Revised California Men’s Colony Medical Inspection Report Cycle 4

Robert A. Barton Office of the Inspector General Inspector General REVISED California Men’s Colony Medical Inspection Results Cycle 4 December 2016 Medical Inspection Unit Page 1 Office of the Inspector General State of California Office of the Inspector General CALIFORNIA MEN’S COLONY Medical Inspection Results Cycle 4 Robert A. Barton Inspector General Roy W. Wesley Chief Deputy Inspector General Shaun R. Spillane Public Information Officer December 2016 Corrections – December 29, 2016 The Office of the Inspector General (OIG) issues this revised Medical Inspection Report for California Men’s Colony (CMC). While the OIG strives to report accurate, clear, consistent, and thorough information, errors do occur. The original inspection report contained two errors. One was in the Medical Inspection Results section. The other was in the Emergency Services indicator. In the Medical Inspection Results, the report incorrectly stated that there were no adverse events for CMC. There were, however, two adverse events. Both adverse events were accurately described in the Emergency Services indicator of the inspection report. The second error was failure to identify case 22 as one of the two adverse events for CMC in the Emergency Services indicator. While the two adverse events were not reported in the Medical Inspection Results, the OIG included these two adverse events with all other results when reaching the overall adequate rating for CMC. Page 12, second paragraph in Adverse Events It should read: Identified During Case Review reads: There were no unsafe conditions or sentinel events There were two adverse events identified in the case identified in the case reviews at CMC. reviews at CMC:  Case 22: a provider inappropriately ordered a three-day follow up for a patient with several days of fever, fast heart rate, and weakness. The patient was sent to an outside hospital six days later, where he died the following week from an infection of the heart.  Case 31: a provider failed to see a patient face-to-face with classic appendicitis symptoms. The patient was transferred to a community hospital two days later for care of a ruptured appendix. Page 18, second bulleted item in Provider It should read: Performance reads:  In case 22, the on-call provider inappropriately  In case 22, the on-call provider inappropriately ordered a three-day follow-up for a patient with ordered a three-day follow-up for a patient with a pacemaker who had experienced five days of a pacemaker who had experienced five days of fever, chills, and severe generalized weakness. fever, chills, and severe generalized weakness. Prior to the patient’s discharge from the TTA, Prior to the patient’s discharge from the TTA, his fast heart rate increased from 117 to 126 his fast heart rate increased from 117 to 126 beats per minute. The patient inappropriately beats per minute. The patient inappropriately received only acetaminophen and a three-day received only acetaminophen and a three-day follow-up, without a provider evaluation or follow-up, without a provider evaluation or provider note to address possible unstable vital provider note to address possible unstable vital signs. The patient was hospitalized five days signs. The patient was hospitalized five days later for a heart infection, and died. later for a heart infection, and died. The OIG reported this case as one of the two adverse events during the inspection for CMC. TABLE OF CONTENTS Executive Summary ................................................................................................................ i Overall Assessment: Adequate .................................................................................. iii Clinical Case Review and OIG Clinician Inspection Results ................................... iii Compliance Testing Results ...................................................................................... iv Population-Based Metrics ....................................................................................... viii 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 ..................................................................................... 14 Recommendations .................................................................................................... 15 Diagnostic Services ..................................................................................................... 16 Case Review Results ................................................................................................ 16 Compliance Testing Results ..................................................................................... 16 Recommendations .................................................................................................... 17 Emergency Services ..................................................................................................... 18 Case Review Results ................................................................................................ 18 Recommendations .................................................................................................... 21 Health Information Management (Medical Records) ................................................. 22 Case Review Results ................................................................................................ 22 Compliance Testing Results ..................................................................................... 24 Recommendations .................................................................................................... 25 Health Care Environment ........................................................................................... 26 Compliance Testing Results ..................................................................................... 26 Recommendations .................................................................................................... 28 California Men’s Colony, Cycle 4 Medical Inspection Table of Contents Office of the Inspector General State of California Inter- and Intra-System Transfers ............................................................................... 29 Case Review Results ................................................................................................ 29 Compliance Testing Results ..................................................................................... 31 Recommendations .................................................................................................... 32 Pharmacy and Medication Management .................................................................... 33 Case Review Results ................................................................................................ 33 Compliance Testing Results ..................................................................................... 34 Recommendations .................................................................................................... 37 Preventive Services ...................................................................................................... 38 Compliance Testing Results ..................................................................................... 38 Recommendations .................................................................................................... 39 Quality of Nursing Performance ................................................................................. 40 Case Review Results ................................................................................................ 40 Recommendations .................................................................................................... 42 Quality of Provider Performance ................................................................................ 43 Case Review Results ................................................................................................ 43 Recommendation for CCHCS .................................................................................. 47 Recommendations for CMC ..................................................................................... 48 Specialized Medical Housing (OHU, CTC, SNF, Hospice) ........................................ 49 Case Review Results ................................................................................................ 49 Compliance Testing Results ..................................................................................... 50 Recommendations .................................................................................................... 51 Specialty Services ........................................................................................................ 52 Case Review Results ................................................................................................ 52 Compliance Testing Results ..................................................................................... 53 Recommendations .................................................................................................... 54 Secondary (Administrative) Quality Indicators of Health Care ........................................ 55 Internal Monitoring, Quality Improvement, and Administrative Operations ............. 56 Compliance Testing Results ..................................................................................... 56 Recommendations .................................................................................................... 58 Job Performance, Training, Licensing, and Certifications ......................................... 59 Compliance Testing Results ..................................................................................... 59 Recommendations .................................................................................................... 60 Population-Based Metrics ................................................................................................. 61 Appendix A — Compliance Test Results ............................................................................ 64 Appendix B — Clinical Data ............................................................................................... 78 Appendix C — Compliance Sampling Methodology .......................................................... 81 California Correctional Health Care Services’ Response .................................................... 88 California Men’s Colony, 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 CMC Executive Summary Table ......................................................................................... vii CMC Health Care Staffing Resources as of May 2016 ..........................................................2 CMC Master Registry Data as of May 2, 2016 ......................................................................3 Commonly Used Abbreviations ..............................................................................................4 CMC Results Compared to State and National HEDIS Scores ............................................63 California Men’s Colony, 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 the California Men’s Colony (CMC). The OIG performed its Cycle 4 medical inspection at CMC from May to July 2016. The inspection included in-depth reviews of 92 inmate-patient files conducted by clinicians, as well as reviews of documents from 470 inmate-patient files, covering 94 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 CMC 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 CMC was adequate. California Men’s Colony, Cycle 4 Medical Inspection Page i Office of the Inspector General State of California Health Care Quality Indicators All Institutions– CMC 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 an OHU, CTC, SNF, Not Applicable (OHU, CTC, SNF, Hospice) or Hospice Both case review 14–Specialty Services All institutions and compliance All Institutions– CMC Two Secondary Indicators (Administrative) Applicability Applicability 15–Internal Monitoring, Quality Improvement, All institutions Compliance only and Administrative Operations 16–Job Performance, Training, Licensing, and All institutions Compliance only Certifications California Men’s Colony, Cycle 4 Medical Inspection Page ii Office of the Inspector General State of California Overall Assessment: Adequate Based on the clinical case reviews and compliance testing, the OIG’s overall assessment rating for CMC was adequate. Of the Overall Assessment 12 primary (clinical) quality indicators applicable to CMC, the Rating: OIG found one proficient, seven adequate, and four inadequate. Of the two secondary (administrative) quality indicators, the OIG Adequate found one proficient and one inadequate. To determine the overall assessment for CMC, 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 CMC. Clinical Case Review and OIG Clinician Inspection Results The clinicians’ case reviews sampled patients with high medical needs and included a review of 1,504 patient care events.1 Of the 12 primary indicators applicable to CMC, 10 were evaluated by clinician case review; nine were adequate, and one 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  The chief medical executive and the chief physician & surgeon provided good leadership.  The providers were proactive about communicating with specialty consultants, as evidenced by cases in which the provider called the specialist or the emergency room physician for either clarification or verification of critical medical information.  The institution’s pharmacy provided an anticoagulation clinic. This allowed patients to receive the appropriate and timely care needed for this complex medication process. 1 Each OIG clinician team includes a board-certified physician and registered nurse consultant with experience in correctional and community medical settings. California Men’s Colony, Cycle 4 Medical Inspection Page iii Office of the Inspector General State of California Program Weaknesses — Clinical  The on-call provider services at CMC were weak. Provider assessment on the telephone was poor compared to the high quality provided when face-to-face with patients. Patients in the TTA with high-risk conditions such as abdominal pain were sent back to their housing unit without the provider coming into the institution to see them. Also, the providers often failed to provide telephone progress notes.  Diabetes management and chest pain treatment were very poor.  CMC providers did not routinely sign hospital discharge reports, specialty consultations, or diagnostic reports to evidence their review prior to medical records staff scanning them into the eUHR. Compliance Testing Results Of the 14 health care indicators applicable to CMC, 11 were evaluated by compliance inspectors.2 There were 94 individual compliance questions within those 11 indicators, generating 1,410 data points, that tested CMC’s compliance with California Correctional Health Care Services (CCHCS) policies and procedures.3 Those 94 questions are detailed in Appendix A — Compliance Test Results. The institution’s inspection scores in the 11 applicable indicators ranged from 61.1 percent to 88.0 percent, with the primary (clinical) indicator Preventive Services receiving the lowest score, and the primary indicator Specialized Medical Housing receiving the highest. Of the nine primary indicators applicable to compliance testing, the OIG rated two proficient, four adequate, and three inadequate. Of the two secondary indicators, which involve administrative health care functions, one was rated proficient and one, inadequate. Program Strengths — Compliance As the CMC Executive Summary Table on page vii indicates, the institution’s compliance scores were proficient, above 85 percent, in two primary indicators, Inter- and Intra-System Transfers and Specialized Medical Housing. The institution also received a proficient score in the secondary indicator Internal Monitoring, Quality Improvement, and Administrative Operations. The following are some of CMC’s strengths based on its compliance scores on individual questions in all the primary health care indicators:  Nursing staff reviewed patients’ health care requests and conducted face-to-face visits with patients within required time frames. 2 The OIG’s compliance inspectors are trained deputy inspectors general and registered nurses with expertise in CDCR policies regarding medical staff and processes. 3 The OIG used its own clinicians to provide clinical expert guidance for testing compliance in certain areas where CCHCS policies and procedures did not specifically address an issue. California Men’s Colony, Cycle 4 Medical Inspection Page iv Office of the Inspector General State of California  The institution provided radiology and pathology services for patients within the time frames ordered.  Clinical areas had operable sinks and sufficient quantities of hygiene supplies, and reusable invasive and non-invasive medical equipment was properly sterilized. Also, clinic common areas had adequate environments conducive to providing medical services.  Nursing staff ensured that patients who transferred from CMC to other institutions had complete transfer packets and all applicable medications.  Nursing staff employed and followed hand hygiene contamination control protocols during medication preparation and administration processes. They also followed proper administrative protocols when preparing medications for patients.  In its main pharmacy, CMC followed general security, organization, and cleanliness management protocols; properly stored and monitored refrigerated, frozen, and non-refrigerated medications; and properly accounted for narcotic medications.  Patients timely received their high-priority and routine specialty services.  The institution timely denied provider requests for specialty services, and providers communicated the denials of services to patients within required time frames. The following are some of the strengths identified within the two secondary administrative indicators:  The Quality Management Committee met monthly, evaluated program performance and took action when improvement opportunities were identified, and took adequate steps to ensure the accuracy of its Dashboard data reporting.  All providers received complete clinical performance appraisals, and all nursing staff who administered medications possessed current clinical competency validations. Program Weaknesses — Compliance The institution received scores of inadequate, below 75 percent, in three primary indicators, Health Information Management, Pharmacy and Medication Management, and Preventive Services. The institution also received an inadequate score in the secondary indicator Job Performance, Training, Licensing, and Certifications. The following are some of the weaknesses identified by CMC’s compliance scores on individual questions in all the primary health care indicators:  Patients with chronic care conditions did not always receive provider follow-up appointments within required time frames. California Men’s Colony, Cycle 4 Medical Inspection Page v Office of the Inspector General State of California  Patients who transferred into CMC from other CDCR institutions and received a nurse referral to see a provider did not always receive their appointments within the required time frame.  