Richard J. Donovan Correctional Facility Medical Inspection Report Cycle 5

Roy W. Wesley Office of the Inspector General Inspector General Richard J. Donovan Correctional Facility Medical Inspection Results Cycle 5 November 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 5 Roy W. Wesley Inspector General Shaun R. Spillane Public Information Officer November 2017 TABLE OF CONTENTS Foreword ............................................................................................................................................... i Executive Summary ........................................................................................................................... iii Overall Rating: Adequate ............................................................................................................... iii Clinical Case Review and OIG Clinician Inspection Results ................................................. v Compliance Testing Results .................................................................................................. vi Population-Based Metrics .................................................................................................... vii Recommendations ............................................................................................................... vii Introduction ......................................................................................................................................... 1 About the Institution ......................................................................................................................... 1 Objectives, Scope, and Methodology .................................................................................................. 3 Case Reviews ................................................................................................................................... 4 Patient Selection for Retrospective Case Reviews ................................................................. 4 Benefits and Limitations of Targeted Subpopulation Review ................................................ 5 Case Reviews Sampled ........................................................................................................... 5 Compliance Testing .......................................................................................................................... 7 Sampling Methods for Conducting Compliance Testing ....................................................... 7 Scoring of Compliance Testing Results ................................................................................. 8 Overall Quality Indicator Rating for Case Reviews and Compliance Testing ................................. 8 Population-Based Metrics ................................................................................................................ 8 Medical Inspection Results .................................................................................................................. 9 1 — Access to Care ................................................................................................................. 11 Case Review Results ............................................................................................................ 11 Compliance Testing Results ................................................................................................. 13 2 — Diagnostic Services ......................................................................................................... 15 Case Review Results ............................................................................................................ 15 Compliance Testing Results ................................................................................................. 17 3 — Emergency Services ......................................................................................................... 18 Case Review Results ............................................................................................................ 18 4 — Health Information Management..................................................................................... 20 Case Review Results ............................................................................................................ 20 Compliance Testing Results ................................................................................................. 22 5 — Health Care Environment ................................................................................................ 24 Compliance Testing Results ................................................................................................. 24 6 — Inter- and Intra-System Transfers.................................................................................... 27 Case Review Results ............................................................................................................ 27 Compliance Testing Results ................................................................................................. 28 7 — Pharmacy and Medication Management ......................................................................... 30 Case Review Results ............................................................................................................ 30 Compliance Testing Results ................................................................................................. 32 8 — Prenatal and Post-Delivery Services ............................................................................... 36 Richard J. Donovan Correctional Facility, Cycle 5 Medical Inspection Table of Contents Office of the Inspector General State of California 9 — Preventive Services .......................................................................................................... 37 Compliance Testing Results ................................................................................................. 37 10 — Quality of Nursing Performance .................................................................................... 39 Case Review Results ............................................................................................................ 39 11 — Quality of Provider Performance .................................................................................. 43 Case Review Results ............................................................................................................ 43 12 — Reception Center Arrivals .............................................................................................. 46 13 — Specialized Medical Housing ......................................................................................... 47 Case Review Results ............................................................................................................ 47 Compliance Testing Results ................................................................................................. 48 14 — Specialty Services ........................................................................................................... 49 Case Review Results ............................................................................................................ 49 Compliance Testing Results .................................................................................................. 50 15 — Administrative Operations (Secondary) ......................................................................... 52 Compliance Testing Results ................................................................................................. 52 Recommendations.............................................................................................................................. 55 Population-Based Metrics .................................................................................................................. 56 Appendix A — Compliance Test Results .......................................................................................... 59 Appendix B — Clinical Data ............................................................................................................. 72 Appendix C — Compliance Sampling Methodology ........................................................................ 76 California Correctional Health Care Services’ Response .................................................................. 83 Richard J. Donovan Correctional Facility, Cycle 5 Medical Inspection Table of Contents Office of the Inspector General State of California LIST OF TABLES AND FIGURES RJD Executive Summary Table .......................................................................................................... iv RJD Health Care Staffing Resources as of April 2017 ........................................................................ 2 RJD Master Registry Data as of April 10, 2017 .................................................................................. 