Richard J. Donovan Medical Inspection Report Cycle 4

Robert A. Barton Office of the Inspector General Inspector General Richard J. Donovan Correctional Facility Medical Inspection Results Cycle 4 January 2017 Medical Inspection Unit Page 1 Office of the Inspector General State of California Office of the Inspector General RICHARD J. DONOVAN CORRECTIONAL FACILITY Medical Inspection Results Cycle 4 Robert A. Barton Inspector General Roy W. Wesley Chief Deputy Inspector General Shaun R. Spillane Public Information Officer January 2017 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 ..................................................................................................... ix Introduction ......................................................................................................................................... 1 About the Institution ........................................................................................................................... 1 Objectives, Scope, and Methodology.................................................................................................. 5 Case Reviews ................................................................................................................................... 6 Patient Selection for Retrospective Case Reviews .................................................................... 6 Benefits and Limitations of Targeted Subpopulation Review .................................................. 7 Case Reviews Sampled ............................................................................................................. 8 Compliance Testing ......................................................................................................................... 9 Sampling Methods for Conducting Compliance Testing .......................................................... 9 Scoring of Compliance Testing Results .................................................................................... 9 Dashboard Comparisons ......................................................................................................... 10 Overall Quality Indicator Rating for Case Reviews and Compliance Testing .............................. 10 Population-Based Metrics .............................................................................................................. 11 Medical Inspection Results ............................................................................................................... 12 Primary (Clinical) Quality Indicators of Health Care .................................................................... 12 Access to Care ......................................................................................................................... 13 Case Review Results ............................................................................................................ 13 Compliance Testing Results................................................................................................. 14 Recommendations ................................................................................................................ 15 Diagnostic Services ................................................................................................................. 16 Case Review Results ............................................................................................................ 16 Compliance Testing Results................................................................................................. 17 Recommendation ................................................................................................................. 18 Emergency Services................................................................................................................. 19 Case Review Results ............................................................................................................ 19 Recommendations ................................................................................................................ 21 Health Information Management (Medical Records) ............................................................. 22 Case Review Results ............................................................................................................ 22 Compliance Testing Results................................................................................................. 23 Recommendations ................................................................................................................ 24 Health Care Environment ....................................................................................................... 25 Compliance Testing Results................................................................................................. 25 Recommendation for CCHCS .............................................................................................. 27 Recommendations for RJD .................................................................................................. 27 Richard J. Donovan Correctional Facility, Cycle 4 Medical Inspection Table of Contents Office of the Inspector General State of California Inter- and Intra-System Transfers ........................................................................................... 28 Case Review Results ............................................................................................................ 28 Compliance Testing Results................................................................................................. 31 Recommendations ................................................................................................................ 31 Pharmacy and Medication Management ................................................................................ 32 Case Review Results ............................................................................................................ 32 Compliance Testing Results................................................................................................. 33 Recommendation ................................................................................................................. 37 Preventive Services ................................................................................................................. 38 Compliance Testing Results................................................................................................. 38 Recommendations ................................................................................................................ 39 Quality of Nursing Performance ............................................................................................. 40 Case Review Results ............................................................................................................ 40 Recommendation ................................................................................................................. 42 Quality of Provider Performance ............................................................................................ 43 Case Review Results ............................................................................................................ 43 Recommendations ................................................................................................................ 47 Specialized Medical Housing (OHU, CTC, SNF, Hospice) .................................................... 48 Case Review Results ............................................................................................................ 48 Compliance Testing Results................................................................................................. 50 Recommendations ................................................................................................................ 50 Specialty Services .................................................................................................................... 51 Case Review Results ............................................................................................................ 51 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 Richard J. Donovan Correctional Facility, 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 RJD Executive Summary Table ....................................................................................................... viii RJD Health Care Staffing Resources as of May 2016 ...................................................................... 2 RJD Master Registry Data as of May 27, 2016 ................................................................................... 3 Commonly Used Abbreviations .......................................................................................................... 4 RJD Results Compared to State and National HEDIS Scores ........................................................... 63 Richard J. Donovan Correctional Facility, 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 Richard J. Donovan Correctional Facility (RJD). The OIG performed its Cycle 4 medical inspection at RJD from June to August 2016. The inspection included in-depth reviews of 66 inmate-patient files conducted by clinicians, as well as reviews of documents from 420 inmate-patient files, covering 93 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 RJD 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 RJD was adequate. Richard J. Donovan Correctional Facility, Cycle 4 Medical Inspection Page i Office of the Inspector General State of California Health Care Quality Indicators All Institutions– Fourteen Primary Indicators (Clinical) RJD Applicability Applicability Both case review 1–Access to Care All institutions and compliance Both case review 2–Diagnostic Services All institutions and compliance 3–Emergency Services All institutions Case review only 4–Health Information Management Both case review All institutions (Medical Records) and compliance 5–Health Care Environment All institutions Compliance only Both case review 6–Inter- and Intra-System Transfers All institutions and compliance Both case review 7–Pharmacy and Medication Management All institutions and compliance Female institutions 8–Prenatal and Post-Delivery Services Not Applicable only 9–Preventive Services All institutions Compliance only 10–Quality of Nursing Performance All institutions Case review only 11–Quality of Provider Performance All institutions Case review only Institutions with 12–Reception Center Arrivals Not Applicable reception centers All institutions with 13–Specialized Medical Housing Both case review and an OHU, CTC, SNF, (OHU, CTC, SNF, Hospice) compliance or Hospice Both case review 14–Specialty Services All institutions and compliance Two Secondary Indicators All Institutions– RJD Applicability (Administrative) Applicability 15–Internal Monitoring, Quality Improvement, and Administrative All institutions Compliance only Operations 16–Job Performance, Training, Licensing, All institutions Compliance only and Certifications Richard J. Donovan Correctional Facility, 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 RJD was adequate. Of the Overall Assessment 12 primary (clinical) quality indicators applicable to RJD, the OIG Rating: found one proficient, six adequate, and five inadequate. Of the two secondary (administrative) quality indicators, the OIG found Adequate both inadequate. To determine the overall assessment for RJD, 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 RJD. Clinical Case Review and OIG Clinician Inspection Results The clinicians’ case reviews sampled patients with high medical needs and included a review of 2,117 patient care events.1 Of the 12 primary indicators applicable to RJD, 10 were evaluated by clinician case review; one was proficient, five were adequate, and four were 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  Strong medical leadership at RJD was evident, and this was voiced by the medical providers.  The daily provider morning report meetings and morning huddles in the clinics were informative, pertinent, and effective in relaying necessary information.  The pharmacy staff effectively managed the anticoagulation clinic, which allowed providers more time for other medical issues and care.  Continuous quality improvement in RJD’s emergency medical response reviews and transfer process was evidenced by RJD’s own recognition of problems with these processes and its implementation of solutions.  The orientation to correctional medicine at RJD for new providers was comprehensive. 1 Each OIG clinician team includes a board-certified physician and registered nurse consultant with experience in correctional and community medical settings. Richard J. Donovan Correctional Facility, Cycle 4 Medical Inspection Page iii Office of the Inspector General State of California Program Weaknesses — Clinical  Emergency services at RJD were inadequate due to poor nursing assessment and documentation.  Health information management at RJD was inadequate, mainly due to delays in the retrieval and review of hospital, specialty, and diagnostic reports.  The inter- and intra-system transfer processes at RJD were inadequate.  Pharmacy and medication management at RJD was inadequate.  Nursing performance was subpar as it related to specialized medical housing.  The quality of provider performance was only borderline adequate. Providers sometimes conducted poor review of medical records and used legacy, “cloned,” progress notes, which resulted in patients’ conditions being incorrectly described in progress notes. Compliance Testing Results Of the 14 health care indicators applicable to RJD, 11 were evaluated by compliance inspectors.2 There were 93 individual compliance questions within those 11 indicators, generating 1,335 data points that tested RJD’s compliance with California Correctional Health Care Services (CCHCS) policies and procedures.3 Those 93 questions are detailed in Appendix A — Compliance Test Results. The institution’s inspection scores in the 11 applicable indicators ranged from 58.3 percent to 92.0 percent, with the secondary (administrative) indicator Internal Monitoring, Quality Improvement, and Administrative Operations receiving the lowest score, and the primary indicator Specialized Medical Housing (OHU, CTC, SNF, Hospice) receiving the highest. Of the nine primary indicators applicable to compliance testing, the OIG rated three proficient, three adequate, and three inadequate. Of the two secondary indicators, which involve administrative health care functions, both were rated inadequate. 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. Richard J. Donovan Correctional Facility, Cycle 4 Medical Inspection Page iv Office of the Inspector General State of California Program Strengths — Compliance As the RJD Executive Summary Table on page viii indicates, the institution’s compliance ratings were proficient, scoring above 85 percent, in the following three primary indicators: Access to Care, Diagnostic Services, and Specialized Medical Housing (OHU, CTC, SNF, and Hospice). The following are some of RJD’s strengths based on its compliance scores on individual questions in all the primary health care indicators:  Patients had a standardized process to obtain and submit request forms for health care services, and nursing staff timely reviewed patients’ requests and completed face-to-face visits with patients. Both nurse-requested and provider-ordered follow-up appointments were timely.  Upon discharge from a community hospital, patients received timely follow-up appointments.  Patients received their radiology, laboratory, and pathology services timely. In addition, providers timely reviewed the diagnostic reports related to radiology and laboratory services and communicated those results to patients.  Health records staff timely scanned specialty reports into patients’ electronic medical records.  Clinical areas were appropriately disinfected, cleaned, and sanitized. Clinical staff properly controlled exposure to blood-borne pathogens and contaminated waste in health care areas. Clinical staff properly sterilized or disinfected reusable invasive and non-invasive medical equipment.  Patients received from other institutions had a nurse complete the assessment and disposition section of the Initial Health Screening form (CDCR Form 7277), were referred to the TTA if required, and were assessed the day of their arrival.  Nursing staff timely administered or delivered newly ordered medications to patients and employed appropriate administrative controls and protocols when preparing medications.  In its main pharmacy, RJD followed general security, organization, and cleanliness management protocols; properly stored and monitored refrigerated, frozen, and non-refrigerated medications; and properly accounted for narcotic medications.  RJD timely offered colorectal cancer screenings and influenza vaccinations.  Nurses timely completed initial patient assessments in the correctional treatment center (CTC), and providers timely evaluated patients upon admission and completed a history and physical exam within 72 hours. Richard J. Donovan Correctional Facility, Cycle 4 Medical Inspection Page v Office of the Inspector General State of California  The institution’s specialized medical housing unit had properly working call buttons, and medical staff could timely access and enter patient cells during emergent events.  Providers timely reviewed high-priority and routine specialty services reports.  When providers’ requests for specialty services were denied, the denials occurred within the required time frame. The following are some of the strengths identified within the two secondary administrative indicators:  The institution promptly processed inmate medical appeals and addressed all of the patients’ appealed issues in second-level medical appeals.  Providers, nursing staff, and the pharmacist in charge were current with their professional licenses; the pharmacy and authorized providers who prescribed controlled substances maintained current Drug Enforcement Agency registrations.  Medical staff timely reviewed and submitted initial inmate death reports to the CCHCS Death Review Unit. Program Weaknesses — Compliance The institution received ratings of inadequate, scoring below 75 percent, in the following three primary indicators: Health Information Management, Pharmacy and Medication Management, and Preventive Services. The institution also received an inadequate score in both of the two secondary indicators, Internal Monitoring, Quality Improvement, and Administrative Operations and Job Performance, Training, Licensing, and Certifications. The following are some of the weaknesses identified by RJD’s compliance scores on individual questions in all the primary health care indicators:  Providers did not conduct timely appointments with patients who had been referred by nursing staff following their transfer to RJD from other institutions.  Providers routinely failed to communicate pathology results to their patients within required time frames.  Health information management staff did not always properly label documents scanned into patients’ electronic health records.  Clinical staff did not follow universal hand hygiene protocols before or after patient encounters or during medication preparation and administration.  Most clinics lacked essential medical equipment and supplies. Richard J. Donovan Correctional Facility, Cycle 4 Medical Inspection Page vi Office of the Inspector General State of California  For many patients, including those who suffered with chronic care conditions and those who were en route to other CDCR institutions, nursing staff did not timely deliver or administer prescribed medications.  The institution’s clinic and medication line locations did not employ strong medication security controls over narcotic medications. RJD also did not properly store non-narcotic medications, or employ appropriate administrative controls and protocols when distributing medications to patients.  