Providers did not always review pathology reports or communicate the results to patients within required time frames.  The institution’s providers did not always timely review hospital discharge reports for patients who returned to CMC.  In most clinics, essential equipment and supplies, such as biohazard receptacles or bags, Snellen eye charts, and a medication refrigerator were missing in exam rooms and common areas.  The institution had poor control narcotic medications at several medication line locations, and nursing staff did not always employ appropriate administrative controls and protocols when distributing medications to patients.  Nursing staff did not always administer tuberculosis (TB) medications as ordered to TB patients, and monthly or weekly monitoring of patients on TB medications was poor.  Providers did not always review high-priority and routine specialty services reports within the required time frames. The following weakness was identified within one of the two secondary administrative indicators:  Supervising nurses did not complete periodic reviews of nursing staff, and several nurses hired in the most recent 12-month period did not receive new employee training. The CMC 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. California Men’s Colony, Cycle 4 Medical Inspection Page vi Office of the Inspector General State of California CMC Executive Summary Table Case Review Compliance Overall Indicator Primary Indicators (Clinical) Rating Rating Rating Access to Care Adequate Adequate Adequate Diagnostic Services Adequate Adequate Adequate Emergency Services Inadequate Not Applicable Inadequate Health Information Management Adequate Inadequate Inadequate (Medical Records) Health Care Environment Not Applicable Adequate Adequate Inter- and Intra-System Transfers Adequate Proficient Proficient Pharmacy and Medication Management Adequate Inadequate Inadequate Preventive Services Not Applicable Inadequate Inadequate Quality of Nursing Performance Adequate Not Applicable Adequate Quality of Provider Performance Adequate Not Applicable Adequate Specialized Medical Housing Adequate Proficient Adequate (OHU, CTC, SNF, Hospice) Specialty Services Adequate Adequate Adequate The Prenatal and Post-Delivery Services and Reception Center Arrivals indicators did not apply to this institution. Case Review Compliance Overall Indicator Secondary Indicators (Administrative) Rating Rating Rating Internal Monitoring, Quality Improvement, Not Applicable Proficient Proficient and Administrative Operations Job Performance, Training, Licensing, Not Applicable Inadequate Inadequate and 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). California Men’s Colony, Cycle 4 Medical Inspection Page vii Office of the Inspector General State of California Population-Based Metrics The institution generally performed adequately as measured by population-based metrics. Statewide, CMC outperformed Medi-Cal in all five diabetic measures, and outperformed Kaiser in four of five measures, with Kaiser scoring better than CMC in blood pressure control. Nationally, CMC outperformed Medicaid, Medicare, and commercial health plans in all five diabetic measures, but only outperformed the United States Department of Veterans Affairs (VA) in two of the four applicable measures; the VA performed better than CMC in diabetic blood pressure control and eye exams. With regard to immunizations for younger adults, CMC outperformed all statewide and national health care organizations. CMC also outperformed Medicare and matched the VA for influenza immunizations for older adults. The institution outperformed Medicare for pneumococcal vaccinations, but performed poorly in comparison to the VA for the same measure. For colorectal cancer screenings, the institution matched commercial plans, but performed poorly compared to Kaiser, Medicare, and the VA. However, the high refusal rate for the cancer screening negatively affected the institution’s score. Overall, CMC’s performance calculated by population-based metrics demonstrated a generally adequate chronic care and preventive services program. The institution could improve by making interventions to lower the refusal rates for colorectal cancer screening. California Men’s Colony, Cycle 4 Medical Inspection Page viii Office of the Inspector General State of California INTRODUCTION Under the authority of 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. California Men’s Colony (CMC) was the 29th 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 CMC has two physically separated housing complexes, commonly referred to as “East” and “West”. The institution places an emphasis on providing programs for self-improvement to all inmates. These include academic and vocational education, work skills in prison industries, and inmate self-help group activities. The Level III housing complex (East), which houses medium-security general population inmates, is divided into four buildings. The Levels I and II housing complex (West) houses minimum-security general population inmates in dormitory settings in three buildings. The West housing complex also contains a Level I fire camp program. CMC has been designated an “intermediate care” prison. These institutions are predominantly located in urban areas, close to tertiary care centers and specialty care providers, for the most cost-effective care. The institution runs multiple medical clinics where staff members handle non-urgent requests for medical services, and it treats inmates needing urgent or emergency care in its triage and treatment area (TTA). The East housing complex has a fully licensed correctional treatment center (CTC) providing inpatient care. CMC received accreditation on August 16, 2015, from the Commission on Accreditation for Corrections, a professional peer review process based on national standards set by the American Correctional Association. California Men’s Colony, Cycle 4 Medical Inspection Page 1 Office of the Inspector General State of California Based on staffing data the OIG obtained from the institution, CMC’s vacancy rate among licensed medical managers, primary care providers (PCPs), supervisors, and nonsupervisory nurses was approximately 6 percent in May 2016, with the highest vacancy percentages among primary care providers at 22 percent. Based on the reported data, CMC had three vacant primary care practitioner positions, eight vacant nursing staff positions, and one primary care practitioner and eight nursing staff who were on long-term medical leave. The institution employed three registry primary care practitioners and two registry nurses. CMC Health Care Staffing Resources as of May 2016 Primary Care Nursing Management Nursing Staff Totals Providers Supervisors Description Number % Number % Number % Number % Number % Authorized 5 3% 13.5 7% 18 10% 147.1 80% 183.6 100% Positions Filled 5 100% 10.5 78% 18 100% 139 94% 172.5 94% Positions Vacancies 0 0% 3 22% 0 0% 8.1 6% 11.1 6% Recent Hires (within 12 1 20% 0 0% 4 22% 20 14% 25 14% months) Staff Utilized 0 0% 3 29% 0 0% 2 1% 5 3% from Registry Redirected Staff 0 0% 0 0% 0 0% 0 0% 0 0% (Non-Patient Care Areas) Staff on Long-term 0 0% 1 10% 0 0% 8 6% 9 5% Medical Leave Note: CMC Health Care Staffing Resources data was not validated by the OIG. California Men’s Colony, Cycle 4 Medical Inspection Page 2 Office of the Inspector General State of California As of May 2, 2016, the Master Registry for CMC showed that the institution had a total population of 4,148. Within that total population, 2.6 percent were designated as high medical risk, Priority 1 (High 1), and 10.6 percent were designated as high medical risk, Priority 2 (High 2). Patients’ assigned risk levels are based on the complexity of their required medical care related to their specific diagnoses, frequency of higher levels of care, age, and abnormal laboratory reports 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. CMC Master Registry Data as of May 2, 2016 Medical Risk Level # of Inmate-Patients Percentage High 1 107 2.58% High 2 441 10.63% Medium 1,918 46.24% Low 1,682 40.55% Total 4,148 100.00% California Men’s Colony, 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 & 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 California Men’s Colony, 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 CMC, 14 of the quality indicators were applicable, consisting of 12 primary clinical indicators and 2 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 California Men’s Colony, 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. A majority of the patients selected for retrospective chart review were classified by CCHCS as high-risk patients. The reason the OIG targeted these patients for review is twofold: 1. The goal of retrospective chart review is to evaluate all aspects of the health care system. Statewide, high-risk and high-utilization patients consume medical services at a disproportionate rate; 11 percent of the total patient population are considered high-risk and account for more than half of the institution’s pharmaceutical, specialty, community hospital, and emergency costs. California Men’s Colony, 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 California Men’s Colony, 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: CMC Sample Sets, the OIG clinicians evaluated medical charts for 92 unique inmate-patients. Appendix B, Table B–4: CMC Case Review Sample Summary, clarifies that both nurses and physicians reviewed charts for 16 of those patients, for 108 reviews in total. Physicians performed detailed reviews of 30 charts, and nurses performed detailed reviews of 17 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 60 inmate-patients. These generated 1,504 clinical events for review (Appendix B, Table B–3: CMC Event-Program). The inspection tool provides details on whether the encounter was adequate or had significant deficiencies, and identifies deficiencies by programs and processes to help the institution focus on improvement areas. While the sample method specifically pulled only six chronic care patient records, i.e., three diabetes patients and three anticoagulation patients (Appendix B, Table B–1: CMC Sample Sets), the 92 unique inmate-patients sampled included patients with 337 chronic care diagnoses, including 24 additional patients with diabetes (for a total of 27) and 2 additional anticoagulation patients (for a total of 5) (Appendix B, Table B–2: CMC Chronic Care Diagnoses). The OIG’s sample selection tool allowed evaluation of many chronic care programs because the complex and high-risk patients selected from the different categories often had multiple medical problems. While the OIG did not evaluate every chronic disease or health care staff member, the overall operation of the institution’s system and staff were assessed for adequacy. The OIG’s case review methodology and sample size matched other qualitative research. The empirical findings, supported by expert statistical consultants, showed adequate conclusions after 10 to 15 charts had undergone full clinician review. In qualitative statistics, this phenomenon is known as “saturation.” The OIG asserts that the physician sample size of 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. California Men’s Colony, Cycle 4 Medical Inspection Page 8 Office of the Inspector General State of California 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 confidential CMC 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 May to July 2016, deputy inspectors general and registered nurses attained answers to 94 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 470 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 May 16, 2016, field inspectors conducted a detailed onsite inspection of CMC’s medical facilities and clinics; interviewed key institutional employees; and reviewed employee records, logs, medical appeals, death reports, and other documents. This generated 1,410 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 CMC’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- and Intra-System Transfers, Pharmacy and Medication Management, Preventive Services, Specialized Medical Housing (OHU, CTC, SNF, Hospice), and Specialty Services. California Men’s Colony, Cycle 4 Medical Inspection Page 9 Office of the Inspector General State of California  Secondary indicators: Internal Monitoring, Quality Improvement, and Administrative Operations; and Job Performance, Training, Licensing, and Certifications. After compiling the answers to the 94 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 (from 75 percent to 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 incomparable. 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. California Men’s Colony, 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 CMC, the OIG reviewed some of the compliance testing results, randomly sampled additional inmate-patients’ records, and obtained CMC data from the CCHCS Master Registry. The OIG compared those results to HEDIS metrics reported by other statewide and national health care organizations. California Men’s Colony, 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 CMC. Of those 12 indicators, 7 were rated by both the case review and compliance components of the inspection, 3 were rated by the case review component alone, and 2 were rated by the compliance component alone. The CMC Executive Summary Table on page vii 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 CMC. Of these ten indicators, OIG clinicians rated nine adequate and one inadequate. The OIG physicians rated the overall adequacy of care for each of the 30 detailed case reviews they conducted. Of these 30 cases, one was proficient, 22 were adequate, and 7 were inadequate. In the 1,504 events reviewed, there were 305 deficiencies, of which 80 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 two adverse events identified in the case reviews at CMC:  Case 22: a provider inappropriately ordered a three-day follow up for a patient with several days of fever, fast heart rate, and weakness. The patient was sent to an outside hospital six days later, where he died the following week from an infection of the heart.  Case 31: a provider failed to see a patient face-to-face with classic appendicitis symptoms. The patient was transferred to a community hospital two days later for care of a ruptured appendix. Summary of Compliance Results: The compliance component assessed 9 of the 12 primary (clinical) indicators applicable to CMC. Of these nine indicators, OIG inspectors rated two proficient, four adequate, and three inadequate. The results of those assessments are summarized within this section of the report. The test questions used to assess compliance for each indicator are detailed in Appendix A. California Men’s Colony, 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 Adequate follow-ups, face-to-face nurse appointments when an inmate-patient (76.8%) requests to be seen, provider referrals from nursing lines, and Overall Rating: follow-ups after hospitalization or specialty care. Compliance Adequate testing for this indicator also evaluates whether inmate-patients have Health Care Services Request forms (CDCR Form 7362) available in their housing units. Case Review Results The OIG rated the Access to Care indicator adequate. The OIG clinicians reviewed 590 provider and nurse encounters and identified 22 deficiencies relating to Access to Care. Six of the deficiencies were significant. One patient died from endocarditis (infection of the heart), which was possibly preventable:  In case 22, a provider ordered a three-day follow-up from the TTA for a patient who presented with fast heart rate, fever, and generalized weakness. This appointment did not occur, and the delayed evaluation resulted in an emergent hospitalization, during which the patient later died. Other significant deficiencies:  In case 19, an electrocardiogram (EKG) was ordered for evaluation of a prolonged QT interval (measurement that predisposes an unstable heart rhythm), but it was never performed while the patient was in the CTC.  In case 23, a provider ordered an MRI of the abdomen to evaluate the patient’s liver cancer. The oncologist had recommended the MRI to determine treatment opportunities. This MRI was delayed nearly two months.  In case 31, the patient’s follow-up appointment for a ruptured appendix was delayed by three weeks.  In case 33, an appointment for a wound evaluation was delayed two weeks.  In case 39, an appointment for a poorly controlled diabetic patient was delayed two weeks. California Men’s Colony, Cycle 4 Medical Inspection Page 13 Office of the Inspector General State of California RN Sick Call Access CMC nursing staff did reasonably well scheduling and completing face-to-face appointments within required time frames. However, patients in cases 25, 30, 33, 61, and 83 were seen from one to 34 days late for scheduled appointments. Intra-System Transfers In Patients who transferred into CMC and who were referred to the provider by an RN were generally seen timely. The OIG clinicians reviewed three transfer-in patients, one of whom a provider saw one day late (case 8). Department of State Hospitals Transfers The institution performed well in providing initial provider visits for history and physical examinations. The majority of these exams were completed timely. Of the five patients reviewed, all but one had a provider visit within seven days. The patient in case 15 was seen four days later than scheduled. Compliance Testing Results The institution received an adequate compliance score of 76.8 percent in the Access to Care indicator, scoring within the proficient range in the following three tests:  Inspectors sampled 30 Health Care Services Request forms (CDCR Form 7362) submitted by patients across all facility clinics. Nursing staff reviewed all of them the same day they were received (MIT 1.003). Nursing staff also timely completed face-to-face encounters with the same 30 patients within one business day of reviewing the request forms (MIT 1.004).  