients who transfer out of the facility, 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. Case Review Results Clinicians reviewed 116 encounters relating to Inter- and Intra-System Transfers, including information from both the sending and receiving institutions. These included 54 hospitalization events, each of which resulted in a transfer back to the institution. The clinicians noted 37 deficiencies, with three being significant (cases 9,19, and 76). Overall, the inter- and intra-system transfer processes at PVSP were adequate. Transfers In There were a few minor deficiencies noted during initial health care screenings when patients transferred into PVSP from other CDCR institutions. In three different screenings, patients did not have their vital signs or weights taken; in one of those cases, a tuberculosis screening was not completed; in another case, the valley fever screening was not done. Transfers Out When patients transferred out from PVSP to other CDCR institutions, the health care transfer form (CDCR Form 7371) was thoroughly completed with the following exceptions:  In cases 34 and 35, the receiving and release (R&R) nurse failed to document a pending referral and appointment. Pleasant Valley State Prison, Cycle 4 Medical Inspection Page 26 Office of the Inspector General State of California  In addition, cases 34 and 35, the nurse failed to identify the patient’s coccidioidomycosis restriction status on the transfer form.  In case 76, the R&R nurse failed to document that the patient had a wired jaw with a metal plate still present, and that the patient had a pending request for an oral surgery follow-up. This was a significant deficiency. 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. Only two cases returning from the hospital to PVSP lacked coordination for continuity of care.  In case 9, the patient required hospital care after traumatic chest injuries and collapsed lungs. The hospital discharge instructions did not arrive with the patient, resulting in missed recommendations for care. This case is also discussed in the Health Information Management indicator and was a significant deficiency.  In case 18, the custody transportation team failed to deliver hospital records to the TTA nurse. The nurse did not notify the provider or the nursing supervisor that the hospital records were not available. The records were available in the eUHR two days later and, fortunately, did not include any critical recommendations.  In case 19, the custody transportation team again failed to deliver the hospital record to the TTA nurse. The same nurse again failed to notify the provider that the hospital record was not available. This resulted in discharge recommendations that were not implemented until two days later. Consequently, the patient missed two doses of antibiotics for severe infection of the tonsils. This was a significant deficiency. Onsite Visit PVSP had two permanent nurses in the R&R who processed patients and completed the initial health screening forms for patients transferring into the institution and the transfer forms for patients transferring out to other CDCR institutions. PVSP policy was to obtain vital signs and weights for patients with high blood pressure or diabetes and for those exhibiting acute symptoms during the initial health care screening. This process is inconsistent with the current CCHCS health care transfer policy, which is to obtain vital signs and weights on every patient transferring into the facility. PVSP patients were processed through the TTA after returning from hospitalization and evaluated by the TTA RN. The TTA RN notified the provider, communicated the hospitalization discharge summary, and obtained orders for housing designation, medications, and other recommended treatments. During the interview, the TTA nurse indicated that when hospital records did not Pleasant Valley State Prison, Cycle 4 Medical Inspection Page 27 Office of the Inspector General State of California accompany the patient, the provider was notified, the hospital was contacted to obtain hospital records, and the nursing supervisor was contacted for further instructions if hospital records could not be obtained. The utilization management nurse at PVSP followed hospitalized patients and completed the initial progress note, which was scanned into the eUHR. Consecutive patient updates were documented into the Census and Discharge Data Information System (CADDIS). This information was shared with the facility leadership and the primary care team. The utilization management nurse verbalized that subsequent patient updates would be documented in a daily progress note, which would be available in the medical chart. The OIG’s inspection results confirmed this practice was in place. Compliance Testing Results The institution obtained an adequate score of 75.8 percent in the Inter- and Intra-System Transfers indicator and scored in the proficient range in the following three test areas:  Inspectors reviewed 30 Initial Health Screening forms (CDCR Form 7277) for patients who transferred to PVSP from another CDCR facility to determine if nursing staff signed and dated the form on the same day they completed it. Inspectors found that all forms were signed and dated timely (MIT 6.002).  During onsite testing, OIG inspectors examined the transfer packages for four inmates who were transferring out of the facility. Out of the four inmates, only two were on chronic care medications. Inspectors concluded that the transfer packages for both chronic care patients included all required medications, required documentation, and that the patients had their rescue medications on their persons, when applicable (MIT 6.101).  OIG inspectors examined 30 patients’ health records who transferred into PVSP of which nine patients had medications that required administration or delivery to occur at the next dosing interval after arrival. Of the nine patients, eight of them (89 percent) had received their medications timely. However, one patient arrived without his two authorized keep-on-person asthma inhalers and he did not receive them until the next day (MIT 6.003). The institution scored poorly in the following two areas:  The OIG tested 30 patients who transferred into PVSP from other CDCR institutions to determine whether they received a complete initial health screening assessment from nursing staff on their day of arrival. Nursing staff timely filled out the assessment form for all 30 patients. However, nursing staff did not properly complete the assessment form for 18 of those patients (40 percent). Specifically for 16 of those 18, staff did not record results of all patient interview questions. In addition, for 4 of those 16, staff used a preprinted form referencing the “med profile” (medication list), even though it was indicated on the form the Pleasant Valley State Prison, Cycle 4 Medical Inspection Page 28 Office of the Inspector General State of California patient did not receive medications. On the remaining 2 of 18 forms, staff did not document additional explanatory information as required (MIT 6.001).  Among 20 sampled patients who transferred out of PVSP to other CDCR institutions, only ten had their scheduled specialty service appointments properly included on the health care transfer form (50 percent) (MIT 6.004). Recommendations No specific recommendations. Pleasant Valley State Prison, Cycle 4 Medical Inspection Page 29 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 management, Proficient encompassing the process from the written prescription to the Compliance Score: administration of the medication. By combining both a quantitative Proficient (92.5%) compliance test with case review analysis, this assessment identifies issues in various stages of the medication management process, Overall Rating: including ordering and prescribing, transcribing and verifying, Proficient dispensing and delivering, administering, and documenting and reporting. Because effective medication management is affected by numerous entities across various departments, this assessment considers internal review and approval processes, pharmacy, nursing, health information systems, custody processes, and actions taken by the prescriber, staff, and patient. Case Review Results The OIG clinicians evaluate pharmacy and medication management as secondary processes since they relate to the quality of clinical care provided to patients. Compliance testing, which is a more targeted approach, was given more weight in determining the overall rating for this indicator. During the onsite visit, the OIG clinicians met with medical, nursing, and pharmacy representatives to discuss their case review findings. OIG clinicians reviewed 177 pharmacy and medication management events and identified 16 deficiencies, of which only two were significant (cases 19 and 31). Most deficiencies related to continuity of medication administration and delays in dispensing prescribed medications, and did not pose a danger to the wellbeing of the patient. Therefore, the OIG clinicians rated the Pharmacy and Medication Management indicator as proficient. Medication Errors The deficiencies in continuity of medication administration were identified in both the outpatient and inter- and intra-system transfer processes. These deficiencies were mostly minor and involved delayed or missed medications due to nursing, pharmacy, or system issues that were noted in nine cases. The following was the only significant deficiency identified:  In case 19, a delay in obtaining and reviewing hospital discharge information led to the patient, who had been discharged following an admission for treatment of severe infection of the tonsils, missing two doses of antibiotics. This was a significant deficiency and is also discussed in the Inter- and Intra-Systems Transfer indicator. Pleasant Valley State Prison, Cycle 4 Medical Inspection Page 30 Office of the Inspector General State of California Pharmacy Errors Delays in dispensing prescribed medication were noted in five cases; as indicated below, one of the errors was significant:  In case 31, an iron supplement, prescribed for a patient with severe iron deficiency anemia, was not dispensed until the provider wrote a second order. As a result, there was a delay of more than one month before the patient received his medication. This significant deficiency was also discussed in the Quality of Provider Performance indicator. Compliance Testing Results The institution received a proficient compliance score of 92.5 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 This sub-indicator category consists of five applicable questions, in which the institution received an average score of 84.9 percent. The institution scored proficient in the following areas:  Ordered chronic care medications were provided timely to all 23 patients sampled (MIT 7.001).  PVSP ensured that all 30 patients sampled who transferred from one housing unit to another received their medications without interruption (MIT 7.005).  