2 RJD Results Compared to State and National HEDIS Scores ........................................................... 58 Table B-1: RJD Sample Sets ............................................................................................................. 72 Table B-2: RJD Chronic Care Diagnoses .......................................................................................... 73 Table B-3: RJD Event – Program ...................................................................................................... 74 Table B-4: RJD Review Sample Summary ....................................................................................... 75 Richard J. Donovan Correctional Facility, Cycle 5 Medical Inspection List of Tables and Figures Office of the Inspector General State of California This page intentionally left blank. Richard J. Donovan Correctional Facility, Cycle 5 Medical Inspection Office of the Inspector General State of California FOREWORD Pursuant to California Penal Code Section 6126 et seq., which assigns the Office of the Inspector General (OIG) responsibility for oversight of the California Department of Corrections and Rehabilitation (CDCR), the OIG conducts a comprehensive inspection program to evaluate the delivery of medical care at each of CDCR’s 35 adult prisons. The OIG explicitly makes no determination regarding the constitutionality of care in the prison setting. That determination is left to the Receiver and the federal court. The assessment of care by the OIG is just one factor in the court’s determination whether care in the prisons meets constitutional standards. The OIG’s inspections are mandated by the Penal Code and not aimed at specifically resolving the court’s questions on constitutional care. To the degree that they provide another factor for the court to consider, the OIG is pleased to provide added value to the taxpayers of California. In Cycle 5, for the first time, the OIG will be inspecting institutions delegated back to CDCR from the Receivership. There is no difference in the standards used for assessment of a delegated institution versus an institution not yet delegated. At the time of the Cycle 5 inspection of the Richard J. Donovan Correctional Facility inspection, the Receiver had not delegated this institution back to CDCR. This fifth cycle of inspections will continue evaluating the areas addressed in Cycle 4, which included clinical case review, compliance testing, and a population-based metric comparison of selected Healthcare Effectiveness Data Information Set (HEDIS) measures. In agreement with stakeholders, the OIG made changes to both the case review and compliance components. The OIG found that in every inspection in Cycle 4, larger samples were taken than were needed to assess the adequacy of medical care provided. As a result, the OIG reduced the number of case reviews and sample sizes for compliance testing. Also, in Cycle 4, compliance testing included two secondary (administrative) indicators (Internal Monitoring, Quality Improvement, and Administrative Operations; and Job Performance, Training, Licensing, and Certifications). For Cycle 5, these have been combined into one secondary indicator, Administrative Operations. Richard J. Donovan Correctional Facility, Cycle 5 Medical Inspection Page i Office of the Inspector General State of California This page intentionally left blank. Richard J. Donovan Correctional Facility, Cycle 5 Medical Inspection Page ii Office of the Inspector General State of California EXECUTIVE SUMMARY The OIG performed its Cycle 5 medical inspection at Richard J. Donovan Correctional Facility (RJD) from April to June 2017. The OVERALL RATING: inspection included in-depth reviews of 73 patient files conducted by clinicians, as well as reviews of documents from 396 patient Adequate files, covering 90 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 13 health care quality indicators applicable to the institution. To conduct clinical case reviews, the OIG employs a clinician team consisting of a physician and a registered nurse consultant, while compliance testing is done by a team of registered nurses trained in monitoring medical policy compliance. Of the indicators, seven were rated by both case review clinicians and compliance inspectors, three were rated by case review clinicians only, and three were rated by compliance inspectors only. The RJD Executive Summary Table on the following page identifies the applicable individual indicators and scores for this institution. Richard J. Donovan Correctional Facility, Cycle 5 Medical Inspection Page iii Office of the Inspector General State of California RJD Executive Summary Table Cycle 5 Cycle 4 Case Review Compliance Inspection Indicators Overall Overall Rating Rating Rating Rating 1—Access to Care Adequate Proficient Proficient Proficient 2—Diagnostic Services Adequate Inadequate Adequate Adequate 3—Emergency Services Adequate Not Applicable Adequate Inadequate 4—Health Information Inadequate Inadequate Inadequate Inadequate Management 5—Health Care Environment Not Applicable Inadequate Inadequate Adequate 6—Inter- and Intra-System Adequate Adequate Adequate Inadequate Transfers 7—Pharmacy and Medication I Inadequate Inadequate Inadequate n Inadequate Management a 8—Prenatal and Post-Delivery Not Applicable Not Applicable Not Applicable Not Applicable Services 9—Preventive Services Not Applicable Inadequate Inadequate Inadequate 10—Quality of Nursing Adequate Not Applicable Adequate Adequate Performance 11—Quality of Provider Adequate Not Applicable Adequate Adequate Performance 12—Reception Center Arrivals Not Applicable Not Applicable Not Applicable Not Applicable 13—Specialized Medical Housing Adequate Adequate Adequate Adequate 14—Specialty Services Proficient Adequate Adequate Adequate 15—Administrative Operations Not Applicable Proficient Proficient Inadequate* (Secondary) *In Cycle 4, there were two secondary (administrative) indicators. This score reflects the average of those two scores. Richard J. Donovan Correctional Facility, Cycle 5 Medical Inspection Page iv Office of the Inspector General State of California Clinical Case Review and OIG Clinician Inspection Results The clinicians’ case reviews sampled patients with high medical needs and included a review of 1,252 patient care events.1 Of the 13 indicators applicable to RJD, 10 were evaluated by clinician case review; one was proficient, 7 were adequate, and 2 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. Well performing ancillary services are crucial to all medical facilities. For the Cycle 5 medical inspection, the institution performed well with ancillary services, showing strengths in the Access to Care, Diagnostic Services, and Specialty Services indicators. Important provider appointments occurred timely, as did a majority of specialty appointments. In addition, specialty reports were timely retrieved and scanned. Program Strengths — Clinical • RJD provided good access to care. Most provider and nurse appointments occurred timely. Each clinic had a designated staff member who attended daily clinic huddles and coordinated with the providers to ensure all-important follow-up appointments were scheduled. There were minimal backlogs of provider appointments in the five clinics. • Specialty services staff worked closely with custody staff to ensure that escorts were readily available to all offsite specialty appointments. The institution performed very well with specialty services; most specialty appointments were met and specialty reports were retrieved timely and scanned into the electronic medical record. Program Weaknesses — Clinical • The institution performed poorly with medication administration. There were four significant deficiencies related to nurse-administered medications that placed patients at risk of harm. One medication error contributed to a patient’s death. 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 5 Medical Inspection Page v Office of the Inspector General State of California Compliance Testing Results Of the 13 health care indicators applicable to RJD, 10 were evaluated by compliance inspectors.2 They rated two indicators proficient, three adequate, and five inadequate. There were 90 individual compliance questions within those 10 indicators, generating 1,157 data points, that tested RJD’s compliance with California Correctional Health Care Services (CCHCS) policies and procedures.3 Those 90 questions are detailed in Appendix A — Compliance Test Results. Program Strengths — Compliance The following are some of RJD’s strengths based on its compliance scores on individual questions in all applicable health care indicators: • Access to care at RJD was good. Nursing staff reviewed patient health care service requests the same day they were received and saw patients within the required time frames. In addition, patients received timely provider follow-up appointments when they returned from a community hospital and specialty service appointments. • Nursing staff completed the assessment and disposition sections of the initial health care assessment document for all patients tested that transferred into RJD. Also, for patients that transferred out of RJD, nursing staff properly completed the transfer packages with all necessary medication documents. • Patients were offered influenza immunizations and colorectal cancer screenings within required time frames. • Nursing staff completed an initial health assessment for patients admitted to the Correctional Treatment Center (CTC) within required time frames. Providers timely completed history and physical exams. • Patients received their routine specialty service appointments within required time frames and providers timely reviewed the routine specialty reports. • The institution held Quality Management Committee (QMC), Emergency Medical Response Review Committee (EMRRC), and Local Governing Body (LGB) meetings in compliance with CCHCS policy. 