Patients had access to health care services request forms at all six housing units inspected (MIT 1.101). The institution scored in the adequate range in the following test area:  Among 30 sampled patients who were discharged from a community hospital, 23 (77 percent) received a timely follow-up appointment with a provider. Seven patients received their appointments from one to 16 days late (MIT 1.007). The institution scored in the inadequate range in the following areas:  The OIG sampled 21 patients who transferred into CMC from other institutions and were referred to a provider based on nursing staff’s initial health care screening. Only 11 were seen timely (52 percent). For ten patients, provider appointments were held between one and 19 days late (MIT 1.002). California Men’s Colony, Cycle 4 Medical Inspection Page 14 Office of the Inspector General State of California  Inspectors reviewed recent appointments for 40 patients who suffered with one or more chronic care conditions; only 23 of the patients (58 percent) had received timely follow-up appointments. The 17 other patients received their follow-up appointments from one to 24 days late (MIT 1.001).  Among 30 sampled patients who received a specialty service, only 19 (63 percent) received timely follow-up appointments with a provider. Eleven patients received their appointments from one to 39 days late (MIT 1.008).  Inspectors initially sampled 30 patients who submitted a health care services request. Of these, ten patients received a nurse referral to a provider for their condition, and only seven of these (70 percent) received a timely provider visit. Three patients received their provider visit from one to four days late (MIT 1.005). Providers subsequently ordered follow-up appointments for seven of the ten patients, of whom only five received a timely appointment (71 percent). Two patients received their follow-up appointments 11 and 16 days late (MIT 1.006). Recommendations No specific recommendations. California Men’s Colony, Cycle 4 Medical Inspection Page 15 Office of the Inspector General State of California DIAGNOSTIC SERVICES This indicator addresses several types of diagnostic services. Case Review Rating: Specifically, it addresses whether radiology and laboratory services Adequate were timely provided to inmate-patients, whether the primary care Compliance Score: provider (PCP) timely reviewed the results, and whether the results Adequate were communicated to the inmate-patient within the required time (79.7%) frames. In addition, for pathology services, the OIG determines Overall Rating: whether the institution received a final pathology report and Adequate whether the PCP 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 236 diagnostic events and found 20 deficiencies, one of which was significant:  In case 23, a laboratory report revealed a critically low blood glucose level, but there was no documentation that the provider or the TTA was notified. The provider reviewed the report three days later. This is also discussed in the Health Information Management indicator. Minor patterns of deficiencies were also noted. In cases 20, 21, and 23 (another laboratory report in this case), there were several delayed notifications of diagnostic test results to the providers and the patients. In cases 21 and 42, there were deficiencies that occurred with scanning of pertinent documentation prior to a provider signature. Clinician Summary Overall, diagnostic services were performed well, and the majority of them were performed in a timely manner. CMC’s performance was adequate in the Diagnostic Services indicator. Compliance Testing Results The institution received an adequate compliance score of 79.7 percent in the Diagnostic Services indicator, which encompasses radiology, laboratory, and pathology services. For clarity, each diagnostic service type is discussed separately below. Radiology Services  All ten of the radiology services sampled were timely performed (MIT 2.001). Providers also reviewed and communicated the radiology results timely for nine of ten patients California Men’s Colony, Cycle 4 Medical Inspection Page 16 Office of the Inspector General State of California sampled (90 percent). For one patient, the provider reviewed the report and communicated the results to the patient 24 days late (MIT 2.002, 2.003). Laboratory Services  Eight of the ten sampled laboratory services were completed within the ordered time frame (80 percent). Two patients received their laboratory service three and nine days late (MIT 2.004). Ordering providers also timely reviewed the laboratory report and communicated the diagnostic report results for nine of the ten sampled patients (90 percent). The provider reviewed the report for one patient and communicated the results to him two days late (MIT 2.005, 2.006). Pathology Services  The institution timely received the final pathology report for nine of ten patients sampled (90 percent). For one patient, the final pathology report was neither received nor scanned into the eUHR (MIT 2.007). Providers documented sufficient evidence that they timely reviewed the final report results for only four of eight patients (50 percent); for the other four patients, there was no evidence that the provider reviewed the pathology report at all (MIT 2.008). Providers timely communicated the final pathology test results to only three of eight patients sampled (38 percent). For three patients, the provider communicated the pathology test results from one to seven days late; for two other patients, there was no evidence that the provider communicated the test results at all (MIT 2.009). Recommendations No specific recommendations. California Men’s Colony, Cycle 4 Medical Inspection Page 17 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, Inadequate treatment, and transportation 24 hours per day. Provision of urgent Compliance Score: or 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: Inadequate support (BLS), and advanced cardiac life support (ACLS) consistent with the American Heart Association guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiovascular care, and the provision of services by knowledgeable staff appropriate to each individual’s training, certification, and authorized scope of practice. The OIG evaluates this quality indicator entirely through clinicians’ reviews of case files and conducts no separate compliance testing element. Case Review Results The OIG clinicians reviewed 94 urgent or emergent events and found 58 deficiencies. Of the deficiencies discovered, 26 were significant and likely contribute to harm if left unaddressed. For cases 2, 22, 27, and 31, the deficiencies contributed to harm. Provider Performance While emergency services were inadequate overall, the TTA providers at CMC performed expertly when patients were evaluated in person, making accurate assessments and triage decisions. However, on-call providers who consulted by telephone occasionally performed inadequate assessments that led to poor decisions and inappropriate follow-ups. All seven of the serious provider deficiencies occurred during on-call provider encounters.  In cases 4, 6, and 43, the on-call providers failed to start aspirin for patients with chest pain who were transferred to the emergency room for possible acute coronary syndrome (impending heart attack).  In case 22, the on-call provider inappropriately ordered a three-day follow-up for a patient with a pacemaker who had experienced five days of fever, chills, and severe generalized weakness. Prior to the patient’s discharge from the TTA, his fast heart rate increased from 117 to 126 beats per minute. The patient inappropriately received only acetaminophen and a three-day follow-up, without a provider evaluation or provider note to address possible unstable vital signs. The patient was hospitalized five days later for a heart infection, and died. The OIG reported this case as one of the two adverse events during the inspection for CMC. California Men’s Colony, Cycle 4 Medical Inspection Page 18 Office of the Inspector General State of California  In case 27, the patient had labored breathing and a productive cough. Although the provider ordered two breathing treatments, the provider failed to consider steroids, antibiotics, or even a face-to-face encounter to help manage the patient’s condition.  In case 31, the on-call provider failed to perform a face-to-face evaluation when a patient had fever, fast heart rate, eight days of right lower abdominal pain and tenderness, and an abnormal laboratory report showing significant inflammation. The provider also inappropriately ordered a routine follow-up instead of sending the patient to a higher level of care. The patient was hospitalized two days later for a ruptured appendix. The OIG reported this case as one of the two adverse events during the inspection for CMC. Nursing Performance The nursing care provided during emergency medical responses was inadequate. A pattern of nursing deficiencies involved delays in provider notification, poor assessments and communication with the providers during an emergency, and delays calling the ambulance. The following examples demonstrate significant deficiencies:  In case 4, nurses twice delayed contacting the provider for a patient with chest pain. Nurses also failed to note vital signs, level of consciousness, and levels of oxygen in the blood, and failed to administer nitroglycerin and aspirin per nursing protocol. Nurses did not call the ambulance until custody was ready, causing a 21-minute delay.  In case 5, the nurse failed to adequately assess or monitor the patient with severe chest pain for the hour the patient was in the TTA prior to being discharged to an outside emergency room.  In case 6, the patient in the CTC had chest pain and an abnormal EKG. There were delays in care with CTC psychiatric technicians (PTs) contacting the on-call provider through the TTA nurses; then waiting for the provider to contact the PTs for information. TTA nurses waiting to call an ambulance caused more delays. Finally, the CTC nursing staff failed to give aspirin, assess the effectiveness of the nitroglycerin (heart medication), or check vital signs and blood oxygen levels.  In case 22, the patient had five days of fever, chills, and severe body pain. Nurses checked the patient’s temperature three times, and each time it was abnormal. The patient was given acetaminophen for fever, but nursing staff failed to evaluate the effectiveness of the medication. Six days after that nursing encounter, the patient’s condition became worse. His heart rate was fast and his oxygen level was extremely low. There was a delay in calling the ambulance for almost 40 minutes. A 9-1-1 call should have been made immediately due to the patient’s worsening condition. California Men’s Colony, Cycle 4 Medical Inspection Page 19 Office of the Inspector General State of California  In case 29, upon the patient’s arrival to the TTA, the nurse checked his vital signs but then failed to recheck them for over two hours even though his heart rate was initially very slow. In addition, the patient’s complaint of severe headache was assessed only one time while he was in the TTA for two and a half hours. Finally, the nurse failed to assess the patient’s condition before CMC medical staff sent him to the community emergency room.  In case 30, the nurse failed to notify the provider of the patient’s new severe chest pain and shortness of breath. The patient had a rare bleeding disorder, and the nurse should have assessed for signs and symptoms of bleeding. The nurse failed to initiate an urgent referral to the provider, and did not assess vital signs or blood oxygen levels before sending him back to his housing unit.  In case 31, the TTA nurse saw the patient who reported a week of abdominal pain, fever, and a fast heart rate. The provider was contacted, and the provider ordered a routine follow-up. Later the same day, the patient went to the clinic with the same symptoms. The second nurse failed to contact a provider. The nurse treated the patient for constipation, which was inappropriate for a patient with appendicitis, and sent the patient back to his housing unit. Two days later, the patient was again seen in the clinic by a third nurse who referred the patient to the provider. The patient was then transferred to an emergency room for a ruptured appendix with widespread infection.  In case 32, nurses responded to an 82-year-old patient with severe back and leg pain. The next day, he was seen again for severe hip pain. Even though nurses noted that they reviewed the patient’s medications, they were unaware that the patient’s prescription for acetaminophen had expired ten days before these emergency calls. The nurses did not contact a provider, refer the patient to his provider for evaluation, or implement interventions to alleviate the patient’s severe pain.  In case 34, the TTA nurse failed to give the patient aspirin ordered by the provider for chest pain. In addition, medical staff waited 40 minutes until custody was ready before calling for an ambulance. The nurse noted that per protocol, the ambulance was to be called after custody transport was ready. Patient Care Environment  In case 2, the patient was found by custody hanging by the neck. The patient was unresponsive and had dried blood and lacerations on his neck. Custody contacted medical staff for an emergency response. When the nurse arrived, custody was outside the patient’s cell and had not rendered first aid or initiated CPR.4 4 This incident did not result in a case review deficiency for CMC in the Emergency Services indicator, but is included in this report because it was a critical finding. The OIG notified CDCR about this incident in a separate report. California Men’s Colony, Cycle 4 Medical Inspection Page 20 Office of the Inspector General State of California Emergency Medical Response Review Committee In cases 4, 6, and 7, the Emergency Medical Response Review Committee failed to identify deficiencies in nursing care. Clinician Onsite Inspection CMC is a large institution with two physically separate facilities. The East complex clinic included medical clinics for yards A through D, the CTC, and the TTA. The West complex clinic had nursing treatment areas, sick call areas, and medical clinics for yards E, F, G, and M. The West complex clinic did not function as a TTA or have the same equipment or staffing. The West complex clinic was a large building that was orderly and quiet with separate exam rooms. Each provider clinic had its support personnel nearby. The huddles were held separately for each yard. Some West dormitory patients with urgent medical problems had delays in care when they were first brought to the West complex clinic and then transported to the TTA in the East complex clinic. This type of transport required going through two sally ports, which, along with waiting to call the ambulance until after custody was ready, further delayed some critical patient transports. The OIG clinicians repeatedly saw late notification to providers and delayed calls for ambulances. In addition, there were inadequate assessments and monitoring of patient status. In the majority of emergency response cases reviewed, nurses acted alone without the benefit of a provider’s input. There were occasions when nurses responded inappropriately or provided no action at all. Clinician Summary The staff at CMC provided inadequate care overall with regard to emergency services. The serious deficiencies by the off-hours providers, coupled with the nurses’ cumulative deficiencies, were significant enough to create an environment of concern in the acute care setting of these patients. Recommendations The OIG recommends the institution change its policy to ensure that an ambulance is called as soon as it is needed, not after notification that custody is ready for transport. The OIG recommends further education to on-call providers regarding the following:  Telephone management of common serious medical problems, such as chest pain, abdominal pain, fever, and neurologic emergencies.  The necessity of face-to-face patient evaluations when patients are sent back to their housing with potentially serious conditions.  Effective next-day transfer of care for patients with potentially serious conditions. California Men’s Colony, Cycle 4 Medical Inspection Page 21 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 Inadequate information. This includes determining whether the information is (65.1%) correctly labeled and organized and available in the electronic unit Overall Rating: health record (eUHR); whether the various medical records (internal Inadequate 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. For this indicator, the case review and compliance scores yielded different results, with case review providing an adequate rating, and compliance testing resulting in an inadequate score. The OIG internal review process considered the factors that lead to both results. Although the case review found minor issues concerning provider review of documents, legibility, and timely scanning of records into the eUHR, compliance testing was more robust and revealed poor performance in scanning accuracy of documents, legibility, and providers’ timely review of hospital discharge reports. As a result, the OIG medical inspection team determined the overall score for this indicator was inadequate. Case Review Results During case review, the OIG found in CMC’s health information management 66 total deficiencies, six of which were significant (cases 5, 20, 23, 30, 31, and 32). Providers did not routinely review and sign specialty, diagnostic, and hospital records prior to staff scanning the documents into the eUHR. In one encounter, nursing care plans were labeled as Interdisciplinary Patient Education Records, and in another, pre-operative instructions were labeled as a Nursing Assessment Protocol. One sick call nursing protocol, which the nurse referenced in a different nursing note, was not located in the eUHR. Hospital Records In cases 4, 5, 7, and the following, hospital records were scanned without the provider having signed them to indicate review:  In case 30, documentation from the hospital was scanned without a provider signature. The provider failed to acknowledge the hospital visit during the five-day follow-up encounter. Despite this oversight, no harm came to the patient. California Men’s Colony, Cycle 4 Medical Inspection Page 22 Office of the Inspector General State of California Specialty Services In cases 7, 21, 27, 30, 31, 37, 40, 42, and 43, specialty notes and important imaging studies were scanned into the eUHR without a signature to indicate review by a provider. These minor deficiencies could have led the providers to miss pertinent information or to delays in care. The following three cases had significant deficiencies:  In case 5, a urology report was scanned without being reviewed by a provider. The report contained multiple records, including a different patient’s record of cystoscopy (surgical bladder inspection). Fortunately, the provider was able to discern the recommendations related only to the correct patient. This is also discussed in the Specialty Services indicator.  