Inspectors found that 29 of 30 patients sampled (97 percent) received their newly ordered medication in a timely manner. One patient received his directly observed therapy medication one day late (MIT 7.002). The institution received an adequate score on the following test:  Clinical staff timely provided new and previously prescribed medications to seven of nine patients sampled who had been discharged from a community hospital and returned to the institution (78 percent). One patient received ordered KOP medication two days late. For another patient, there was no evidence found in the eUHR that the patient received his ordered KOP medication at all (MIT 7.003). The institution showed room for improvement in the following medication administration areas:  Nursing staff administered medications without interruption to one of two patients who were en route from one institution to another and had a temporary layover at PVSP (50 percent). Pleasant Valley State Prison, Cycle 4 Medical Inspection Page 31 Office of the Inspector General State of California For one patient, there was no eUHR evidence that medications, including those for diabetes and high blood pressure, were administered as ordered (MIT 7.006). Observed Medication Practices and Storage Controls This sub-indicator category consists of six applicable questions in which the institution received an average score of 92.6 percent. The institution scored proficient in the following five areas:  The institution properly stored non-narcotic medications that required refrigeration at all nine applicable clinics and medication line locations (MIT 7.103).  At all six of the inspected medication line locations, nursing staff were compliant with proper hand hygiene protocols (MIT 7.104).  Nursing staff at all six of the inspected medication line locations employed appropriate administrative controls and followed appropriate protocols during medication preparation (MIT 7.105).  At all six medication areas inspected, PVSP employed appropriate administrative controls and protocols when medications were distributed to patients (MIT 7.106).  The institution properly stored non-narcotic medications that did not require refrigeration at 13 of the 14 applicable clinics and medication line storage locations inspected (93 percent). At one LVN workstation desk, inspectors observed unsecured non-narcotic medications (MIT 7.102). The institution showed opportunity to improve in the following area:  The institution employed adequate security controls over narcotic medications in five of the eight applicable clinic and medication line locations where narcotics were stored (63 percent). At three clinics, the narcotics log book lacked evidence on multiple dates that a controlled substance inventory was performed by two licensed nursing staff (MIT 7.101). Pharmacy Protocols This sub-indicator category consists of five questions, in which the institution received a proficient score of 100 percent.  In its main pharmacy, the institution followed general security, organization, and cleanliness management protocols; properly stored and monitored non-narcotic medications that required refrigeration and those that did not; and maintained adequate controls over and properly accounted for narcotic medications (MIT 7.107, 7.108, 7.109, 7.110).  PVSP followed all key medication error reporting protocols for the 30 incidents reviewed by inspectors (MIT 7.111). Pleasant Valley State Prison, Cycle 4 Medical Inspection Page 32 Office of the Inspector General State of California Non-Scored Tests In addition to testing reported medication errors, OIG inspectors follow up on any significant medication errors found during the case reviews or compliance testing to determine whether the errors were properly identified and reported. The OIG provides those results for informational purposes only; however, at PVSP, the OIG did not find any applicable medication errors subject to this test (MIT 7.998). Inspectors interviewed patients housed in isolation units to determine if they had immediate access to their prescribed KOP rescue inhalers and nitroglycerin medications. Eight of nine applicable patients interviewed indicated they had access to their rescue medications. One inmate indicated that he previously exhausted their inhaler but did not tell anyone. Upon notification, PVSP took timely action to replace the patient’s inhaler (MIT 7.999). Recommendations No specific recommendations. Pleasant Valley State Prison, Cycle 4 Medical Inspection Page 33 Office of the Inspector General State of California PREVENTIVE SERVICES This indicator assesses whether various preventive medical services Case Review Rating: are offered or provided to inmate-patients. These include cancer Not Applicable screenings, tuberculosis screenings, and influenza and chronic care Compliance Score: Adequate immunizations. This indicator also assesses whether certain (81.9%) institutions take preventive actions to relocate inmate-patients identified as being at higher risk for contracting coccidioidomycosis Overall Rating: (valley fever). Adequate The OIG rates this indicator entirely through the compliance testing component; the case review process does not include a separate qualitative analysis for this indicator. Compliance Testing Results The institution obtained an adequate score of 81.9 percent in the Preventive Services indicator and scored in the proficient range in the three test areas discussed below:  PVSP timely administered tuberculosis (TB) medications to patients. All 20 sampled patients received their required doses of TB medications in the most recent three-month period reviewed (MIT 9.001).  All 30 patients sampled timely received or were offered influenza vaccinations during the most recent influenza season (MIT 9.004).  PVSP offered colorectal cancer screenings to 29 of 30 sampled patients subject to the annual screening requirement (97 percent). For one patient, there was no eUHR evidence either that health care staff offered a colorectal cancer screening within the previous 12 months or that the patient had a normal colonoscopy within the last ten years (MIT 9.005). The institution scored within the adequate range in the following two tests:  The OIG reviewed PVSP’s monitoring of 20 sampled patients who received TB medications and noted that the institution was in compliance for 17 of them (85 percent). For two patients, their required weekly monitoring visit was late by one day; for another patient, two visits were two days late (MIT 9.002).  Inspectors tested whether patients who suffered from chronic care conditions were offered vaccinations for influenza, pneumonia, and hepatitis. At PVSP, 15 of 20 sampled patients (75 percent) received all recommended vaccinations at required intervals. For three patients, there was no evidence they received or refused a pneumococcal immunization within the last five years; for two patients, there was no evidence they received or refused an influenza vaccination within the last 12 months (MIT 9.008). Pleasant Valley State Prison, Cycle 4 Medical Inspection Page 34 Office of the Inspector General State of California PVSP showed room for improvement in the following two areas:  OIG inspectors sampled 30 inmate-patients to determine whether they received a tuberculosis screening within the last year. Fifteen of the sampled patients were classified as a Code 22 (requiring a tuberculosis skin test in addition to a signs and symptoms check), and 15 sampled patients were classified as Code 34 (subject only to an annual signs and symptoms check). Of the 30 sample patients, nursing staff timely and appropriately conducted those screenings for only 17 of them (57 percent). More specifically, nurses properly screened 8 of the 15 Code 22 patients and 9 of the 15 Code 34 patients. Inspectors identified the following deficiencies (MIT 9.003): o For six of the Code 22 patients, an LVN or psychiatric technician read the test results rather than an RN, public health nurse, or primary care provider as required by CCHCS policy in place at the time of the OIG’s review; for one other Code 22 patient, nursing staff’s documentation of the “signs and symptoms” review was incomplete. o For six Code 34 patients, nursing staff did not complete the required signs and symptoms review of the Tuberculin Testing/Evaluation Report (CDCR Form 7331).  The OIG sampled 20 patients at high risk for contracting the coccidioidomycosis infection (valley fever) who were medically restricted and ineligible to reside at PVSP, to determine if the patients were transferred out of the institution within 60 days from the time they were initially determined ineligible. The institution was compliant for 12 of the 20 patients sampled (60 percent). However, eight of the patients were not timely transferred, including the following (MIT 9.009): o Four patients were transferred out of the institution between 9 and 171 days late. o Four patients who were initially identified on February 4, 2016 as ineligible to be housed at PVSP were still there as of December 19, 2016. After allowing a 60 days grace period for the institution to transfer the patients out of the facility, the patients were still housed at the facility for more than 319 days. Recommendations No specific recommendations. Pleasant Valley State Prison, Cycle 4 Medical Inspection Page 35 Office of the Inspector General State of California QUALITY OF NURSING PERFORMANCE The Quality of Nursing Performance indicator is a qualitative Case Review Rating: evaluation of the institution’s nursing services. The evaluation is Adequate completed entirely by OIG nursing clinicians within the case Compliance Score: review process, and, therefore, does not have a score under the Not Applicable compliance testing component. The OIG nurses conduct case reviews that include reviewing face-to-face encounters related to Overall Rating: nursing sick call requests identified on the Health Care Services Adequate Request form (CDCR Form 7362), urgent walk-in visits, referrals for medical services by custody staff, RN case management, RN utilization management, clinical encounters by licensed vocational nurses (LVNs) and licensed psychiatric technicians (LPTs), and any other nursing service performed on an outpatient basis. The OIG case review also includes activities and processes performed by nursing staff that are not considered direct patient encounters, such as the initial receipt and review of CDCR Form 7362 service requests and follow-up with primary care providers and other staff on behalf of the patient. Key focus areas for evaluation of outpatient 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 including patient education and referrals, and documentation that is accurate, thorough, and legible. Nursing services provided in the outpatient housing unit (OHU), correctional treatment center (CTC), or other inpatient units are reported under the Specialized Medical Housing indicator. Nursing services provided in the triage and treatment area (TTA) or related to emergency medical responses are reported under Emergency Services. Case Review Results The OIG evaluated 252 nursing encounters during the case reviews, of which 165 were outpatient encounters. Of those, approximately 100 were for sick call requests or primary care clinic nurse follow-up visits, four were for nursing care management, and the others were for a variety of services such as: public health or medical equipment and supplies. In general, PVSP nurses performed adequately. Twenty deficiencies were related to outpatient nursing services, the majority of which were unlikely to contribute to patient harm. Nevertheless, these deficient areas are clearly established in CCHCS policy as requirements for nursing care and practice. Two cases (16 and 47) had deficiencies with the potential for adverse outcomes or unnecessary delays in needed health care services for patients requesting outpatient care for a medical problem. OIG nursing clinicians rated the Quality of Nursing Performance at PVSP adequate. Nursing Sick Call The majority of sick call RNs adequately triaged complaints, assessed symptoms, and provided appropriate interventions for patients who requested or received care in the outpatient clinics. The following two deficiencies resulted in unnecessary delays in care and could have resulted in adverse outcomes: Pleasant Valley State Prison, Cycle 4 Medical Inspection Page 36 Office of the Inspector General State of California  In case 16, the patient submitted a sick call request for severe pain in his back and knee due to injuries sustained while cleaning rainwater from his cell. The nurse reviewed the request and made a routine referral (within 14 days) to the primary care provider, but did not assess the patient’s injuries.  