2 The OIG’s compliance inspectors are trained registered nurses with expertise in CDCR policies regarding medical staff and processes. 3 The OIG used its own clinicians to provide clinical expert guidance for testing compliance in certain areas where CCHCS policies and procedures did not specifically address an issue. Richard J. Donovan Correctional Facility, Cycle 5 Medical Inspection Page vi Office of the Inspector General State of California Program Weaknesses — Compliance The following are some of the weaknesses identified by RJD’s compliance scores on individual questions in all applicable health care indicators: • RJD providers did not always communicate radiology and pathology results to the patient within the required time frame or did not communicate the results at all. • OIG inspectors found several mislabeled or misfiled patient records in the electronic medical record. • At several clinic locations, clinicians did not practice good hand hygiene by washing their hands before and after patient encounters. Several clinics had poor medical supply management practices; medical supplies were stored beyond the manufacturers’ guidelines, and staff stored personal items with medication supplies. • Several patients did not receive their chronic care medications within required time frames. Patients who transferred from one yard to another yard at RJD did not always receive their prescribed medication at the next dosing interval. OIG inspectors observed poor medication administration practices at several medication lines; nurses did not observe patients taking direct observation therapy (DOT) medications, and failed to sign medication administration records (MARs) before administering medication to patients. • The institution did not always properly administer medications to patients taking tuberculosis (TB) medications. RJD clinicians did not properly monitor those same patients in compliance with CCHCS policy. Recommendations No specific recommendations. Richard J. Donovan Correctional Facility, Cycle 5 Medical Inspection Page vii Office of the Inspector General State of California Population-Based Metrics In general, RJD performed well as measured by population-based metrics. In comprehensive diabetes care, RJD outperformed most statewide and national health care plans in most of the five diabetic measures, but scored less well in a few measures, mainly diabetic eye exams. With regard to influenza immunization measures for both young and older RJD patients, the institution outperformed all health care plans. When administering pneumococcal vaccines, RJD scored similarly to the other reporting entities. RJD scored higher than all health care plans, statewide and nationally with respect to colorectal cancer screening. Overall, RJD performed well in comparison to the statewide and national health care entities reviewed. Richard J. Donovan Correctional Facility, Cycle 5 Medical Inspection Page viii Office of the Inspector General State of California INTRODUCTION Pursuant to California Penal Code Section 6126 et seq., which assigns the Office of the Inspector General (OIG) responsibility for oversight of the California Department of Corrections and Rehabilitation (CDCR), and at the request of the federal Receiver, the OIG developed a comprehensive medical inspection program to evaluate the delivery of medical care at each of CDCR’s 35 adult prisons. The OIG conducts a clinical case review and a compliance inspection, ensuring a thorough, end-to-end assessment of medical care within CDCR. Richard J. Donovan Correctional Facility (RJD) was the 12th medical inspection of Cycle 5. During the inspection process, the OIG assessed the delivery of medical care to patients using the primary clinical health care indicators applicable to the institution. The Administrative Operations indicator is purely administrative and is not reflective of the actual clinical care provided. ABOUT THE INSTITUTION RJD is located in unincorporated San Diego County, near San Diego, and is approximately one and a half miles from the Mexico-United States border. The institution, which opened in July 1987, provides housing for general population and Level I, II, III, and IV inmates. RJD is a CDCR designated institution for inmates with severe mental illness as well as inmates with developmental disabilities. RJD has multiple clinics where medical staff members respond to non-urgent requests for medical services and a treatment and triage area (TTA) to provide urgent and emergent care. The facility has a licensed correctional treatment center (CTC) to provide health care to patients who are in need of professionally supervised health care beyond that normally provided on an outpatient basis. CDCR has designated RJD as 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. 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. Based on staffing data the OIG obtained from the institution, RJD’s vacancy rate among medical managers, primary care providers, supervisors, and rank-and-file nurses was 9 percent in April 2017, with the highest vacancy percentage among primary care providers at 24 percent, which equated to four vacancies out of 16.5 approved positions. As indicated in the following table, RJD had 175 budgeted health care positions, of which 160 were filled. Based on its authorized and filled positions, the institution reported 15 vacant positions. Richard J. Donovan Correctional Facility, Cycle 5 Medical Inspection Page 1 Office of the Inspector General State of California RJD Health Care Staffing Resources as of April 2017 Primary Care Nursing Management Nursing Staff Totals Providers Supervisors Description Number % Number % Number % Number % Number % Authorized 5 3% 16.5 9% 21.3 12% 132.2 76% 175 100% Positions Filled Positions 4 80% 12.5 76% 17.5 82% 126 95% 160 91% Vacancies 1 20% 4 24% 3.8 18% 6.2 5% 15 9% Recent Hires (within 12 1 25% 2 16% 8 41% 29 21% 40 23% months) Staff Utilized 0 0% 9 72% 0 0% 40 29% 49 28% from Registry Redirected Staff (to Non-Patient 0 0% 0 0% 0 0% 0 0% 0 0% Care Areas) Staff on Long-term 0 0% 0 0% 1 5% 5 4% 6 3% Medical Leave Note: RJD Health Care Staffing Resources data was not validated by the OIG. As of April 10, 2017, the Master Registry for RJD showed that the institution had a total population of 3,695. Within that total population, 16.0 percent were designated as high medical risk, Priority 1 (High 1), and 21.9 percent were designated as high medical risk, Priority 2 (High 2). Patients’ assigned risk levels are based on the complexity of their required medical care related to their specific diagnoses, frequency of higher levels of care, age, and abnormal labs and procedures. High 1 has at least two high-risk conditions; High 2 has only one. Patients at high medical risk are more susceptible to poor health outcomes than those at medium or low medical risk. Patients at high medical risk also typically require more health care services than do patients with lower assigned risk levels. The chart below illustrates the breakdown of the institution’s medical risk levels at the start of the OIG medical inspection. RJD Master Registry Data as of April 10, 2017 Medical Risk Level # of Patients Percentage High 1 592 16.0% High 2 809 21.9% Medium 1,773 48.0% Low 521 14.1% Total 3,695 100.0% Richard J. Donovan Correctional Facility, Cycle 5 Medical Inspection Page 2 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 15 indicators (14 primary (clinical) indicators and one secondary (administrative) indicator) of health care to measure. The primary quality indicators cover clinical categories directly relating to the health care provided to patients, whereas the secondary quality indicator addresses the administrative functions that support a health care delivery system. These 15 indicators are identified in the RJD Executive Summary Table on page iv of this report. The OIG rates each of the quality indicators applicable to the institution under inspection based on case reviews conducted by the OIG clinicians and compliance tests conducted by OIG registered nurses. The ratings may be derived from the case review