In case 20, an EKG revealed a critical finding of a very large (8 cm) abdominal aneurysm. The provider neither signed nor reviewed the document before it was scanned into the eUHR. The provider did not review the ultrasound until six days after the report was scanned into the eUHR. Although the patient died from the aneurysm, this delay did not contribute to his death. This is also discussed in the Specialty Services indicator.  In case 32, another urology consult note was scanned without a provider having signed or reviewed it. The recommendations by the urologist for further laboratory testing for prostate cancer were not followed. This is also discussed in the Specialty Services indicator. Diagnostic Reports In cases 20, 21, and the following, there were delays in providers reviewing the laboratory reports:  In case 23, a laboratory report noted a critically low blood glucose level, and there was no documentation that a provider or the TTA was notified of this critical result. The provider reviewed the laboratory report three days later. This is also discussed in the Diagnostic Services indicator. Scanning Performance In case 31, a provider’s TTA telephone consult note regarding abdominal pain and fever was not scanned until six days after the telephone consultation. The patient was sent to the hospital with a ruptured appendix two days later. The scanning delay did not contribute to the delay in care. Legibility Since providers dictated the majority of progress notes, the reports were legible. California Men’s Colony, Cycle 4 Medical Inspection Page 23 Office of the Inspector General State of California Clinician Onsite Inspection Providers maintained open lines of communication with their local hospitals and many outside specialists. The providers had the phone numbers of the specialists readily available and called them for clarification or to ensure proper transfers of care. Clinician Summary CMC performed at a borderline adequate level with regard to health information management. Medical records were usually successfully retrieved from hospitals or specialists within appropriate time frames. In addition, communication between providers was favored by the physical location where most of the providers worked near each other. The proximity of their clinics led to a more collegial atmosphere and fostered the ability to provide a quick consult or clarification of a medical plan. Providers showed room for improvement in their review and signature of medical records prior to scanning the documents into the eUHR. Correcting this deficiency could ensure timely access to important documentation and prevent delays in medical care. Compliance Testing Results The institution received an inadequate compliance score of 65.1 percent in the Health Information Management (Medical Records) indicator, showing need for improvement in the following four areas:  The institution scored zero in its labeling and filing of documents scanned into patients’ electronic unit health records; some documents were mislabeled, such as a primary care provider note that was scanned and labeled as a physician’s orders, and other documents that were missing from the eUHR altogether. 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 CMC medical inspection, inspectors identified 19 documents with errors, seven more than the maximum allowable number of errors (MIT 4.006).  Inspectors reviewed eUHR files for 30 patients sent or admitted to the hospital. Providers reviewed 16 of the 30 hospital discharge reports or treatment records within three calendar days of discharge (53 percent). Providers reviewed discharge reports for 14 patients from one to 18 days late (MIT 4.008).  The institution timely scanned 7 of 11 sampled non-dictated progress notes, Initial Health Screening forms (CDCR 7727), requests for health care services, and specialty services consultant documents into patients’ eUHRs, scoring 64 percent. Four documents were scanned from one to two days late (MIT 4.001).  When the OIG reviewed various medical documents such as hospital discharge reports, initial health screening forms, certain medication records, and specialty services reports to California Men’s Colony, Cycle 4 Medical Inspection Page 24 Office of the Inspector General State of California ensure that clinical staff legibly documented their names on the forms, only 22 of 32 samples (69 percent) showed compliance (MIT 4.007). The institution scored in the adequate range in the following areas:  The institution timely scanned 16 of 20 dictated or transcribed progress notes within the required time frame (80 percent). Four progress notes were scanned from one to five days late (MIT 4.002).  CMC also timely scanned 15 of 20 sampled medication administration records into patients’ eUHRs, scoring 75 percent in this test. Five medication administration records were scanned into the eUHR from one to three days late (MIT 4.005). The institution scored in the proficient range in the following two tests:  The institution timely scanned 19 of 20 sampled specialty services consultant documents into patients’ eUHRs, scoring 95 percent. One high-priority specialty service report was scanned into the eUHR six days late (MIT 4.003).  CMC timely scanned 17 of the 20 sampled community hospital discharge reports or treatment records into the patient’s eUHR (85 percent); three reports were scanned one day late (MIT 4.004). Recommendations No specific recommendations. California Men’s Colony, Cycle 4 Medical Inspection Page 25 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: Adequate availability of both auditory and visual privacy for inmate-patient (81.8%) 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 Adequate observations inspectors make at the institution during their onsite visit. Compliance Testing Results The institution scored well in the Health Care Environment indicator, with an adequate compliance score of 81.8 percent. The institution performed at a proficient level in the following six areas:  Health care staff in all 16 applicable clinics ensured that medical staff properly sterilized and disinfected reusable invasive and non-invasive medical equipment (MIT 5.102).  Inspectors examined the institution’s 17 clinics to verify that adequate hygiene supplies were available and sinks were operable; all clinics were compliant (MIT 5.103).  CMC’s non-clinic medical storage areas generally met the supply management process and support needs of the medical health care program, earning a score of 100 percent on this test (MIT 5.106).  Clinic common areas at 16 of 17 clinics (94 percent) had an adequate environment conducive to providing medical services. One clinic’s wound care station was within audible range of a triage and vital signs area (MIT 5.109).  Of the 17 clinics, 16 followed adequate protocols for managing and storing bulk medical supplies (94 percent). One clinic’s storage area did not properly label supplies for easy identification (MIT 5.107).  Of the 17 clinics examined, 15 (88 percent) were appropriately disinfected, cleaned, and sanitary. Two clinics had cleaning logs that were not properly signed on two separate days in one month (MIT 5.101). The following areas received scores in the adequate range:  Inspectors examined emergency response bags to determine if they were inspected daily and inventoried monthly and whether they contained all essential items. Emergency response California Men’s Colony, Cycle 4 Medical Inspection Page 26 Office of the Inspector General State of California bags were compliant in 9 of 11 clinics (82 percent). One clinic’s bag did not have a glucose gel, and another clinic’s bag did not have a fully charged oxygen tank (MIT 5.111).  OIG inspectors observed clinician encounters with patients at 13 of the institution’s clinics. Clinicians followed good hand hygiene practices in ten of those clinics (77 percent). In three clinics, clinicians did not sanitize their hands before or after patient contact, or before putting on gloves (MIT 5.104).  The OIG inspected selected exam rooms in 17 clinics to determine if appropriate space, configuration, supplies, and equipment allowed clinicians to perform a proper clinical exam. The exam rooms or treatment spaces in 13 (76 percent) were compliant. In three clinics, the exam room did not ensure visual privacy. One of the same three clinics had an exam table that impeded access to the room, and another had an exam table with torn vinyl . One additional exam room had a gurney with torn vinyl (Figure 1) (MIT 5.110). Figure 1: Torn vinyl on gurney CMC showed room for improvement in two areas:  Clinic common areas and exam rooms were sometimes missing core equipment or other essential supplies necessary to conduct a comprehensive exam. As a result, only 6 of 17 clinic locations were compliant (35 percent). Deficiencies in the other 11 clinic locations consisted of the following: nine clinic exam rooms did not have biohazard receptacles or bags; three clinic locations did not have a Snellen eye chart or the chart was not at the proper distance; two clinics did not have hemoccult cards and developer, and one of those two clinic locations was also missing lubricating jelly; and one other clinic location did not have a medication refrigerator, peak flow meter and tips, an exam table, oto-ophthalmoscope and tips, or tongue depressors (MIT 5.108).  When inspecting for proper protocols to mitigate exposure to blood-borne pathogens and contaminated waste, the OIG inspectors found 9 of 17 clinics compliant (53 percent). Seven clinic locations did not have a sharps container in the provider exam room, Figure 2: Unsecured sharps container and one clinic had a sharps container that was not secured (Figure 2) (MIT 5.105). California Men’s Colony, Cycle 4 Medical Inspection Page 27 Office of the Inspector General State of California 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. Overall, CMC’s health care managers did not have any significant concerns about the institution’s existing infrastructure or its ability to provide adequate health care to the inmate population. However, as discussed below, there were several projects underway to improve the delivery of health care at CMC, and there was a system in place to identify and report facility infrastructure problems when they occurred. At the time of the OIG’s inspection, CMC had nine ongoing projects. These consisted of remodeling and major renovations to the TTA and other existing clinics, as well as new construction, including a new laboratory and pharmacy building, to enhance treatment capability. The projects began in March 2016 and are projected to be fully completed in early 2018 (MIT 5.999). Recommendations No specific recommendations. California Men’s Colony, Cycle 4 Medical Inspection Page 28 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 Proficient facilities and inmates transferring out of CMC to another CDCR (87.0%) facility. The OIG review includes evaluation of the institution’s Overall Rating: ability to provide and document health screening assessments, Proficient 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. In this indicator, the OIG’s case review and compliance review yielded different results, with the case review earning adequate rating, and the compliance testing resulting in a proficient score. The OIG’s internal review process reviewed both scores, and determined an overall rating of proficient was appropriate for this indicator. Although the case review found some problems with patients returning from the Department of State Hospitals and community hospitals, compliance testing had a larger sample size, and the scores for all tests were in the proficient or adequate range. Case Review Results Clinicians reviewed 81 encounters relating to the Inter- and Intra-System Transfers indicator, including information from both the sending and receiving CDCR institutions and regarding patients arriving from non-CDCR facilities. These included 55 hospitalization events, each of which resulted in a transfer back to the institution. There were 24 deficiencies found in case reviews, four of which were significant (cases 14, 15, 30, and 31). Transfers In Patients transferring into CMC were processed accurately and appropriately. Transfers Out Overall, nursing documentation on the Health Care Transfer Information forms (CDCR Form 7371) for patients transferring out of CMC was complete. However, in case 6, the nurse incorrectly documented that the patient had no suicide history; the patient had a prior overdose and California Men’s Colony, Cycle 4 Medical Inspection Page 29 Office of the Inspector General State of California self-inflicted neck laceration. The nurse also failed to include the patient’s previous heart attack for which he had pending tests. Returns from the Department of State Hospitals  In case 14, the nurse failed to recheck a mildly elevated blood pressure. While the initial health screening form listed diabetes as a diagnosis, the nurse accepted the patient’s verbal denial of diabetes and failed to check the patient’s blood sugar.  In case 15, there were three deficiencies. The patient arrived from an outside facility without medications, but the nurse failed to document the names of the missing medications. Also, the nurse referred the patient for a chronic care appointment within 14 days, but the patient was seen by the provider four days late. Finally, the nurse erroneously recorded the patient’s blood oxygen level. Hospitalizations Patients returning from hospitalizations are some of the highest-risk encounters due to two factors. First, these patients are generally hospitalized for a severe illness or injury. Second, they are at risk due to potential lapses in care that can occur during any transfer.  In case 30, hospital discharge records were scanned into the patient’s health record prior to being reviewed by the provider. The provider saw the patient five days after his return to the institution, but was unaware of the patient’s recent hospitalization. This is also discussed in the Health Information Management indicator.  In case 31, a patient’s surgical follow-up after hospitalization for perforated appendix was significantly delayed by 21 days. Upon the patient’s return to CMC after hospital discharge, the nurse failed to get antibiotic orders, and the patient missed one day of antibiotics for his infection. Clinician Onsite Inspection During the visit, there were no inmates being processed for intra-system transfers. Nurses reported there were no major issues with processing inmates in or out of the institution. An Omnicell (electronic medication storage) was available to nursing staff as needed for patient medication administration. Nurses received schedules for transferring inmates one week in advance, allowing nurses sufficient time to review and resolve transfer issues. Trained backup relief nurses were available for staff vacancies. Nursing staff were confident and felt supported by nursing administration. Clinical Summary CMC provided adequate care to patients arriving at the facility. Patients had multiple diagnoses and mental health issues. Providers’ reviewed the initial health screening forms and clinical information California Men’s Colony, Cycle 4 Medical Inspection Page 30 Office of the Inspector General State of California from the sending facilities and ordered essential medications and required laboratory tests. Providers ordered and patients received all medications timely and without interruptions. Nursing assessments were generally thorough, except for the few deficiencies discussed above. Conclusion The OIG clinicians rated the Inter- and Intra-System Transfers indicator at CMC adequate. Compliance Testing Results The institution obtained a proficient compliance score of 87.0 percent in the Inter- and Intra-System Transfers indicator. CMC performed in the proficient range in the following two tests:  OIG inspectors observed scheduled transfers of ten inmates being sent out of the institution to ensure that their transfer packages contained required medications and corresponding documentation; only nine of them were patients with prescribed medications and thus subject to the test. All nine applicable transfer packages included all required medications and support documentation (MIT 6.101).  For 29 of the 30 sampled patients who transferred into the institution (97 percent), nursing staff timely completed the assessment and disposition sections of the initial health screening form on the same day that they performed each patient’s initial health screening (MIT 6.002). The institution scored within the adequate range in the following tests:  Nursing staff properly completed the initial health screening form the same day the patient arrived for 25 of 30 sampled patients who transferred into the institution tested (83 percent). For five patients, nursing staff did not answer all of the questions on the form (MIT 6.001).  Out of 30 patients who transferred into the institution, only 15 had an existing medication order that required nursing staff to issue or administer medications upon arrival. Twelve of the 15 patients received their medications timely and without interruption (80 percent). One patient received his keep-on-person (KOP) medication two days late, and another patient received his nurse-administered medication one day late. Lastly, one other patient refused his directly observed therapy (DOT) medication, but the nurse did not properly document the reason for refusal (MIT 6.003).  Inspectors sampled 20 patients who transferred out of CMC to another CDCR institution to determine whether the institution listed their scheduled specialty service appointments on the Health Care Transfer Information form (CDCR form 7371). CMC nursing staff documented the previously approved but still pending specialty service appointments for 15 patients (75 percent), but failed to do so for five others (MIT 6.004). California Men’s Colony, Cycle 4 Medical Inspection Page 31 Office of the Inspector General State of California Recommendations No specific recommendations. California Men’s Colony, Cycle 4 Medical Inspection Page 32 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, Adequate encompassing the process from the written prescription to the Compliance Score: administration of the medication. By combining both a quantitative Inadequate (71.9%) 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, Inadequate 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 PCP prescriber, staff, and patient. In this indicator, the OIG’s case review and compliance review processes yielded different results, with the case review giving an adequate rating and the compliance review resulting in an inadequate score. The OIG’s internal review process considered those factors that led to both scores and ultimately rated this indicator inadequate, as the compliance testing is more robust than the case review is in this area. Case Review Results The OIG clinicians rated the Pharmacy and Medication Management indicator adequate. The OIG reviewed 85 pharmacy and medication management events and found 12 deficiencies, three of which were significant (two in case 24 and one in case 34). Nursing Medication Errors The majority of medication management nursing events demonstrated that patients received medications timely and as prescribed. Medication errors revealed during case reviews were rare, with only the following deficiencies:  In case 3, no explanation was documented for three missed doses within one month of a seizure medication. An illegible explanation was documented for a fourth missing dose.  