In case 47, the patient submitted a sick call request for a sports injury. The nurse reviewed the request and made a routine referral (within 14 days) directly to the primary care provider, but did not assess the patient’s injury. Care Management/Care Coordination OIG clinicians reviewed four cases that involved an LVN care manager and case coordinator, and found no significant deficiencies. Offsite Medical Return and Specialty Services At PVSP, patients returning from offsite specialty appointments were processed in the TTA. The OIG clinicians reviewed seven nursing encounters and found only minor deficiencies. See the Specialty Services indicator for specific findings on nursing performance. Emergency Services The OIG clinicians reviewed 33 urgent or emergent encounters and found 17 deficiencies related to nursing care. Nursing performance was generally good. Specialized Medical Housing Overall, the nursing care provided in PVSP’s specialized medical housing unit was adequate. See the Specialized Medical Housing indicator for specific findings. Medication Administration With the exception of two significant medication errors (cases 19 and 31) that are discussed in the Pharmacy and Medication Management indicator, the OIG clinicians found no significant problems with medication administration. Inter- and Intra-System Transfers PVSP’s processes for patient transfers and hospitalizations were adequate. See the Inter- and Intra-System Transfers indicator for specific findings. Clinician Onsite Inspection Nurses at PVSP were active participants in the daily morning huddle. Pleasant Valley State Prison, Cycle 4 Medical Inspection Page 37 Office of the Inspector General State of California Recommendations No specific recommendations. Pleasant Valley State Prison, Cycle 4 Medical Inspection Page 38 Office of the Inspector General State of California QUALITY OF PROVIDER PERFORMANCE In this indicator, the OIG physicians provide a qualitative Case Review Rating: evaluation of the adequacy of provider care at the institution. Adequate Appropriate evaluation, diagnosis, and management plans are Compliance Score: reviewed for programs including, but not limited to, nursing sick Not Applicable call, chronic care programs, TTA, specialized medical housing, and specialty services. The assessment of provider care is Overall Rating: performed entirely by OIG physicians. There is no compliance Adequate testing component associated with this quality indicator. Case Review Results The OIG clinicians reviewed 287 medical provider encounters and identified 39 deficiencies related to provider performance at PVSP. Ten of these were significant. Deficiencies were noted in several aspects of provider performance, most notably in the assessment and decision-making process and review of patient records. Errors were most evident in the management of patients with moderately complex medical problems. Despite these findings, the OIG clinicians rated provider performance adequate because the majority of deficiencies did not pose a significant medical risk to PVSP’s low-complexity patient population. Review of Records Adequate review of records is essential, especially when the provider is not familiar with the patient’s history, after investigations have been performed, following evaluation by a specialist, or when the patient has returned from a higher level of care. Inadequate review of records led to failure to act in two cases (cases 20 and 31, described below) and to documentation of erroneous information in another case (case 20). Delays in reviewing laboratory test results and failure of providers to review and notify the patient of diagnostic study results are described in the Health Information Management indicator. Assessment and Decision-Making OIG clinicians identified 12 patient records where providers made errors in assessment and decision-making. This was also the main reason that the OIG clinicians rated the only two detailed case reviews as inadequate.  In case 12, the provider failed to recognize that this patient with cirrhosis (advanced scarring of the liver) needed to undergo surveillance for hepatocellular carcinoma (liver cancer) every six months. This was a significant deficiency.  In case 15, the provider did not confirm if the patient had a hole in the eardrum before ordering water cleaning of the ear. Pleasant Valley State Prison, Cycle 4 Medical Inspection Page 39 Office of the Inspector General State of California  In case 16, the provider did not address the patient’s low score results from an Asthma Control Assessment Tool (ACAT) that had been previously documented by the care management LVN.  In case 20, a mid-level provider did not review the patient’s records and recognize that the patient had a second seizure following a previous one that led to a February 2016 hospital admission.  In case 23, a mid-level provider did not assess the patient’s complaint of blurred vision. The provider also did not order more frequent checks of blood pressure levels after noting on several occasions that the blood pressure, in this patient with multiple cardiovascular risk factors and chronic kidney disease, was above the goal range.  In case 31, multiple significant deficiencies were noted on review of a patient’s care from a mid-level provider: o The provider incorrectly informed the patient that the results of stool tests for occult blood and colonoscopic biopsies were normal. o Failure to recognize that the results of the colonoscopic biopsies had been received led to a delay in the patient returning to see the gastroenterologist. o The provider prescribed oral iron supplements to treat severe iron deficiency anemia but did not recognize for almost six weeks that the patient was not receiving his medication. The provider discontinued the iron supplement but did not consider using an alternative method to administer iron, and did not order tests to check the patient’s hemoglobin level or the status of his body iron stores. o A nurse noted that a patient was experiencing abnormal abdominal pain and a provider failed to evaluate the patient on the same day.  In case 37, the provider incorrectly informed the patient that the computerized tomography (CT) scan of his spine showed mild changes, when actually they showed severe change. The severe changes could have been the reason for the patient’s symptoms of severe pain in his back and his legs. This was a significant deficiency.  In case 78, the provider did not obtain the patient’s history or conduct an examination of the patient until two days after he was admitted to the correctional treatment center.  In case 79, the provider did not examine the spine or the back of a patient complaining of sharp pain in his lower back. During a subsequent visit, the provider did not document any symptoms or examination findings to support the diagnosis of neuropathic (injured nerve) pain. Pleasant Valley State Prison, Cycle 4 Medical Inspection Page 40 Office of the Inspector General State of California Chronic Care Identification and appropriate management of chronic health problems, such as diabetes mellitus, hypertension, and hyperlipidemia, is important in reducing the risk for both acute and long-term complications. In most instances, PVSP’s providers appropriately managed their patient’s chronic health conditions. Emergency Care The PVSP providers appropriately managed patients presenting to the TTA. Specialty Services The PVSP providers appropriately referred patients for specialty consultations. Provider Continuity In the majority of cases OIG clinicians reviewed, PVSP displayed adequate continuity of care in both the outpatient setting and in its specialized medical housing. Pharmacy and Medication Management  In case 19, the provider did not write an order reducing the dose of lisinopril (blood pressure medication) as intended based on the provider’s progress notes. The patient continued to receive the higher dose of the drug for the remainder of his institutional stay and when he received his parole discharge medications. Onsite Inspection PVSP, classified as a basic institution, had seven allocated medical provider positions. At the time of the July 2016 onsite inspection, six positions were filled; the providers worked a ten-hour per day, four-day per week schedule. PVSP management also anticipated recruitment of an additional mid-level provider to fill the vacant position. At the time of the OIG’s onsite visit, three physicians and one nurse practitioner were assigned to the four primary yards. In addition, a physician’s assistant functioned as a “rover” covering the four providers on their scheduled days off. An additional physician was responsible for patient care in the CTC and TTA. However, this provider was scheduled to take medical leave starting on the day following the OIG team’s onsite visit. According to the clinicians, the TTA was not very busy; most encounters were related to altercations or contraband drugs. Finally, the institution had one borrowed telemedicine provider who assisted with care for patients in short-term restricted housing and the minimum-security yard; however, this provider belonged to CCHCS’ headquarters office and not technically an allocated position of PVSP. The providers started their day by participating in their yard’s multidisciplinary team huddle. A typical workday included evaluating 14 to 18 patients, some of these may include patients who are added to daily caseloads on an emergent basis. In addition, the providers routinely spent time to Pleasant Valley State Prison, Cycle 4 Medical Inspection Page 41 Office of the Inspector General State of California answer nurses’ consultation requests. With an enforced policy that all scheduled patients should be seen on the same day, none of the clinics reported a backlog. All but one of the providers had been working at the institution for several years. Overall, the morale among the providers was high, and all reported that the chief physician and surgeon and the chief medical executive were supportive. Clinic staff also reportedly had a good working relationship with custody staff. The chief medical executive stated that the strengths of the institution were the providers who were experienced in correctional environment patient care, the low-acuity patient population, and well-established processes that were shared with a neighboring institution (for which the CME also had responsibility). Difficulty in recruiting staff and the lack of nearby hospitals were weaknesses. The recent implementation of care coordination utilizing an LVN was reported to have facilitated the management of patients with hypertension and diabetes, and of preventive screening efforts. The four-day workweek schedule was described as a valuable incentive to recruitment and retention. Providers were evaluated not only by their annual reviews, but also by review of records of their patients with more complex health care needs. Recommendation The OIG recommends that PVSP evaluate whether sufficient oversight is being provided to mid- level providers who work on more complex cases to help ensure that the providers receive timely and valuable feedback regarding their performance, as well as provide optimal patient care. Pleasant Valley State Prison, Cycle 4 Medical Inspection Page 42 Office of the Inspector General State of California SPECIALIZED MEDICAL HOUSING (OHU, CTC, SNF, HOSPICE) This indicator addresses whether the institution follows appropriate Case Review Rating: policies and