Patients at RJD did not always timely receive their tuberculosis medications, and the institution’s monthly monitoring of these patients was poor. In addition, RJD was subpar in performing annual tuberculosis screenings.  Providers in RJD’s CTC did not always complete subjective, objective, assessment, plan, and education (SOAPE) notes on patients at the required intervals.  Patients who arrived at RJD from other institutions with pending specialty services appointments did not always receive their appointments within the required time frame.  Providers did not always timely inform patients of denied requests for specialty services. The following are some of the weaknesses identified within the two secondary administrative indicators:  Nursing supervisors did not timely conduct periodic reviews of nurses or ensure those passing medications were current on their competency evaluations.  The institution’s Emergency Medical Response Review Committee meeting minutes did not always include all required documentation about discussed incidents.  The institution did not ensure that recently hired nurses timely completed new employee orientation training. The RJD 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. Richard J. Donovan Correctional Facility, Cycle 4 Medical Inspection Page vii Office of the Inspector General State of California RJD Executive Summary Table Case Compliance Overall Indicator Primary Indicators (Clinical) Review Rating Rating Rating Access to Care Proficient Proficient Proficient Diagnostic Services Adequate Proficient Adequate Emergency Services Inadequate Not Applicable Inadequate Health Information Management Inadequate Inadequate Inadequate (Medical Records) Health Care Environment Not Applicable Adequate Adequate Inter- and Intra-System Transfers Inadequate Adequate Inadequate Pharmacy and Medication Management Inadequate 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 Compliance Overall Indicator Secondary Indicators (Administrative) Review Rating Rating Rating Internal Monitoring, Quality Improvement, Not Applicable Inadequate Inadequate and Administrative Operations Job Performance, Training, Licensing, and Not Applicable Inadequate Inadequate 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). Richard J. Donovan Correctional Facility, Cycle 4 Medical Inspection Page viii Office of the Inspector General State of California Population-Based Metrics In general, RJD performed well as measured by population-based metrics. In four of the five comprehensive diabetes care measures, RJD outperformed other State and national organizations, including Medi-Cal, Kaiser Permanente (typically one of the highest scoring health organizations in California), Medicaid, Medicare, commercial entities, and the United States Department of Veterans Affairs (VA). Only for diabetic eye exams did RJD’s score was lower than Kaiser’s (South region) and the VA’s. With regard to immunization measures, RJD’s rates were mixed. RJD outperformed all statewide and national health management organizations for administering influenza vaccinations for younger adults. However, the institution did not perform as well with regard to administering influenza vaccines for older adults when compared to Medicare and the VA, but a high rate of patient refusals negatively affected the institution’s score. With regard to administering pneumococcal vaccines to older adults, RJD scored higher than Medicare but lower than the VA. RJD’s rates for colorectal cancer screening were better than those of all other reporting entities. Overall, RJD’s performance demonstrated by the population-based metrics indicated that the chronic care program was above average in regard to diabetes care and colorectal cancer screenings. Immunizations were average; however, the institution may improve by making interventions to educate patients to reduce refusals. Richard J. Donovan Correctional Facility, Cycle 4 Medical Inspection Page ix 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. Richard J. Donovan Correctional Facility (RJD) was the 32nd 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 2 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 Richard J. Donovan Correctional Facility (RJD) is named for the late Assemblyman and Judge Richard J. Donovan, who sponsored legislation to build a State prison facility in Southern California. The facility opened in July 1987. RJD is designated an “intermediate care prison”; these institutions are located in predominantly urban areas close to tertiary care centers and specialty care providers for the most cost-effective care. The facility consists of a correctional treatment center (CTC), general population housing, and special needs yard (SNY) housing. Along with multiple clinics that daily handle non-urgent requests for medical services, RJD has a treatment and triage area (TTA, or standby emergency room) to provide urgent care. On August 5, 2016, RJD received national accreditation from the Commission on Accreditation for Corrections. The accreditation program is a professional peer review process based on national standards set by the American Correctional Association. Richard J. Donovan Correctional Facility, Cycle 4 Medical Inspection Page 1 Office of the Inspector General State of California Based on staffing data the OIG obtained from the institution, RJD’s vacancy rate among medical managers, providers, nursing supervisors, and non-supervisory nurses was 3 percent in May 2016, with the highest vacancy percentages among nursing supervisors. As indicated in the following table, RJD had 144.6 budgeted health care positions, of which 140.5 were filled. Based on its authorized and filled positions, the institution reported 4.1 vacant positions. Lastly, the CEO reported that in May 2016, there were four staff members under CDCR disciplinary review, one of whom was redirected to a non-patient-care setting. RJD 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% 12.5 9% 12.5 9% 114.6 79% 144.6 100% Positions Filled Positions 4 80% 12 96% 11.5 92% 113 99% 140.5 97% Vacancies 1 20% 0.5 4% 1 8% 1.6 1% 4.1 3% Recent Hires (Within 12 0 0% 5 42% 3 26% 53 47% 61 43% Months) Staff Utilized 0 0% 0 0% 0 0% 0 0% 0 0% from Registry Redirected Staff (to Non-Patient 0 0% 0 0% 0 0% 1 1% 1 1% Care Areas) Staff on Long-Term 0 0% 0 0% 0 0% 2 2% 2 1% Medical Leave Note: RJD’s Health Care Staffing Resources data was not validated by the OIG. Richard J. Donovan Correctional Facility, Cycle 4 Medical Inspection Page 2 Office of the Inspector General State of California As of May 27, 2016, the Master Registry for RJD showed that the institution had a total population of 3,126. Within that total population, 17.4 percent were designated as high medical risk, Priority 1 (High 1), and 19.8 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 are. 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. RJD Master Registry Data as of May 27, 2016 Medical Risk Level # of Inmate-Patients Percentage High 1 545 17.43% High 2 618 19.77% Medium 1,518 48.56% Low 445 14.24% Total 3,126 100.00% Richard J. Donovan Correctional Facility, Cycle 4 Medical Inspection Page 3 Office of the Inspector General State of California Commonly Used Abbreviations ACLS Advanced Cardiovascular Life Support HIV Human Immunodeficiency Virus AHA American Heart Association HTN Hypertension ASU Administrative Segregation Unit INH Isoniazid (anti-tuberculosis medication) BLS Basic Life Support IV Intravenous CBC Complete Blood Count KOP Keep-on-Person (in taking medications) CC Chief Complaint LPT Licensed Psychiatric Technician CCHCS California Correctional Health Care Services LVN Licensed Vocational Nurse CCP Chronic Care Program MAR Medication Administration Record California Department of Corrections and CDCR MRI Magnetic Resonance Imaging Rehabilitation CEO Chief Executive Officer MD Medical Doctor CHF Congestive Heart Failure NA Nurse Administered (in taking medications) CME Chief Medical Executive N/A Not Applicable CMP Comprehensive Metabolic (Chemistry) Panel NP Nurse Practitioner CNA Certified Nursing Assistant OB Obstetrician CNE Chief Nurse Executive OHU Outpatient Housing Unit C/O Complains of OIG Office of the Inspector General COPD Chronic Obstructive Pulmonary Disease P&P Policies and Procedures (CCHCS) CP&S Chief Physician and Surgeon PA Physician Assistant CPR Cardio-Pulmonary Resuscitation PCP Primary Care Provider CSE Chief Support Executive POC Point of Contact CT Computerized Tomography PPD Purified Protein Derivative CTC Correctional Treatment Center PRN As Needed (in taking medications) DM Diabetes Mellitus RN Registered Nurse Directly Observed Therapy (in taking DOT Rx Prescription medications) Dx Diagnosis SNF Skilled Nursing Facility Subjective, Objective, Assessment, Plan, EKG Electrocardiogram SOAPE Education ENT Ear, Nose and Throat SOMS Strategic Offender Management System ER Emergency Room S/P Status Post eUHR electronic Unit Health Record TB Tuberculosis FTF Face-to-Face TTA Triage and Treatment Area History and Physical (reception center H&P UA Urinalysis examination) HIM Health Information Management UM Utilization Management Richard J. Donovan Correctional Facility, 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 RJD, 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 Richard J. Donovan Correctional Facility, 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. Richard J. Donovan Correctional Facility, 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 Richard J. Donovan Correctional Facility, 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: RJD Sample Sets, the OIG clinicians evaluated medical charts for 66 unique inmate-patients. Appendix B, Table B–4: RJD Case Review Sample Summary clarifies that both nurses and physicians reviewed charts for 19 of those patients, for 85 reviews in total. Physicians performed detailed reviews of 30 charts, and nurses performed detailed reviews of 19 charts, totaling 49 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 36 inmate-patients. These generated 2,117 clinical events for review (Appendix B, Table B–3: RJD 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: RJD Sample Sets), the 66 unique inmate-patients sampled included patients with 299 chronic care diagnoses. This includes 26 additional patients with diabetes (for a total of 29) and two additional anticoagulation patients (for a total of five) (Appendix B, Table B–2: RJD 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. Richard J. Donovan Correctional Facility, 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 RJD Supplemental Medical Inspection Results: Individual Case Review Summaries report details the case reviews OIG clinicians conducted and is available to specific stakeholders. For further details regarding the sampling methodologies and counts, see Appendix B — Clinical Data, Table B–1; Table B–2; Table B–3; and Table B–4. COMPLIANCE TESTING SAMPLING METHODS FOR CONDUCTING COMPLIANCE TESTING From June to August 2016, deputy inspectors general and registered nurses attained answers to 93 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 420 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 June 13, 2016, field inspectors conducted a detailed onsite inspection of RJD’s medical facilities and clinics; interviewed key institutional employees; and reviewed employee records, logs, medical appeals, death reports, and other documents. This generated 1,335 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 RJD’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, Emergency Services, Health Information Management (Medical Records), Health Care Environment, Inter- and Intra-System Transfers, Pharmacy and Medication Management, Preventive Services, Specialized Medical Housing (OHY, CTC, CNF, Hospice), and Specialty Services. Richard J. Donovan Correctional Facility, 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 93 questions, the OIG derived a score for each primary and secondary quality indicator identified above by calculating the percentage score of all Yes answers for each of the questions applicable to a particular indicator, then averaging those scores. Based on those results, the OIG assigned a rating to each quality indicator of proficient (greater than 85 percent), adequate (between 75 percent and 85 percent), or inadequate (less than 75 percent). DASHBOARD COMPARISONS In the first ten medical inspection reports of Cycle 4, the OIG identified where similar metrics for some of the individual compliance questions were available within the CCHCS Dashboard, which is a monthly report that consolidates key health care performance measures statewide and by institution. However, there was not complete parity between the metrics due to differing time frames for data collecting and differences in sampling methods, rendering the metrics unable to be compared. The OIG has removed the Dashboard comparisons to eliminate confusion. Dashboard data is available on CCHCS’s website, www.cphcs.ca.gov. OVERALL QUALITY INDICATOR RATING FOR CASE REVIEWS AND COMPLIANCE TESTING The OIG derived the final rating for each quality indicator by combining the ratings from the case reviews and from the compliance testing, as applicable. When combining these ratings, the case review evaluations and the compliance testing results usually agreed, but there were instances when the rating differed for a particular quality indicator. In those instances, the inspection team assessed the quality indicator based on the collective ratings from both components. Specifically, the OIG clinicians and deputy inspectors general discussed the nature of individual exceptions found within that indicator category and considered the overall effect on the ability of patients to receive adequate medical care. To derive an overall assessment rating of the institution’s medical inspection, the OIG evaluated the various rating categories assigned to each of the quality indicators applicable to the institution, giving more weight to the rating results of the primary quality indicators, which directly relate to the health care provided to inmate-patients. Based on that analysis, OIG experts made a considered and measured overall opinion about the quality of health care observed. Richard J. Donovan Correctional Facility, 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 RJD, the OIG reviewed some of the compliance testing results, randomly sampled additional inmate-patients’ records, and obtained RJD data from the CCHCS Master Registry. The OIG compared those results to HEDIS metrics reported by other statewide and national health care organizations. Richard J. Donovan Correctional Facility, 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 RJD. 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 RJD Executive Summary Table on page viii shows the case review and 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 RJD. Of these ten indicators, OIG clinicians rated one proficient, five adequate, and four inadequate. The OIG physicians rated the overall adequacy of care for each of the 30 detailed case reviews they conducted. Of these 30 cases, none was proficient, 24 were adequate, and 6 were inadequate. In the 2,117 events reviewed, there were 840 deficiencies, of which 68 were considered to be of such magnitude that, if left unaddressed, they would likely contribute to patient harm. Adverse Events Identified During Case Review: Medical care is a complex dynamic process with many moving parts, subject to human error even within the best health care organizations. Adverse events are typically identified and tracked by all major health care organizations for the purpose of quality improvement. They are not generally representative of medical care delivered by the organization. The OIG identified adverse events for the dual purposes of quality improvement and the illustration of problematic patterns of practice found during the inspection. Because of the anecdotal description of these events, the OIG cautions against drawing inappropriate conclusions regarding the institution based solely on adverse events. There were no adverse event/events identified in the case reviews at RJD. Summary of Compliance Results: The compliance component assessed 9 of the 12 primary (clinical) indicators applicable to RJD. Of these nine indicators, OIG inspectors rated three proficient, three adequate, and three inadequate. The results of those assessments are summarized within this section of the report. The test questions used to assess compliance for each indicator are detailed in Appendix A. Richard J. Donovan Correctional Facility, 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 Proficient inmate-patients’ access to care are reviewed, such as initial Compliance Score: assessments of newly arriving inmates, acute and chronic care Proficient follow-ups, face-to-face nurse appointments when an inmate-patient (89.5%) requests to be seen, provider referrals from nursing lines, and Overall Rating: follow-ups after hospitalization or specialty care. Compliance Proficient testing for this indicator also evaluates whether inmate-patients have Health Care Services Request forms (CDCR Form 7362) available in their housing units. Case Review Results The OIG clinicians reviewed 1,313 provider and nurse encounters and identified 27 deficiencies relating to Access to Care. The majority of deficiencies were due to provider follow-up appointments not occurring as ordered and provider follow-up visits after specialty appointments not occurring in a timely manner. The only significant deficiency in this indicator occurred when a newly transferred patient was not seen by a provider in the requested time frame (case 37). Provider-to-Provider Follow-up Appointments Provider-ordered follow-up appointments did not occur in the time frame ordered in in five cases. Nurse Sick Call Access RJD nurses performed well in addressing sick calls in a timely manner. Nurse-to-Provider Referrals Nurse-requested provider follow-up appointments did not occur timely in three cases. Provider Follow-up After Specialty Services Provider follow-up appointments after specialty services did not occur timely in six cases. Intra-System Transfers  In case 37, a nurse ordered a newly transferred patient with multiple medical problems to be seen in 14 days; he was not seen by a provider for almost three months. This case is discussed further in the Inter- and Intra-System Transfers indicator. Richard J. Donovan Correctional Facility, Cycle 4 Medical Inspection Page 13 Office of the Inspector General State of California Follow-up After Hospitalization Provider follow-up appointments generally occurred in a timely manner. Urgent/Emergent Care Follow-up appointments after urgent or emergent care did not occur timely in three cases. Specialized Medical Housing RJD provided patients sufficient access to providers in the correctional treatment center (CTC). Specialty Access Access to specialty services is discussed in the Specialty Services indicator. Clinician Summary RJD performed well with regard to Access to Care, so the case review rating was proficient. Compliance Testing Results The institution received a proficient compliance score of 89.5 percent in the Access to Care indicator, and scored in the proficient range in the following test areas:  Nursing staff reviewed all 30 sampled health care services request on the same day they were received (MIT 1.003). In addition, nursing staff completed a face-to-face encounter within one business day of reviewing the request for 29 patients (97 percent). The only exception was when a health care services request indicated that a nursing protocol was completed, but it was not located in the eUHR (MIT 1.004).  Inmates had access to health care services requests at all six housing units inspected (MIT 1.101).  The OIG tested 30 patients discharged from a community hospital to determine if they received a provider follow-up appointment at RJD within five calendar days of their return to the institution, or earlier if a TTA provider ordered the appointment to occur sooner. Of 30 patients, 28 (93 percent) received a timely provider follow-up appointment. One patient received his follow-up appointment four days late, and another patient refused his follow-up appointment, but it was offered six days late (MIT 1.007).  