In case 32, the CTC patient did not receive his insulin injection as ordered by the provider. This is also discussed in the Specialized Medical Housing indicator.  In case 34, the patient was given a blood-thinning medication after the provider had placed a temporary hold on the medication. California Men’s Colony, Cycle 4 Medical Inspection Page 33 Office of the Inspector General State of California Pharmacy Medication Errors  In case 24, the patient did not receive one dose of his multiple sclerosis medication to prevent flare-ups of his disease. Also, the same patient did not pick up his blood pressure medication for ten days; nursing documentation did not reveal whether nursing staff attempted to contact the patient about picking up his medication. Anticoagulation Clinic CMC’s pharmacy department ran the warfarin (anti-coagulation) clinic. The pharmacist performed clinical evaluations at appropriate intervals, ordered and reviewed laboratory reports, and made warfarin medication adjustments according to the CCHCS anticoagulation protocol.  In case 34, a significant deficiency occurred when the warfarin clinic failed to transfer a patient with a dangerously elevated blood pressure to the TTA for an evaluation. In addition, the warfarin clinic documented the wrong medical reason the patient was receiving warfarin.  In case 35, the pharmacist documented that a medical provider would be consulted for a non-specific rash, but the consultation never occurred.  In case 36, the warfarin clinic documented the wrong dose of warfarin that the patient was prescribed. Conclusion The OIG rated the case review portion of Pharmacy and Medication Management performance adequate. Compliance Testing Results The institution received an inadequate compliance score of 71.9 percent in the Pharmacy and Medication Management indicator. For discussion purposes below, this indicator is divided into three sub-indicators: Medication Administration, Observed Medication Practices and Storage Controls, and Pharmacy Protocols. Medication Administration In this sub-indicator, the institution received an average score of 69.5 percent, which fell into the inadequate range. The institution showed room for improvement in the following three areas:  Nursing staff administered medications without interruption to only four of ten patients who were en route from one institution to another and had a temporary layover at CMC (40 percent). There was no documented eUHR evidence that four patients received their medications while temporarily housed at the institution, and for two other patients, nursing staff did not properly document the reason the medication was not given (MIT 7.006). California Men’s Colony, Cycle 4 Medical Inspection Page 34 Office of the Inspector General State of California  The institution properly administered chronic care medications to 18 of 28 patients (64 percent). For ten patients, there were deficiencies related to the proper and timely receipt of their medications. Four patients missed one or more doses of their directly observed medication and did not receive provider counseling; three patients did not receive their KOP medication for one or more months; two patients received their KOP medication one and two days late; and one other patient received his KOP medication seven days late, and never received provider counseling for missing a dose of his diabetes medication (MIT 7.001).  CMC timely provided hospital discharge medications to only 21 of 29 patients sampled who had returned from a community hospital (72 percent). Six patients received their medications one to four days late, and for two other patients, there was no evidence in the eUHR that they received their medication (MIT 7.003). The institution scored well in the following two tests:  The institution timely administered or delivered new medication orders to 35 of the 40 patients sampled (88 percent). Four patients received their new medication orders one to four days late, and for one patient, no medication administration record (MAR) was found in the eUHR to indicate that he ever received his medication (MIT 7.002).  Of the 30 patients at CMC who had transferred from one housing unit to another, 25 (83 percent) received their prescribed DOT medications without interruption. For three patients, the nurse documented on the MAR that the patient was a “no-show,” but did not document any efforts to contact custody to get the patient to the medication line. Nurses indicated on the MARs for two other patients that the patients refused the medication. However, the nurses failed to properly document the refusal on the correct refusal form (MIT 7.005). Observed Medication Practices and Storage Controls In this sub-indicator, the institution received an inadequate average score of 61.7 percent, scoring poorly in the following four tests:  The OIG interviewed nursing staff and inspected storage areas specifically for the storage of narcotics at nine applicable locations to assess whether strong narcotics security controls existed. Only three of the nine areas (33 percent) were adequately controlled. At six locations, nursing staff failed to properly co-sign the narcotics inventory log for several shifts during April and May 2016. One of the six medication line locations had missing narcotic medication when the OIG inspector performed a spot inventory check (MIT 7.101).  Non-narcotic medications not requiring refrigeration were properly stored at only 7 of 16 applicable clinic and medication line storage locations (44 percent). At eight clinics, there was no system in place to temporarily store medications pending return to the pharmacy, and California Men’s Colony, Cycle 4 Medical Inspection Page 35 Office of the Inspector General State of California at another clinic, nurses were unable to secure a medication drawer that contained patients’ medications because the drawer was broken (MIT 7.102).  At only three of the seven observed medication line locations, the medication distribution process was compliant with protocols (43 percent). At two locations, nursing staff administered insulin to ten different patients without verifying their blood glucose levels on their glucometers. At one location, the licensed psychiatric technician did not float the medication in water as ordered by the provider. Another location had inadequate overhang and shade to protect patients waiting for medication from inclement weather (MIT 7.106).  Refrigerated non-narcotic medications were properly stored at only 9 of 18 locations inspected (50 percent). At six clinics, there was no established process to separate refrigerated medication awaiting return to the pharmacy from other medications intended for patient use. At three other clinics, the temperature log showed recorded refrigerator temperature reading that were outside of the range required by CCHCS policy during two consecutive months (MIT 7.103). The institution scored 100 percent on the following tests:  Nursing staff at all seven sampled medication preparation and administration locations followed proper hand hygiene contamination control protocols during the medication preparation and administration processes (MIT 7.104).  Nursing staff at all seven of the medication and preparation administration locations employed appropriate administrative controls and protocols during medication preparation (MIT 7.105). Pharmacy Protocols In this sub-indicator, the institution received a proficient score of 86.7 percent, and scored 100 percent on the following four tests:  In its main pharmacy, the institution followed general security, organization, and cleanliness management protocols; properly stored non-refrigerated, refrigerated, and frozen medications; and properly accounted for narcotic medications (MIT 7.107, 7.108, 7.109, 7.110). The institution scored poorly on the following test:  The institution’s pharmacist in charge properly processed only 10 of 30 sampled medication error reports (33 percent). Fifteen of the medication error follow-up reports were from one to 50 days late. In five sampled months, there was no evidence to prove that the medication error statistic report was shared with applicable quality improvement committees (MIT 7.111). California Men’s Colony, Cycle 4 Medical Inspection Page 36 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 CMC, the OIG did not find any applicable medication errors (MIT 7.998).  The OIG tested patients housed in isolation units to determine if they had immediate access to their prescribed KOP rescue inhalers and nitroglycerin medications. At CMC, three applicable patients housed in isolation units did not have immediate access to their prescribed KOP rescue medications. Inspectors immediately notified the institution’s CEO, who took action to ensure that inhalers were issued to the three patients (MIT 7.999). Recommendations No specific recommendations. California Men’s Colony, Cycle 4 Medical Inspection Page 37 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: Inadequate immunizations. This indicator also assesses whether certain (61.1%) institutions take preventive actions to relocate inmate-patients identified as being at higher risk for contracting coccidioidomycosis Overall Rating: (valley fever). Inadequate The OIG rates this indicator entirely through the compliance testing component; the case review process does not include a separate qualitative analysis for this indicator. Compliance Testing Results The institution performed in the inadequate range in the Preventive Services indicator, with a compliance score of 61.1 percent. The institution showed room for improvement in the following areas:  The institution scored poorly for monitoring and administering tuberculosis (TB) medications to patients with TB. Only 9 of 17 patients received their TB medications timely (53 percent). Five patients did not receive their medication for one or more months, and three other patients missed one or more doses of their medication and did not receive timely medication counseling (MIT 9.001). The institution scored zero for performing monitoring of patients on TB medications. For the same 17 patients with TB, the institution either failed to complete monitoring for one or more months or weeks, or did not timely scan the monitoring form into the eUHR (MIT 9.002).  The OIG tested 20 patients who, during the test period, were medically restricted from residing at CMC because of their high risk of coccidioidomycosis infection (valley fever). Inspectors found CMC only transferred eight patients timely, scoring 40 percent on this test. Six patients were transferred from seven months to over two years late. Four patients were placed on medical holds and were still at CMC at the time of the OIG inspection, but the provider did not place the patient on medical hold until after the 60-day transfer date when the institution should have transferred the patient per CCHCS policy. Two other patients were still at the institution, and had not been transferred as of the date of testing (MIT 9.009).  OIG inspectors sampled 30 patients to determine whether they received a TB screening within the last year. Fifteen of the sampled patients were classified as Code 34 (subject only to an annual signs and symptoms check), and 15 sampled patients were classified as a Code 22 (requiring a TB skin test in addition to a signs and symptoms check). CMC only scored California Men’s Colony, Cycle 4 Medical Inspection Page 38 Office of the Inspector General State of California 70 percent for its ability to timely and properly conduct these annual TB screenings. More specifically, nurses timely screened 12 of 15 sampled Code 34 patients, with only three incidents which the nurses did not complete the history section of CDCR Form 7331. For sampled Code 22 patients, only 9 of 15 received properly completed nurse screenings. Inspectors identified six instances in which the nurses did not properly complete the history section (MIT 9.003). The institution scored in the adequate range on the following test area:  The OIG initially sampled 40 patients with various chronic medical conditions, of whom 28 required one or more vaccinations. Among the 28 sampled chronic patients, 21 were timely offered vaccinations for influenza, pneumonia, and hepatitis (75 percent). For seven patients, there was no evidence in the eUHR that they received or were offered a pneumococcal vaccination, and one of the seven patients did not receive or was not offered the hepatitis A vaccination (MIT 9.008). CMC scored in the proficient range in the following two tests:  The institution timely offered 29 of the 30 patients sampled an influenza vaccination for the most recent influenza season (97 percent). The only exception was one patient who was not offered an influenza vaccination within the most current 12 months (MIT 9.004).  Of 30 patients aged 50 through 75 whom the OIG sampled for colorectal cancer screening, 28 either had a normal colonoscopy within the last ten years or had been offered a colon cancer screening in the last year (93 percent). Two patients had no evidence in the eUHR that the patients received, refused, or were offered a colon cancer screening (MIT 9.005). Recommendations No specific recommendations. California Men’s Colony, Cycle 4 Medical Inspection Page 39 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 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 OIG clinicians rated the Quality of Nursing Performance indicator at CMC adequate. The OIG evaluated 414 nursing encounters during the case review, of which 212 were outpatient nursing encounters. Nursing services were generally performed well, with only 32 deficiencies found, 10 of which were significant. Nursing Sick Call Sick call RNs usually assessed complaints and symptoms appropriately and provided necessary interventions for patients presenting with medical issues in the outpatient clinics. However, the following significant deficiencies posed potential harm to patients:  In case 4, the patient was seen by the sick call nurse for dizziness and tightness in the chest. The patient also had questions about his diabetes. The nurse failed to assess the patient’s symptoms and address his complaints, and did not refer the patient to the provider.  In case 5, the diabetic patient requested a health care visit for a urinary tract infection and genital swelling. Instead of providing an immediate visit, the nurse assessed him four days California Men’s Colony, Cycle 4 Medical Inspection Page 40 Office of the Inspector General State of California after reviewing his request form. In addition, when testing showed the patient had extremely high blood sugar (over 500), the nurse failed to immediately notify the provider.  In case 25, the sick call nurse failed to see the patient for severe lower back pain.  In case 37, the nurse failed to fully assess or refer to a provider a patient with diabetes who had a week of low blood sugar readings.  In case 70, the patient requested to stop his depression medication. The nurse instructed that it was okay to stop taking the medication, and gave directions to refuse the nurse-administered medication when the patient came to the medication line. This was inappropriate without provider direction, and the medication had pharmacy warnings about suddenly stopping it.  In case 75, the patient had ear pressure, sinus congestion, fatigue, loss of balance, and loss of concentration. The nurse failed to complete an assessment of each complaint, and did not refer the patient to the provider. His next appointment with a provider was scheduled for almost five weeks later.  In case 77, the patient with metastatic cancer had severe side pain and burning sensation when urinating. The nurse failed to do a complete physical assessment, ask pertinent questions about symptoms, or refer to the provider for evaluation. The patient was seen the next day by the primary care nurse, who referred him to the provider for an urgent visit. The provider evaluated the patient and sent him out to the hospital for treatment of urinary obstruction.  In case 79, the sick call nurse failed to consult a provider for a patient with chronic obstructive pulmonary disease (COPD), fever, and shortness of breath. Medication Administration Medication administration was generally timely and reliable. See the Pharmacy and Medication Management indicator for specific findings. Emergency Care See the Emergency Services indicator for specific findings. Inter- and Intra-System Transfers See the Inter- and Intra-System Transfers and Diagnostic Services indicators for specific findings. Specialized Medical Housing See the Specialized Medical Housing indicator for specific findings. California Men’s Colony, Cycle 4 Medical Inspection Page 41 Office of the Inspector General State of California Clinician Onsite Inspection The nurses in outpatient clinic settings were active participants in the primary care team morning huddles. The huddles started and ended on time and were attended well by the providers, sick call nurses, medication line nurses, schedulers, and custody officers. In the West complex clinic, the OIG observed several huddles in progress at the same time, each in distinct areas. All participants contributed to discussions about currently hospitalized and newly discharged patients, TTA visits, on-call provider reports, mental health concerns, and any other issues related to current patient issues and the day’s clinic. Recommendations The OIG recommends that CMC provide training for nurses on the following:  Reinforcing a focused subjective and objective nursing assessment for each medical complaint based on both the patient’s current complaints and past health history.  