procedures when admitting inmate-patients to onsite Proficient inpatient facilities, including completion of timely nursing and Compliance Score: provider assessments. The chart review assesses all aspects of Proficient medical care related to these housing units, including quality of (90.0%) provider and nursing care. Overall Rating: Proficient PVSP’s only specialized medical housing is a 15-bed correctional treatment center (CTC), which includes seven medical patient beds, six mental health patient beds, one room for patients needing use of 5-point restrains, and one padded cell. The CTC has one designated medical provider to ensure continuity of care; a cross-cover provider is assigned to the CTC during the designated provider’s absence. The CTC has its own dietician who joins the care team for multidisciplinary rounds on Thursdays. After a morning huddle, the CTC provider makes daily rounds accompanied by the RN and occasionally by a LVN, pharmacist, and psychiatric technician. The chief physician and surgeon joins the team for rounds once a week and is available at other times for assistance with challenging clinical cases. Case Review Results OIG clinicians reviewed 123 encounters that resulted from eight patients’ housed in the institution’s CTC. Twenty-seven deficiencies were identified, three significant, all related to access to care. Providers regularly evaluated and appropriately managed patients in the CTC. Nursing care was adequate. Overall, patient care in the CTC was proficient. Access to Care Based on the patients examined during OIG’s case review, PVSP providers usually evaluated their CTC patients at least once every 72 hours. However, delays in provider follow-up appointments after discharge were noted in cases 9 and 11. These are discussed in the Access to Care indicator. Delay in specialty follow-up was noted in case 76. This deficiency is discussed in the Specialty Services indicator. Health Information Management Deficiencies in retrieving outside records are discussed in the Health Information Management indicator. Pharmacy and Medication Management Identified issues related to pharmacy and medication management are discussed in the Pharmacy and Medication Management indicator. Pleasant Valley State Prison, Cycle 4 Medical Inspection Page 43 Office of the Inspector General State of California Nursing Performance Overall, nursing care provided to patients in the CTC was adequate. Nurses completed patient admission assessments timely, carried out provider orders as written, and appropriately performed and documented daily nursing assessments. However, the following minor deficiencies were noted:  In case 74, the patient developed a skin rash and the nursing care plan was not updated to reflect the patient’s change in condition and needs.  Discrepancies in documentation were also found in cases 9, 15, and 75. Other examples of documentation errors included missing and incorrect documentation in the nursing record. Provider Performance Patients in the CTC whose records were reviewed had straightforward medical problems and received adequate care. However, one minor deficiency was noted:  In case 78, the provider did not complete documentation of the history and physical examination findings until three days after the patient was admitted to the CTC. CCHCS policy requires that the provider complete a progress note on the day of admission and perform a more detailed evaluation within 24 hours after admission. Compliance Testing Results The institution received a proficient score of 90.0 percent in the Specialized Medical Housing indicator, which focused on the institution’s CTC. PVSP scored 100 percent in the following compliance test areas:  For all ten patients sampled, nursing staff timely completed an initial health assessment on the day the patient was admitted to the CTC (MIT 13.001).  Based on a sample of ten applicable patients, providers evaluated all the patients within 24 hours of CTC admission and completed a history and physical within 72 hours of admission (MIT 13.002, 13.003).  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). The institution showed room for improvement in the following area:  Providers completed their CTC subjective, objective, assessment, plan, and education (SOAPE) notes at required three-day intervals for only five of the ten sampled patients Pleasant Valley State Prison, Cycle 4 Medical Inspection Page 44 Office of the Inspector General State of California (50 percent). Five patients had one or more SOAPE notes completed one to two days late (MIT 13.004). Recommendations No specific recommendations. Pleasant Valley State Prison, Cycle 4 Medical Inspection Page 45 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, (92.4%) 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 inmate-patient is updated on the plan of care. Case Review Results The OIG clinicians reviewed 60 events related to Specialty Services, the majority of which were specialty consultations. Thirteen deficiencies were found in this category, of which two were significant (cases 37 and 76). Patients at PVSP were appropriately referred and given timely access to specialty services. Overall, the OIG clinicians rated the Specialty Services indicator proficient. Access to Specialty Services Specialty services were provided in a timely manner for most of the patients whose records were reviewed. However, in cases 15 and 17, the patients did not receive surgical follow-up appointments as intended by their providers; while the services were ultimately provided, they were provided late. Other exceptions were as follows:  In case 10, the provider failed to order a timely postoperative follow-up appointment. The patient was seen five weeks, rather than the recommended two weeks, after surgery.  In case 76, the patient had surgery to treat a fractured jaw, but was not scheduled for timely follow-up visits with the oral surgeon on two consecutive occasions. The delay in the patient’s initial postoperative visit was a significant deficiency.  In case 78, the patient was not evaluated by physical therapy as ordered by the provider; while the services were ultimately provided, they were provided late. Nursing Performance The nursing performance was generally adequate when patients were seen following specialty appointments, and follow-up recommendations were timely communicated to the provider. However, in cases 15 and 41, the nurse did not communicate the specialist’s recommendations to the provider. Pleasant Valley State Prison, Cycle 4 Medical Inspection Page 46 Office of the Inspector General State of California Provider Performance Providers at PVSP made appropriate requests for specialty services, and the institution’s CME or designee timely reviewed those requests. Health Information Management While diagnostic reports were almost always promptly retrieved and reviewed, a significant deficiency occurred in case 37 when an EEG report was not retrieved in a timely manner. This is discussed in the Health Information Management indicator. Onsite Inspection The OIG clinicians learned that the telemedicine RN scanned consultants’ notes and sent them to the providers via e-mail. The office technician had responsibility for offsite consultations obtained and sent these consultants’ notes to the health information management unit to be scanned to the eUHR. These processes helped PVSP obtain their proficient performance rating for this indicator. Compliance Testing Results The institution received a proficient compliance score of 92.4 percent in the Specialty Services indicator, scoring within the proficient range in the following test areas:  Twenty sampled patients had specialty service requests that PVSP’s health care management denied. In each instance, the denial occurred timely. Additionally, the providers timely informed their patients of the denials so that they could consider alternate treatment options (MIT 14.006, 14.007).  For all 15 patients sampled, routine specialty service appointments occurred within 90 calendar days of the provider’s order (MIT 14.003).  For all 15 patients sampled, high-priority specialty service appointments occurred within 14 calendar days of the provider’s order. In addition, following patients’ specialty service appointments, providers timely received and reviewed the specialists’ reports for 14 of the 15 sampled appointments (93 percent). In one instance, the specialty service report was received two days late, and the provider’s review of that note was one day late (MIT 14.001, 14.002). In the following test area, PVSP scored in the adequate range:  Specialists’ reports were timely reviewed by a provider following routine specialty service appointments for 11 of the 14 cases reviewed (79 percent). One report was reviewed one day late, one was reviewed three days late, and in a third case, no evidence was found that the specialty report was reviewed by the provider at all (MIT 14.004). Pleasant Valley State Prison, Cycle 4 Medical Inspection Page 47 Office of the Inspector General State of California  When an institution approves or schedules a patient for specialty services appointments and then transfers the patient to another institution, policy requires that the receiving institution ensure a patient’s appointment occurs timely. At PVSP, 15 of the 20 sampled transfer in patients received their specialty services appointment within the required time frame (75 percent). Three patients received their appointments between 21 and 67 days late, and for one patient, there was no evidence in the eUHR that he received an appointment. Finally, one patient’s appointment was canceled after it was determined by the provider that it was no longer necessary, but the cancellation was untimely by 26 days (MIT 14.005). Recommendations No specific recommendations. Pleasant Valley State Prison, Cycle 4 Medical Inspection Page 48 Office of the Inspector General State of California SECONDARY (ADMINISTRATIVE) QUALITY INDICATORS OF HEALTH CARE The last two quality indicators (Internal Monitoring, Quality Improvement, and Administrative Operations; and Job Performance, Training, Licensing, and Certifications) involve health care administrative systems and processes. Testing in these areas applies only to the compliance component of the process. Therefore, there is no case review assessment associated with either of the two indicators. As part of the compliance component of the first of these two indicators, the OIG does not score several questions. Instead, the OIG presents the findings for informational purposes only. For example, the OIG describes certain local processes in place at PVSP. To test both the scored and non-scored areas within these two secondary quality indicators, OIG inspectors interviewed key institutional employees and reviewed documents during their onsite visit to PVSP in April 2016. They also reviewed documents obtained from the institution and from CCHCS prior to the start of the inspection. Of these two secondary indicators, OIG compliance inspectors rated one inadequate and one proficient. The test questions used to assess compliance for each indicator are detailed in Appendix A. Pleasant Valley State Prison, Cycle 4 Medical Inspection Page 49 Office of the Inspector General State of California INTERNAL MONITORING, QUALITY IMPROVEMENT, AND ADMINISTRATIVE OPERATIONS 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 inmate-patient medical appeals and addresses Compliance Score: all appealed issues. Inspectors also verify that the institution follows Inadequate reporting requirements for adverse/sentinel events and inmate (68.5%) deaths, and whether the institution is making progress toward its Overall Rating: Performance Improvement Work Plan initiatives. In addition, the Inadequate OIG verifies that the Emergency Medical Response Review Committee (EMRRC) performs required reviews and that 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. Compliance Testing Results The institution scored within the inadequate range in the Internal Monitoring, Quality Improvement, and Administrative Operations indicator, receiving a compliance score of 68.5 percent. The following areas present opportunities for improvement:  The institution did not meet the emergency response drill requirements for the most recent quarter for one of its three watches, resulting in a score of 67 percent. More specifically, the institution’s first watch drill package did not contain a Cardiopulmonary Resuscitation Record (CDCR Form 7462) as required by CCHCS policy (MIT 15.101).  