Among 12 health care services requests for which nursing staff referred the patient for a provider appointment, 11 patients (92 percent) received timely appointments. One patient received his provider appointment one day late (MIT 1.005). Out of those 12 provider appointments, providers ordered five of the patients to return for a follow-up visit. All five Richard J. Donovan Correctional Facility, Cycle 4 Medical Inspection Page 14 Office of the Inspector General State of California patients received their follow-up appointments within the provider’s ordered time frame (MIT 1.006).  Inspectors sampled 30 patients who received a specialty service, and found 27 of them (90 percent) received or timely refused a provider follow-up appointment. Three patients received their follow-up appointments from one to 30 days late (MIT 1.008). RJD performed in the adequate range on the following test:  Routine appointments were timely for 33 of the 40 sampled patients with chronic conditions (83 percent). One patient received his follow-up appointments 11 days late, while four others’ were from four months to over one year late. Two patients did not receive a follow-up appointment at all (MIT 1.001). The institution scored in the inadequate range on the following test:  Primary care provider visits occurred timely for 15 of the 29 sampled patients who transferred into RJD with a pre-existing chronic care provider visit or who, upon arrival, received a new provider referral from the RJD screening nurse (52 percent). Provider visits were from 5 to 44 days late for 13 patients. While one patient refused his provider appointment, it was offered 19 days late (MIT 1.002). Recommendations No specific recommendations. Richard J. Donovan Correctional Facility, 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 timely reviewed the results, and whether the results were Proficient communicated to the inmate-patient within the required time (88.4%) frames. In addition, for pathology services, the OIG determines Overall Rating: whether the institution received a final pathology report and Adequate whether the provider timely reviewed and communicated the pathology results to the patient. The case reviews also factor in the appropriateness, accuracy, and quality of the diagnostic tests ordered and the clinical response to the results. In this indicator, the OIG’s case review and compliance review processes yielded different results, with 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 results and ultimately rated this indicator adequate. The key factor warranting the lower overall rating was that case review identified a number of missing diagnostic reports in the health record and reports that were not reviewed in a timely manner, which did not support an overall indicator rating higher than adequate. Case Review Results The OIG clinicians reviewed 338 diagnostic events and found 57 deficiencies, of which 3 were significant. The majority of the deficiencies related to health information management, such as diagnostic reports missing from the health records and diagnostic reports that providers did not properly review and sign in a timely manner. Other deficiencies included diagnostic tests not being performed in the time frame ordered. The following examples are provided for quality improvement purposes:  In five cases, laboratory results were not retrieved and scanned into the eUHR.  In eight cases, x-ray reports were not retrieved and scanned into the eUHR.  In nine cases, providers did not review and sign laboratory reports in a timely manner. In ten cases, laboratory tests were not completed as ordered. The following three cases contained significant deficiencies that increased the risk of harm to patients.  In case 8, laboratory results indicating a possible intestinal bleed were not addressed in a timely manner. Richard J. Donovan Correctional Facility, Cycle 4 Medical Inspection Page 16 Office of the Inspector General State of California  In case 32, an immediate urine test was ordered, but it was not collected until the following day.  In case 36, clinical staff did not draw laboratory tests to monitor kidney function as ordered for this patient, who had just been discharged from the hospital with a diagnosis of acute kidney injury. The order was for the laboratory tests to be drawn in one to two days, but they were not drawn until one month later, after they were reordered. Clinician Summary The vast majority of deficiencies were unlikely to contribute to patient harm. When RJD transitions to the new electronic medical record system in 2017, the number of these deficiencies will likely dramatically decrease. RJD’s performance was satisfactory with regard to diagnostic services, and the indicator rating was thus adequate. Compliance Testing Results The institution received a proficient compliance score of 88.4 percent in the Diagnostic Services indicator, which encompasses radiology, laboratory, and pathology services. For clarity, each type of diagnostic service is discussed separately, below: Radiology Services  All ten of the radiology services sampled were timely performed (MIT 2.001). RJD providers initialed and dated the radiology reports and communicated the results within the required time frame for nine of those patients (90 percent). The provider reviewed the radiology report and communicated the results to one patient one day late (MIT 2.002, 2.003). Laboratory Services  RJD performed nine of ten laboratory services sampled within the required time frame (90 percent). For one patient, the laboratory service was provided three days late (MIT 2.004). The institution’s providers initialed and dated the laboratory reports and communicated the results within the required time frame for nine of ten sampled patients (90 percent). A provider reviewed and communicated the laboratory results to one patient one day late (MIT 2.005, 2.006). Pathology Services  The institution timely received a final pathology report for nine of ten patients sampled (90 percent). For one patient, the institution never received a pathology report (MIT 2.007). Further, for the nine samples where the institution received a final report, providers timely reviewed the results for eight of them (89 percent). For one patient, the OIG could find no evidence in the eUHR that a provider reviewed the pathology report (MIT 2.008). Also, six Richard J. Donovan Correctional Facility, Cycle 4 Medical Inspection Page 17 Office of the Inspector General State of California of the nine patients for whom the institution received a final pathology report (67 percent) had their pathology results communicated to them by a provider within the required time frame. Providers communicated results to two patients 8 and 14 days late, while another patient never received his result (MIT 2.009). Recommendation The OIG recommends that RJD review flow processes to improve the timeliness of diagnostic reports being performed, reviewed, signed by primary care providers, and scanned into patients’ charts. Richard J. Donovan Correctional Facility, Cycle 4 Medical Inspection Page 18 Office of the Inspector General State of California EMERGENCY SERVICES An emergency medical response system is essential to providing Case Review Rating: effective and timely emergency medical response, assessment, Inadequate treatment, and transportation 24 hours per day. Provision of Compliance Score: urgent/emergent care is based on a patient’s emergency situation, Not Applicable clinical condition, and need for a higher level of care. The OIG reviews emergency response services including first aid, basic life Overall Rating: support (BLS), and advanced cardiac life support (ACLS) Inadequate 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 114 urgent/emergent events and found 94 deficiencies, the majority of which related to nursing performance. There were marked problems with initiation of BLS and airway assessment and management. There were 11 significant deficiencies (two each in cases 12 and 14, and one each in cases 1, 2, 4, 9, 13, 21, and 24). Provider Performance The TTA providers generally saw patients timely, made adequate assessments and sound triage decisions, and sent patients to higher levels of care appropriately. There were a few exceptions, also discussed in the Quality of Provider Performance indicator. In cases 9 and 14, providers failed to consider cardiac causes for chest pain in patients with cardiac risk factors. In three cases, orders for transfer should have been ACLS instead of BLS. Fortunately, this did not affect the patients’ outcomes. Nursing Performance On several occasions, nurses failed to perform timely, appropriate interventions.  In case 1, the first BLS responders failed to initiate CPR immediately on a patient who had collapsed on the yard.  In case 2, the first medical responders and the TTA nurses failed to timely attach an automated external defibrillator (AED).  In case 7, the patient had chest pain and difficulty breathing. The emergency response nurse noted respiratory distress and audible wheezing, but the first medical responders did not Richard J. Donovan Correctional Facility, Cycle 4 Medical Inspection Page 19 Office of the Inspector General State of California administer oxygen or assess vital signs. After the patients’ breathing treatment in the TTA, the nurse failed to assess lung sounds and failed to assess prior rescue inhaler use. Additionally, the nurse failed to assess if the rescue inhaler was with the patient.  In case 12, the patient was unresponsive, was not breathing, and had no pulse. RJD staff initiated CPR and used an AED. Soon thereafter, staff found a pulse and noted agonal breaths, but the nurse failed to initiate rescue breathing.  In case 14, the patient reported ingesting 20 ibuprofen tablets. He had a weak pulse, labored breathing, and low blood pressure. The TTA nurse did not call 9-1-1 or contact a provider for 33 minutes.  In four cases, the first responders failed to arrive on scene within the required time frame.  In case 24, the patient had a prolonged seizure. RJD nursing staff administered seizure medications known to cause low blood pressure and respiratory depression. However, the nurse failed to assess vital signs after administration. Nursing staff failed to timely assess vital signs in three other cases. Emergency nursing services deficiencies often related to inadequate documentation. Nursing documentation was incomplete and sometimes disorganized.  In case 7, medical alarms were activated when the patient had difficulty breathing on two separate occasions. The first responders failed to document on-scene arrival times for both events. Failure to document emergency timelines was also identified in four other cases.  In case 11, transfers via state vehicle for a higher level of care were ordered on two separate occasions. On both occasions, the nurses inappropriately placed the patient in a holding cell and failed to document reassessment and times of departure to the hospital. Emergency Medical Response Review In five cases, the medical review process failed to identify nursing deficiencies. Clinician Onsite Visit The OIG identified problems with medication changes not implemented upon return to RJD after outside hospitalization. The institution’s leadership indicated these issues had been identified, and that they were using quality improvement principles and tools to rectify them. Currently, RJD has one provider assigned to the TTA. In addition to providing urgent or emergent care, this provider is also responsible for ensuring orders were appropriately reconciled for patients returning from the hospital and specialty appointments during business hours. These issues are further discussed in the Intra- and Inter-System Transfers indicator. Richard J. Donovan Correctional Facility, Cycle 4 Medical Inspection Page 20 Office of the Inspector General State of California The Emergency Medical Response Review Committee (EMRRC) had recently modified its processes. RJD reported that reviewing all unscheduled send-outs for emergent care was not practical during the monthly EMRRC meeting due to the high volume. Knowing this resulted in poor reviews, unscheduled send-outs were reviewed weekly by members of the committee, and specific cases with pertinent teaching issues were brought forward to monthly meetings which resulted in better-quality reviews and learning. Leadership also included TTA staff in these processes. Conclusion A large number of nursing deficiencies were identified in the Emergency Services indicator. Issues with BLS performance, incomplete first medical responder and TTA nursing documentation, and poor nursing assessment resulted in an inadequate rating for this indicator. Recommendations The OIG recommends that RJD conduct periodic training for providers regarding the appropriateness of ACLS versus BLS transfers. The OIG recommends that RJD leadership audit documentation and enforce complete, accurate, organized, and timely documentation of urgent and emergent care, compliant with standards. Richard J. Donovan Correctional Facility, 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 Inadequate 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 (58.6%) 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. Case Review Results The OIG clinicians noted 99 deficiencies during case review of RJD’s health information management. Three deficiencies were significant (cases 8, 21, and 36). The majority of deficiencies were delays in the retrieval and review of hospital, specialty, and diagnostic reports. At times, reports were missing altogether. Inter-Departmental Transmission While inter-departmental transmission was generally satisfactory at RJD, there were instances when this was questionable. When diagnostic reports were missing and there were no indications of a review of results, it was questionable as to whether or not they were completed. Hospital Records Of the 60 hospitalizations or emergency room visits reviewed resulting in patients returning to RJD, there were eight instances (in seven cases) in which hospital records were not available in a timely manner or were missing altogether. Specialty Services Frequent problems with specialty services reports involved delays in the reports being retrieved, reviewed, and signed timely, or staff not scanning reports into the eUHR. This is further discussed in the Specialty Services indicator. There were also instances when the specialty services nurse did not provide the specialists with pertinent information, such as diagnostic reports and medications. Diagnostic Reports There were several instances of diagnostic reports that were missing from patient health records and providers not reviewing and signing reports timely. This is further discussed in the Diagnostic Services indicator. Richard J. Donovan Correctional Facility, Cycle 4 Medical Inspection Page 22 Office of the Inspector General State of California Urgent/Emergent Records Health information management as it related to urgent/emergent records was generally satisfactory. There were occasional occurrences when nurses did not properly document their urgent/emergent encounters, and when on-call providers did not document their telephone encounters. Scanning Performance Case review found occasional documents misfiled in the wrong patient’s record. As noted above, specialty and diagnostic reports were not always available for review in the health records; it was unclear if this was because reports were not retrieved or because of poor scanning performance. Legibility Since providers dictated the majority of their progress notes, there were no concerns about legibility. However, nursing notes were difficult to read in cases 6, 12, 13, 17, 21, 24, 31, and 43. Miscellaneous There were other occurrences of missing documents, including medication administration records, wound care notes, and nursing and provider notes. On several occasions, providers used legacy (cloned) notes. This is further discussed in the Quality of Provider Performance indicator. Compliance Testing Results The institution received an inadequate compliance score of 58.6 percent in the Health Information Management (Medical Records) indicator and scored in the inadequate range in the following six tests:  The institution scored zero in its labeling and filing of documents scanned into patients’ electronic unit health records (eUHR); most documents were mislabeled, such as Tuberculosis Patient Plans (CDCR Form 7405) that were commonly mislabeled as Confidential Morbidity Reports (CDCR Form PM-110). For this test, once the OIG identifies 12 mislabeled or misfiled documents, the maximum points are lost and the resulting score is zero. During the RJD medical inspection, inspectors identified a total of 15 documents with scanning errors, three more than the maximum allowable number (MIT 4.006).  Among 20 sampled provider-dictated progress notes, 6 (30 percent) were scanned within five business days of the patient encounter date. The other 14 were scanned one to nine days late (MIT 4.002).  RJD timely scanned 11 of the 20 sampled community hospital discharge reports or treatment records into patients’ eUHRs (55 percent); nine reports were scanned one to four days late (MIT 4.004). Richard J. Donovan Correctional Facility, Cycle 4 Medical Inspection Page 23 Office of the Inspector General State of California  RJD staff timely scanned 12 of the 20 sampled medication administration records (MARs) into the patient’s eUHR (60 percent). Eight MARs were scanned one to three days late (MIT 4.005).  The OIG reviewed hospital discharge reports and treatment records for 30 sampled patients whom the institution sent to the hospital for a higher level of care; 20 were complete, included key elements, and were reviewed timely by a RJD provider (67 percent). Providers reviewed six reports one to three days late. Two reports did not include either the discharge date or the admission date. One report included neither admission nor discharge date, and it was one day late. One other report was not found in the eUHR (MIT 4.008).  When the OIG reviewed various medical documents such as hospital discharge reports, initial health screening forms, certain medication administration records, and specialty services reports to ensure that clinical staff legibly documented their names on the forms, only 23 of 32 samples (72 percent) showed compliance. Nine of the samples tested did not have a legible signature or stamp to identify the clinician (MIT 4.007). The institution scored in the proficient range on the following tests:  For 19 of 20 specialty service consultant reports sampled, RJD staff scanned the reports into the patient’s eUHR file within five calendar days (95 percent). The institution scanned one urgent specialty services report four days late (MIT 4.003).  Among ten sampled miscellaneous non-dictated documents, including providers’ progress notes and patients’ initial health screening forms and requests for health care services, the institution timely scanned nine of the documents (90 percent). One initial health screening form was scanned one day late (MIT 4.001). Recommendations No specific recommendations. Richard J. Donovan Correctional Facility, Cycle 4 Medical Inspection Page 24 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 (82.6%) 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 received an adequate compliance score of 82.6 percent in the Health Care Environment indicator with the following four tests receiving scores in the proficient range:  RJD appropriately disinfected, cleaned, and sanitized all 12 clinic locations tested. Specifically, all clinics observed were clean, and cleaning logs were present and completed (MIT 5.101).  Staff members at all 12 clinic locations followed proper protocols to mitigate exposure to blood-borne pathogens and contaminated waste (MIT 5.105).  RJD’s non-clinic medical storage areas met the supply management process and support needs of the medical health care program (MIT 5.106).  