Documenting accurate, legible nursing notes, according to subjective, objective, assessment, plan, and education (SOAPE) note format requirements, including a legible signature and the time of the encounter. California Men’s Colony, Cycle 4 Medical Inspection Page 42 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: Adequate performed entirely by OIG physicians. There is no compliance testing component associated with this quality indicator. Case Review Results The OIG clinicians reviewed 356 CMC medical provider encounters and identified 89 deficiencies related to provider performance. Of those 89, 32 were serious enough to place patients at an increased risk of harm. Among the 30 detailed physician case reviews, one was proficient, 22 were adequate, and 7 were inadequate. Assessment and Decision-Making Twenty-four of the provider deficiencies were due to incomplete assessment documentation and inappropriate plans. Eight of the significant deficiencies were from telephone consultation, where there was no provider face-to-face encounter with the patient.  In case 4, the on-call provider failed to document an encounter for a critically high blood sugar (543). Telephone orders were conveyed to nursing to have the patient drink more water. An urgent appointment with a health care provider, instead of a 21-day follow-up, should have been provided.  In case 5, on several patient encounters, providers failed to ask questions to rule out hypertensive emergency for the patient’s high blood pressure.  Also in case 5, the provider failed to review the records of a recent colonoscopy (showing hemorrhoids) as well as perform a routine rectal examination when the patient had rectal bleeding. The provider inappropriately ordered a repeat colonoscopy, which was medically unnecessary and risky due to the patient’s poorly controlled diabetic and hypertensive conditions.  In case 30, the provider evaluated a patient with exertional chest pain exacerbated by climbing stairs to go to the dining hall. The provider failed to provide reasonable, lower-tier accommodations until an urgent stress test was performed.  In case 32, the provider used copied (legacy) notes from prior visits. This resulted in incorrect vital signs, which did not match the nurse’s vital sign records. California Men’s Colony, Cycle 4 Medical Inspection Page 43 Office of the Inspector General State of California  In case 33, the provider evaluated the patient during a chronic care appointment. However, the provider did not complete a physical exam. The provider also failed to address the continuing care of the patients’ wound. Review of Records Sixteen provider deficiencies were discovered, three of which were serious and related to poor medical records review. Most of the serious deficiencies involved diabetic management.  In case 5, the providers failed to review the patient’s blood sugar logs for several months. This was a missed opportunity to adjust medications and control elevated blood sugar.  Also in case 5, the provider reviewed laboratory reports but failed to address critically high blood sugar (537) urgently. This caused a two-month delay in treating the patient’s poorly controlled blood sugar.  In case 22, the provider inappropriately designated a patient with a pacemaker as a low-risk medical patient with vigorous duty capabilities, so the patient was cleared for fire camp. CCHCS policy clearly indicates that a patient with a pacemaker is a high-risk medical patient and is forbidden from fire camp duties. Emergency Care Fourteen deficiencies were noted in emergency care services. Nine were serious deficiencies in the emergency care setting. The OIG clinicians found that CMC providers almost always made appropriate triage decisions when patients received emergent face-to-face care from the provider in the TTA. Their care in the acute setting was managed well overall. However, the majority of the serious deficiencies occurred after hours. The OIG did not discover such deficiencies in emergency care when the providers were present to evaluate the patient. These cases are also discussed in the Emergency Services indicator.  In case 4, several on-call providers on different encounters failed to start aspirin for a patient with chest pain who was transferred to an outside facility for concern of acute coronary syndrome.  In case 6, the on-call provider failed to start aspirin for a patient with chest pain who was transferred to an outside facility for concern of acute coronary syndrome.  In case 21, the on-call provider was notified that a patient with end-stage liver disease had a productive cough that was worsening. In the last several days, due to coughing episodes, he had several episodes of vomiting and wheezing and an episode of fainting. The administration of a breathing treatment was ordered without an urgent evaluation. The provider’s on-call note during this telephone encounter was absent from the eUHR. California Men’s Colony, Cycle 4 Medical Inspection Page 44 Office of the Inspector General State of California  In case 22, the on-call provider inappropriately ordered a three-day follow-up for a patient with a pacemaker who had five days of fever, chills, and severe generalized weakness. Prior to his discharge from the TTA, the patient had an unstable heart rate (117 to 126 beats per minute). The patient received acetaminophen and a three-day follow-up, without a provider evaluation or provider progress note to address this decision.  In case 23, the oncologist notified the provider that a patient with liver cirrhosis had an episode of coffee-ground emesis (indicating stomach bleeding). The provider did not perform an urgent evaluation prior to ordering a two-week follow-up.  In case 27, the on-call provider ordered two breathing treatments when notified of a patient with labored breathing and a productive cough. The provider failed to consider a steroid, antibiotics, or even a face-to-face encounter at the time.  In case 31, the on-call provider failed to perform a face-to-face evaluation on a patient with eight days of abdominal pain and an acute presentation (strongly suggesting appendicitis) of right lower abdomen tenderness, fever, leukocytosis (elevated white blood cell count), and fast heart rate. The provider inappropriately ordered a routine follow-up.  In case 43, the on-call provider failed to start aspirin when the patient had chest pain and was transferred to an outside facility for possible acute coronary syndrome. Chronic Care The OIG found 34 of the provider deficiencies were from inadequate chronic care delivery. Ten of the deficiencies were serious. Among the chronic care patients housed at CMC, most conditions were mild and stable, and required no significant medical intervention. The institution was designated for immunocompetent patients due to coccidioidomycosis restrictions. At the time of the OIG’s inspection, the CTC was functioning in a limited capacity because mobility-impaired patients were temporarily transferred out of the facility due to fire code restrictions. The OIG reviewed cases in which chronic care interventions were needed and found lacking performance, predominantly in diabetes care, in which six of the ten serious deficiencies were discovered. The providers also displayed deficiencies by failing to add preventive medical treatment for some patients at risk for cardiac disease.  In case 3, the provider failed to review and address cholesterol treatment opportunities, as the prior progress note indicated that the patient’s 10-year risk for heart disease was 22 percent, with strong recommendations of a statin (cholesterol lowering medication).  In case 4, the provider started the patient on insulin, but failed to consider fasting blood glucose testing and a sliding scale (test to measure blood sugar levels), and failed to follow up within the month to achieve tighter glucose control. California Men’s Colony, Cycle 4 Medical Inspection Page 45 Office of the Inspector General State of California  In case 25, the patient was unable to be seen for his chronic care appointment due to illness. However, the provider inappropriately scheduled the medically complex patient for a chronic care appointment in six months instead of much sooner.  In case 28, the provider failed to address why a statin and aspirin were not provided to a 67-year-old diabetic patient with a 10-year risk of heart disease greater than 10 percent.  In case 32, the provider noted an increasing blood glucose average (HgA1c 9.4) with documented normal fasting blood sugar. The provider failed to ask the patient about any episodes of low blood sugar. After-meal blood sugar levels should have been considered to determine if the patient’s blood sugar worsened during the day. No changes in diabetic medications, nor a repeat glucose average testing (HgA1c), had been ordered for more than six months. Also in case 32, the providers did not address the patient’s poorly controlled diabetes while the patient was being treated in the CTC for a retroperitoneal abscess (infection). No documented blood sugar checks were noted, and the providers’ progress notes frequently lacked mention of the patient’s diabetes.  In case 34, the provider documented that a hypertensive, morbidly obese 43-year-old patient had the onset of chest pain with exercise. The provider failed to address the need for cardiac risk stratification but did order nitroglycerin as needed for pain presumed to be from the heart.  In case 37, the provider ordered morphine for a patient who had just transferred into the institution without pain medication. The provider cited the reason for starting the low-dose morphine was that the pain management committee had approved the morphine nearly two years prior. However, the patient had no issues of pain documented on the provider’s evaluation.  In case 39, the provider evaluated the patient with poorly controlled diabetes with an elevated average glucose (HgA1c of 8.9), and increased his Lantus (long-acting insulin) dosage with an inappropriately timed follow-up of four months. A pattern of delayed follow-ups was found in this case review.  Also in case 39, the provider had this patient, with a 10-year risk of heart disease of 8.3 percent, on a continued, reduced dose of statin (cholesterol medication). Current guidelines recommend a higher-intensity statin.  On another encounter in case 39, the provider continued 28 units of Lantus daily because the patient’s fasting blood sugars were adequately controlled; however, the patient’s average glucose (HgA1c) was elevated. No blood glucose testing was ordered to address after-meal blood sugars, which was likely the reason for the discrepancy between normal fasting morning glucose and elevated three-month average glucose levels. Blood sugar tests at noon or the evening should have been completed with regular insulin coverage when elevated to California Men’s Colony, Cycle 4 Medical Inspection Page 46 Office of the Inspector General State of California improve the HgA1c and glucose control, or, at least, there should have been an endocrinology consult. Specialty Services Five of the provider deficiencies were due to specialty services. Two of the deficiencies were significant. These cases are also discussed in the Specialty Services indicator.  In case 23, an MRI of the abdomen was ordered to evaluate progression of the patient’s liver cancer. The oncologist recommended the MRI to be completed in October 2015 to further determine treatment opportunities. This MRI was delayed two months and was completed at the end of November 2015. No documentation to expedite the imaging study was found in the eUHR.  In case 44, a delay of two weeks occurred for an urgent consult. The patient needed pacemaker placement for a Mobitz type 2 heart block and fainting. Pharmacy and Medication Management Two of the provider deficiencies were due to pharmacy and medical management. Neither was serious. Pharmacy and medication management were appropriate. Clinician Onsite Inspection The OIG found the CMC providers were content generally with their work, medical leadership, and ancillary services. They mostly felt the workload was appropriate and manageable. The providers reported that ancillary services, including laboratory, pharmacy, radiology, and specialty services, were functioning well. CMC providers expressed dissatisfaction with the change to the after-hours coverage system. CMC had changed from onsite provider coverage to offsite, on-call coverage, which had negatively affected the morale of the staff and decreased the quality and efficiency of after-hours care. The providers were also concerned over the attrition and retirement of several providers. Conclusion The care provided by CMC medical providers was adequate. Many of the significant deficiencies occurred during on-call care and with the management of patients with diabetes and chest pain. Of the 30 cases detailed physician cases reviewed, one was proficient, 22 were adequate, and 7 were inadequate. Recommendation for CCHCS  The OIG recommends continued support from CCHCS in filling current and future provider vacancies. California Men’s Colony, Cycle 4 Medical Inspection Page 47 Office of the Inspector General State of California Recommendations for CMC  The OIG recommends providers receive training in diabetes management.  The OIG recommends that on-call providers provide appropriate documentation of pertinent telephone consultations.  The OIG recommends on-call providers receive training to manage patients with serious symptoms that require a face-to-face evaluation after hours.  The OIG recommends that cardiac risk assessment be applied to all cases of chest pain prior to transferring a patient to a higher level of care.  The OIG recommends that medical leadership encourage complex cases be brought to the provider meetings to create a consensus with regard to specialty consultations, and that these consensus opinions be focused on chronic pain patients and the medical indications for elective surgeries.  The OIG recommends optimizing each patient’s medical condition prior to considering elective surgery. California Men’s Colony, Cycle 4 Medical Inspection Page 48 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 Adequate 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 (88.0%) provider and nursing care. CMC’s only specialized medical housing Overall Rating: unit was a CTC. Adequate For this indicator, the OIG’s case review and compliance review processes yielded different results, with the case review giving an adequate rating and the compliance testing resulting in a proficient score. The OIG’s internal review process considered those factors that led to both scores and ultimately rated this indicator adequate. The key factors were that the case review had a larger sample size, and the case review focused on the quality of care provided. As a result, the case review testing results were a more accurate reflection of the appropriate overall rating. Case Review Results The OIG clinicians reviewed 293 events and found 29 deficiencies, 6 of which were significant. The OIG clinicians identified deficient areas that needed improvement in both nursing and provider care, as demonstrated by findings in the following cases:  In case 6, the nurse failed to recheck the patient’s chest pain for 25 minutes after giving nitroglycerin to relieve chest pain. In addition, some of the nursing documentation was illegible, with inappropriate document changes. Nurses failed to make error corrections in their progress notes with only a single line through the change (not multiple), with initials and dates.  In case 19, an EKG was ordered for evaluation of the heart for unstable rhythm risk (prolonged QT). However, the procedure was never performed while the patient was in the CTC.  In case 32, the providers managed the patient’s poorly controlled diabetes while he was being treated in the CTC for an internal abscess. The provider copied prior progress notes, which inappropriately documented false vital signs. These did not match nursing notes from the same encounter. Additionally, CTC nurses failed to administer insulin as ordered and failed to take vital signs. Although nurses administered milk of magnesia for constipation, they failed to assess for relief of symptoms. Nurses also failed to develop a care plan to provide the same direction to all nursing staff. This is also discussed in the Pharmacy and Medication Management indicator. California Men’s Colony, Cycle 4 Medical Inspection Page 49 Office of the Inspector General State of California  In case 90, the CTC nurses failed to notify the provider of an elevation of blood pressure in a patient with hypertension, and failed to reassess the effectiveness of medication given for pain.  In case 91, two times within ten days, the patient had extensive surgery involving moving flaps of skin to cover a wound and removal of nonliving tissue. Nurses in the CTC completed dressing changes, but failed to assess and describe the wound to determine if treatment was working. Clinician Onsite Inspection During the onsite evaluation, only 4 of the 35 beds were occupied, and there were two nurses on duty. The CTC had few patients because of new coccidioidomycosis and temporary fire code restrictions. The hospitalist hired to provide care within the CTC cared for the four patients while performing other duties within the institution, such as consulting on patients with kidney disease and filling in for several absent providers. While the OIG found overall care in specialized housing adequate, there were some additional deficiencies noted while onsite. One patient had a recently fractured and wired jaw. Since the patient was unable to eat solid food, the OIG asked the nurses if the patient had a weight change since the surgery. Neither nurse was able to answer. Another patient had high blood pressure, and nurses were unable to answer what medications he was on to lower his blood pressure. A third patient had seizures, and nurses were unable to state when his last seizure had occurred. The care plan for the patient indicated the patient’s bedside rails were padded for safety, but the rails were not padded during the tour. Clinician Summary CMC provided appropriate CTC care to patients. Most deficiencies did not place patients at risk of harm, but instead indicated that more attention to documentation was required. The OIG clinicians rated this indicator adequate. Compliance Testing Results The institution received a proficient score of 88.0 percent in the Specialized Medical Housing indicator, which focused on the institution’s CTC. The institution scored well in the following four tests:  For each one of the ten patients sampled, nursing staff timely completed an initial assessment on the day a provider admitted him to the CTC (MIT 13.001).  