The PVSP’s 2015 Performance Improvement Work Plan (PIWP) only included sufficient evidence demonstrating that the institution made progress in achieving targeted performance objectives for three of its five applicable quality improvement initiatives. As a result, PVSP received a score of 60 percent on this test (MIT 15.005).  PVSP only had one inmate death that occurred during the OIG’s sample test period; however, the institution did not timely notify the CCHCS’ Death Review Unit of the death or utilize the correct form to report the death. More specifically, PVSP’s medical staff incorrectly submitted the Initial Inmate Death Report (CDCR Form 7229A); however, because the death was a suicide the Initial Inmate Suicide Report (CDCR Form 7229B) should have been utilized. In addition, the notification was required to be made by noon on the next business day following the date of death. PVSP made the notification 11 minutes late. As a result of the two deviations, the institution received a score of zero for this test (MIT 15.103). Pleasant Valley State Prison, Cycle 4 Medical Inspection Page 50 Office of the Inspector General State of California  The OIG reviewed the only reported adverse/sentinel event (ASE) that occurred at PVSP during the prior six-month period, which required a root cause analysis and four monthly status reports per the plan of action. The event was reported to CCHCS’s ASE Committee three days late, and only one status report for the four-month period was submitted. As a result, PVSP received a score of zero on this test (MIT 15.002). The institution scored in the adequate range in the following two test areas:  Of the 12 sampled incident packages for emergency medical responses reviewed by the institution’s Emergency Medical Response Review Committee (EMRRC) during the prior 12-month period, 10 (83 percent) complied with policy. Two of the incident review packages were not timely reviewed at the next corresponding EMRRC meeting (MIT 15.007).  PVSP’s Local Governing Body (LGB) met quarterly and exercised its overall responsibilities for the quality management of patient health care in three of the four prior quarters (75 percent). Inspectors were unable to determine if, during the fourth quarter, the LGB meeting minutes were approved timely; while the minutes were signed they were not dated (MIT 15.006). The institution received a proficient score of 100 percent in the following test areas:  During the most recent 12 months, PVSP timely processed all inmate medical appeals. In addition, based on the OIG’s review of ten second-level medical appeals, the institution’s appeal responses addressed the inmates’ initial complaints (MIT 15.001, 15.102).  Inspectors reviewed six recent months of QMC meeting minutes and confirmed that the QMC met monthly, evaluated program performance, and took action when improvement opportunities were identified (MIT 15.003). Further, PVSP took adequate steps to ensure the accuracy of its reported Dashboard data (MIT 15.004). Other Information Obtained from Non-Scored Areas  The OIG gathered non-scored data regarding the completion of death review reports by CCHCS’s Death Review Committee (DRC). Only one death occurred during the OIG’s review period, an unexpected (Level 1) death. The DRC was required to complete its death review summary report within 60 calendar days from the date of death and submit the report to the institution’s chief executive officer (CEO) within seven calendar days thereafter. However, the DRC completed its report 43 days late (103 days after the death) and submitted it to PVSP’s CEO 22 days later (125 days after the death) (MIT 15.996).  Inspectors met with PVSP’s CEO to inquire about the institution’s protocols for tracking appeals. The CEO reported that the health care appeals coordinator provided management staff with weekly medical appeal tracking reports which included various information on the Pleasant Valley State Prison, Cycle 4 Medical Inspection Page 51 Office of the Inspector General State of California processing status and resolution due dates for appeals. The reports identified and ranked appeals by category, such as staff complaints, treatments, ADA compliance, and effective communication. The institution’s Health Care Resource Management Committee reviewed the reports to identify and address potential problems, as applicable. If additional evaluation was required, the committee referred issues to the QMC for further review and action. The health care management team sometimes initiates resolution on a department level and, if the issue was systemic, assigned it to a review committee for further process evaluation. During the six months preceding the OIG’s inspection, management determined that appeals regarding specific staff complaints proved to be valid and worthy of further action. The problems were addressed through a peer review process, which involved the initiation of progressive disciplinary measures (MIT 15.997).  Non-scored data gathered regarding the institution’s practices for implementing local operating procedures (LOPs) indicated that the institution had the following process in place for developing LOPs: The health program specialist (HPS) maintained a tracking log of the institution’s LOPs. Changes to LOPs were made by the HPS with input from stakeholders, then forwarded to the QMC for approval by the CEO and to the warden for final approval. Once a new or revised LOP was approved, appropriate management notified and trained the affected staff. At the time of the OIG’s inspection in April 2016, PVSP had implemented 35 of the 49 applicable stakeholder recommend LOP’s (71 percent) (MIT 15.998).  The OIG discusses the institution’s health care staffing resources in the About the Institution section on page 2 (MIT 15.999). Recommendations No specific recommendations. Pleasant Valley State Prison, Cycle 4 Medical Inspection Page 52 Office of the Inspector General State of California JOB PERFORMANCE, TRAINING, LICENSING, AND CERTIFICATIONS In this indicator, the OIG examines whether the institution Case Review Rating: adequately manages its health care staffing resources by evaluating Not Applicable whether job performance reviews are completed as required; Compliance Score: specified staff possess current, valid credentials and professional Proficient licenses or certifications; nursing staff receive new employee (90.5%) orientation training and annual competency testing; and clinical and Overall Rating: custody staff have current medical emergency response Proficient certifications. Compliance Testing Results The institution received a proficient compliance score of 90.5 percent in the Job Performance, Training, Licensing, and Certifications indicator. PVSP scored 100 percent in the following tests:  All providers at the institution were current with their professional licenses. Similarly, all nursing staff and the pharmacist in charge were current with their professional licenses and certification requirements (MIT 16.001, 16.105).  All ten nurses sampled who administered medications possessed current clinical competency validations, and all nursing staff hired within the last year timely received new employee orientation training (MIT 16.102, 16.107).  The OIG’s inspectors examined the nursing reviews completed by five different nursing supervisors for their subordinate nurses; in all instances, the reviews were sufficiently completed (MIT 16.101).  All pharmacy staff and providers who prescribed controlled substances had current Drug Enforcement Agency registrations (MIT 16.106). While the institution scored well in the areas above, the following areas showed room for improvement:  Required emergency response certifications were current for all providers, nurses, and custody staff, with the exception of custody managers. PVSP does not require its custody managers of the captain or higher rank to maintain certifications. The OIG acknowledges that the California Penal Code exempts custody managers who primarily perform managerial duties from medical emergency response certification training; however, CCHCS policy does not allow for such exemption. As a result, the institution received a score of 67 percent for this test area (MIT 16.104). Pleasant Valley State Prison, Cycle 4 Medical Inspection Page 53 Office of the Inspector General State of California  Four of seven PVSP providers had a proper clinical performance appraisal completed by their supervisor (57 percent). Three other providers did not have either timely or properly completed appraisals, including the following (16.103): o One provider’s evaluation was overdue by 15 months. o Two provider’s evaluations were overdue by 2 months. In addition, one of these provider’s most recently completed evaluation did not include the required Unit Health Clinical Appraisal or a core competency based evaluation. Recommendations No specific recommendations. Pleasant Valley State Prison, Cycle 4 Medical Inspection Page 54 Office of the Inspector General State of California POPULATION-BASED METRICS 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 Pleasant Valley State Prison, nine HEDIS measures were selected and are listed below in the following PVSP Results Compared to State and National HEDIS Scores; however, due to the institution’s patient demographic, PVSP ultimately only had comparable statistics for seven of the measures (see the table on p. 57). 