Clinical health care staff at 11 of the 12 applicable clinics (92 percent) ensured that reusable invasive and non-invasive medical equipment was properly sterilized or disinfected. The only exception was one clinic in which staff utilized a chemical solution for soaking invasive medical equipment between patient uses, but nursing staff were unable to submit evidence of a current local operating procedure for the chemical sterilization process (MIT 5.102). RJD performed in the adequate range on the following five test areas:  Ten of the 12 clinics (83 percent) had operable sinks and adequate hand hygiene supplies. At one clinic’s patient restroom, there were no disposable towels. In another clinic, staff did not have access to a sink near a blood-draw station (MIT 5.103).  Inspectors examined emergency response bags to determine if they were inspected daily and inventoried monthly and whether they contained all essential items. Emergency response bags were compliant in seven of the nine clinical locations where bags were stored (78 percent). In one clinic, the inventory log did not match the physical tag on the Richard J. Donovan Correctional Facility, Cycle 4 Medical Inspection Page 25 Office of the Inspector General State of California emergency response bag. In another clinic, staff on each watch did not conduct the required daily inspections, and the bag was not sealed and properly tagged (MIT 5.111).  Of the 12 clinics tested, 10 (83 percent) followed adequate medical supply storage and management protocols. Two clinics’ storage rooms for bulk medical supplies were not labeled for easy identification, and one of the two clinics had staff’s personal belongings stored together with medical supplies (Figure 1) (MIT 5.107).  The clinic common areas at 9 of 12 clinics (75 percent) had an adequate environment Figure 1: Personal belongings stored conducive to providing medical services. Two with medical supplies clinics did not provide protection for the outside waiting areas from inclement weather. In another clinic, the vital sign station was within audible range of the nurse’s exam room, which compromised patients’ auditory privacy (MIT 5.109).  Inspectors examined 12 clinics to determine if appropriate space, configuration, supplies, and equipment allowed clinicians to perform a proper clinical exam. Nine clinic locations (75 percent) were in compliance. At one clinic, oto-ophthalmoscopes were not easily accessible to be used at the exam table, and at another clinic, the RN exam room did not provide visual privacy for patients. One other clinic had a provider’s desk in disrepair, an exam table with torn vinyl (Figure 2), a supply cabinet/drawer Figure 2: Exam table with ripped vinyl not labeled for easy identification, an RN exam area that could harbor infection room that did not ensure visual privacy, and a confidential shred bin that was full and easily accessible to inmate-porters (MIT 5.110). Richard J. Donovan Correctional Facility, Cycle 4 Medical Inspection Page 26 Office of the Inspector General State of California The institution scored within the inadequate range on the following two tests:  Inspectors observed clinician encounters with patients in nine clinics. Clinicians at five clinic locations (56 percent) followed good hand hygiene practices. Clinicians at four clinics did not routinely sanitize their hands before or after patient contact or before putting on gloves (MIT 5.104).  Of the 12 clinics inspected, 8 (67 percent) met compliance requirements for essential core medical equipment and supplies. One clinic had a weight scale for wheelchairs and an oto-ophthalmoscopethat were not operational, and two other clinics had pulse oximeters and the blood pressure component on the vital sign machines working only intermittently. One other clinic had expired lubricating jelly in a provider exam room (MIT 5.108). Other Information Obtained from Non-Scored Results The OIG gathered information to determine if the institution’s physical infrastructure was maintained in a manner that supported health care management’s ability to provide adequate health care. The OIG did not score this question. When OIG inspectors interviewed health care managers, they did not express concerns about the facility’s infrastructure or its effect on staff’s ability to provide adequate health care. RJD had a number of significant infrastructure projects underway, including a new administrative segregation primary care clinic, medication distribution room additions at certain housing units, a new pharmacy and dialysis building, primary care clinic renovations on four yards, renovations to the central health services building, and a new health care administration building. These projects started in March 2015, and are expected to be completed by December 2017 (MIT 5.999). Recommendation for CCHCS The OIG recommends that CCHCS develop a statewide policy to identify required core equipment and supplies for each type of clinical setting, including primary care clinics, specialty clinics, TTA, R&R, and inpatient units. Recommendations for RJD The OIG recommends that RJD conduct periodic training and refresher courses on proper hand sanitation techniques and protocols for staff to follow when applying and removing protective gloves before, during, and after patient encounters. The OIG recommends the institution develop local operating procedures that help to ensure that all clinical areas supply a standardized full complement of core equipment. Specifically, clinic areas should include operational weight scales, oto-ophthalmoscopes, pulse oximeters, and vital sign machines, as well as providing lubricating jelly in exam rooms. Richard J. Donovan Correctional Facility, Cycle 4 Medical Inspection Page 27 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 Inadequate intra-facility transfer process. The patients reviewed for Inter- and Compliance Score: Intra-System Transfers include inmates received from other CDCR Adequate facilities and inmates transferring out of RJD to another CDCR (81.4%) facility. The OIG review includes evaluation of the institution’s Overall Rating: ability to provide and document health screening assessments, Inadequate 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 processes yielded different results, with the case review giving an inadequate rating and the compliance testing resulting in an adequate score. After considering both case review and compliance testing results, the OIG inspection team determined the final overall rating was inadequate. Case review’s concerns were related to hospital discharge returns, specifically, the availability of the hospital discharge reports and the reconciliation of hospital discharge medication for patients. Case Review Results Clinicians reviewed 210 encounters relating to Inter- and Intra-System Transfers, including information from both the sending and receiving institutions. These included 172 hospital-related events, including 69 hospitalizations, 60 of which resulted in a transfer back to RJD (the remaining nine resulted in transfers to other facilities or deaths at the hospital). Transfers In OIG clinicians reviewed 22 events relating to patients transferring into RJD and noted 14 deficiencies. Incomplete nursing assessment and inadequate medication continuity were the cause of most patient arrival deficiencies. The following case displayed the only significant deficiency in this category.  In case 37, the newly arrived patient complained of musculoskeletal pains and worsening depression. The nurse failed to thoroughly assess the patient’s complaints, failed to note the Richard J. Donovan Correctional Facility, Cycle 4 Medical Inspection Page 28 Office of the Inspector General State of California frequency of his use of his rescue asthma-inhaler and self-administered nitroglycerin, and failed to document any recent seizure activity. In this same case, the provider follow-up, ordered to be 14 days, occurred almost three months later. Transfers Out OIG clinicians reviewed 16 events relating to transfers out, and 8 minor deficiencies were noted. Nurses failing to thoroughly complete Health Care Transfer Information forms (CDCR Form 7371) contributed to most of the deficiencies for patients transferring out of RJD.  In case 10, the nurse failed to list the patient’s recent hospital visit for seizures and his pending neurology and audiology referrals.  In case 40, the nurse failed to list the patient’s diagnosis of chronic hepatitis C and his pending podiatry follow-up.  In case 42, the nurse completed a transfer form 13 days prior to the patient’s transfer. The nurse failed to document the patient’s pending rheumatology appointment and recent arm wound. Also, prior to the patient’s transfer and after the transfer form was completed, provider referrals for a podiatry consult and a hepatitis follow-up were not reflected on the transfer documents. Fortunately, the utilization management nurse contacted the receiving facility regarding the pending podiatry appointment. Hospitalizations Patients returning from hospitalizations or from outside emergency departments 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, such as from the hospital to the institution. Case review highlighted these risks at RJD. OIG clinicians reviewed 172 hospital-related events, including 69 hospitalizations, 60 of which resulted in patients transferring back to RJD. Of the 74 noted deficiencies, 11 were significant and increased the risk of harm to patients. In several cases, hospital discharge summaries were not always readily available for review. Cases 1, 10, 12, 21, 41, and the cases below illustrate how the lack of attention to detail can result in transfer errors, increasing risk of harm for patients returning from the hospital:  In case 8, the patient was hospitalized for sepsis, during which time he was diagnosed with possible adrenal insufficiency. Upon the patient’s return to RJD, the diagnosis of possible adrenal insufficiency was missed, and the patient did not receive the recommended hormone supplements. Fortunately, no harm occurred to the patient, as he did not have adrenal insufficiency. Richard J. Donovan Correctional Facility, Cycle 4 Medical Inspection Page 29 Office of the Inspector General State of California  In case 36, hospital discharge recommendations included medications to prevent urinary retention. When these medications were not ordered upon the patient’s return to RJD, this resulted in re-hospitalization with acute kidney failure. In other cases, the medication reconciliation process failed, resulting in patient medications inappropriately prescribed or discontinued. This occurred in cases, 7, 11, 21, 23, 25, 33, and the following:  In case 2, a RJD provider, anticipating the patient’s return from a community hospital, ordered medications. However, when the patient returned to RJD, the hospital recommended discontinuation of a blood pressure medication, but the RJD provider failed to discontinue the medication. Clinician Onsite Visit Case review revealed concerns about hospital returns, so the OIG clinicians brought them to the attention of leadership at RJD. The institution’s leadership had already identified these concerns, used quality improvement principles and tools to better analyze the issues, and had put processes in place to rectify them. The OIG also learned that community hospital nurses routinely contacted the RJD TTA nurse and performed a “handoff” prior to discharge; however, at the time of the OIG clinical case reviews, documentation of this handoff was not identified in the eUHR. Statewide Transfer Challenges In reviewing inter- and intra-system transfers, the OIG acknowledges system wide challenges common to all institutions. Nurses are responsible for accurately communicating pertinent information, identifying health care conditions that need treatment and monitoring, and facilitating continuity of care during the transfer process. While this is sufficient for most CDCR patients, it has not been adequate for patients with complex medical conditions or patients referred for complex specialty care. Often, nurses not familiar with the patient’s care or not part of the primary care team initiate the transfer forms. In addition, providers are often left out of the transfer process altogether, and patients are transferred without the provider’s knowledge. Without a sending and receiving provider, the risk for lapses in care increase significantly. Conclusion The OIG rated the case review portion of the Inter- and Intra-System Transfers indicator inadequate. Richard J. Donovan Correctional Facility, Cycle 4 Medical Inspection Page 30 Office of the Inspector General State of California Compliance Testing Results The institution earned an adequate compliance score of 81.4 percent in the Inter- and Intra-System Transfers indicator. RJD performed within the proficient range on the following tests:  Nursing staff properly completed the initial health screening form on the same day the patient arrived for 26 of 30 patients sampled who transferred into the institution (87 percent). For three of the patient screenings, nurses did not answer all of the necessary questions. For one of the other patients screened, the nurse did not complete the initial health screening form on the same day the patient arrived (MIT 6.001). For all of the 30 sampled patients who transferred into the institution, nurses completed the assessment and disposition sections of the screening form on the same day that they performed the initial health screening (MIT 6.002). The institution scored in the adequate range on the following test:  Of the 30 sampled patients who transferred into the institution, 19 had an existing medication order that RJD should have administered or delivered without interruption. Of those 19 patients, 15 (79 percent) received their medications timely. Four patients did not receive their medication at the next required dosing interval; all four received their medication one day late (MIT 6.003). The institution scored in the inadequate range on the following tests:  Inspectors sampled 20 patients who transferred out of RJD to another CDCR institution to determine whether RJD listed their scheduled specialty service appointments on the transfer form. RJD nursing staff correctly listed the pending specialty services for 14 of 20 patients sampled (70 percent) (MIT 6.004).  Among transfer packages of seven patients transferring out of the facility, five (71 percent) included required medications and support documentation. Two of the patients who transferred from RJD to another institution did not have their required KOP medications in their transfer packages (MIT 6.101). Recommendations The OIG recommends that medical leadership at RJD continue monitoring the efficacy of processes put in place to ensure RJD medical staff appropriately manages patients upon their return from hospitals. The OIG recommends that RJD nursing staff document in the medical records the communication with community hospital nurses. Richard J. Donovan Correctional Facility, Cycle 4 Medical Inspection Page 31 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, Inadequate encompassing the process from the written prescription to the Compliance Score: administration of the medication. By combining both a quantitative Inadequate (70.4%) 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 prescriber, staff, and patient. Case Review Results The OIG clinicians evaluate pharmacy and medication management as secondary processes as they relate to the quality of clinical care provided. Compliance testing is a more targeted approach and is heavily relied on for the overall rating for this indicator. During case review, 90 deficiencies were related to pharmacy and medication management, 12 of which were significant and increased the risk for harm to patients. Medication Administration There were several occasions of inappropriately managed medications. In some cases, nursing staff dispensed or administered medications late; in other cases, nursing staff did not give medications at all. Minor deficiencies of this nature occurred in eight cases, but four significant deficiencies occurred as follows:  In case 8, a five-day course of a medication to stimulate growth of white blood cells to help the body fight infections was ordered but not administered to this patient undergoing chemotherapy, which can cause a drop in the white blood cell count. There were also repeated instances of a weekly dose medication not being administered.  In case 9, the patient requested his medications and eye drops be nurse-administered (NA) as he had trouble remembering to take his medications, and had difficulty self-administering the eye drops. Following this request, it was unclear why the orders for these medications repeatedly oscillated from NA to KOP.  In case 16, antibiotics ordered “stat,” meaning immediately, were not administered for two days. Richard J. Donovan Correctional Facility, Cycle 4 Medical Inspection Page 32 Office of the Inspector General State of California  In case 20, a provider stopped two medications for heart disease in anticipation of a surgery. Following the surgery, the medications were not restarted for almost two months. The CTC nursing medication reconciliation process failed to ensure provider medication orders were accurately reflected on medication administration records (MARs). An important example of this failure was rescue inhalers for asthma and chronic obstructive pulmonary disease. Although providers prescribed these inhalers to be KOP, the MAR routinely noted them to be NA. This is also discussed below, and in the Specialized Medical Housing indicator. Pharmacy Errors In six cases, rescue inhalers were changed from KOP to NA upon the patient’s admission to the CTC due to some inappropriate pharmacy process. This issue was discussed with the medical leadership during the OIG clinicians’ onsite visit and is further discussed in the Specialized Medical Housing indicator. Medication Continuity Multiple problems related to medication continuity were found. In four cases, nursing staff did not administer or dispense medications to patients transferring to RJD from other CCHCS facilities. Issues with medication continuity were especially prevalent for patients returning from local hospitals. In large part due to inadequate reviews of hospital discharge records, providers oftentimes prescribed recommended medications inaccurately, late, or not at all upon the patients’ return to RJD. This was seen in nine cases. This is further discussed in the Inter- and Intra-System Transfers indicator. Anticoagulation Medication Pharmacy staff performed much of the anticoagulation management. Pharmacists reviewed laboratory anticoagulation values and made appropriate recommendations for adjustments in dosages, subsequent laboratory tests, and follow-ups; providers then ordered the medication adjustments based on the pharmacist recommendations. Conclusion Due to the patterns and high number of deficiencies, the OIG rated the case review portion of the Pharmacy and Medication Management indicator inadequate. Compliance Testing Results The institution received an inadequate compliance score of 70.4 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. Richard J. Donovan Correctional Facility, Cycle 4 Medical Inspection Page 33 Office of the Inspector General State of California Medication Administration In this sub-indicator, the institution received an average score of 69.5 percent, which fell into the inadequate range. The institution scored poorly in the following areas:  Three of the ten sampled patients who were in transit to another institution and were temporarily laid over at RJD received their medications without interruption (30 percent). Seven patients each missed at least one dose of their required medications (MIT 7.006).  