results alone, the compliance test results alone, or a combination of both these information sources. For example, the ratings for the primary quality indicators Quality of Nursing Performance and Quality of Provider Performance are derived entirely from the case review done by clinicians, while the ratings for the primary quality indicators Health Care Environment and Preventive Services are derived entirely from compliance testing done by registered nurse inspectors. As another example, primary quality indicators such as Diagnostic Services and Specialty Services receive ratings derived from both sources. Consistent with the OIG’s agreement with the Receiver, this report only addresses the conditions found related to medical care criteria. The OIG does not review for efficiency and economy of operations. Moreover, if the OIG learns of a patient needing immediate care, the OIG notifies the chief executive officer of health care services and requests a status report. Additionally, if the OIG learns of significant departures from community standards, it may report such departures to the institution’s chief executive officer or to CCHCS. Because these matters involve confidential medical information protected by state and federal privacy laws, specific identifying details related to any such cases are not included in the OIG’s public report. In all areas, the OIG is alert for opportunities to make appropriate recommendations for improvement. Such opportunities may be present regardless of the score awarded to any particular Richard J. Donovan Correctional Facility, Cycle 5 Medical Inspection Page 3 Office of the Inspector General State of California quality indicator; therefore, recommendations for improvement should not necessarily be interpreted as indicative of deficient medical care delivery. CASE REVIEWS The OIG added case reviews to the Cycle 4 medical inspections at the recommendation of its stakeholders, which continues in Cycle 5 medical inspections. The OIG’s clinicians perform a retrospective chart review of selected patient files to evaluate the care given by an institution’s primary care providers and nurses. Retrospective chart review is a well-established review process used by health care organizations that perform peer reviews and patient death reviews. Currently, CCHCS uses retrospective chart review as part of its death review process and in its pattern-of-practice reviews. CCHCS also uses a more limited form of retrospective chart review when performing appraisals of individual primary care providers. Patient Selection for Retrospective Case Reviews Because retrospective chart review is time consuming and requires qualified health care professionals to perform it, the OIG clinicians must carefully sample patient records. Accordingly, the group of patients the OIG targeted for chart review carried the highest clinical risk and utilized the majority of medical services. A majority of the patients selected for retrospective chart review were classified by CCHCS as high-risk patients. The reason the OIG targeted these patients for review is twofold: 1. The goal of retrospective chart review is to evaluate all aspects of the health care system. statewide, high-risk and high-utilization patients consume medical services at a disproportionate rate; 11 percent of the total patient population are considered high-risk and account for more than half of the institution’s pharmaceutical, specialty, community hospital, and emergency costs. 2. Selecting this target group for chart review provides a significantly greater opportunity to evaluate all the various aspects of the health care delivery system at an institution. Underlying the choice of high-risk patients for detailed case review, the OIG clinical experts made the following three assumptions: 1. If the institution is able to provide adequate clinical care to the most challenging patients with multiple complex and interdependent medical problems, it will be providing adequate care to patients with less complicated health care issues. Because clinical expertise is required to determine whether the institution has provided adequate clinical care, the OIG utilizes experienced correctional physicians and registered nurses to perform this analysis. 2. The health of less complex patients is more likely to be affected by processes such as timely appointment scheduling, medication management, routine health screening, and Richard J. Donovan Correctional Facility, Cycle 5 Medical Inspection Page 4 Office of the Inspector General State of California immunizations. To review these processes, the OIG simultaneously performs a broad compliance review. 3. Patient charts generated during death reviews, sentinel events (unexpected occurrences involving death or serious injury, or risk thereof), and hospitalizations are mostly of high-risk patients. Benefits and Limitations of Targeted Subpopulation Review Because the selected patients utilize the broadest range of services offered by the health care system, the OIG’s retrospective chart review provides adequate data for a qualitative assessment of the most vital system processes (referred to as “primary quality indicators”). Retrospective chart review provides an accurate qualitative assessment of the relevant primary quality indicators as applied to the targeted subpopulation of high-risk and high-utilization patients. While this targeted subpopulation does not represent the prison population as a whole, the ability of the institution to provide adequate care to this subpopulation is a crucial and vital indicator of how the institution provides health care to its whole patient population. Simply put, if the institution’s medical system does not adequately care for those patients needing the most care, then it is not fulfilling its obligations, even if it takes good care of patients with less complex medical needs. Since the targeted subpopulation does not represent the institution’s general prison population, the OIG cautions against inappropriate extrapolation of conclusions from the retrospective chart reviews to the general population. For example, if the high-risk diabetic patients reviewed have poorly-controlled diabetes, one cannot conclude that the entire diabetic population is inadequately controlled. Similarly, if the high-risk diabetic patients under review have poor outcomes and require significant specialty interventions, one cannot conclude that the entire diabetic population is having similarly poor outcomes. Nonetheless, the health care system’s response to this subpopulation can be accurately evaluated and yields valuable systems information. In the above example, if the health care system is providing appropriate diabetic monitoring, medication therapy, and specialty referrals for the high-risk patients reviewed, then it can be reasonably inferred that the health care system is also providing appropriate diabetic services to the entire diabetic subpopulation. However, if these same high-risk patients needing monitoring, medications, and referrals are generally not getting those services, it is likely that the health care system is not providing appropriate diabetic services to the greater diabetic subpopulation. Case Reviews Sampled As indicated in Appendix B, Table B–1: RJD Sample Sets, the OIG clinicians evaluated medical charts for 73 unique patients. Appendix B, Table B–4: RJD Case Review Sample Summary, clarifies that both nurses and physicians reviewed charts for 13 of those patients, for 86 reviews in total. Physicians performed detailed reviews of 25 charts, and nurses performed detailed reviews of 13 Richard J. Donovan Correctional Facility, Cycle 5 Medical Inspection Page 5 Office of the Inspector General State of California charts, totaling 38 detailed reviews. For detailed case reviews, physicians or nurses looked at all encounters occurring in approximately six months of medical care. Nurses also performed a limited or focused review of medical records for an additional 47 patients. These generated 1,252 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 73 unique patients sampled included patients with 286 chronic care diagnoses, including 13 additional patients with diabetes (for a total of 16) and one additional anticoagulation patient (for a total of four) (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 found the Cycle 4 medical inspection sample size of 30 for detailed physician reviews far exceeded the saturation point necessary for an adequate qualitative review. At the end of Cycle 4 inspections, the case review results were reanalyzed using 50 percent the number of cases; there were no significant differences in the ratings. To improve inspection efficiency while preserving the quality of the inspection, the samples for Cycle 5 medical inspections were reduced in number. In Cycle 5, for basic institutions with small high-risk populations, case review will use a sample size of detailed physician-reviewed cases 67 percent as large as that used in Cycle 4. For