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. Pleasant Valley State Prison, Cycle 4 Medical Inspection Page 55 Office of the Inspector General State of California Results of Population-Based Metric Comparison Comprehensive Diabetes Care For chronic care management, the OIG chose measures related to the management of diabetes. Diabetes is the most complex common chronic disease requiring a high level of intervention on the part of the health care system in order to produce optimal results. PVSP performed well with its management of diabetes. When compared statewide, PVSP outperformed Medi-Cal and outperformed, or closely matched, Kaiser Permanente in all five diabetic measures. When compared nationally, PVSP outperformed Medicaid, commercial, and Medicare health plans (based on data obtained from health maintenance organizations) in each of the five diabetic measures listed. PVSP also outperformed the U.S. Department of Veterans Affairs (VA) in three of the four applicable measures, but scored slightly lower than the VA in conducting dilated eye exams for diabetic patients. Immunizations Comparative data for immunizations was only fully available for the VA and partially available for Kaiser, commercial plans, and Medicare. With respect to administering influenza vaccines to younger adults, PVSP outperformed all entities’ reported data. Although higher than the other comparable entities, PVSP’s score for this measure was only 60 percent. This low score was attributable to the fact that the other 40 percent of the sampled patients all refused the immunization (a factor that negatively affects the institution’s comparable score). In a related area, PVSP only had one applicable patient over the age of 65 at the time of the OIG’s testing. Due to the statistically low population size, the OIG elected not to present PVSP’s comparative data for influenza and pneumococcal vaccinations to adults aged 65 and older. Cancer Screening With respect to colorectal cancer screening, PVSP performed higher than commercial entities and the same as Medicare, but scored lower than both Kaiser and the VA. Similar to the results for immunizations, the institution offered the preventive service to all patients sampled but 33 percent of them refused the offer. This resulted in PVSP receiving a comparably low score of only 67 percent for this measure. Summary Overall, PVSP’s HEDIS performance reflects a well-performing chronic care program, with the exception of colorectal cancer screening which was adversely affected by patient refusals. The institution’s adequate ratings in the Quality of Provider Performance, Quality of Nursing Performance, and Preventive Services indicators, and its proficient rating in the Access to Care indicator corroborated PVSP’s HEDIS performance. Regarding the immunization and cancer screening measures, the institution could improve its scores by educating patients regarding their refusals of these preventive services. Pleasant Valley State Prison, Cycle 4 Medical Inspection Page 56 Office of the Inspector General State of California PVSP Results Compared to State and National HEDIS Scores California National Kaiser Kaiser PVSP HEDIS (No.CA) (So.CA) HEDIS Clinical Measures Medi- HEDIS HEDIS HEDIS Com- HEDIS VA Cycle 4 Cal Scores Scores Medicaid mercial Medicare Average Results1 20152 20153 20153 20154 20154 20154 20145 Comprehensive Diabetes Care HbA1c Testing (Monitoring) 100% 86% 95% 94% 86% 91% 93% 99% Poor HbA1c Control (>9.0%)6,7 5% 39% 18% 24% 44% 31% 25% 19% HbA1c Control (<8.0%)6 84% 49% 70% 62% 47% 58% 65% - Blood Pressure Control (<140/90)6 84% 63% 84% 85% 62% 65% 65% 78% Eye Exams 87% 53% 69% 81% 54% 56% 69% 90% Immunizations Influenza Shots - Adults (18–64) 60% - 54% 55% - 50% - 58% Influenza Shots - Adults (65+)8 - - - - - - 72% 76% Immunizations: Pneumococcal8 - - - - - - 70% 93% Cancer Screening Colorectal Cancer Screening 67% - 80% 82% - 64% 67% 82% 1. Unless otherwise stated, data was collected in March 2016 by reviewing medical records from a sample of PVSP’s population of applicable inmate-patients. These random statistical sample sizes were based on a 95 percent confidence level with a 15 percent maximum margin of error. 2. HEDIS Medi-Cal data was obtained from the California Department of Health Care Services 2015 HEDIS Aggregate Report for the Medi-Cal Managed Care Program. 3. Data was obtained from Kaiser Permanente November 2015 reports for the Northern and Southern California regions. 4. National HEDIS data for Medicaid, commercial, and Medicare was obtained from the 2015 State of Health Care Quality Report, available on the NCQA website: www.ncqa.org. The results for commercial were based on data received from various health maintenance organizations. 5. The Department of Veterans Affairs (VA) data was obtained from the VA’s website, www.va.gov. For the Immunizations: Pneumococcal measure only, the data was obtained from VHA Facility Quality and Safety Report - Fiscal Year 2014 Data. 6. For this indicator, the entire applicable PVSP 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. 8. Population limited to only one inmate-patient over the age of 65; therefore, sample omitted from the comparative analysis. Pneumococcal is also only applicable to inmate-patients over the age of 65. Pleasant Valley State Prison, Cycle 4 Medical Inspection Page 57 Office of the Inspector General State of California APPENDIX A — COMPLIANCE TEST RESULTS Pleasant Valley State Prison Range of Summary Scores: 68.50% - 97.98% Indicator Overall Score (Yes %) Access to Care 93.33% Diagnostic Services 91.11% Emergency Services Not Applicable Health Information Management (Medical Records) 75.43% Health Care Environment 97.98% Inter- and Intra-System Transfers 75.78% Pharmacy and Medication Management 92.49% Prenatal and Post-delivery Services Not Applicable Preventive Services 81.90% Quality of Nursing Performance Not Applicable Quality of Provider Performance Not Applicable Reception Center Arrivals Not Applicable Specialized Medical Housing (OHU, CTC, SNF, Hospice) 90.00% Specialty Services 92.41% Internal Monitoring, Quality Improvement, and Administrative Operations 68.50% Job Performance, Training, Licensing, and Certifications 90.48% Pleasant Valley State Prison, Cycle 4 Medical Inspection Page 58 Office of the Inspector General State of California Scored Answers Yes Reference + Access to Care Number Yes No No Yes % N/A 1.001 Chronic care follow-up appointments: Was the inmate-patient’s most 29 1 30 96.67% 0 recent chronic care visit within the health care guideline’s maximum allowable interval or within the ordered time frame, whichever is shorter? 1.002 For endorsed inmate-patients received from another CDCR 19 11 30 63.33% 0 institution: If the nurse referred the inmate-patient to a provider during the initial health screening, was the inmate-patient seen within the required time frame? 1.003 Clinical appointments: Did a registered nurse review the 30 0 30 100.00% 0 inmate-patient’s request for service the same day it was received? 1.004 Clinical appointments: Did the registered nurse complete a 30 0 30 100.00% 0 face-to-face visit within one business day after the CDCR Form 7362 was reviewed? 1.005 Clinical appointments: If the registered nurse determined a referral to 14 1 15 93.33% 15 a primary care provider was necessary, was the inmate-patient seen within the maximum allowable time or the ordered time frame, whichever is the shorter? 1.006 Sick call follow-up appointments: If the primary care provider 12 0 12 100.00% 18 ordered a follow-up sick call appointment, did it take place within the time frame specified? 1.007 Upon the inmate-patient’s discharge from the community hospital: 10 0 10 100.00% 0 Did the inmate-patient receive a follow-up appointment within the required time frame? 1.008 Specialty service follow-up appointments: Do specialty service 26 4 30 86.67% 0 primary care physician follow-up visits occur within required time frames? 1.101 Clinical appointments: Do inmate-patients have a standardized 6 0 6 100.00% 0 process to obtain and submit health care services request forms? Overall Percentage: 93.33% Pleasant Valley State Prison, Cycle 4 Medical Inspection Page 59 Office of the Inspector General State of California Scored Answers Yes Reference + Diagnostic Services Number Yes No No Yes % N/A 2.001 Radiology: Was the radiology service provided within the time frame 9 0 9 100.00% 1 specified in the provider’s order? 2.002 Radiology: Did the primary care provider review and initial the 10 0 10 100.00% 0 diagnostic report within specified time frames? 2.003 Radiology: Did the primary care provider communicate the results of 10 0 10 100.00% 0 the diagnostic study to the inmate-patient within specified time frames? 2.004 Laboratory: Was the laboratory service provided within the time 10 0 10 100.00% 0 frame specified in the provider’s order? 2.005 Laboratory: Did the primary care provider review and initial the 9 1 10 90.00% 0 diagnostic report within specified time frames? 2.006 Laboratory: Did the primary care provider communicate the results of 9 1 10 90.00% 0 the diagnostic study to the inmate-patient within specified time frames? 2.007 Pathology: Did the institution receive the final diagnostic report within 8 2 10 80.00% 0 the required time frames? 2.008 Pathology: Did the primary care provider review and initial the 9 1 10 90.00% 0 diagnostic report within specified time frames? 2.009 Pathology: Did the primary care provider communicate the results of 7 3 10 70.00% 0 the diagnostic study to the inmate-patient within specified time frames? Overall Percentage: 91.11% Emergency Services Scored Answers Assesses reaction times and responses to emergency situations. The OIG RN clinicians will use detailed information obtained from the institution’s incident Not Applicable packages to perform focused case reviews. Pleasant Valley State Prison, Cycle 4 Medical Inspection Page 60 Office of the Inspector General State of California Scored Answers Health Information Management Yes Reference + (Medical Records) Number Yes No No Yes % N/A 4.001 Are non-dictated progress notes, initial health screening forms, and 18 2 20 90.00% 0 health care service request forms scanned into the eUHR within three calendar days of the inmate-patient encounter date? 4.002 Are dictated / transcribed documents scanned into the eUHR within 5 5 10 50.00% 0 five calendar days of the inmate-patient encounter date? 4.003 Are specialty documents scanned into the eUHR within the required 20 0 20 100.00% 0 time frame? 4.004 Are community hospital discharge documents scanned into the eUHR 10 0 10 100.00% 0 within three calendar days of the inmate-patient date of hospital discharge? 4.005 Are medication administration records (MARs) scanned into the eUHR 15 0 15 100.00% 0 within the required time frames? 4.006 During the eUHR review, did the OIG find that documents were 0 12 12 0.00% 0 correctly labeled and included in the correct inmate-patient’s file? 4.007 Did clinical staff legibly sign health care records, when required? 26 15 41 63.41% 0 4.008 For inmate-patients discharged from a community hospital: Did 10 0 10 100.00% 0 the preliminary hospital discharge report include key elements and did a PCP review the report within three calendar days of discharge? Overall Percentage: 75.43% Pleasant Valley State Prison, Cycle 4 Medical Inspection Page 61 Office of the Inspector General State of California Scored Answers Yes Reference + Health Care Environment Number Yes No No Yes % N/A 5.101 Infection Control: Are clinical health care areas appropriately 9 0 9 100.00% 0 disinfected, cleaned and sanitary? 5.102 Infection control: Do clinical health care areas ensure that reusable 8 1 9 88.89% 0 invasive and non-invasive medical equipment is properly sterilized or disinfected as warranted? 5.103 Infection Control: Do clinical health care areas contain operable sinks 9 0 9 100.00% 0 and sufficient quantities of hygiene supplies? 5.104 Infection control: Does clinical health care staff adhere to universal 9 0 9 100.00% 0 hand hygiene precautions? 5.105 Infection control: Do clinical health care areas control exposure to 9 0 9 100.00% 0 blood-borne pathogens and contaminated waste? 5.106 Warehouse, Conex and other non-clinic storage areas: Does the 1 0 1 100.00% 0 medical supply management process adequately support the needs of the medical health care program? 5.107 Clinical areas: Does each clinic follow adequate protocols for 9 0 9 100.00% 0 managing and storing bulk medical supplies? 5.108 Clinical areas: Do clinic common areas and exam rooms have 8 1 9 88.89% 0 essential core medical equipment and supplies? 5.109 Clinical areas: Do clinic common areas have an adequate environment 9 0 9 100.00% 0 conducive to providing medical services? 5.110 Clinical areas: Do clinic exam rooms have an adequate environment 9 0 9 100.00% 0 conducive to providing medical services? 5.111 Emergency response bags: Are TTA and clinic emergency medical 9 0 9 100.00% 0 response bags inspected daily and inventoried monthly, and do they contain essential items? 