The institution timely and correctly administered all required chronic care medications or followed proper protocols for only 21 of 35 patients sampled when they refused or did not show up to receive their medications (60 percent). Many notable instances led to the low score in this sub-indicator, and for some patients sampled there was more than one identified problem area, as follows (MIT 7.001): o Four patients’ DOT MARs indicated they did not show for their medication. o One patient was taking his critical HIV medication by directly observed therapy (DOT), but it is unknown whether the patient actually took them because there was no MAR scanned into the eUHR. o Two patients never received their monthly supply of KOP chronic care medications. o Nine patients missed or refused doses of critical medications and never received medication counseling. o One patient was taking chronic care medications by KOP, then the provider switched the medication to DOT, but the patient did not receive the medications as DOT for seven days. The institution performed in the adequate range on the following test:  RJD timely provided hospital discharge medications to 19 of 25 patients sampled who had returned from a community hospital (76 percent). For five patients, discharge medications were one to six days late, and one patient did not receive his discharge medication at all (MIT 7.003). RJD scored in the proficient range on the following tests:  The institution timely administered or delivered new medication orders to 38 of the 40 patients sampled (95 percent). Two patients received their medications one day late (MIT 7.002).  Among 30 sampled patients at RJD who had transferred from one housing unit to another, 26 (87 percent) received their prescribed medications without interruption. Four patients did Richard J. Donovan Correctional Facility, Cycle 4 Medical Inspection Page 34 Office of the Inspector General State of California not receive their medications by the next dosing interval after the transfer occurred (MIT 7.005). Observed Medication Practices and Storage Controls For this sub-indicator, the institution received an average score of 48.2 percent, scoring in the inadequate range on the following tests:  The OIG interviewed nursing staff and inspected narcotics storage areas at ten applicable locations to assess narcotics security controls, and only two clinic locations (20 percent) were in compliance. At eight other sampled locations, nursing staff did not always complete required control log entries. More specifically, during the OIG’s 30-day review period, log books at seven locations were missing from one to 11 required signature entries, generally relating to shift change narcotics count reconciliations, and nursing staff at one other location did not update the narcotics log after administering the narcotic medication, which resulted a narcotics discrepancy during the physical count (MIT 7.101).  Non-narcotic medications that required refrigeration were properly stored in only 5 of 17 inspected clinics and medication line storage locations (29 percent). Some inspected locations had more than one identified problem area. Deficiencies consisted of the following: eight sampled locations did not have a designated area for return-to-pharmacy medications; four locations had recorded temperatures above or below CCHCS guideline levels; three locations had refrigerators with temperature logs missing entries; another two locations had stored medications beyond the recommended time frame; two locations had refrigeration units that were unsanitary; and one location had an unlocked refrigerator (MIT 7.103).  Nursing staff at only three of eight sampled medication preparation and administration locations followed proper hand hygiene contamination control protocols during the medication preparation and administration processes (38 percent). Nursing staff at three locations did not always sanitize their hands prior to initially putting on protective gloves or between subsequent glove changes, and staff at two other locations did not have an accessible sink to wash their hands (MIT 7.104).  Only three of eight observed medication areas demonstrated appropriate administrative controls and protocols when staff administered medications to patients (38 percent). Nursing staff at two locations did not verify the identification of two patients prior to administering medication, and the nurse at one location did not crush and float medications per the provider’s orders. A nurse at another location administered medication to a patient who did not have an order for it. At one location, neither clinical staff nor custody staff verified that patients taking medications by DOT had swallowed their medication. Lastly, two clinic locations did not have an adequate overhang at the medication line to protect patients from extreme heat and inclement weather (MIT 7.106). Richard J. Donovan Correctional Facility, Cycle 4 Medical Inspection Page 35 Office of the Inspector General State of California  Non-narcotic medications that did not require refrigeration were properly stored at only 13 of 20 applicable clinics and medication line storage locations (65 percent). Inspected locations had one or more of the following deficiencies: five locations had opened bottles of medications that were not labeled with the date opened; one location had expired medication on hand; two locations did not have a designated area for return-to-pharmacy medications; and one location stored internal and external medications together (MIT 7.102). RJD scored in the proficient range on the following test:  Nursing staff at all eight of the inspected medication and preparation administration locations followed appropriate administrative controls and protocols during medication preparation (MIT 7.105). Pharmacy Protocols For this sub-indicator, the institution received an average score of 98.0 percent, scoring in the proficient range in the following test areas:  RJD’s main pharmacy followed general security, organization, and cleanliness management protocols; properly stored non-refrigerated and refrigerated or frozen medications; and maintained adequate controls and properly accounted for narcotic medications (MIT 7.107, 7.108, 7.109, 7.110).  RJD’s pharmacist in charge timely processed 27 out of 30 sampled medication error reports and related monthly statistical reports (90 percent). One medication error report was completed one day late, and the related monthly statistical report for the same month did not properly report the number of level 4 errors for the month. The monthly statistical report for another month was not shared with the applicable quality improvement committees (MIT 7.111). Non-Scored Tests  In addition to the OIG’s testing of reported medication errors, inspectors follow up with institution management about any significant medication errors that were found during the case reviews or compliance testing to determine whether the errors were properly identified and reported. The OIG provides those results for information purposes only. At RJD, the OIG did not find any applicable medication errors (MIT 7.998).  The OIG tested patients in isolation units to determine if they had immediate access to their prescribed KOP rescue asthma inhalers or nitroglycerin medications, and identified 18 patients whom this test applied. Inspectors found that 17 of the patients had possession of their prescribed inhalers or nitroglycerin medications. One patient stated he did not have his prescribed nitroglycerin, and inspectors immediately notified the institution’s CEO. The Richard J. Donovan Correctional Facility, Cycle 4 Medical Inspection Page 36 Office of the Inspector General State of California CEO took immediate action and made contact with the patient, who then admitted to the CEO that he actually had his rescue medication in his possession (MIT 7.999). Recommendation The OIG recommends that RJD ensure rescue medications such as rescue inhalers and sublingual nitroglycerin are dispensed to patients as KOP and not nurse administered. Richard J. Donovan Correctional Facility, 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 (60.4%) 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 60.4 percent. The institution scored in the inadequate range on the following tests:  The institution scored 17 percent in conducting annual tuberculosis screenings. Although RJD screened all 30 patients sampled for tuberculosis within the prior year, zero of the 15 patients identified as Code 22 (requiring a tuberculosis skin test in addition to screening of signs and symptoms) were properly tested. For all 15 of these patients, inspectors identified one or more of the following errors: the 48-to-72-hour window to read test results was not clear because nursing staff did not document either the administered (start) or read (end) date and time; an LVN read the test results rather than a registered nurse, public health nurse, or provider; or nursing staff did not complete all required sections of the Tuberculin Testing/Evaluation Report (CDCR Form 7331). In addition, 10 of the 15 patients identified as Code 34 (requiring only a signs and symptoms screening) did not receive a proper evaluation because nursing staff did not properly complete the history section of the TB form. For one of the ten patients, the history section of the TB form was completely blank (MIT 9.003).  RJD scored 33 percent in regard to the timely administration of TB medications. Of six patients sampled, two received all required doses of their medications in the most recent 3-month or 12-week period. Four patients did not receive all of their TB medications and did not receive provider counseling regarding missed doses (MIT 9.001). Of the six patients tested that were taking TB medications, only two of them (33 percent) received timely monthly or weekly monitoring while taking TB medications. One patient did not receive monthly monitoring for two months. Three other patients received all the required monitoring, but the monitoring forms were not scanned into the eUHR after each monitoring visit (MIT 9.002). Richard J. Donovan Correctional Facility, Cycle 4 Medical Inspection Page 38 Office of the Inspector General State of California The institution scored in the adequate range on the following test:  The OIG tested whether RJD offered required influenza, pneumonia, and hepatitis vaccinations to patients who suffered from chronic conditions; 19 of the 24 patients sampled (79 percent) received or were offered the vaccinations. The institution did not offer five patients one or more of the vaccinations (MIT 9.008). The institution scored in the proficient range on the following two areas:  All 30 patients sampled timely received or were offered influenza vaccinations during the most recent influenza season (MIT 9.004).  All 30 patients sampled timely received or were offered colorectal cancer screenings subject to the annual screening requirement, or had a normal colonoscopy within the last 10 years (MIT 9.005). Recommendations No specific recommendations. Richard J. Donovan Correctional Facility, 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 requests, 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 health care services 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) are reported under the Specialized Medical Housing indicator. Nursing services provided in the triage and treatment area (TTA) or related to emergency medical responses are reported under Emergency Services. Case Review Results The OIG evaluated 766 nursing encounters during case review, of which 491 were outpatient nursing encounters. In general, nursing performed well. In all, 144 deficiencies were found in outpatient nursing services, the majority of which were unlikely to contribute to patient harm. Nevertheless, these deficient areas are clearly established in CCHCS policy as requirements for nursing care and, therefore, require quality improvement strategies. Three cases (7, 8, and 16) did display deficiencies with the potential for adverse outcomes or unnecessary delays in needed health care services, as identified below. Outpatient Nursing Encounters The majority of outpatient nursing encounters appropriately assessed complaints and symptoms, and provided necessary interventions for patients presenting with medical issues. The quality of nursing performance was affected by patterns of deficiencies that included poor assessment, improper interventions based on assessment, and inadequate nursing documentation, as identified in the cases below:  In case 7, the patient, who had a history of respiratory failure, tracheal stenosis (narrowing of the windpipe), asthma, and chronic obstructive pulmonary disease (COPD), was seen for Richard J. Donovan Correctional Facility, Cycle 4 Medical Inspection Page 40 Office of the Inspector General State of California throat pain, nasal congestion, and cough. He complained his tracheal stent (tube to keep his airway open) was moving. The nurse failed to assess the patient’s rescue inhaler use and did not contact a provider or initiate a provider referral. On a separate occasion, the patient’s blood pressure was elevated at 138/109, but the LVN failed to contact a provider or nurse and to recheck the patient’s blood pressure.  In case 8, the patient complained of abdominal pain and diarrhea. The triage nurse failed to perform a same-day face-to-face evaluation. The next day, the patient reported having had abdominal pain and diarrhea for three days, his pulse was 112 beats a minute, and his blood pressure was low at 98/62. He had decreased lung sounds and localized edema (swelling). Fortunately, RJD staff transferred the patient to the TTA, and ultimately transported by ambulance to the hospital.  In case 9, the patient’s abdomen was distended and the nurse noted dizziness related to liver issues with possible hepatic encephalopathy (loss of brain function due to a damaged liver) and provided hepatic encephalopathy educational information, but the patient did not have a history of liver disease. The nurse did not further assess the patient’s abdominal distention and dizziness.  In case 43, the diabetic patient had throat pain and hoarseness. He attributed his symptoms to heartburn. The nurse failed to assess the patient for initial onset and frequency of symptoms; did not assess for associated symptoms such as nausea, vomiting, and epigastric pain; and failed to assess non-steroidal anti-inflammatory medication use and whether prescribed antacids improved symptoms. The nurse inappropriately advised the patient to gargle with warm water and did not initiate a follow-up appointment. Wound Care On several occasions, nurses failed to document thorough wound care and assessment and failed to provide appropriate interventions, including notifying providers. Often, nurses did not document wound size, but even when they did, the documentation was often inconsistent. Nursing staff also did not document the condition of surrounding skin or characteristics of drainage.  In case 16, a diabetic patient was receiving wound care. When an additional toe wound was noted, the nurse did not document the size and appearance of the wound, and a provider was not contacted. Instead, nursing staff started wound care without provider orders.  In case 19, the diabetic patient had a knee wound following an incision and drainage procedure. Wound assessments and documentation were often inconsistent. An initial wound description was not completed, and some wound assessments noted more than one wound while others noted just one wound. On several occasions, the nurse did not document the wound size and drainage characteristics. Richard J. Donovan Correctional Facility, Cycle 4 Medical Inspection Page 41 Office of the Inspector General State of California  In case 20, the diabetic patient was receiving wound care. Initially, nursing staff noted the wound was healing. However, soon thereafter, the nurse noted the wound to be red and swollen and to have drainage and decreased sensation. The nurse failed to notify a provider of this change. Medication Administration On several occasions, nursing staff did not administer new outpatient medication orders within required time frames. There were instances when provider orders indicated medication line nurses were notified of the orders, but nursing follow-up did not occur when medications or medication records were not received. This is also discussed in the Pharmacy and Medication Management indicator. These types of errors occurred in cases 7, 9, 16, 18, 20, 25, and the following:  In case 8, an order to discontinue warfarin and begin aspirin was sent to the medication line. The nurse discontinued warfarin, but aspirin was not started. On a separate occasion, an RJD provider ordered filgrastim (bone marrow stimulant prescribed after chemotherapy), but not administered. Clinician Onsite Visit The nursing staff expressed satisfaction with their leadership and worked well with providers. The outpatient nurses were active participants in the primary care team morning huddles, where the discussion topics included the current hospital census, intra-system transfers, and newly discharged TTA patients. Staff also brought forward and addressed specific patient concerns. The medication line nurses verbalized having good communication with the medical clinic providers and nurses. They reported receiving new medications orders electronically, which were reconciled with incoming medications and MARs. Recommendation The OIG recommends that RJD educate on and monitor nurses’ wound care assessments and documentation. Richard J. Donovan Correctional Facility, 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: performed entirely by OIG physicians. There is no compliance Adequate testing component associated with this quality indicator. Case Review Results The OIG clinicians reviewed 428 medical provider encounters and identified 169 deficiencies related to provider performance. Of these 169 deficiencies, 38 increased the risk of harm to patients. The providers generally performed well managing complex medical patients. Providers usually made sound and accurate diagnoses, and treatment plans were appropriate. While review of medical records was not always thorough, provider performance as it related to emergency care, chronic care, and specialty services was generally adequate. The main issue found with health information management by providers was the use of legacy notes. Pharmacy and medication management by providers was adequate. Despite the relatively high number of deficiencies noted, taking into account the complexity of patients and the fact that the majority of deficiencies were due to inadequate review of records and use of legacy notes, the OIG clinicians rated this indicator adequate. Assessment and Decision-Making The assessment and decision-making by RJD providers was generally appropriate. The majority of deficiencies in this subcategory were inappropriately lengthy follow-up intervals, found in cases 7, 8, 10, 21, 31, and 32. Examples of other isolated deficiencies are as follows:  In case 12, the provider noted the patient’s high blood pressure was “under control” when, in fact, it was significantly elevated at 188/85.  In case 31, the provider noted the patient’s diabetes was “very well controlled,” when, in fact, a recent blood test showed it was not.  In case 32, the provider did not document a testicular exam for a patient complaining of testicular pain. Review of Records Approximately one-third of the provider deficiencies were related to inadequate review of records. Multiple deficiencies involved inadequate reviews of diagnostic reports, provider and nursing Richard J. Donovan Correctional Facility, Cycle 4 Medical Inspection Page 43 Office of the Inspector General State of California progress notes, medication reconciliation and administration records, hospital records, and specialty reports.  In case 7, the provider did not correctly order hospital discharge recommendations for various medications. Providers incorrectly noted medications the patient was taking and failed to note that the patient had repeatedly requested inhalers that the provider had prescribed but the patient had not received.  