intermediate institutions and basic institutions housing many high-risk patients, case review physicians will use a sample 83 percent as large as that in Cycle 4. Finally, for the most medically complex institution, California Health Care Facility (CHCF), the OIG will continue to use a sample size 100 percent of that used in Cycle 4. With regard to reviewing charts from different providers, the case review is not intended to be a focused search for poorly performing providers; rather, it is focused on how the system cares for those patients who need care the most. Nonetheless, while not sampling cases by each provider at the institution, the OIG inspections adequately review most providers. Providers would only escape OIG case review if institutional management successfully mitigated patient risk by having the more poorly performing providers care for the less complicated, low-utilizing, and lower-risk patients. The OIG’s clinicians concluded that the case review sample size was more than adequate to assess the quality of services provided. Based on the collective results of clinicians’ case reviews, the OIG rated each quality indicator as either proficient (excellent), adequate (passing), inadequate (failing), or not applicable. A separate Richard J. Donovan Correctional Facility, Cycle 5 Medical Inspection Page 6 Office of the Inspector General State of California confidential RJD Supplemental Medical Inspection Results: Individual Case Review Summaries report details the case reviews the OIG clinicians conducted and is available to specific stakeholders. For further details regarding the sampling methodologies and counts, see Appendix B — Clinical Data, Table B–1; Table B–2; Table B–3; and Table B–4. COMPLIANCE TESTING Sampling Methods for Conducting Compliance Testing From April to June 2017, registered nurse inspectors attained answers to 90 objective medical inspection test (MIT) questions designed to assess the institution’s compliance with critical policies and procedures applicable to the delivery of medical care. To conduct most tests, inspectors randomly selected samples of patients for whom the testing objectives were applicable and reviewed their electronic medical records. In some cases, inspectors used the same samples to conduct more than one test. In total, inspectors reviewed health records for 396 individual patients and analyzed specific transactions within their records for evidence that critical events occurred. Inspectors also reviewed management reports and meeting minutes to assess certain administrative operations. In addition, during the week of April 24, 2017, registered nurse 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 1,157 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 Cycle 5 medical inspection testing, the OIG reduced the number of compliance samples tested for 18 indicator tests from a sample of 30 patients to a sample of 25 patients. The OIG also removed some inspection tests upon stakeholder agreement that either were duplicated in the case reviews or had limited value. Lastly, for Cycle 4 medical inspections, the OIG tested two secondary (administrative) indicators; Internal Monitoring, Quality Improvement, and Administrative Operations; and Job Performance, Training, Licensing, and Certifications, and have combined these tests into one Administrative Operations indicator for Cycle 5 inspections. For details of the compliance results, see Appendix A — Compliance Test Results. For details of the OIG’s compliance sampling methodology, see Appendix C — Compliance Sampling Methodology. Richard J. Donovan Correctional Facility, Cycle 5 Medical Inspection Page 7 Office of the Inspector General State of California Scoring of Compliance Testing Results After compiling the answers to the 90 questions for the 10 applicable indicators, the OIG derived a score for each quality indicator by calculating the percentage score of all Yes answers for each of the questions applicable to a particular indicator, then averaging those scores. Based on those results, the OIG assigned a rating to each quality indicator of proficient (greater than 85 percent), adequate (between 75 percent and 85 percent), or inadequate (less than 75 percent). OVERALL QUALITY INDICATOR RATING FOR CASE REVIEWS AND COMPLIANCE TESTING The OIG derived the final rating for each quality indicator by combining the ratings from the case reviews and from the compliance testing, as applicable. When combining these ratings, the case review evaluations and the compliance testing results usually agreed, but there were instances when the rating differed for a particular quality indicator. In those instances, the inspection team assessed the quality indicator based on the collective ratings from both components. Specifically, the OIG clinicians and registered nurse inspectors discussed the nature of individual exceptions found within that indicator category and considered the overall effect on the ability of patients to receive adequate medical care. To derive an overall assessment rating of the institution’s medical inspection, the OIG evaluated the various rating categories assigned to each of the quality indicators applicable to the institution, giving more weight to the rating results of the primary quality indicators, which directly relate to the health care provided to patients. Based on that analysis, OIG experts made a considered and measured overall opinion about the quality of health care observed. POPULATION-BASED METRICS The OIG identified a subset of Healthcare Effectiveness Data Information Set (HEDIS) measures applicable to the CDCR patient population. To identify outcomes for RJD, the OIG reviewed some of the compliance testing results, randomly sampled additional patients’ records, and obtained RJD’s 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 5 Medical Inspection Page 8 Office of the Inspector General State of California MEDICAL INSPECTION RESULTS The quality indicators assess the clinical aspects of health care. As shown on the RJD Executive Summary Table on page iv of this report, 13 of the OIG’s indicators were applicable to RJD. Of those 13 indicators, 7 were rated by both the case review and compliance components of the inspection, 3 were rated by the case review component alone, and 3 were rated by the compliance component alone. The Administrative Operations indicator is a secondary indicator, and, therefore, was not relied upon for the overall score for the institution. Based on the analysis and results in all the primary indicators, the OIG experts made a considered and measured opinion that the quality of health care at RJD was adequate. Summary of Case Review Results: The clinical case review component assessed 10 of the 13 indicators applicable to RJD. Of these ten indicators, the OIG clinicians rated one proficient, seven adequate, and two inadequate. The OIG physicians rated the overall adequacy of care for each of the 25 detailed case reviews they conducted. Of these 25 cases, 24 were adequate, and one was inadequate. In the 1,252 events reviewed, there were 139 deficiencies, of which 33 were considered to be of such magnitude that, if left unaddressed, they would likely contribute to patient harm. Adverse Events Identified During Case Review: Adverse events are medical errors that are more likely than not cause grave patient harm. Medical care is a complex and dynamic process with many moving parts, subject to human error even within the best health care organizations. Adverse events are typically identified and tracked by all major health care organizations for the purpose of quality improvement. They are not generally representative of medical care delivered by the organization. The OIG identified adverse events for the dual purposes of quality improvement and the illustration of problematic patterns of practice found during the inspection. Because of the anecdotal description of these events, the OIG cautions against drawing inappropriate conclusions regarding the institution based solely on adverse events. There was one adverse event identified in the case reviews at RJD. • In case 73, the patient was anti-coagulated with warfarin (a blood thinning medication) and had a high INR level (a blood test for monitoring the effects of warfarin levels). The high INR level increased the patient’s risk of serious bleeding complications. A provider appropriately placed orders to stop giving the warfarin for two days, and then to restart the medication at a lower dose. Unfortunately, the medication nurses stopped the medication for only one day. On the second day, the nurses resumed giving the warfarin at the higher dose instead of the lower dose the provider prescribed. Five days later, the patient developed a diminished mental status and the institution transferred him to a community hospital. In the hospital, the patient’s warfarin level had risen to a critically dangerous level. The patient had bled into his brain and subsequently died. This medication error was an adverse event