5.999 For Information Purposes Only: Does the institution’s health care management believe that all clinical areas have physical plant Information Only infrastructures sufficient to provide adequate health care services? Overall Percentage: 97.98% Pleasant Valley State Prison, Cycle 4 Medical Inspection Page 62 Office of the Inspector General State of California Scored Answers Yes Reference + Inter- and Intra-System Transfers Number Yes No No Yes % N/A 6.001 For endorsed inmate-patients received from another CDCR 12 18 30 40.00% 0 institution or COCF: Did nursing staff complete the initial health screening and answer all screening questions on the same day the inmate-patient arrived at the institution? 6.002 For endorsed inmate-patients received from another CDCR 30 0 30 100.00% 0 institution or COCF: When required, did the RN complete the assessment and disposition section of the health screening form; refer the inmate-patient to the TTA, if TB signs and symptoms were present; and sign and date the form on the same day staff completed the health screening? 6.003 For endorsed inmate-patients received from another CDCR 8 1 9 88.89% 21 institution or COCF: If the inmate-patient had an existing medication order upon arrival, were medications administered or delivered without interruption? 6.004 For inmate-patients transferred out of the facility: Were scheduled 10 10 20 50.00% 0 specialty service appointments identified on the Health Care Transfer Information Form 7371? 6.101 For inmate-patients transferred out of the facility: Do medication 2 0 2 100.00% 2 transfer packages include required medications along with the corresponding Medication Administration Record (MAR) and Medication Reconciliation? Overall Percentage: 75.78% Pleasant Valley State Prison, Cycle 4 Medical Inspection Page 63 Office of the Inspector General State of California Scored Answers Yes Reference + Pharmacy and Medication Management Number Yes No No Yes % N/A 7.001 Did the inmate-patient receive all chronic care medications within the 23 0 23 100.00% 7 required time frames or did the institution follow departmental policy for refusals or no-shows? 7.002 Did health care staff administer or deliver new order prescription 29 1 30 96.67% 0 medications to the inmate-patient within the required time frames? 7.003 Upon the inmate-patient’s discharge from a community hospital: 7 2 9 77.78% 1 Were all medications ordered by the institution’s primary care provider administered or delivered to the inmate-patient within one calendar day of return? 7.004 For inmate-patients received from a county jail: Were all medications ordered by the institution’s reception center provider Not Applicable administered or delivered to the inmate-patient within the required time frames? 7.005 Upon the inmate-patient’s transfer from one housing unit to 30 0 30 100.00% 0 another: Were medications continued without interruption? 7.006 For inmate-patients en route who lay over at the institution: If the 1 1 2 50.00% 3 temporarily housed inmate-patient had an existing medication order, were medications administered or delivered without interruption? 7.101 All clinical and medication line storage areas for narcotic 5 3 8 62.50% 8 medications: Does the institution employ strong medication security controls over narcotic medications assigned to its clinical areas? 7.102 All clinical and medication line storage areas for non-narcotic 13 1 14 92.86% 2 medications: Does the institution properly store non-narcotic medications that do not require refrigeration in assigned clinical areas? 7.103 All clinical and medication line storage areas for non-narcotic 9 0 9 100.00% 7 medications: Does the institution properly store non-narcotic medications that require refrigeration in assigned clinical areas? 7.104 Medication preparation and administration areas: Do nursing staff 6 0 6 100.00% 10 employ and follow hand hygiene contamination control protocols during medication preparation and medication administration processes? 7.105 Medication preparation and administration areas: Does the 6 0 6 100.00% 10 institution employ appropriate administrative controls and protocols when preparing medications for inmate-patients? 7.106 Medication preparation and administration areas: Does the 6 0 6 100.00% 10 institution employ appropriate administrative controls and protocols when distributing medications to inmate-patients? 7.107 Pharmacy: Does the institution employ and follow general security, 1 0 1 100.00% 0 organization, and cleanliness management protocols in its main and satellite pharmacies? Pleasant Valley State Prison, Cycle 4 Medical Inspection Page 64 Office of the Inspector General State of California Scored Answers Yes Reference + Pharmacy and Medication Management Number Yes No No Yes % N/A 7.108 Pharmacy: Does the institution’s pharmacy properly store 1 0 1 100.00% 0 non-refrigerated medications? 7.109 Pharmacy: Does the institution’s pharmacy properly store refrigerated 1 0 1 100.00% 0 or frozen medications? 7.110 Pharmacy: Does the institution’s pharmacy properly account for 1 0 1 100.00% 0 narcotic medications? 7.111 Pharmacy: Does the institution follow key medication error reporting 30 0 30 100.00% 0 protocols? 7.998 For Information Purposes Only: During eUHR compliance testing and case reviews, did the OIG find that medication errors were Information Only properly identified and reported by the institution? 7.999 For Information Purposes Only: Do inmate-patients in isolation housing units have immediate access to their KOP prescribed rescue Information Only inhalers and nitroglycerin medications? Overall Percentage: 92.49% Prenatal and Post-Delivery Services Scored Answers This indicator is not applicable to this institution. Not Applicable Pleasant Valley State Prison, Cycle 4 Medical Inspection Page 65 Office of the Inspector General State of California Scored Answers Yes Reference + Preventive Services Number Yes No No Yes % N/A 9.001 Inmate-patients prescribed TB medications: Did the institution 20 0 20 100.00% 1 administer the medication to the inmate-patient as prescribed? 9.002 Inmate-patients prescribed TB medications: Did the institution 17 3 20 85.00% 1 monitor the inmate-patient monthly for the most recent three months he or she was on the medication? 9.003 Annual TB Screening: Was the inmate-patient screened for TB within 17 13 30 56.67% 0 the last year? 9.004 Were all inmate-patients offered an influenza vaccination for the most 30 0 30 100.00% 0 recent influenza season? 9.005 All inmate-patients from the age of 50 through the age of 75: Was 29 1 30 96.67% 0 the inmate-patient offered colorectal cancer screening? 9.006 Female inmate-patients from the age of 50 through the age of 74: Was the inmate-patient offered a mammogram in compliance with Not Applicable policy? 9.007 Female inmate-patients from the age of 21 through the age of 65: Not Applicable Was the inmate-patient offered a pap smear in compliance with policy? 9.008 Are required immunizations being offered for chronic care 15 5 20 75.00% 0 inmate-patients? 9.009 Are inmate-patients at the highest risk of coccidioidomycosis (valley 12 8 20 60.00% 0 fever) infection transferred out of the facility in a timely manner? Overall Percentage: 81.90% Pleasant Valley State Prison, Cycle 4 Medical Inspection Page 66 Office of the Inspector General State of California Quality of Nursing Performance Scored Answers The quality of nursing performance will be assessed during case reviews, conducted by OIG clinicians, and is not applicable for the compliance portion of the medical inspection. The methodologies OIG clinicians use to evaluate the quality of nursing Not Applicable performance are presented in a separate inspection document entitled OIG MIU Retrospective Case Review Methodology. Quality of Provider Performance Scored Answers The quality of provider performance will be assessed during case reviews, conducted by OIG clinicians, and is not applicable for the compliance portion of the medical inspection. The methodologies OIG clinicians use to evaluate the quality of Not Applicable provider performance are presented in a separate inspection document entitled OIG MIU Retrospective Case Review Methodology. Reception Center Arrivals Scored Answers This indicator is not applicable to this institution. Not Applicable Pleasant Valley State Prison, Cycle 4 Medical Inspection Page 67 Office of the Inspector General State of California Scored Answers Specialized Medical Housing Yes Reference + (OHU, CTC, SNF, Hospice) Number Yes No No Yes % N/A 13.001 For all higher-level care facilities: Did the registered nurse complete 10 0 10 100.00% 0 an initial assessment of the inmate-patient on the day of admission, or within eight hours of admission to CMF’s Hospice? 13.002 For OHU, CTC, & SNF only: Did the primary care provider for OHU 10 0 10 100.00% 0 or attending physician for a CTC & SNF evaluate the inmate-patient within 24 hours of admission? 13.003 For OHU, CTC, & SNF only: Was a written history and physical 10 0 10 100.00% 0 examination completed within 72 hours of admission? 13.004 For all higher-level care facilities: Did the primary care provider 5 5 10 50.00% 0 complete the Subjective, Objective, Assessment, Plan, and Education (SOAPE) notes on the inmate-patient at the minimum intervals required for the type of facility where the inmate-patient was treated? 13.101 For OHU and CTC Only: Do inpatient areas either have properly 1 0 1 100.00% 0 working call systems in its OHU & CTC or are 30-minute patient welfare checks performed; and do medical staff have reasonably unimpeded access to enter inmate-patient’s cells? Overall Percentage: 90.00% Pleasant Valley State Prison, Cycle 4 Medical Inspection Page 68 Office of the Inspector General State of California Scored Answers Yes Reference + Specialty Services Number Yes No No Yes % N/A 14.001 Did the inmate-patient receive the high-priority specialty service within 15 0 15 100.00% 0 14 calendar days of the PCP order? 14.002 Did the PCP review the high priority specialty service consultant report 14 1 15 93.33% 0 within the required time frame? 14.003 Did the inmate-patient receive the routine specialty service within 90 15 0 15 100.00% 0 calendar days of the PCP order? 14.004 Did the PCP review the routine specialty service consultant report 11 3 14 78.57% 1 within the required time frame? 14.005 For endorsed inmate-patients received from another CDCR 15 5 20 75.00% 0 institution: If the inmate-patient was approved for a specialty services appointment at the sending institution, was the appointment scheduled at the receiving institution within the required time frames? 14.006 Did the institution deny the primary care provider request for specialty 20 0 20 100.00% 0 services within required time frames? 14.007 Following the denial of a request for specialty services, was the 19 0 19 100.00% 1 inmate-patient informed of the denial within the required time frame? Overall Percentage: 92.41% Pleasant Valley State Prison, Cycle 4 Medical Inspection Page 69 Office of the Inspector General State of California Scored Answers Internal Monitoring, Quality Improvement, and Yes Reference + Administrative Operations Number Yes No No Yes % N/A 15.001 Did the institution promptly process inmate medical appeals during the 12 0 12 100.00% 0 most recent 12 months? 15.002 Does the institution follow adverse/sentinel event reporting 0 1 1 0.00% 0 requirements? 15.003 Did the institution Quality Management Committee (QMC) meet at 6 0 6 100.00% 0 least monthly to evaluate program performance, and did the QMC take action when improvement opportunities were identified? 15.004 Did the institution’s Quality Management Committee (QMC) or other 1 0 1 100.00% 0 forum take steps to ensure the accuracy of its Dashboard data reporting? 15.005 For each initiative in the Performance Improvement Work Plan 3 2 5 60.00% 1 (PIWP), has the institution performance improved or reached the targeted performance objective(s)? 