In case 8, aspirin was restarted despite a positive stool test for blood and a hospital discharge report recommending that aspirin not be restarted. A separate hospital discharge report recommended two medications for adrenal insufficiency; these were not prescribed. This case is also discussed in the Inter- and Intra-System Transfers indicator.  In case 9, medication orders changed from NA to KOP and back several times. Had providers reviewed the chart, they would have noted that a provider ordered the medications NA because the patient reported that he forgot to take his medication when the medication was prescribed as KOP. Emergency Care Provider performance related to emergency care was generally adequate. There were eight deficiencies out of the 56 TTA encounters reviewed. In general, TTA and on-call providers made accurate assessments and triage decisions and appropriately transferred patients requiring higher levels of care. There were a few exceptions. In two cases, providers failed to consider cardiac causes for chest pain in patients with cardiac risk factors. In three cases, orders for transfer should have been for ACLS instead of for BLS. Chronic Care Provider performance related to chronic care was also generally adequate. While providers demonstrated adequate skills and knowledge in caring for patients with complicated chronic medical issues, there were some exceptions. In two cases, blood sugar logs to monitor diabetes were not reviewed. In two other cases, insulin management was subpar for uncontrolled diabetes. Specialty Services Provider performance related to specialty services was generally adequate, though at times suboptimal. The majority of deficiencies noted were inadequate reviews of specialty reports (discussed above). Other issues included intended referrals noted on progress notes not ordered by providers on order forms, and specialty referrals not always ordered appropriately. More notable examples (also discussed in the Specialty Services indicator) included the following:  In case 12, two referrals for cancer screening tests were inappropriately submitted and approved for this patient, whose life expectancy was less than six months. Richard J. Donovan Correctional Facility, Cycle 4 Medical Inspection Page 44 Office of the Inspector General State of California  In case 15, the patient with newly diagnosed cancer required specialty diagnostic imaging to determine the next course of care. The provider should have submitted the referral for this diagnostic imaging as urgent rather than routine.  In case 17, the provider submitted a routine referral for a patient with possible periorbital shingles. The provider should have submitted the referral as urgent because timely diagnosis and management are critical. Fortunately, the patient was seen by optometry right away.  In case 20, the provider should have submitted referrals for cardiology and cardiac diagnostic tests as urgent rather than routine for this patient with cardiac symptoms. Health Information Management While the majority of progress notes were adequate, a pattern of legacy notes was found in a few cases. These notes were cloned copies of prior notes with few changes made. In some of these cases, portions of the notes were misleading or confusing, and often resulted in inconsistencies in the progress notes. The use of legacy notes can cause confusion for subsequent providers and creates a risk of harm to patients.  In case 6, after the patient’s recent altercation and hospitalization, the provider’s review of systems noted no labored breathing on exertion, no chest pain, and no recent bruising. The subjective portion of the same note noted bruised ribs and pain with deep inspiration.  In case 7, the provider’s review of systems noted the patient denied cough, shortness of breath, and wheezing. However, the patient was being seen for difficulty breathing, and the nurse noted the patient complained of a productive cough.  In case 13, the provider indicated effective communication had been reached with the patient having asked questions and summarized information despite having elsewhere noted the patient was not responding.  In case 25, the progress note indicated the wound had healed, but then the provider ordered daily dressing changes “until healed.”  In two cases, the provider noted stable vital signs after elsewhere noting the patient had refused vital signs. In other cases, while providers noted plans in the progress notes for various orders, they failed to do so by writing them on the order forms. In cases 8 and 33, providers did not order intended laboratory tests; in cases 24 and 28, providers did not order intended referrals to specialists, and in case 42, the provider did not order an intended ultrasound. Richard J. Donovan Correctional Facility, Cycle 4 Medical Inspection Page 45 Office of the Inspector General State of California Pharmacy and Medication Management Pharmacy and medication management by the RJD providers was generally adequate. In the CTC, a pattern was found in which rescue inhalers were NA even though providers had prescribed them as KOP. This appeared to be a pharmacy error, and not a provider error (this is further discussed in the Pharmacy and Medication Management indicator). There were, however, a few instances when patients discharged from the CTC had their rescue inhalers renewed by providers as NA rather than KOP, likely due to an inadequate review of records, noted in cases 2, 7, 24, and the following:  In case 9, the patient’s daily low-dose aspirin taken for prevention of heart attack and stroke was inappropriately stopped when ibuprofen was started.  In case 33, the provider failed to realize the drug interaction between doxycycline and warfarin. This resulted in an increased risk of bleeding. Clinician Onsite Visit During the onsite visit, the OIG clinicians found that the providers were generally content with their work, and felt they were given adequate time and tools necessary to provide appropriate medical care. Providers reported good working relationships with clinic staff and custody. Ancillary services, including laboratory, pharmacy, radiology, and specialty services, generally functioned well. The providers felt well supported by their leadership, and many mentioned that one of the strengths at RJD was the medical leadership. Another strength was the collegiality and camaraderie among the providers. New providers were given a comprehensive orientation over a period of weeks before providing medical care on their own. In addition to shadowing experienced providers in different yards at RJD, new providers rotated through various departments relevant to patient care and were educated on the various processes involved, such as diagnostics, pharmacy, and specialty services. Many providers voiced concern with the volume of phone calls when on call after business hours and on weekends. This was due to the complexity of RJD’s patients, and included the multiple offsite hospital and specialty appointment returns after hours. There was additional concern with the soon-to-open E yard, which was to house approximately 800 inmates, and a dialysis center under construction. Provider meetings occurred at the start of each weekday. During these meetings, providers discussed various issues, including patients addressed by the on-call provider overnight or over the weekend, patients seen in the TTA, and patients transported in and out of the institution. Providers also discussed challenging cases and specialty referrals. Richard J. Donovan Correctional Facility, Cycle 4 Medical Inspection Page 46 Office of the Inspector General State of California The OIG clinicians also observed the morning huddle meetings for two different yards. The issues discussed were comprehensive and pertinent to each yard, following the outline provided by CCHCS to all institutions. Recommendations The OIG recommends that RJD management conduct training for providers in the importance of thorough review of all medical records, including interim nursing notes, medication administration records, and laboratory reports, with special attention to hospital records and specialty reports. The OIG further recommends that leadership audit this process to ensure thorough reviews are completed. The OIG recommends that RJD management conduct training for providers on the dangers of legacy notes and on thorough review of notes to ensure they are consistent and up to date. Richard J. Donovan Correctional Facility, Cycle 4 Medical Inspection Page 47 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 (92.0%) provider and nursing care. RJD’s only specialized medical housing Overall Rating: unit is the Correctional Treatment Center (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 deemed a more accurate reflection of the appropriate overall rating. Case Review Results The CTC at RJD had 28 beds, 14 of which were dedicated to medical care, and the other 14 to mental health care. The OIG reviewed 410 CTC-related events for 11 patients admitted to the CTC for a higher level of supervised medical treatment and monitoring. Of the 189 deficiencies found, 7 were significant (twice each in cases 7 and 33, and once in cases 2, 13, and 32). There were 41 provider deficiencies, 3 of which were significant and increased the risk of harm to patients. There were 120 minor nursing deficiencies identified. Provider Performance The quality of provider performance in the CTC was consistent with the quality of provider performance in general. The majority of the deficiencies in this area involved legacy charting (cloned progress notes) and inadequate review of records. These issues are discussed further in the Health Information Management and Quality of Provider Performance indicators. Nursing Performance The CTC nursing performance was also generally adequate, with some care issues identified at times. The majority of deficiencies found were due to inadequate assessment, intervention, and documentation. On a few occasions specialist recommendations were not acknowledged by nursing staff. While most nursing deficiencies related to the CTC were unlikely to cause patient harm, the number and pattern of these deficiencies is of concern. A few examples are listed below.  In case 7, the patient was admitted to the CTC on several occasions due to respiratory issues. When he had expiratory wheezing, the CTC nurse failed to initiate a breathing treatment and Richard J. Donovan Correctional Facility, Cycle 4 Medical Inspection Page 48 Office of the Inspector General State of California did not reassess lung sounds. Failure to examine the chest for lung sounds was seen throughout this review.  In case 8, the patient with diarrhea had a heart rate of 122 beats per minute (bpm). Reassessment did not occur for six hours, at which time he had a fever of 101.4 °F and a heart rate of 120 bpm. He was subsequently transferred to a higher level of care. After seven days in the hospital for infectious diarrhea, he returned to RJD. The following day, his heart rate was 113 bpm; the nurse failed to reassess the rate and assess for further diarrhea. Two days later, the patient reported diarrhea and his rate was 112 bpm. The nurse failed to assess the frequency of diarrhea, assess oral intake, and assess for dehydration signs.  Case 12 had nearly half of the nursing deficiencies related to the CTC. While the patients’ mental capacity and multiple refusals complicated the care of this complex patient, inadequate documentation suggested assessments and interventions were not attempted (e.g. nurses continued to administer stool softeners for five days while the patient had diarrhea). When staff documented assessments, they were often incomplete. On a different occasion, after a wound care specialist saw the patient, the nurse failed to assess the new wound, and failed to review the specialist’s recommendations. Medication Management Rescue inhalers in the CTC were routinely changed from KOP to NA despite provider orders. This inappropriate practice is discussed in the Pharmacy and Medication Management indicator. Clinician Onsite Visit The OIG clinicians learned RJD had one provider assigned to the CTC beds for continuity of care. In addition to providing medical care to patients residing in the medical beds, the provider also performed consultations for patients residing in the mental health beds. The OIG also learned CTC patients returning from offsite specialty services returned directly to the CTC rather than via the TTA as most other patients did. Therefore, the CTC nurse completed an assessment and review of records rather than the TTA nurse. The CTC nursing supervisor reported the CTC nurse performed nursing care audits monthly. Nursing care plans, changes in level of care and condition, patient education, discharge education, and unusual occurrences were audited for ten patients monthly (five mental health and five medical patients). Clinician Summary RJD provided generally adequate care to patients housed in the CTC. While most deficiencies did not place patients at increased risk of harm, there were a high number of nursing deficiencies (inadequate nursing assessments, interventions, and documentation). Richard J. Donovan Correctional Facility, Cycle 4 Medical Inspection Page 49 Office of the Inspector General State of California Compliance Testing Results The institution received a proficient compliance score of 92.0 percent in the Specialized Medical Housing indicator, which focused on the institution’s CTC. The institution scored in the proficient range on the following tests:  RJD utilized a working call-button system in the CTC, and CTC staff properly documented call-button tests in a daily log. Knowledgeable staff who regularly worked in the CTC collectively indicated that during an emergent event, responding staff could generally access a patient’s room in under one minute, which management determined to be a reasonable response time. As a result, the institution scored 100 percent on this test (MIT 13.101).  For all ten patients sampled, nursing staff timely completed an initial assessment on the day the patient was admitted to the CTC (MIT 13.001).  Providers evaluated all 10 patients within 24 hours of each patient’s admission to the CTC. In addition, providers completed a history and physical within 72 hours of admission to the CTC for all 10 patients sampled (MIT 13.002, 13.003). RJD scored in the inadequate range on the following test:  Providers completed their Subjective, Objective, Assessment, Plan, and Education (SOAPE) notes at the required three-day intervals for six of ten sampled patients (60 percent). For four patients, providers’ SOAPE notes were completed one to two days late (MIT 13.004). Recommendations The OIG recommends that RJD leadership audit and enforce complete, accurate, organized, and timely documentation of up-to-date progress notes by both providers and nursing staff. The OIG recommends that RJD leadership review its current CTC nursing audit process to ensure accuracy of the nurse reviewer, and provide additional training and education when deficiencies are noted. Richard J. Donovan Correctional Facility, Cycle 4 Medical Inspection Page 50 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, (80.7%) 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 442 events related to Specialty Services, the majority of which were specialty consultations and procedures. Other events related to provider and nursing follow-up visits and orders after specialty consultations and procedures. There were 93 deficiencies found in this category, with 11 significant deficiencies (once each in cases 2, 15, 17, 21, and 36; twice in case 28; and four times in case 20). Access to Specialty Services While specialty services were generally provided within adequate time frames for both routine and urgent services, delays in specialty follow-ups occurred in multiple cases. Fortunately, the delays, ranging from days to months, did not significantly affect patient care. In one case, follow-up did not occur:  In case 20, an orthopedic follow-up was ordered due to a leg fracture. At the time of this review, the follow-up had yet to occur, indicating a delay of at least three months. OIG clinicians discussed this issue with the medical leadership at RJD, and a follow-up was scheduled. Nursing Performance Nursing care after an offsite specialty appointment was most often adequate. However, when CTC patients returned directly to the CTC rather than via the TTA, nursing staff did not always thoroughly review the recommendations. On several occasions, the telemedicine nurses failed to provide diagnostic results to the specialist.  In case 2, the patient was admitted to the CTC after a cardiac bypass procedure. A few weeks later, he was seen for an offsite vascular surgery follow-up and then returned directly to the CTC. The CTC nurse failed to perform a return assessment and did not note the specialist appointment at all. The specialist’s concern regarding the cardiac graft function Richard J. Donovan Correctional Facility, Cycle 4 Medical Inspection Page 51 Office of the Inspector General State of California and the specialist’s recommendation for a lower extremity ultrasound were not addressed or ordered. Specialty CTC nursing deficiencies are also discussed in the Specialized Medical Housing indicator.  In case 8, the telemedicine nurse failed to ensure recent laboratory results were available during an oncology appointment. The nurse did not provide a urinalysis result to the urologist.  In case 41, the nurse failed to contact a supervisor or provider when the patient did not receive an urgent CT scan after a custody lockdown. Provider Performance Provider performance as it related to specialty services was generally adequate, though at times suboptimal. Some of the issues noted included providers that did not follow-up on specialty recommendations, providers not documenting why specialty recommendations were not followed, referrals for services noted on progress notes that were never ordered by a provider, and referrals not always being ordered appropriately. Some of these issues were likely due to an inadequate review of records. These issues are also noted in the Health Information Management and Quality of Provider Performance indicators. The more notable examples are again noted here:  In case 12, two referrals for cancer screening tests were inappropriately submitted and approved for this patient with a life expectancy of less than six months.  In case 15, the patient with newly diagnosed cancer required specialty diagnostic imaging to determine the next course of care. The provider should have submitted the referral for diagnostic imaging as urgent rather than routine.  In case 17, the provider submitted a routine referral for a patient with possible periorbital shingles. The referral should have been submitted as urgent because timely diagnosis and management are critical. Fortunately, optometry saw the patient right away.  In case 20, this patient had known heart disease and was experiencing cardiac symptoms. The referrals for cardiology and cardiac diagnostic tests should have been submitted as urgent rather than routine.  In case 28, a provider failed to order an ophthalmology follow-up, although the intent was noted in the progress note. At the time of this review, follow-up still had not occurred for this patient with diabetic retinopathy, glaucoma, and cataracts. Richard J. Donovan Correctional Facility, Cycle 4 Medical Inspection Page 52 Office of the Inspector General State of California Health Information Management Health information management deficiencies related to specialty services included specialty reports that were not found in the eUHR; delays in specialty reports being retrieved, reviewed, and signed by providers; and patient health records and diagnostic reports not being available to specialists. The more serious deficiencies were as follows:  In case 21, the handwritten consult note included recommendations but also that final recommendations and follow-up would be specified in the dictated report. This dictated report was retrieved three months later, which delayed patient care.  