and Richard J. Donovan Correctional Facility, Cycle 5 Medical Inspection Page 9 Office of the Inspector General State of California contributed to the patient’s death. This case is also discussed in the Pharmacy and Medication Management indicator. Summary of Compliance Results: The compliance component assessed 10 of the 13 indicators applicable to RJD. Of these ten indicators, OIG inspectors rated two proficient, three adequate, and five 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 5 Medical Inspection Page 10 Office of the Inspector General State of California 1 — ACCESS TO CARE This indicator evaluates the institution’s ability to provide patients Case Review Rating: with timely clinical appointments. Areas specific to patients’ access Adequate to care are reviewed, such as initial assessments of newly arriving Compliance Score: inmates, acute and chronic care follow-ups, face-to-face nurse Proficient appointments when a patient requests to be seen, provider referrals (85.9%) from nursing lines, and follow-ups after hospitalization or specialty Overall Rating: care. Compliance testing for this indicator also evaluates whether Proficient patients have Health Care Services Request forms (CDCR Form 7362) available in their housing units. In this indicator, the OIG case review and compliance review processes yielded different results, with the case review giving an adequate rating and the compliance review resulting in a proficient score. The OIG’s internal review process considered those factors that led to both scores and ultimately rated this indicator proficient, placing a heavier reliance on compliance testing. Compliance testing found the institution performed well in patient sick call access, and patients received provider follow-up appointments for hospitalizations and specialty services within required time frames. Also, case review identified only a few significant deficiencies, and found the overall access to services sufficient. Case Review Results The OIG clinicians reviewed 537 provider and nurse encounters and identified nine deficiencies relating to access to care. Of those nine deficiencies, four were significant, or likely to cause patient harm. Significant deficiencies were identified in cases 2, 17, 19, and 27. The case review rating for the Access to Care indicator was adequate. Provider-to-Provider Follow-up Appointments The institution performed well with provider-ordered follow-up appointments, an important part of the access to care indicator. Only one significant deficiency of a provider appointment that was not timely was identified: • In case 17, the patient had a traumatic facial injury. The provider ordered a follow-up appointment in five days, but the appointment did not occur until nine days later. RN-to-Provider Referrals After assessing patients, the registered nurse (RN) was required to refer the patient to a provider if the situation needed a higher level of care. No significant deficiencies were found in provider appointments generated by nurses. Richard J. Donovan Correctional Facility, Cycle 5 Medical Inspection Page 11 Office of the Inspector General State of California RN Sick Call Access The sick call process at RJD was organized and provided patients with timely access to health care. RN Follow-up Appointments The institution performed well with scheduling and completing RN follow-up appointments requested by the providers or nurses. Only one significant deficiency was identified: • In case 19, the patient with an allergic reaction was wheezing and had facial swelling. The patient’s condition improved after treatment in the TTA. The provider requested the patient follow up with a nurse in one day, but the appointment never occurred. Fortunately, the patient’s allergic reaction did not recur. Intra-System Transfers There were no significant nursing deficiencies related to access to care during transfers into or out of the institution. Follow-up after Hospitalization After hospitalization, patients should receive a provider follow-up appointment no later than five days from hospital discharge to ensure patient safety and optimal clinical outcomes. RJD had only one significant deficiency related to follow-up after a patient’s hospitalization: • In case 2, the patient returned from an outside emergency department (ED) and was supposed to see a provider within five days; however, the appointment occurred 21 days later. Follow-up after Urgent/Emergent Care The institution performed well with follow-up appointments after patients were seen in the TTA. OIG clinicians identified only one significant deficiency in which a provider appointment was not timely. • In case 17, the patient had a facial injury after an altercation. The TTA provider ordered a follow-up for the patient in five days. However, the patient did not receive the follow-up appointment until nine days later. Specialized Medical Housing The RJD provider saw patients timely in the correctional treatment center (CTC) and performed history and physical exams on all newly admitted patients. There were no problems related to provider follow-up after CTC discharge. Richard J. Donovan Correctional Facility, Cycle 5 Medical Inspection Page 12 Office of the Inspector General State of California Provider Follow-Up after Specialty Service Visits After a specialty service visit, the patient should receive a follow-up appointment to be evaluated by a provider within 14 days or earlier if indicated. The institution performed well with provider follow-up appointments after specialty service visits; however, there was one significant deficiency identified: • In case 27, the patient saw an oral surgeon and was supposed to follow up with a provider in 5 days, but the patient was not seen until 21 days later. Clinician Onsite Inspection During the onsite visit, clinic nurses reported seeing 8 to 10 patients each day, and providers were seeing around 12 patients each day. Each clinic had a designated office technician who attended daily clinic huddles and coordinated with providers to ensure all important follow-up appointments were scheduled. According to the office technicians, there were no significant backlogs of provider appointments in the five clinics. Case Review Conclusion The institution performed well with regard to access to care; most provider and nurse appointments occurred timely. The OIG clinicians rated this indicator adequate. Compliance Testing Results The institution performed in the proficient range in the Access to Care indicator, with a compliance score of 85.9 percent. RJD performed in the proficient range on the following tests: • Inspectors sampled 45 Health Care Services Request forms (CDCR Form 7362) submitted by patients across all facility clinics. Nursing staff reviewed all 45 patients’ request forms on the same day they were received. In addition, nursing staff timely completed a face-to-face triage encounter for the same 45 patients (MIT 1.003, 1.004). • Of 25 sampled patients who received a high-priority or routine specialty service, 23 (92 percent) received a timely follow-up appointment with a provider. One patient’s routine specialty service follow-up appointment occurred one day late, and one other patient’s routine specialty service follow-up appointment was three days late at the time of his parole; as a result, a provider never saw him (MIT 1.008). • Among 24 sampled patients who were discharged from a community hospital, 21 (88 percent) received timely provider follow-up appointments upon their return to RJD. Three patients received their follow-up appointments from one to two days late (MIT 1.007). Richard J. Donovan Correctional Facility, Cycle 5 Medical Inspection Page 13 Office of the Inspector General State of California The following tests scored in the adequate range: • Among 25 recent chronic care appointments, 21 patients (84 percent) received timely follow-up appointments with a provider. Two patients received their chronic care appointments 11 and 14 days late. Two other patients each received two appointments late; one patient’s two appointments were 6 and 119 days late, and another patient’s two appointments were 12 and 28 days late (MIT 1.001). • Patients had access to health care services request forms at five of six housing units inspected (83 percent). At one housing unit, request forms were not available to patients (MIT 1.101). • Among five sampled patients who transferred into RJD from another institution and were referred to a provider based on nursing staff’s initial health care screening, four (80 percent) were seen within the required time frame. For one other patient, there was no evidence that a provider visit ever occurred (MIT 1.002). • Of nine sampled patients who nursing staff referred to a provider after submitting a health care services request form and were ordered a follow-up appointment by a provider, seven (78 percent) received their follow-up appointments timely. Two patients received appointments one day and seven days late (MIT 1.006). The