The OIG observed some call buttons that were not in working condition, but were clearly labeled as out of order, and the call buttons that were out of order were clearly identified in the CTC medical and mental health crisis bed patient rooms. The 30-minute welfare check California Men’s Colony, Cycle 4 Medical Inspection Page 50 Office of the Inspector General State of California log was up to date and complete. Lastly, according to knowledgeable staff working in the CTC, custody officers and clinicians were able to respond and access patients’ rooms in less than one minute when an emergent event occurred. CMC scored 100 percent on this test (MIT 13.101).  For nine of ten sampled patients (90 percent), providers performed a face-to-face evaluation within 24 hours of CTC admission. One patient received his provider visit two hours late (MIT 13.002).  Providers completed a history and physical examination (H&P) within 72 hours of CTC admission for nine of ten patients sampled (90 percent). The H&P exam for one patient was completed 16 days late (MIT 13.003). CMC showed room for improvement in the following area:  Providers completed their SOAPE notes at required three-day intervals for only six of ten sampled patients, scoring 60 percent. Providers completed required SOAPE notes from one to five days late for the four other sampled patients (MIT 13.004). Recommendations No specific recommendations. California Men’s Colony, Cycle 4 Medical Inspection Page 51 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 Adequate time of receipt of related recommendations from specialists. This Compliance Score: indicator also evaluates the providers’ timely review of specialist Adequate records and documentation reflecting the patients’ care plans, (75.7%) including course of care when specialist recommendations were not Overall Rating: ordered, and whether the results of specialists’ reports are Adequate communicated to the patients. For specialty services denied by the institution, the OIG determines whether the denials are timely and appropriate, and whether the inmate-patient is updated on the plan of care. Case Review Results The OIG clinicians reviewed 204 events related to the Specialty Services indicator, the majority of which were specialty consultations and procedures; there were 51 deficiencies in this category, 6 of which were significant. Access to Specialty Services  In case 23, the provider ordered an MRI of the abdomen to evaluate progression of the patient’s liver cancer and to assist the oncologist in planning treatment needed by October 2015. However, the MRI was delayed until November 2015. This case is also discussed in the Access to Care and Quality of Provider Performance indicators.  In case 44, the patient had an unstable heart rhythm, which caused loss of consciousness. His pacemaker surgery to address this was delayed two weeks. This case is also discussed in the Quality of Provider Performance indicator. Nursing Performance Nurses performed adequate assessments on patients returning from specialty appointments. Provider Performance  In case 23, the oncologist notified the provider that a patient with liver cirrhosis vomited blood. The provider failed to obtain an urgent evaluation and, instead, ordered a two-week follow-up. This case is also discussed in the Quality of Provider Performance indicators. Health Information Management  In case 5, a urology surgical report containing another patient’s records was scanned prior to the provider having reviewed and signed it. Fortunately, the provider was able to discern the California Men’s Colony, Cycle 4 Medical Inspection Page 52 Office of the Inspector General State of California recommendations related only to this patient. This case is also discussed in the Health Information Management indicator.  In case 20, an EKG revealed a critical finding of a very large abdominal aneurysm. The ultrasound was not reviewed by a provider until six days after the report was scanned into the electronic medical record. This is also discussed in the Health Information Management indicator.  In case 32, a urology consult note was scanned prior to a provider having signed it to indicate review. The providers in subsequent progress notes had not reviewed the urology consult, and failed to implement recommendations of repeating the prostate laboratory test in six months. This case is also discussed in the Health Information Management indicator. Clinician Onsite Inspection The institution generally performed well in the Specialty Services indicator. CMC staff noted that access to specialists was timely, and that the institution received specialty provider documentation timely after specialty appointments. Discussion with staff revealed that although there was adequate access to consultations, there was only one local cardiology provider available. In addition, the gastroenterology consultant was no longer available, resulting in a backlog of endoscopies (imaging studies of the digestive tract). The administration was working diligently at the time of the inspection to replace that gastroenterologist. Clinician Summary Most appointments occurred timely and although the consultation notes were not reviewed by the providers prior to scanning, they were often reviewed by the providers on subsequent visits. The OIG clinicians rated the Specialty Services indicator adequate. Compliance Testing Results The institution received an adequate compliance score of 75.7 percent in the Specialty Services indicator, scoring in proficient range in the following four tests areas:  All 15 patients sampled received their routine specialty service appointments within 90 days of the provider’s order (MIT 14.003). In addition, 14 of the 15 patients (93 percent) received or refused their high-priority specialty services appointment within 14 calendar days of the provider’s order. One patient received his high-priority specialty service appointment six days late (MIT 14.001).  When patients did not meet the minimum requirements for a specialty service, the institution timely denied providers’ specialty service requests for all 20 patients sampled (MIT 14.006). Also, of the same 20 patients who had a specialty service denied, all received a timely California Men’s Colony, Cycle 4 Medical Inspection Page 53 Office of the Inspector General State of California provider visit to notify them of the denial and discuss alternate treatment strategies (MIT 14.007). CMC scored in the inadequate range on the following tests:  Providers timely received and reviewed only 3 of the 15 sampled specialists’ reports for patients who received a routine specialty service (20 percent). For 11 patients’ reports, the provider’s review was completed from one to 114 days late. There was no evidence in the eUHR that a provider reviewed one other report (MIT 14.004).  When a patient is approved or scheduled for a specialty services appointment at one institution and then transfers to another institution, policy requires that the receiving institution ensure that the patient’s appointment is timely rescheduled or scheduled, and held. Only 10 of the 20 patients sampled (50 percent) received their specialty services appointments timely. Eight patients received their specialty appointments between 18 and 99 days late, and there was no evidence in the eUHR that two other patients received their specialty services at all (MIT 14.005).  Providers received and reviewed high-priority specialists’ reports within the required time frame for only 10 of the 15 applicable patients sampled (67 percent). Four patients’ reports were reviewed one to 34 days late, and one other report was received 11 days late and never reviewed by a provider (MIT 14.002). Recommendations No specific recommendations. California Men’s Colony, Cycle 4 Medical Inspection Page 54 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 CMC. 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 CMC in May 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 proficient and one inadequate. The test questions used to assess compliance for each indicator are detailed in Appendix A. California Men’s Colony, Cycle 4 Medical Inspection Page 55 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 Proficient reporting requirements for adverse/sentinel events and inmate (86.9%) deaths, and whether the institution is making progress toward its Overall Rating: Performance Improvement Work Plan initiatives. In addition, the Proficient 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 received a proficient score of 86.9 percent in the Internal Monitoring, Quality Improvement, and Administrative Operations indicator. CMC scored in the proficient range in the following seven test areas:  The institution promptly processed all inmate medical appeals in each of the most recent 12 months (MIT 15.001). In addition, based on a sample of ten second-level medical appeals, the institution’s responses addressed all of the patients’ appealed issues (MIT 15.102).  The institution’s QMC met monthly, evaluated program performance, and took action when improvement opportunities were identified (MIT 15.003). Additionally, the institution scored 100 percent for taking adequate steps to ensure the accuracy of its Dashboard data reporting (MIT 15.004).  The institution’s local governing body (LGB) met at least quarterly over the most recent 12 months, exercised responsibility for the quality management of patient health care each quarter, and documented the timely approved meeting minutes (MIT 15.006).  The OIG inspected documentation for 12 emergency medical response incidents reviewed by the institution’s EMRRC during the prior six-month period. All 12 sampled incident packages complied with policy (MIT 15.007).  Medical staff properly reviewed and signed and promptly submitted the Initial Inmate Death Report (CDCR Form 7229A) to CCHCS’s Death Review Unit for nine of the ten applicable deaths (90 percent) that occurred at CMC in the prior 12-month period. The CEO or chief medical executive did not sign one inmate’s death report (MIT 15.103). California Men’s Colony, Cycle 4 Medical Inspection Page 56 Office of the Inspector General State of California The institution performed in the inadequate range in the following two test areas:  CMC improved or reached targeted performance objectives for only one of four quality improvement initiatives identified in its 2015 Performance Improvement Work Plan, resulting in a score of 25 percent. For three of the four initiatives, CMC provided insufficient data to assess whether the institution improved or met its goal (MIT 15.005).  Inspectors reviewed the summary reports and related documentation for three medical emergency response drills conducted in the prior quarter. Documentation provided from the first-watch response drill indicated it was an actual incident, and not a drill. Therefore, the institution received a score of 67 percent on this test (MIT 15.101). Other Information Obtained from Non-Scored Areas  The OIG gathered non-scored data regarding the completion of death review reports. During the time frame of the OIG’s review, CCHCS’s Death Review Committee (DRC) was required to complete a death review summary within 30 business days of an inmate’s death and to further communicate the results to the institution’s CEO within five additional business days for six of the sampled deaths (deaths prior to November 2015). For an additional four deaths, CCHCS’s DRC was required to complete a death review summary within 30 days for an expected death and 60 days for an unexpected death, and to communicate the results to the institution’s CEO within seven calendar days (deaths in and after November 2015). The DRC did not timely complete its summary death reports and timely notify the CEO for nine of the ten sampled death reviews (10 percent). For the CMC inmate deaths OIG inspectors reviewed, the DRC completed its death review summary from 15 to 68 days late (or 57 to 110 calendar days after the death). In addition, the CEO was notified of the results from 12 to 80 days late (or 76 to 129 days after death). Consequently, the DRC did not provide timely results to the CEO (MIT 15.996).  Inspectors met with the institution’s CEO to inquire about CMC’s protocols for tracking appeals. According to the CEO, the health care appeals coordinator provided several different items, including appeal trends and increases in appeals. Weekly and sometimes daily reports were generated internally at the institution. Monthly reports were generated externally and reviewed at the institution. The health care appeals coordinator compiled quarterly reports at the institution and submitted them to CDCR headquarters, as required. Executive management staff used the reports to look for repetitive issues, location of issues, and the unit or person responsible. When identified, issues were addressed immediately through the disciplinary or training process (MIT 15.997).  Non-scored data gathered regarding the institution’s practices for implementing local operating procedures (LOPs) indicated that the institution had an effective and efficient process in place for developing LOPs. Each department was expected to review its respective LOP’s annually and make revisions as necessary. If an LOP required revision, the California Men’s Colony, Cycle 4 Medical Inspection Page 57 Office of the Inspector General State of California department head coordinated the revision and submitted the LOP to the CEO for review. The CEO then submitted the LOP to the appropriate sub-committee for approval. The institution had implemented 90 percent of the applicable stakeholder-recommended LOPs (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. California Men’s Colony, Cycle 4 Medical Inspection Page 58 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 Inadequate licenses or certifications; nursing staff receive new employee (65.6%) orientation training and annual competency testing; and clinical and Overall Rating: custody staff have current medical emergency response Inadequate certifications. Compliance Testing Results The institution received an inadequate compliance score of 65.6 percent in the Job Performance, Training, Licensing, and Certifications indicator. CMC scored in the inadequate range in the following tests:  Nursing supervisors failed to complete the required number of nursing reviews for all five of the nurses the OIG sampled, scoring zero on this test (MIT 16.101).  The institution hired five new nursing staff within the prior 12 months, none of whom received new employee orientation training within 60 days of arrival. The institution also scored zero on this test (MIT 16.107).  The OIG tested records of providers, nurses, and custody officers to determine if the institution ensured that those staff members had current emergency response certifications. The institution’s provider and nursing staff were all compliant, but custody managers were not. While the California Penal Code exempts custody managers who primarily perform managerial duties from medical emergency response certification training, CCHCS policy does not allow for such an exemption. As a result, the institution received a score of 67 percent in this area (MIT 16.104).  The institution’s three pharmacies and providers who prescribed controlled substances were current with their Drug Enforcement Agency (DEA) registrations. However, at the main pharmacy, the pharmacist in charge did not have a system or process in place to ensure providers were current with their DEA registration. As a result, the institution scored 67 percent on this test (MIT 16.106). The institution received a proficient score of 100 percent in the following test areas:  All providers, nursing staff, and the pharmacist in charge were current with their professional licenses and certification requirements (MIT 16.001, 16.105). California Men’s Colony, Cycle 4 Medical Inspection Page 59 Office of the Inspector General State of California  All ten nurses sampled were current on their clinical competency validations (MIT 16.102).  OIG inspectors reviewed structured clinical performance appraisals for 12 providers; 11 of them received timely and complete annual performance appraisals, including applicable Unit Health Record Clinical Appraisals, 360-Degree Evaluations, and Core Competency-Based Evaluations (92 percent). Inspectors did not find evidence that one provider received an annual performance appraisal, 360-Degree Evaluation, or Core Competency-Based Evaluation (MIT 16.103). Recommendations No specific recommendations. California Men’s Colony, Cycle 4 Medical Inspection Page 60 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 inmate-patient population. Selection of the measures was based on the availability, reliability, and feasibility of the data required for performing the measurement. The OIG collected data utilizing various information sources, including the eUHR, the Master Registry (maintained by CCHCS), as well as a random sample of patient records analyzed and abstracted by trained personnel. Data obtained from the CCHCS Master Registry and Diabetic Registry was not independently validated by the OIG and is presumed to be accurate. For some measures, the OIG used the entire population rather than statistically random samples. While the OIG is not a certified HEDIS compliance auditor, the OIG uses similar methods to ensure that measures are comparable to those published by other organizations. Comparison of Population-Based Metrics For California Men’s Colony (CMC), nine HEDIS measures were selected and are listed below in the following CMC Results Compared to State and National HEDIS Scores table. Multiple health plans publish their HEDIS performance measures at the State and national levels. The OIG has provided selected results for several health plans in both categories for comparative purposes. California Men’s Colony, Cycle 4 Medical Inspection Page 61 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. CMC performed very well with its management of diabetes. When compared statewide, CMC outperformed Medi-Cal in all five diabetic measures selected, and outperformed Kaiser in all measures except blood pressure control. When compared nationally, CMC scored exceptionally well, higher than the averages for Medicaid, commercial plans, and Medicare in each of the five diabetic measures listed. CMC outperformed the United States Department of Veterans Affairs (VA) in two diabetic measures, but performed less well than the VA in blood pressure control and eye exam measures. Immunizations Comparative data for immunizations was only fully available for the VA and partially available for Kaiser, Medicare, and commercial plans. Regarding the administration of influenza shots to younger adults, CMC significantly outperformed all applicable health plans. With respect to administering influenza shots to older patients, CMC matched the VA and outperformed Medicare. Regarding pneumococcal vaccinations, CMC outperformed Medicare by 3 percentage points, but the VA outperformed the institution by 20 percentage points. Cancer Screening For colorectal cancer screening, CMC’s scores were significantly