In case 36, a patient was to begin chemotherapy following surgery for colon cancer. Possibly due to a consult report being retrieved late, chemotherapy did not begin, and the oncology follow-up did not occur. Compliance Testing Results The institution received an adequate score of 80.7 percent in the Specialty Services indicator. RJD scored in the proficient range on the following tests:  The institution timely denied providers’ specialty services requests for all 20 patients sampled (MIT 14.006).  Providers timely received and reviewed the specialist’s reports within the required time frame for 14 of 15 sampled patients who received a high-priority specialty service as well as for 14 of 15 sampled patients who received a routine specialty service. Both tests resulted in proficient scores of 93 percent. For the high-priority test, one specialist’s report was received three days late; for the routine priority test, the specialists’ report was received 12 days late (MIT 14.002, 14.004).  High-priority specialty service appointments occurred within 14 calendar days of the provider’s order for 13 of the 15 patients sampled (87 percent). Two patients received their specialty services one and two days late (MIT 14.001).  Routine specialty service appointments occurred within the required time frame for 13 of the 15 patients tested (87 percent). One patient received his specialty service 21 days late. Another patient had two specialties services; one was four days late, and the other never occurred (MIT 14.003). The institution scored in the inadequate range in the following areas:  Among 18 patients sampled who had a specialty service denied by the institution’s health care management, only 9 (50 percent) received timely notification of the denied service that included the provider meeting with the patient within 30 days to discuss alternate treatment strategies. For eight patients, the provider’s follow-up visit occurred from 8 to 62 days late, Richard J. Donovan Correctional Facility, Cycle 4 Medical Inspection Page 53 Office of the Inspector General State of California and another patient never received communication regarding his denied service (MIT 14.007).  When patients at one institution have an approved, pending, or scheduled specialty service appointments, and then transfer to a different institution, policy requires that the receiving institution reschedule or provide the patient’s appointment within the required time frame. Of 20 sampled patients who transferred in to RJD with an approved specialty services, only 11 timely received their specialty service appointments (55 percent). Six patients received their specialty appointments from one to 131 days late, and three patients never received their appointment (MIT 14.005). Recommendations The OIG recommends RJD review current processes to ensure access to specialty services occurs timely. The OIG recommends RJD conduct training for providers regarding the appropriateness of routine versus urgent referrals. Richard J. Donovan Correctional Facility, 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 RJD. 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 RJD in June 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 both inadequate. The test questions used to assess compliance for each indicator are detailed in Appendix A. Richard J. Donovan Correctional Facility, 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 Inadequate reporting requirements for adverse/sentinel events and inmate (58.3%) deaths, and whether the institution is making progress toward its Overall Rating: Performance Improvement Work Plan initiatives. In addition, the Inadequate OIG verifies that the Emergency Medical Response Review Committee (EMRRC) performs required reviews and that staff perform required emergency response drills. Inspectors also assess whether the Quality Management Committee (QMC) meets regularly and adequately addresses program performance. For those institutions with licensed facilities, inspectors also verify that required committee meetings are held. Compliance Testing Results The institution scored within the inadequate range in the Internal Monitoring, Quality Improvement, and Administrative Operations indicator, with a compliance score of 58.3 percent. RJD received an inadequate score in the following test areas:  RJD’s 2015 Performance Improvement Work Plan did not include adequate evidence demonstrating the institution’s improvement in achieving targeted performance objectives for any of its five quality improvement initiatives. In general, the work plan included insufficient progress information to demonstrate that, in each of its performance objectives, the institution either improved or reached the targeted level (MIT 15.005).  None of the 12 sampled incident packages reviewed by the EMRRC included the required Emergency Medical Response Review Event Checklist Form (MIT 15.007).  Inspectors reviewed drill packages for three medical emergency response drills conducted in the prior quarter, and all of the packages lacked the completion of required forms. However, the drills did include participation by both health care and custody staff (MIT 15.101).  Inspectors reviewed RJD’s local governing body (LGB) meeting minutes to determine if the LGB met quarterly to exercise its responsibility for the quality management of patient health care. However, the LGB only met during two of the four most recent quarters; there was no LGB meeting during the July 2015 to September 2015 quarter or the October 2015 to December 2015 quarter. The January 2016 meeting did not discuss general management and planning, and the next meeting did not timely approve the minutes. RJD scored 25 percent on this test (MIT 15.006). Richard J. Donovan Correctional Facility, Cycle 4 Medical Inspection Page 56 Office of the Inspector General State of California The institution scored in the proficient range on each of the following tests:  RJD processed inmate medical appeals timely for all 12 of the most recent months. In addition, inspectors sampled ten second level inmate medical appeals and found that all of the appeal responses addressed the inmate’s initial complaint (MIT 15.001, 15.102).  Inspectors reviewed six recent months of QMC meeting minutes and confirmed that RJD’s QMC did meet monthly. During those meetings, the QMC evaluated program performance and took action when it identified improvement opportunities. Consequently, RJD received a score of 100 percent on this test (MIT 15.003). Additionally, RJD scored 100 percent regarding taking adequate steps to ensure the accuracy of its Dashboard data reporting (MIT 15.004).  Medical staff promptly submitted the Initial Inmate Death Report (CDCR Form 7229A) to the CCHCS Death Review Unit for the ten applicable deaths that occurred at RJD in the prior 12-month period (MIT 15.103). Other Information Obtained from Non-Scored Areas  The OIG gathered non-scored data regarding the completion of death review reports. CCHCS’s Death Review Committee (DRC) did not timely complete its death review summary for any of the ten deaths that occurred during the testing period. The DRC is required to complete a death review summary within 30 business days for deaths that occurred prior to November 2015, and within either 30 or 60 calendar days for deaths that occurred after November 1, 2015 (depending on whether the death was expected or unexpected). The DRC then notifies the institution’s CEO of the review results so that any needed corrective action can be promptly pursued. For five of the ten inmate deaths tested, the committee completed its summary from 25 to 46 days late (55 to 76 days after the death) and then notified the institution’s CEO of the review results from 2 to 13 days after that. For one inmate, the death review was completed timely, but the CEO was notified 35 days late. However, for four patients’ deaths, there was no final report issued; therefore, the CEO had yet to be notified of the review results. As of the time of this report, all four death reports were late (MIT 15.996).  Inspectors met with the institution’s CEO to inquire about RJD’s protocols for tracking appeals. The institutions management team received from CCHCS a weekly report as well as a monthly report, in which appeals were broken down by category. RJD management reviewed the reports and responded accordingly. The CEO reported that RJD received the greatest number of appeals related to pain management, specifically patients requesting an increase in narcotic medication for pain. In response to this, RJD developed a pain management consultation meeting, which included medical personnel and the patient to discuss the patient’s concerns (MIT 15.997). Richard J. Donovan Correctional Facility, Cycle 4 Medical Inspection Page 57 Office of the Inspector General State of California  Non-scored data gathered regarding RJD’s practices for implementing local operating procedures (LOPs) indicated that the institution had an effective process in place for developing LOPs. The Chief Support Executive stated the institution had an LOP workgroup that met with the appropriate stakeholders to review each LOP annually. After the LOP was signed, it was sent to the QMC committee. Once the QMC approved of the revised LOP, an email was then sent out to staff informing them of the change. The LOP was also placed in the institution’s shared drive, to allow RJD staff access to the revised LOP. At the time of the OIG’s inspection, RJD had implemented all 49 applicable LOPs relating to the core topical areas recommended by the clinical experts who helped develop the OIG’s medical inspection compliance program (MIT 15.998).  The OIG discusses the institution’s health care staffing resources in the About the Institution section on page 2 of this report (MIT 15.999). Recommendations No specific recommendations. Richard J. Donovan Correctional Facility, 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 (67.5%) 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 67.5 percent in the Job Performance Training, Licensing, and Certifications indicator, scoring in the inadequate range on the following four tests:  When the institution hires new nursing staff, it is required to provide new employee orientation within 30 days of their being hired. However, RJD did not timely provide new employee orientation for 18 new nurses hired in the most recent 12 months. As a result, the institution scored zero in this test area (MIT 16.107).  Inspectors examined records to determine if nursing supervisors completed the required number of monthly performance reviews for subordinate nurses and discussed the results of those reviews. The OIG sampled reviews completed for five subordinate nurses. Four of the five nurses had the required number of reviews completed by their supervisors, but only two were complete. In two instances, the nursing supervisor failed to address the positive, well-performed aspects of the employee’s performance. Finally, for one nurse, there was no signature proof that the findings or review itself was discussed with the nurse (40 percent) (MIT 16.101).  Four of the ten nurses sampled (40 percent) were current on their clinical competency validations. Six nurses did not receive a clinical competency validation within the required time frame (MIT 16.102).  OIG inspectors examined provider, nursing, and custody staff records to determine if the institution ensured that those staff members had current emergency response certifications. RJD’s provider and nursing staff were all compliant, but custody staff did not always have current certifications. Specifically, managerial custody officers above the rank of captain did not have current certifications. Although the California Penal Code exempts those 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 inspection area (MIT 16.104). Richard J. Donovan Correctional Facility, Cycle 4 Medical Inspection Page 59 Office of the Inspector General State of California While RJD scored low in the areas above, it received proficient scores in the following test areas:  OIG inspectors found that 14 of 15 providers (93 percent) received timely clinical performance evaluations. However, one provider (the chief physician and surgeon), who periodically performed patient evaluations, did not receive a performance evaluation (MIT 16.103).  All providers were current with their professional licenses, and nursing staff and the pharmacist in charge were current with their professional licenses and certification requirements (MIT 16.001, 16.105).  The pharmacy and providers who prescribed controlled substances had current Drug Enforcement Agency registrations (MIT 16.106). Recommendations No specific recommendations. Richard J. Donovan Correctional Facility, 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 the Richard J. Donovan Correctional Facility, nine HEDIS measures were selected and are listed in the following RJD 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. Richard J. Donovan Correctional Facility, 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. RJD performed very well with its management of diabetes. When compared statewide, RJD outperformed Medi-Cal in all five measures, and outperformed Kaiser in four of five diabetic measures selected. Kaiser South performed 4 percentage points higher than RJD for eye exams. When compared nationally, RJD outperformed Medicaid, Medicare, and commercial health plans in all five diabetic measures. RJD outscored the United States Department of Veterans Affairs (VA) in three of the applicable measures, but scored 13 percentage points lower than the VA in diabetic eye exams. Immunizations Comparative data for immunizations was only fully available for the VA and partially available for Kaiser, commercial plans, and Medicare. With respect to administering influenza vaccinations to younger adults, RJD outperformed all Statewide and national plans. For administering influenza vaccinations to older adults, the institution scored lower than Medicare by 1 percentage point, and the VA by 5 percentage points. However, the institution’s score was negatively affected by the 29 percent refusal rate. With regard to administering pneumococcal vaccines to older adults, RJD scored higher than Medicare, but 9 percentage points lower than the VA. Cancer Screening With respect to colorectal cancer screening, RJD scored higher than all health care plans, statewide and nationally, by more than 4 percentage points. Summary RJD’s population-based metrics performance reflected an adequate chronic care program, corroborated by the institutions adequate ratings in Quality of Provider Performance, Access to Care, and Quality of Nursing Performance indicators. The institution may improve its scores for immunizations by reducing patient refusals through patient education. Richard J. Donovan Correctional Facility, Cycle 4 Medical Inspection Page 62 Office of the Inspector General State of California RJD Results Compared to State and National HEDIS Scores California National HEDIS Clinical Measures RJD Kaiser HEDIS HEDIS HEDIS (No. Kaiser HEDIS Com- HEDIS VA Cycle 4 Medi-Cal CA) (So.CA) 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 15% 39% 18% 24% 44% 31% 25% 19% HbA1c Control (<8.0%)6 75% 49% 70% 62% 47% 58% 65% - Blood Pressure Control (<140/90)6 90% 63% 84% 85% 62% 65% 65% 78% Eye Exams 77% 53% 69% 81% 54% 56% 69% 90% Immunizations Influenza Shots - Adults (18–64) 65% - 54% 55% - 50% - 58% Influenza Shots - Adults (65+) 71% - - - - - 72% 76% Immunizations: Pneumococcal 84% - - - - - 70% 93% Cancer Screening Colorectal Cancer Screening 86% - 80% 82% - 64% 67% 82% 1. Unless otherwise stated, data was collected in June 2016 by reviewing medical records from a sample of RJD’s population of applicable inmate-patients. These random statistical sample sizes were based on a 95 percent confidence level with a 15 percent maximum margin of error. 2. HEDIS Medi-Cal data was obtained from the California Department of Health Care Services 2015 HEDIS Aggregate Report for Medi-Cal Managed Care. 3. Data was obtained from Kaiser Permanente November 2015 reports for the Northern and Southern California regions. 4. National HEDIS data for Medicaid, commercial plans, 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 plans were based on data received from various health maintenance organizations. 5. The Department of Veterans Affairs (VA) data was obtained from the VA’s website, www.va.gov. For the Immunizations: Pneumococcal measure only, the data was obtained from the VHA Facility Quality and Safety Report - Fiscal Year 2012 Data. 6. For this indicator, the entire applicable RJD 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. Richard J. Donovan Correctional Facility, Cycle 4 Medical Inspection Page 63 Office of the Inspector General State of California APPENDIX A — COMPLIANCE TEST RESULTS Richard J. Donovan Correctional Facility Range of Summary Scores: 58.33% - 92.00% Indicator Compliance Score (Yes %) Access to Care 89.54% Diagnostic Services 88.40% Emergency Services Not Applicable Health Information Management (Medical Records) 58.57% Health Care Environment 82.58% Inter- and Intra-System Transfers 81.41% Pharmacy and Medication Management 70.44% Prenatal and Post-Delivery Services Not Applicable Preventive Services 60.42% Quality of Nursing Performance Not Applicable Quality of Provider Performance Not Applicable Reception Center Arrivals Not Applicable Specialized Medical Housing (OHU, CTC, SNF, Hospice) 92.00% Specialty Services 80.71% Internal Monitoring, Quality Improvement, and Administrative Operations 58.33% Job Performance, Training, Licensing, and Certifications 67.50% Richard J. Donovan Correctional Facility, 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 33 7 40 82.50% 0 inmate-patient’s most 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 15 14 29 51.72% 1 CDCR 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 29 1 30 96.67% 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 11 1 12 91.67% 18 referral to 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 5 0 5 100.00% 25 provider 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 28 2 30 93.33% 0 community hospital: Did the inmate-patient receive a follow-up appointment within the required time frame? 1.008 Specialty service follow-up appointments: Do specialty 27 3 30 90.00% 0 service primary care physician follow-up visits occur within required time frames? 1.101 Clinical appointments: Do inmate-patients have a 6 0 6 100.00% 0 standardized process to obtain and submit health care services request forms? Overall percentage: 89.54% Richard J. Donovan Correctional Facility, 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 10 0 10 100.00% 0 time frame specified in the provider’s order? 2.002 Radiology: Did the primary care provider review and initial 9 1 10 90.00% 0 the diagnostic report within specified time frames? 2.003 Radiology: Did the primary care provider communicate the 9 1 10 90.00% 0 results of the diagnostic study to the inmate-patient within specified time frames? 2.004 Laboratory: Was the laboratory service provided within the 9 1 10 90.00% 0 time frame specified in the provider’s order? 2.005 Laboratory: Did the primary care provider review and 9 1 10 90.00% 0 initial the diagnostic report within specified time frames? 2.006 Laboratory: Did the primary care provider communicate 9 1 10 90.00% 0 the results of the diagnostic study to the inmate-patient within specified time frames? 2.007 Pathology: Did the institution receive the final diagnostic 9 1 10 90.00% 0 report within the required time frames? 2.008 Pathology: Did the primary care provider review and initial 8 1 9 88.89% 1 the diagnostic report within specified time frames? 2.009 Pathology: Did the primary care provider communicate the 6 3 9 66.67% 1 results of the diagnostic study to the inmate-patient within specified time frames? Overall percentage: 88.40% Emergency Services Scored Answers Assesses reaction times and responses to emergency situations. Not Applicable Richard J. Donovan Correctional Facility, 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 9 1 10 90.00% 0 forms, and health care services 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 6 14 20 30.00% 0 within five calendar days of the inmate-patient encounter date? 4.003 Are specialty documents scanned into the eUHR within the 19 1 20 95.00% 0 required time frame? 