institution showed room for improvement on the following test: • Of 16 sampled health care service requests on which nursing staff referred the patient for a provider appointment, 11 of the patients (69 percent) received a timely appointment. For three patients, follow-up appointments occurred from one to 15 days late. Two other patients did not receive a provider visit at all (MIT 1.005). Richard J. Donovan Correctional Facility, Cycle 5 Medical Inspection Page 14 Office of the Inspector General State of California 2 — DIAGNOSTIC SERVICES This indicator addresses several types of diagnostic services. Case Review Rating: Specifically, it addresses whether radiology and laboratory services Adequate were timely provided to patients, whether the primary care provider Compliance Score: timely reviewed the results, and whether the results were Inadequate communicated to the patient within the required time frames. In (70.0%) addition, for pathology services, the OIG determines whether the Overall Rating: institution received a final pathology report and whether the provider Adequate timely reviewed and communicated the pathology results to the patient. The case reviews also factor in the appropriateness, accuracy, and quality of the diagnostic test(s) ordered and the clinical response to the results. For this indicator, the OIG’s case review and compliance testing processes yielded different results, with the case review giving an adequate rating and the compliance testing resulting in an inadequate score. Both case review and compliance review identified areas where staff did not scan reports into the patient’s electronic medical record, and instances where providers did not communicate diagnostic test results to the patient. However, case review determined that despite these deficiencies, providers were aware of the results and patient care was not affected. The OIG’s internal review process considered those factors that led to both scores and ultimately rated this indicator adequate. Case Review Results The OIG clinicians reviewed 182 events in diagnostic services and found 17 deficiencies, 6 of which were significant. Significant deficiencies were identified in cases 9, 16, 17, 20, 26, and 73. Case review clinicians rated the Diagnostic Services indicator adequate. Test Completion The institution’s laboratory process was effective and most requested laboratory tests completed were timely. There was only one significant deficiency identified: • In case 17, a provider requested a fecal occult blood test (a screening for colon cancer), but the tests were not performed. RJD also had an effective diagnostic procedure process and the institution completed most x-rays, ultrasounds, computerized tomography (CT) scans, and magnetic resonance imaging (MRI) scans timely. OIG clinicians identified just one significant deficiency: • In case 20, a provider ordered a chest x-ray, but the institution never provided the service. Richard J. Donovan Correctional Facility, Cycle 5 Medical Inspection Page 15 Office of the Inspector General State of California Health Information Management During the review period, RJD had not yet transitioned to the EHRS (Electronic Health Records System). RJD staff retrieved and scanned most laboratory reports into the eUHR (electronic Unit Health Record) system; however, OIG clinicians identified four significant deficiencies related to missing laboratory reports: • In case 9, the laboratory test results for a complete blood count was not retrieved or scanned into the electronic medical record. • In case 16, laboratory tests were completed, but the results were not retrieved or scanned into the electronic medical record. • In case 26, urgent laboratory tests for hormone level, seizure medication, and drug screen were completed; however, RJD staff did not retrieve or scan the test results into the electronic medical record. • In case 73, a laboratory report showing persistently elevated warfarin (blood thinning medication) level was not retrieved, reviewed, or scanned into the electronic medical record. The OIG clinicians also found one mislabeled laboratory test: • In case 1, the patient’s laboratory test did not have the correct date of when staff performed the service. RJD staff retrieved and scanned most diagnostic procedure reports into the electronic medical records; however, the OIG clinicians identified ten diagnostic procedure reports that staff did not retrieve or scan into the electronic medical records. Clinician Onsite Inspection The institution’s main clinics had designated staff for blood drawing to ensure the timely completion of laboratory tests. RJD also had an effective tracking process to ensure that diagnostic procedures were completed on time. Case Review Conclusion Even though some diagnostic procedure reports were not scanned into the electronic medical records, the providers reviewed and documented those missing results during follow-up visits. The improperly processed diagnostic orders were infrequent; therefore, the OIG clinicians rated the Diagnostic Services indicator adequate. Richard J. Donovan Correctional Facility, Cycle 5 Medical Inspection Page 16 Office of the Inspector General State of California Compliance Testing Results The institution received an inadequate compliance score of 70.0 percent in the Diagnostic Services indicator, which encompasses radiology, laboratory, and pathology services. For clarity, each type of diagnostic service is discussed separately below: Radiology Services • Radiology services were performed timely for all ten patients sampled (MIT 2.001). However, providers failed to initial and date the radiology report results, which CCHCS policy requires. Therefore, the institution received a zero for this test (MIT 2.002). The institution’s providers timely communicated test results to seven of the ten patients (70 percent). For three patients, providers communicated their test results from one to eight days late (MIT 2.003). Laboratory Services • Seven of the nine applicable patients sampled (78 percent) received their provider-ordered laboratory services timely. For this test, one sample was not applicable because a compliance time frame could not be determined as no evidence of a provider order could be found. Two of the nine patients’ services were provided one and five days late (MIT 2.004). Providers reviewed nine of the ten laboratory service reports (90 percent) within the required time frame. One report was reviewed one day late (MIT 2.005). Providers timely communicated the laboratory results to nine of the ten patients (90 percent). One patient received his test results one day late (MIT 2.006). Pathology Services • Providers timely received the final pathology reports for eight of ten patients sampled (80 percent). Inspectors could not find two of the sampled reports in the patients’ electronic medical records. Though one of the reports was mentioned in a provider’s progress note, the actual report was not found (MIT 2.007). Providers timely reviewed all nine applicable pathology reports sampled, which included the aforementioned report only found within a progress note (MIT 2.008). Providers timely communicated pathology results to only two of the nine patients who received services (22 percent). For five patients, providers communicated the results from two to eight days late. For two other patients, there was no evidence found in their electronic medical records that they received notification of their test results (MIT 2.009). Richard J. Donovan Correctional Facility, Cycle 5 Medical Inspection Page 17 Office of the Inspector General State of California 3 — EMERGENCY SERVICES An emergency medical response system is essential to providing Case Review Rating: effective and timely emergency medical response, assessment, Adequate treatment, and transportation 24 hours per day. Provision of Compliance Score: urgent/emergent care is based on a patient’s emergency situation, Not Applicable clinical condition, and need for a higher level of care. The OIG Overall Rating: reviews emergency response services including first aid, basic life Adequate support (BLS), and advanced cardiac life support (ACLS) consistent with the American Heart Association guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiovascular care, and the provision of services by knowledgeable staff appropriate to each individual’s training, certification, and authorized scope of practice. The OIG evaluates this quality indicator entirely through clinicians’ reviews of case files and conducts no separate compliance testing element. Case Review Results The OIG clinicians reviewed 47 urgent or emergent events and identified 17 deficiencies, 2 of which were significant (cases 6 and 17). The case review rating for the Emergency Services indicator was adequate. CPR Response CPR response was appropriate and there were only minor variations in response time. The quality of care rendered was unaffected. Provider Performance Providers at RJD performed well in emergency