lower than or equal to all other entities that reported data (Kaiser, commercial plans, Medicare, and the VA). Statewide, CMC performed significantly less well than Kaiser, both North and South regions. Nationally, the institution matched commercial plans, but performed less well than Medicare or the VA, scoring 3 and 18 percentage points lower, respectively. However, the high rate of patient refusals (33 percent) significantly affected CMC’s score in this measure. Summary Overall, CMC’s HEDIS performance reflected an adequately performing chronic care program, further corroborated by the institution’s adequate scores in the Access to Care, Quality of Provider Performance, and Quality of Nursing Performance indicators. However, the institution has room for improvement in colorectal cancer screenings. The institution may improve performance for colorectal cancer screenings by making interventions to lower patient refusals. California Men’s Colony, Cycle 4 Medical Inspection Page 62 Office of the Inspector General State of California CMC Results Compared to State and National HEDIS Scores California National Kaiser Kaiser CMC 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 14% 39% 18% 24% 44% 31% 25% 19% HbA1c Control (<8.0%) 6 76% 49% 70% 62% 47% 58% 65% - Blood Pressure Control (<140/90) 72% 63% 84% 85% 62% 65% 65% 78% Eye Exams 85% 53% 69% 81% 54% 56% 69% 90% Immunizations Influenza Shots -Adults (18–64) 8 70% - 54% 55% - 50% - 58% Influenza Shots -Adults (65+) 76% - - - - - 72% 76% Immunizations: Pneumococcal 73% - - - - - 70% 93% Cancer Screening Colorectal Cancer Screening 64% - 80% 82% - 64% 67% 82% 1. Unless otherwise stated, data was collected in May 2016 by reviewing medical records from a sample of CMC’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 measures only, the data was obtained from the VHA Facility Quality and Safety Report -Fiscal Year 2012 Data. 6. For this indicator, the entire applicable CMC 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. The VA data is for the age range 50–64. California Men’s Colony, Cycle 4 Medical Inspection Page 63 Office of the Inspector General State of California APPENDIX A — COMPLIANCE TEST RESULTS California Men’s Colony Range of Summary Scores: 61.13%–88.00% Indicator Overall Score (Yes %) Access to Care 76.81% Diagnostic Services 79.72% Emergency Services Not Applicable Health Information Management (Medical Records) 65.09% Health Care Environment 81.81% Inter- and Intra-System Transfers 87.00% Pharmacy and Medication Management 71.93% Prenatal and Post-Delivery Services Not Applicable Preventive Services 61.13% Quality of Nursing Performance Not Applicable Quality of Provider Performance Not Applicable Reception Center Arrivals Not Applicable Specialized Medical Housing (OHU, CTC, SNF, Hospice) 88.00% Specialty Services 75.71% Internal Monitoring, Quality Improvement, and Administrative Operations 86.85% Job Performance, Training, Licensing, and Certifications 65.62% California Men’s Colony, Cycle 4 Medical Inspection Page 64 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 23 17 40 57.50% 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 11 10 21 52.38% 9 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 7 3 10 70.00% 20 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 5 2 7 71.43% 23 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: 23 7 30 76.67% 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 19 11 30 63.33% 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: 76.81% California Men’s Colony, Cycle 4 Medical Inspection Page 65 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 10 0 10 100.00% 0 specified in the provider’s order? 2.002 Radiology: Did the primary care provider review and initial the 9 1 10 90.00% 0 diagnostic report within specified time frames? 2.003 Radiology: 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? 2.004 Laboratory: Was the laboratory service provided within the time 8 2 10 80.00% 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 9 1 10 90.00% 0 the required time frames? 2.008 Pathology: Did the primary care provider review and initial the 4 4 8 50.00% 2 diagnostic report within specified time frames? 2.009 Pathology: Did the primary care provider communicate the results of 3 5 8 37.50% 2 the diagnostic study to the inmate-patient within specified time frames? Overall Percentage: 79.72% 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. California Men’s Colony, Cycle 4 Medical Inspection Page 66 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 7 4 11 63.64% 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 five 16 4 20 80.00% 0 calendar days of the inmate-patient encounter date? 4.003 Are specialty documents scanned into the eUHR within the required 19 1 20 95.00% 0 time frame? 4.004 Are community hospital discharge documents scanned into the eUHR 17 3 20 85.00% 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 5 20 75.00% 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? 22 10 32 68.75% 0 4.008 For inmate-patients discharged from a community hospital: Did the 16 14 30 53.33% 0 preliminary hospital discharge report include key elements and did a PCP review the report within three calendar days of discharge? Overall Percentage: 65.09% California Men’s Colony, Cycle 4 Medical Inspection Page 67 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 15 2 17 88.24% 0 disinfected, cleaned and sanitary? 5.102 Infection control: Do clinical health care areas ensure that reusable 16 0 16 100.00% 1 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 17 0 17 100.00% 0 and sufficient quantities of hygiene supplies? 5.104 Infection control: Does clinical health care staff adhere to universal 10 3 13 76.92% 4 hand hygiene precautions? 5.105 Infection control: Do clinical health care areas control exposure to 9 8 17 52.94% 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 16 1 17 94.12% 0 managing and storing bulk medical supplies? 5.108 Clinical areas: Do clinic common areas and exam rooms have 6 11 17 35.29% 0 essential core medical equipment and supplies? 5.109 Clinical areas: Do clinic common areas have an adequate environment 16 1 17 94.12% 0 conducive to providing medical services? 5.110 Clinical areas: Do clinic exam rooms have an adequate environment 13 4 17 76.47% 0 conducive to providing medical services? 5.111 Emergency response bags: Are TTA and clinic emergency medical 9 2 11 81.82% 6 response bags inspected daily and inventoried monthly, and do they contain essential items? Overall Percentage: 81.81% California Men’s Colony, Cycle 4 Medical Inspection Page 68 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 25 5 30 83.33% 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 29 1 30 96.67% 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 12 3 15 80.00% 15 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 15 5 20 75.00% 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 9 0 9 100.00% 1 transfer packages include required medications along with the corresponding Medical Administration Record (MAR) and Medication Reconciliation? Overall Percentage: 87.00% California Men’s Colony, Cycle 4 Medical Inspection Page 69 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 18 10 28 64.29% 12 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 35 5 40 87.50% 0 medications to the inmate-patient within the required time frames? 7.003 Upon the inmate-patient’s discharge from a community hospital: 21 8 29 72.41% 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 25 5 30 83.33% 0 another: Were medications continued without interruption? 7.006 For inmate-patients en route who lay over at the institution: If the 4 6 10 40.00% 0 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 3 6 9 33.33% 15 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 7 9 16 43.75% 8 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 9 18 50.00% 6 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 7 0 7 100.00% 0 employ and follow hand hygiene contamination control protocols during medication preparation and medication administration processes? 7.105 Medication preparation and administration areas: Does the 7 0 7 100.00% 0 institution employ appropriate administrative controls and protocols when preparing medications for inmate-patients? 7.106 Medication preparation and administration areas: Does the 3 4 7 42.86% 0 institution employ appropriate administrative controls and protocols when distributing medications to inmate-patients? 7.107 Pharmacy: Does the institution employ and follow general security, 3 0 3 100.00% 0 organization, and cleanliness management protocols in its main and satellite pharmacies? California Men’s Colony, Cycle 4 Medical Inspection Page 70 Office of the Inspector General State of California 7.108 Pharmacy: Does the institution’s pharmacy properly store non-refrigerated 3 0 3 100.00% 0 medications? 7.109 Pharmacy: Does the institution’s pharmacy properly store refrigerated or frozen 3 0 3 100.00% 0 medications? 7.110 Pharmacy: Does the institution’s pharmacy properly account for narcotic 3 0 3 100.00% 0 medications? 7.111 Pharmacy: Does the institution follow key medication error reporting protocols? 10 20 30 33.33% 0 7.998 For Information Purposes Only: During eUHR compliance testing and case reviews, did the OIG find that medication errors were properly identified and Information Only 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 inhalers and nitroglycerin Information Only medications? Overall Percentage: 71.93% Prenatal and Post-Delivery Services Scored Answers This indicator is not applicable to this institution. Not Applicable California Men’s Colony, Cycle 4 Medical Inspection Page 71 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 9 8 17 52.94% 0 administer the medication to the inmate-patient as prescribed? 9.002 Inmate-patients prescribed TB medications: Did the institution 0 17 17 0.00% 0 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 21 9 30 70.00% 0 the last year? 9.004 Were all inmate-patients offered an influenza vaccination for the most 29 1 30 96.67% 0 recent influenza season? 9.005 All inmate-patients from the age of 50 through the age of 75: Was 28 2 30 93.33% 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 21 7 28 75.00% 12 inmate-patients? 9.009 Are inmate-patients at the highest risk of coccidioidomycosis (valley 8 12 20 40.00% 0 fever) infection transferred out of the facility in a timely manner? Overall Percentage: 61.13% California Men’s Colony, Cycle 4 Medical Inspection Page 72 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 California Men’s Colony, Cycle 4 Medical Inspection Page 73 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 9 1 10 90.00% 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 9 1 10 90.00% 0 examination completed within 72 hours of admission? 13.004 For all higher-level care facilities: Did the primary care provider 6 4 10 60.00% 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 2 0 2 100.00% 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: 88.00% California Men’s Colony, Cycle 4 Medical Inspection Page 74 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 14 1 15 93.33% 0 14 calendar days of the PCP order? 14.002 Did the PCP review the high-priority specialty service consultant report 10 5 15 66.67% 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 3 12 15 20.00% 0 within the required time frame? 14.005 For endorsed inmate-patients received from another CDCR 10 10 20 50.00% 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 20 0 20 100.00% 0 inmate-patient informed of the denial within the required time frame? Overall Percentage: 75.71% California Men’s Colony, Cycle 4 Medical Inspection Page 75 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 Not Applicable 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 1 3 4 25.00% 5 (PIWP), has the institution performance improved or reached the targeted performance objective(s)? 15.006 For institutions with licensed care facilities: Does the Local 4 0 4 100.00% 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 12 0 12 100.00% 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 9 1 10 90.00% 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? 15.998 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: 86.85% California Men’s Colony, Cycle 4 Medical Inspection Page 76 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? 13 0 13 100.00% 0 16.101 Does the institution’s Supervising Registered Nurse conduct periodic 0 5 5 0.00% 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? 11 1 12 100.00% 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 2 1 3 66.67% 0 controlled substances maintain current Drug Enforcement Agency (DEA) registrations? 16.107 Are nursing staff current with required new employee orientation? 0 1 1 0.00% 0 Overall Percentage: 65.63% California Men’s Colony, Cycle 4 Medical Inspection Page 77 Office of the Inspector General State of California APPENDIX B — CLINICAL DATA Table B-1: CMC Sample Sets Sample Set Total Anticoagulation 3 CTC/OHU 3 Death Review/Sentinel Events 5 Diabetes 3 Emergency Services – CPR 2 Emergency Services – Non-CPR 5 High Risk 5 Hospitalization 5 Intra-System Transfers In 3 Intra-System Transfers Out 3 RN Sick Call 45 Reception Center Transfers 5 Specialty Services 5 92 California Men’s Colony, Cycle 4 Medical Inspection Page 78 Office of the Inspector General State of California Table B-2: CMC Chronic Care Diagnoses Diagnosis Total Anemia 8 Anticoagulation 5 Arthritis/Degenerative Joint Disease 11 Asthma 14 COPD 14 Cancer 11 Cardiovascular Disease 28 Chronic Kidney Disease 4 Chronic Pain 26 Cirrhosis/End-Stage Liver Disease 3 Coccidioidomycosis 4 DVT/PE 2 Deep Venous Thrombosis/Pulmonary Embolism 4 Diabetes 27 Gastroesophageal Reflux Disease 22 Hepatitis C 25 Hyperlipidemia 33 Hypertension 50 Mental Health 21 Migraine Headaches 3 Seizure Disorder 10 Sickle Cell Anemia 1 Sleep Apnea 7 Thyroid Disease 4 337 California Men’s Colony, Cycle 4 Medical Inspection Page 79 Office of the Inspector General State of California Table B-3: CMC Event—Program Program Total Diagnostic Services 230 Emergency Care 91 Hospitalization 55 Intra-System Transfers In 14 Intra-System Transfers Out 7 Not Specified 6 Outpatient Care 599 Reception Center Care 5 Specialized Medical Housing 293 Specialty Services 204 1,504 Table B-4: CMC Review Sample Summary Total MD Reviews Detailed 30 MD Reviews Focused 1 RN Reviews Detailed 17 RN Reviews Focused 60 Total Reviews 108 Total Unique Cases 92 Overlapping Reviews (MD & RN) 16 California Men’s Colony, Cycle 4 Medical Inspection Page 80 Office of the Inspector General State of California APPENDIX C — COMPLIANCE SAMPLING METHODOLOGY California Men’s Colony Sample Category Quality (number of samples) Indicator 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) (40)  Randomize MIT 1.002 Nursing Referrals OIG Q: 6.001  See Intra-system Transfers (24) 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) (30) 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 California Men’s Colony, Cycle 4 Medical Inspection Page 81 Office of the Inspector General State of California Sample Category Quality (number of samples) Indicator Data Source Filters Health Information Management (Medical Records) MIT 4.001 Timely Scanning OIG Qs: 1.001,  Non-dictated documents (11) 1.002, & 1.004  1st 10 IPs MIT 1.001, 1st 5 IPs MITs 1.002, 1.004 MIT 4.002 OIG Q: 1.001  Dictated documents (20)  First 20 IPs selected MIT 4.003 OIG Qs: 14.002  Specialty documents (20) & 14.004  First 10 IPs for each question MIT 4.004 OIG Q: 4.008  Community hospital discharge documents (20)  First 20 IPs selected MIT 4.005 OIG Q: 7.001  MARs (20)  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, (32) 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 (30) needed) Health Care Environment MIT 5.101-5.105 Clinical Areas OIG inspector  Identify and inspect all onsite clinical areas. & 5.107-5.111 (17) 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 (9) onsite review California Men’s Colony, Cycle 4 Medical Inspection Page 82 Office of the Inspector General State of California Sample Category Quality (number of samples) Indicator 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 (40)  Randomize MIT 7.002 New Medication Master Registry  Rx count Orders  Randomize (40)  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) (30) 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 (10)  NA/DOT meds MITs 7.101-103 Medication Storage OIG inspector  Identify and inspect clinical & med line areas that Areas onsite review store medications (varies by test) MITs 7.104–106 Medication OIG inspector  Identify and inspect onsite clinical areas that Preparation and onsite review prepare and administer medications Administration Areas (7) MITs 7.107-110 Pharmacy OIG inspector  Identify & inspect all onsite pharmacies (3) 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 (10) 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) California Men’s Colony, Cycle 4 Medical Inspection Page 83 Office of the Inspector General State of California Sample Category Quality (number of samples) Indicator 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) (17)  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 (28)  Condition must require vaccination(s) MIT 9.009 Valley Fever Cocci transfer  Reports from past 2–8 months (20) status report  Institution  Ineligibility date (60 days prior to inspection date)  All California Men’s Colony, Cycle 4 Medical Inspection Page 84 Office of the Inspector General State of California Sample Category Quality (number of samples) Indicator 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) (20)  Randomize IUMC/MAR  Meeting date (9 months) Meeting Minutes  Denial upheld (0)  Randomize California Men’s Colony, Cycle 4 Medical Inspection Page 85 Office of the Inspector General State of California Sample Category Quality (number of samples) Indicator 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 (0) 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) (5) 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 (3) 12 months MIT 15.996 Death Review OIG summary  Between 35 business days & 12 months prior Committee log -deaths  CCHCS death reviews (10) MIT 15.998 Local Operating Institution LOPs  All LOPs Procedures (LOPs) (all) California Men’s Colony, Cycle 4 Medical Inspection Page 86 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 (20) 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 (11) 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) California Men’s Colony, Cycle 4 Medical Inspection Page 87 Office of the Inspector General State of California C C ALIFORNIA ORRECTIONAL H C S ’ EALTH ARE ERVICES R ESPONSE California Men’s Colony, Cycle 4 Medical Inspection Page 88 Office of the Inspector General State of California