4.004 Are community hospital discharge documents scanned into 11 9 20 55.00% 0 the eUHR within three calendar days of the inmate-patient date of hospital discharge? 4.005 Are medication administration records (MARs) scanned into 12 8 20 60.00% 0 the eUHR within the required time frames? 4.006 During the eUHR review, did the OIG find that documents 0 12 12 0.00% 0 were correctly labeled and included in the correct inmate-patient’s file? 4.007 Did clinical staff legibly sign health care records, when 23 9 32 71.88% 0 required? 4.008 For inmate-patients discharged from a community 20 10 30 66.67% 0 hospital: Did the preliminary hospital discharge report include key elements and did a PCP review the report within three calendar days of discharge? Overall percentage: 58.57% Richard J. Donovan Correctional Facility, 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 12 0 12 100.00% 0 appropriately disinfected, cleaned and sanitary? 5.102 Infection control: Do clinical health care areas ensure that 11 1 12 91.67% 0 reusable invasive and non-invasive medical equipment is properly sterilized or disinfected as warranted? 5.103 Infection Control: Do clinical health care areas contain 10 2 12 83.33% 0 operable sinks and sufficient quantities of hygiene supplies? 5.104 Infection control: Does clinical health care staff adhere to 5 4 9 55.56% 3 universal hand hygiene precautions? 5.105 Infection control: Do clinical health care areas control 12 0 12 100.00% 0 exposure to blood-borne pathogens and contaminated waste? 5.106 Warehouse, Conex and other non-clinic storage areas: 1 0 1 100.00% 0 Does the medical supply management process adequately support the needs of the medical health care program? 5.107 Clinical areas: Does each clinic follow adequate protocols 10 2 12 83.33% 0 for managing and storing bulk medical supplies? 5.108 Clinical areas: Do clinic common areas and exam rooms 8 4 12 66.67% 0 have essential core medical equipment and supplies? 5.109 Clinical areas: Do clinic common areas have an adequate 9 3 12 75.00% 0 environment conducive to providing medical services? 5.110 Clinical areas: Do clinic exam rooms have an adequate 9 3 12 75.00% 0 environment conducive to providing medical services? 5.111 Emergency response bags: Are TTA and clinic emergency 7 2 9 77.78% 3 medical response bags inspected daily and inventoried monthly, and do they contain essential items? 5.999 For Information Purposes Only: Does the institution’s health care management believe that all clinical areas have Information Only physical plant infrastructures sufficient to provide adequate health care services? Overall percentage: 82.58% Richard J. Donovan Correctional Facility, 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 26 4 30 86.67% 0 CDCR 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 30 0 30 100.00% 0 CDCR 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 15 4 19 78.95% 11 CDCR 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 14 6 20 70.00% 0 scheduled specialty service appointments identified on the Health Care Transfer Information Form 7371? 6.101 For inmate-patients transferred out of the facility: Do 5 2 7 71.43% 3 medication transfer packages include required medications along with the corresponding Medication Administration Record (MAR) and Medication Reconciliation? Overall percentage: 81.41% Richard J. Donovan Correctional Facility, Cycle 4 Medical Inspection Page 69 Office of the Inspector General State of California Scored Answers Pharmacy and Medication Yes Reference + Management Number Yes No No Yes % N/A 7.001 Did the inmate-patient receive all chronic care medications within the 21 14 35 60.00% 5 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 38 2 40 95.00% 0 medications to the inmate-patient within the required time frames? 7.003 Upon the inmate-patient’s discharge from a community hospital: 19 6 25 76.00% 5 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 26 4 30 86.67% 0 another: Were medications continued without interruption? 7.006 For inmate-patients en route who lay over at the institution: If the 3 7 10 30.00% 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 2 8 10 20.00% 10 medications: Does the institution employ strong medication security controls over narcotic medications assigned to its clinical areas? 7.102 All clinical and medication line storage areas for non-narcotic 13 7 20 65.00% 0 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 5 12 17 29.41% 3 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 3 5 8 37.50% 12 employ and follow hand hygiene contamination control protocols during medication preparation and medication administration processes? 7.105 Medication preparation and administration areas: Does the 8 0 8 100.00% 12 institution employ appropriate administrative controls and protocols when preparing medications for inmate-patients? 7.106 Medication preparation and administration areas: Does the 3 5 8 37.50% 12 institution employ appropriate administrative controls and protocols when distributing medications to inmate-patients? 7.107 Pharmacy: Does the institution employ and follow general security, 1 0 1 100.00% 0 organization, and cleanliness management protocols in its main and satellite pharmacies? Richard J. Donovan Correctional Facility, Cycle 4 Medical Inspection Page 70 Office of the Inspector General State of California Scored Answers Pharmacy and Medication Yes Reference + Management Number Yes No No Yes % N/A 7.108 Pharmacy: Does the institution’s pharmacy properly store 1 0 1 100.00% 0 non-refrigerated medications? 7.109 Pharmacy: Does the institution’s pharmacy properly store 1 0 1 100.00% 0 refrigerated or frozen medications? 7.110 Pharmacy: Does the institution’s pharmacy properly account for 1 0 1 100.00% 0 narcotic medications? 7.111 Pharmacy: Does the institution follow key medication error 27 3 30 90.00% 0 reporting protocols? 7.998 For Information Purposes Only: During eUHR compliance testing and case reviews, did the OIG find that medication errors were Information Only properly identified and reported by the institution? 7.999 For Information Purposes Only: Do inmate-patients in isolation housing units have immediate access to their KOP prescribed rescue Information Only inhalers and nitroglycerin medications? Overall percentage: 70.44% Prenatal and Post-Delivery Services Scored Answers This indicator is not applicable to this institution. Not Applicable Richard J. Donovan Correctional Facility, 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 2 4 6 33.33% 0 institution administer the medication to the inmate-patient as prescribed? 9.002 Inmate-patients prescribed TB medications: Did the 2 4 6 33.33% 0 institution 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 5 25 30 16.67% 0 TB within the last year? 9.004 Were all inmate-patients offered an influenza vaccination for 30 0 30 100.00% 0 the most recent influenza season? 9.005 All inmate-patients from the age 50 through the age of 30 0 30 100.00% 0 75: Was 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 Not Applicable compliance with policy? 9.007 Female inmate-patients from the age of 21 through the age of 65: Was the inmate-patient offered a pap smear in Not Applicable compliance with policy? 9.008 Are required immunizations being offered for chronic care 19 5 24 79.17% 6 inmate-patients? 9.009 Are inmate-patients at the highest risk of coccidioidomycosis (valley fever) infection transferred out Not Applicable of the facility in a timely manner? Overall Percentage: 60.42% Richard J. Donovan Correctional Facility, 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 Not Applicable evaluate the quality of nursing 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 Not Applicable evaluate the quality of 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 Richard J. Donovan Correctional Facility, 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 10 0 10 100.00% 0 complete 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 10 0 10 100.00% 0 provider for OHU 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 10 0 10 100.00% 0 physical examination completed within 72 hours of admission? 13.004 For all higher-level care facilities: Did the primary care 6 4 10 60.00% 0 provider 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 1 0 1 100.00% 0 properly 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: 92.00% Richard J. Donovan Correctional Facility, 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 13 2 15 86.67% 0 service within 14 calendar days of the PCP order? 14.002 Did the PCP review the high priority specialty service 14 1 15 93.33% 0 consultant report within three business days after the service was provided? 14.003 Did the inmate-patient receive the routine specialty service 13 2 15 86.67% 0 within 90 calendar days of the PCP order? 14.004 Did the PCP review the routine specialty service consultant 14 1 15 93.33% 0 report within three business days after the service was provided? 14.005 For endorsed inmate-patients received from another 11 9 20 55.00% 0 CDCR 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 20 0 20 100.00% 0 specialty services within required time frames? 14.007 Following the denial of a request for specialty services, was 9 9 18 50.00% 2 the inmate-patient informed of the denial within the required time frame? Overall Percentage: 80.71% Richard J. Donovan Correctional Facility, Cycle 4 Medical Inspection Page 75 Office of the Inspector General State of California Scored Answers Yes Internal Monitoring, Quality Improvement, and Reference + Number Administrative Operations Yes No No Yes % N/A 15.001 Did the institution promptly process inmate medical appeals 12 0 12 100.00% 0 during the 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) 6 0 6 100.00% 0 meet at 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 1 0 1 100.00% 0 (QMC) or other forum take steps to ensure the accuracy of its Dashboard data reporting? 15.005 For each initiative in the Performance Improvement Work 0 5 5 0.00% 1 Plan (PIWP), has the institution performance improved or reached the targeted performance objective(s)? 15.006 For institutions with licensed care facilities: Does the 1 3 4 25.00% 0 local 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 0 12 12 0.00% 0 perform timely incident package reviews that include the use of required review documents? 15.101 Did the institution complete a medical emergency response 0 3 3 0.00% 0 drill for 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 10 0 10 100.00% 0 address all of the inmate-patient’s appealed issues? 15.103 Did the institution’s medical staff review and submit the 10 0 10 100.00% 0 initial inmate death report to the Death Review Unit in a timely manner? 15.996 For Information Only: Did the CCHCS Death Review Committee submit its inmate death review summary to the Information Only institution timely? 15.997 For Information Only: Identify the institution’s protocols Information Only for tracking medical appeals. 15.998 For Information Only: Identify the institution’s protocols Information Only for implementing health care local operating procedures. Richard J. Donovan Correctional Facility, Cycle 4 Medical Inspection Page 76 Office of the Inspector General State of California Scored Answers Yes Internal Monitoring, Quality Improvement, and Reference + Number Administrative Operations Yes No No Yes % N/A 15.999 For Information Only: Identify the institution’s health care Information Only staffing resources. Overall Percentage: 58.33% Scored Answers Yes Job Performance, Training, Licensing, Reference + and Certifications Number Yes No No Yes % N/A 16.001 Do all providers maintain a current medical license? 17 0 17 100.00% 0 16.101 Does the institution’s supervising registered nurse conduct 2 3 5 40.00% 0 periodic reviews of nursing staff? 16.102 Are nursing staff who administer medications current on 4 6 10 40.00% 0 their clinical competency validation? 16.103 Are structured clinical performance appraisals completed 14 1 15 93.33% 0 timely? 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 5 0 5 100.00% 1 their professional licenses and certifications? 16.106 Do the institution’s pharmacy and authorized providers who 1 0 1 100.00% 0 prescribe controlled substances maintain current Drug Enforcement Agency (DEA) registrations? 16.107 Are nursing staff current with required new employee 0 1 1 0.00% 0 orientation? Overall Percentage: 67.50% Richard J. Donovan Correctional Facility, Cycle 4 Medical Inspection Page 77 Office of the Inspector General State of California APPENDIX B — CLINICAL DATA Table B-1: RJD Sample Sets Sample Set Total Anticoagulation 3 Death Review/Sentinel Events 5 Diabetes 3 Emergency Services – CPR 5 Emergency Services – Non-CPR 5 High Risk 5 Hospitalization 4 Intra-System Transfers In 3 Intra-System Transfers Out 3 RN Sick Call 25 Specialty Services 5 66 Richard J. Donovan Correctional Facility, Cycle 4 Medical Inspection Page 78 Office of the Inspector General State of California Table B-2: RJD Chronic Care Diagnoses Diagnosis Total Anemia 11 Anticoagulation 5 Arthritis/Degenerative Joint Disease 3 Asthma 13 COPD 17 Cancer 10 Cardiovascular Disease 17 Chronic Kidney Disease 9 Chronic Pain 15 Cirrhosis/End-Stage Liver Disease 3 Coccidioidomycosis 5 Deep Venous Thrombosis/Pulmonary Embolism 3 Diabetes 29 Gastroesophageal Reflux Disease 25 Gastrointestinal Bleed 1 HIV 2 Hepatitis C 16 Hyperlipidemia 28 Hypertension 49 Mental Health 20 Migraine Headaches 1 Seizure Disorder 5 Sleep Apnea 7 Thyroid Disease 5 299 Richard J. Donovan Correctional Facility, Cycle 4 Medical Inspection Page 79 Office of the Inspector General State of California Table B-3: RJD Event — Program Program Total Diagnostic Services 338 Emergency Care 112 Hospitalization 161 Intra-System Transfers in 20 Intra-System Transfers out 16 Not Specified 1 Outpatient Care 873 Specialized Medical Housing 343 Specialty Services 253 2,117 Table B-4: RJD Case Review Sample Summary Total MD Reviews, Detailed 30 MD Reviews, Focused 0 RN Reviews, Detailed 19 RN Reviews, Focused 36 Total Reviews 85 Total Unique Cases 66 Overlapping Reviews (MD & RN) 19 Richard J. Donovan Correctional Facility, Cycle 4 Medical Inspection Page 80 Office of the Inspector General State of California APPENDIX C — COMPLIANCE SAMPLING METHODOLOGY Richard J. Donovan Correctional Facility Sample Category Quality (number of Indicator samples) Data Source Filters Access to Care MIT 1.001 Chronic Care Patients Master Registry  Chronic care conditions (at least one condition per inmate-patient—any risk level) (40)  Randomize MIT 1.002 Nursing Referrals OIG Q: 6.001  See Intra-system Transfers (30) MITs 1.003-006 Nursing Sick Call MedSATS  Clinic (each clinic tested) (5 per clinic)  Appointment date (2–9 months) (30)  Randomize MIT 1.007 Returns from OIG Q: 4.008  See Health Information Management (Medical Community Hospital Records) (returns from community hospital) (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 Richard J. Donovan Correctional Facility, Cycle 4 Medical Inspection Page 81 Office of the Inspector General State of California Sample Category Quality (number of Indicator samples) Data Source Filters Health Information Management (Medical Records) MIT 4.001 Timely Scanning OIG Qs: 1.001,  Non-dictated documents (10) 1.002, & 1.004  1st 10 IPs MIT 1.001, 1st 5 IPs MITs 1.002, 1.004 MIT 4.002 OIG Q: 1.001  Dictated documents (20)  First 20 IPs selected MIT 4.003 OIG Qs: 14.002  Specialty documents (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 5.101-105 Clinical Areas OIG inspector  Identify and inspect all onsite clinical areas. MIT 5.107–111 (12) 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 (10) onsite review Richard J. Donovan Correctional Facility, Cycle 4 Medical Inspection Page 82 Office of the Inspector General State of California Sample Category Quality (number of Indicator samples) Data Source Filters Pharmacy and Medication Management MIT 7.001 Chronic Care OIG Q: 1.001 See Access to Care Medication  At least one condition per inmate-patient—any risk level (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 (8) MITs 7.107-110 Pharmacy OIG inspector  Identify & inspect all onsite pharmacies (1) onsite review MIT 7.111 Medication Error Monthly  All monthly statistic reports with Level 4 or higher Reporting medication error  Select a total of 5 months (30) reports MIT 7.999 Isolation Unit KOP Onsite active  KOP rescue inhalers & nitroglycerin medications Medications medication for IPs housed in isolation units (18) 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) Richard J. Donovan Correctional Facility, Cycle 4 Medical Inspection Page 83 Office of the Inspector General State of California Sample Category Quality (number of Indicator samples) Data Source Filters Preventive Services MITs 9.001–002 TB Medications Maxor  Dispense date (past 9 months)  Time period on TB meds (3 months or 12 weeks) (6)  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 (30)  Condition must require vaccination(s) MIT 9.009 Valley Fever Cocci transfer  Reports from past 2–8 months (number will vary) status report  Institution  Ineligibility date (60 days prior to inspection date) N/A at this institution  All Richard J. Donovan Correctional Facility, Cycle 4 Medical Inspection Page 84 Office of the Inspector General State of California Sample Category Quality (number of Indicator samples) Data Source Filters Reception Center Arrivals MITs 12.001–008 RC SOMS  Arrival date (2–8 months)  Arrived from (county jail, return from parole, etc.) N/A at this institution  Randomize Specialized Medical Housing MITs 13.001–004 CTC CADDIS  Admit date (1–6 months)  Type of stay (no MH beds)  Length of stay (minimum of 5 days) (10)  Randomize MIT 13.101 Call Buttons OIG inspector  Review by location CTC (all) onsite review Specialty Services Access MITs 14.001–002 High-Priority MedSATS  Approval date (3–9 months) (15)  Randomize MITs 14.003–004 Routine MedSATS  Approval date (3–9 months) (15)  Remove optometry, physical therapy or podiatry  Randomize MIT 14.005 Specialty Services MedSATS  Arrived from (other CDCR institution) Arrivals  Date of transfer (3–9 months) (20)  Randomize MIT 14.006-007 Denials InterQual  Review date (3–9 months) (10)  Randomize IUMC/MAR  Meeting date (9 months) Meeting Minutes  Denial upheld (10)  Randomize Richard J. Donovan Correctional Facility, Cycle 4 Medical Inspection Page 85 Office of the Inspector General State of California Sample Category Quality (number of Indicator samples) Data Source Filters Internal Monitoring, Quality Improvement, & Administrative Operations MIT 15.001 Medical Appeals Monthly medical  Medical appeals (12 months) (all) appeals reports MIT 15.002 Adverse/Sentinel Adverse/sentinel  Adverse/sentinel events (2–8 months) Events events report (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) (6) MIT 15.006 LGB LGB meeting  Quarterly meeting minutes (12 months) (4) minutes MIT 15.007 EMRRC EMRRC meeting  Monthly meeting minutes (6 months) (12) minutes MIT 15.101 Medical Emergency Onsite summary  Most recent full quarter Response Drills reports &  Each watch documentation (3) for ER drills MIT 15.102 2nd Level Medical Onsite list of  Medical appeals denied (6 months) Appeals appeals/closed (10) appeals files MIT 15.103 Death Reports Institution-list of  Most recent 10 deaths deaths in prior  Initial death reports (10) 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) Richard J. Donovan Correctional Facility, 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 (17) 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 (15) 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) Richard J. Donovan Correctional Facility, 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 Richard J. Donovan Correctional Facility, Cycle 4 Medical Inspection Page 88 Office of the Inspector General State of California