15.006 For institutions with licensed care facilities: Does the Local 3 1 4 75.00% 0 Governing Body (LGB), or its equivalent, meet quarterly and exercise its overall responsibilities for the quality management of patient health care? 15.007 Does the Emergency Medical Response Review Committee perform 10 2 12 83.33% 0 timely incident package reviews that include the use of required review documents? 15.101 Did the institution complete a medical emergency response drill for 2 1 3 66.67% 0 each watch and include participation of health care and custody staff during the most recent full quarter? 15.102 Did the institution’s second level medical appeal response address all 10 0 10 100.00% 0 of the inmate-patient’s appealed issues? 15.103 Did the institution’s medical staff review and submit the initial inmate 0 1 1 0.00% 0 death report to the Death Review Unit in a timely manner? 15.996 For Information Purposes Only: Did the CCHCS Death Review Committee submit its inmate death review summary to the institution Information Only timely? 15.997 For Information Purposes Only: Identify the institution’s protocols Information Only for tracking medical appeals. 15.998 For Information Purposes Only: Identify the institution’s protocols Information Only for implementing health care local operating procedures. 15.999 For Information Purposes Only: Identify the institution’s health care Information Only staffing resources. Overall Percentage: 68.50% Pleasant Valley State Prison, Cycle 4 Medical Inspection Page 70 Office of the Inspector General State of California Scored Answers Job Performance, Training, Licensing, and Yes Reference + Certifications Number Yes No No Yes % N/A 16.001 Do all providers maintain a current medical license? 10 0 10 100.00% 0 16.101 Does the institution’s Supervising Registered Nurse conduct periodic 5 0 5 100.00% 0 reviews of nursing staff? 16.102 Are nursing staff who administer medications current on their clinical 10 0 10 100.00% 0 competency validation? 16.103 Are structured clinical performance appraisals completed timely? 4 3 7 57.14% 1 16.104 Are staff current with required medical emergency response 2 1 3 66.67% 0 certifications? 16.105 Are nursing staff and the Pharmacist-in-Charge current with their 5 0 5 100.00% 1 professional licenses and certifications? 16.106 Do the institution’s pharmacy and authorized providers who prescribe 1 0 1 100.00% 0 controlled substances maintain current Drug Enforcement Agency (DEA) registrations? 16.107 Are nursing staff current with required new employee orientation? 1 0 1 100.00% 0 Overall Percentage: 90.48% Pleasant Valley State Prison, Cycle 4 Medical Inspection Page 71 Office of the Inspector General State of California APPENDIX B — CLINICAL DATA Table B-1: PVSP Sample Sets Sample Set Total CTC/OHU 4 Death Review/Sentinel Events 1 Diabetes 10 Emergency Services — CPR 5 Emergency Services — Non-CPR 5 High Risk 5 Hospitalization 5 Intra-System Transfers In 3 Intra-System Transfers Out 3 RN Sick Call 30 Specialty Services 5 76 Pleasant Valley State Prison, Cycle 4 Medical Inspection Page 72 Office of the Inspector General State of California Table B-2 PVSP Chronic Care Diagnoses Diagnosis Total Anemia 1 Arthritis/Degenerative Joint Disease 11 Asthma 12 Chronic Pain 20 Cirrhosis/End-Stage Liver Disease 1 Coccidioidomycosis 1 Diabetes 10 Gastroesophageal Reflux Disease 8 Hepatitis C 28 Hyperlipidemia 17 Hypertension 21 Mental Health 22 Migraine Headaches 1 Seizure Disorder 3 156 Pleasant Valley State Prison, Cycle 4 Medical Inspection Page 73 Office of the Inspector General State of California Table B-3 PVSP Event - Program Program Total Diagnostic Services 83 Emergency Care 42 Hospitalization 54 Intra-System Transfers In 33 Intra-System Transfers Out 13 Not Specified 2 Outpatient Care 651 Reception Center Care 0 Specialized Medical Housing 107 Specialty Services 77 1,062 Table B-4 PVSP Case Review Sample Summary Total MD Reviews, Detailed 31 MD Reviews, Focused 7 RN Reviews, Detailed 16 RN Reviews, Focused 47 Total Reviews 101 Total Unique Cases 76 Overlapping Reviews (MD & RN) 25 Pleasant Valley State Prison, Cycle 4 Medical Inspection Page 74 Office of the Inspector General State of California APPENDIX C — COMPLIANCE SAMPLING METHODOLOGY PLEASANT VALLEY STATE PRISON 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 inmate-patient—any risk level) (30)  Randomize MIT 1.002 Nursing Referrals OIG Q: 6.001  See Intra-system Transfers (30) 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: 4.008  See Health Information Management (Medical Community Hospital Records) (returns from community hospital) (10) MIT 1.008 Specialty Services OIG Q: 14.001 &  See Specialty Services Follow-up 14.003 (30) MIT 1.101 Availability of Health OIG onsite  Randomly select one housing unit from each yard Care Services review Request Forms (6) Diagnostic Services MITs 2.001–003 Radiology Radiology Logs  Appointment date (90 days–9 months)  Randomize (10)  Abnormal MITs 2.004–006 Laboratory Quest  Appt. date (90 days–9 months)  Order name (CBC or CMPs only)  Randomize (10)  Abnormal MITs 2.007–009 Pathology InterQual  Appt. date (90 days–9 months)  Service (pathology related) (10)  Randomize Pleasant Valley State Prison, Cycle 4 Medical Inspection Page 75 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 (20) 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 (10)  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: 4.008  Community hospital discharge documents (10)  First 20 IPs selected MIT 4.005 OIG Q: 7.001  MARs (15)  First 20 IPs selected MIT 4.006 Documents for  Any misfiled or mislabeled document identified (12) any tested inmate during OIG compliance review (12 or more = No) MIT 4.007 Legible Signatures & OIG Qs: 4.008,  First 8 IPs sampled Review 6.001, 6.002,  One source document per IP 7.001, 12.001, (41) 12.002 & 14.002 MIT 4.008 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 inmate-patients from each of the 6 months (if not 5 in a month, supplement from another, as (10) needed) Health Care Environment MIT 5.101-105 Clinical Areas OIG inspector  Identify and inspect all onsite clinical areas. MIT 5.107–111 (9) onsite review Inter- and Intra-System Transfers MIT 6.001-003 Intra-System SOMS  Arrival date (3–9 months) Transfers  Arrived from (another CDCR facility)  Rx count  Randomize (30) MIT 6.004 Specialty Services MedSATS  Date of transfer (3–9 months) Send-Outs  Randomize (20) MIT 6.101 Transfers Out OIG inspector  R&R IP transfers with medication (2) onsite review Pleasant Valley State Prison, Cycle 4 Medical Inspection Page 76 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 inmate-patient—any risk level (30)  Randomize MIT 7.002 New Medication Master Registry  Rx count Orders  Randomize (30)  Ensure no duplication of IPs tested in MIT 7.001 MIT 7.003 Returns from OIG Q: 4.008  See Health Information Management (Medical Community Hospital Records) (returns from community hospital) (10) 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) (30)  Randomize MIT 7.006 En Route SOMS  Date of transfer (2–8 months)  Sending institution (another CDCR facility)  Randomize (5)  NA/DOT meds MITs 7.101-103 Medication Storage OIG inspector  Identify and inspect clinical & med line areas that Areas onsite review store medications (16) MITs 7.104–106 Medication OIG inspector  Identify and inspect onsite clinical areas that Preparation and onsite review prepare and administer medications Administration Areas (16) 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 (30) reports MIT 7.999 Isolation Unit KOP Onsite active  KOP rescue inhalers & nitroglycerin medications Medications medication for IPs housed in isolation units (9) listing Prenatal and Post-Delivery Services MIT 8.001-007 Recent Deliveries OB Roster  Delivery date (2–12 months) N/A at this 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) Pleasant Valley State Prison, Cycle 4 Medical Inspection Page 77 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) (21)  Randomize MIT 9.003 TB Code 22, Annual SOMS  Arrival date (at least 1 year prior to inspection) TST  TB Code (22) (15)  Randomize TB Code 34, Annual SOMS  Arrival date (at least 1 year prior to inspection) Screening  TB Code (34) (15)  Randomize MIT 9.004 Influenza SOMS  Arrival date (at least 1 year prior to inspection) Vaccinations  Randomize (30)  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) (30)  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 (20)  Condition must require vaccination(s) MIT 9.009 Valley Fever Cocci transfer  Reports from past 2–8 months (number will vary) status report  Institution  Ineligibility date (60 days prior to inspection date) (20)  All Pleasant Valley State Prison, Cycle 4 Medical Inspection Page 78 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 Access MITs 14.001–002 High-Priority MedSATS  Approval date (3–9 months) (15)  Randomize MITs 14.003–004 Routine MedSATS  Approval date (3–9 months) (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 MIT 14.006-007 Denials InterQual  Review date (3–9 months) (16)  Randomize IUMC/MAR  Meeting date (9 months) Meeting Minutes  Denial upheld (4)  Randomize Pleasant Valley State Prison, Cycle 4 Medical Inspection Page 79 Office of the Inspector General State of California Sample Category Quality (number of Indicator samples) Data Source Filters Internal Monitoring, Quality Improvement, & 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 (1) MITs 15.003–004 QMC Meetings Quality  Meeting minutes (12 months) Management Committee (6) meeting minutes MIT 15.005 Performance Institution PIWP  PIWP with updates (12 months) Improvement Work  Medical initiatives Plans (PIWP) (6) MIT 15.006 LGB LGB meeting  Quarterly meeting minutes (12 months) (4) minutes MIT 15.007 EMRRC EMRRC meeting  Monthly meeting minutes (6 months) (12) 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  Initial death reports (1) 12 months MIT 15.996 Death Review OIG summary  Between 35 business days & 12 months prior Committee log - deaths  CCHCS death reviews (1) MIT 15.998 Local Operating Institution LOPs  All LOPs Procedures (LOPs) (all) Pleasant Valley State Prison, Cycle 4 Medical Inspection Page 80 Office of the Inspector General State of California Sample Category Quality (number of Indicator samples) Data Source Filters Job Performance, Training, Licensing, and Certifications MIT 16.001 Provider licenses Current provider  Review all listing (at start of (10) inspection) MIT 16.101 RN Review Onsite  RNs who worked in clinic or emergency setting Evaluations supervisor six or more days in sampled month periodic RN  Randomize (5) reviews MIT 16.102 Nursing Staff Onsite nursing  On duty one or more years Validations education files  Nurse administers medications (10)  Randomize MIT 16.103 Provider Annual OIG Q:16.001  All required performance evaluation documents Evaluation Packets (8) MIT 16.104 Medical Emergency Onsite  All staff Response certification o Providers (ACLS) Certifications tracking logs o Nursing (BLS/CPR) (all) o Custody (CPR/BLS) MIT 16.105 Nursing staff and Onsite tracking  All required licenses and certifications Pharmacist in system, logs, or Charge Professional employee files Licenses and Certifications (all) MIT 16.106 Pharmacy and Onsite listing of  All DEA registrations Providers’ Drug provider DEA Enforcement Agency registration #s & (DEA) Registrations pharmacy registration (all) document MIT 16.107 Nursing Staff New Nursing staff  New employees (hired within last 12 months) Employee training logs Orientations (all) Pleasant Valley State Prison, Cycle 4 Medical Inspection Page 81 Office of the Inspector General State of California C C ALIFORNIA ORRECTIONAL H C S ’ EALTH ARE ERVICES R ESPONSE Pleasant Valley State Prison, Cycle 4 Medical Inspection Page 82 Office of the Inspector General State of California