care. There were three deficiencies noted, one of which was significant: • In case 6, during an emergency response, nursing staff attempted to reach the on-call provider three times on the provider’s landline and mobile telephones, but the on-call provider did not respond. Nursing Documentation Nursing performance during emergency responses was good. Only minor nursing deficiencies were identified and did not affect patient care, as noted in the following example: • In case 23, a nurse did not document an assessment of head trauma in a patient who was difficult to arouse or check for needle marks in a suspected overdose. Richard J. Donovan Correctional Facility, Cycle 5 Medical Inspection Page 18 Office of the Inspector General State of California Emergency Medical Response Review Committee The Emergency Medical Response Review Committee (EMRRC) thoroughly reviewed and identified training needs for the unscheduled emergency response incidents. The committee identified deficiencies in documentation. Supervisory registered nurses (SRNs) were assigned to follow up on these deficiencies and provide training on documentation. Prior to the OIG onsite visit, the institution provided a detailed proof of practice binder that included copies of EMRRC minutes, training needs, and completed training. Some nurses who led emergency responses had already received training for deficiencies in documentation. In addition, 50 additional nursing staff, including RNs, licensed vocational nurses (LVNs), SRNs, and psychiatric technicians had received training in cardiac arrest documentation. Training in documentation was both timely and appropriate. Clinician Onsite Inspection During the onsite visit, the TTA had two beds, and was well staffed with nurses. A provider was assigned to the TTA during working hours and on-call providers were available after hours. Case Review Conclusion During emergency responses and events, nursing care was appropriate, but nursing documentation needed improvement. RJD had already provided the needed documentation training for nurses. Thus, the OIG clinicians rated the Emergency Services indicator adequate. Richard J. Donovan Correctional Facility, Cycle 5 Medical Inspection Page 19 Office of the Inspector General State of California 4 — HEALTHINFORMATION MANAGEMENT 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 (62.4%) correctly labeled and organized and available in the electronic Overall Rating: medical record; whether various medical records (internal and Inadequate external, e.g., hospital and specialty reports and progress notes) are obtained and scanned timely into the patient’s electronic medical record; whether records routed to clinicians include legible signatures or stamps; and whether hospital discharge reports include key elements and are timely reviewed by providers. During the OIG’s testing period, RJD had not converted to the new Electronic Health Record System (EHRS) (expected transition October 2017); therefore, all testing for RJD in Cycle 5 occurred in the Electronic Unit Health Record (eUHR) system. Case Review Results The OIG clinicians reviewed 1,252 events and found 33 deficiencies related to health information management, of which 10 were significant. Significant deficiencies were identified once in cases 3, 9, 15, 16, 21, 23, 26, 73, and twice in case 17. Because numerous documents were missing, the OIG clinicians rated the Health Information Management indicator inadequate. Interdepartmental Transmission The OIG did not identify any communication problems between the institution’s departments. Hospital Records The OIG clinicians reviewed 45 community hospital events, including emergency department (ED) visits. RJD staff timely retrieved, reviewed, and scanned hospital records into patients’ electronic medical records. However, there was one significant delay in retrieving an outside ED report: • In case 3, staff did not retrieve the report from the patient’s visit to the outside ED until more than one month later. When the patient was evaluated seven days after his ED visit, the report was not available for review in the electronic medical record. Richard J. Donovan Correctional Facility, Cycle 5 Medical Inspection Page 20 Office of the Inspector General State of California Missing Documents (Progress Notes and Forms) Most nursing and provider progress notes were scanned into the electronic medical record; however, there were nine missing documents, three of which were significant: • In case 17, the provider dictated a progress note, but staff did not retrieve or scan the document into the patient’s electronic medical record. Additionally, the diabetic patient who was dependent on insulin was receiving insulin twice daily as nurse-administered medication. For 13 days, medical record staff failed to scan the patient’s medication administration record (MAR) which documented the administration of his insulin doses into the patient’s electronic medical record. This deficiency is also discussed in the Pharmacy and Medication Management indicator. • In case 21, the provider dictated a two-page progress note, but only the second page was retrieved and scanned into the electronic medical record. Diagnostic Reports There were ten deficiencies identified during case review related to diagnostic service reports. These deficiencies were due to radiology reports not being scanned from the secondary electronic record repository (RIS-PACs) and into the main medical record, eUHR. The ten deficiencies were considered minor because the provider obtained the report information and patient care was not hindered. When RJD transitions to the EHRS, the risk of medical errors will diminish when the radiology reports automatically transfer into the main electronic medical record. Laboratory Reports Institution staff timely retrieved and scanned most laboratory reports into the electronic medical record; however, there were four significant deficiencies related to missing laboratory reports. These are discussed in the Diagnostic Services indicator. Specialty Services Reports Staff timely retrieved and scanned most specialty service reports into the electronic medical record. The performance in this area is further discussed in the Specialty Services indicator. Legibility Most provider and nursing progress notes were dictated or legible. Richard J. Donovan Correctional Facility, Cycle 5 Medical Inspection Page 21 Office of the Inspector General State of California Scanning Performance There were eight deficiencies related to mislabeled documents, one of which was considered significant: • In case 23, institution staff scanned a provider progress note of one patient into another patient’s electronic medical record. For the patient whose progress note was missing, there was an increased risk of error due to the missing information. Case Review Conclusion The numerous missing diagnostic reports and mislabeled documents placed patients at increased risk of harm. The OIG clinicians rated the Health Information Management indicator as inadequate. Compliance Testing Results The institution received an inadequate compliance score of 62.4 percent in the Health Information Management (Medical Records) indicator, showing room for improvement on the following tests: • Throughout compliance testing, the OIG inspectors review documents to determine if they were accurately scanned into the electronic medical records. This test is scored on a scale by which zero errors would result in a 100 percent score, and 24 errors would result in a score of zero. OIG inspectors identified more than 24 mislabeled or misfiled documents for RJD. As a result, the institution scored zero for this test (MIT 4.006). • RJD staff scanned 8 of 20 specialty service consultant reports sampled (40 percent) into the patient’s electronic medical record within five calendar days. However, 12 documents were not timely scanned; five high-priority specialty reports were scanned from one to 20 days late; three other high-priority specialty reports were not found; two routine specialty service forms were scanned two and ten days late; and two other routine specialty service forms were not found (MIT 4.003). • The institution scored 60 percent for the timely scanning of dictated or transcribed provider progress notes into patients’ electronic medical records. Only 12 of the 20 progress notes sampled were scanned timely within five calendar days of the patient encounter. Eight sampled progress notes were scanned between one and 11 days late (MIT 4.002). The institution performed in the adequate range on the following tests: • The OIG tested 20 of the patients’ discharge records to determine if staff timely scanned records into the patients’ electronic medical records. Out of the 20 sampled patient records, 17 were compliant (85 percent). Two patients’ records were scanned three days late, and one other patient’s record was scanned 28 days late (MIT 4.004). Richard J. Donovan Correctional Facility, Cycle 5 Medical Inspection Page 22 Office of the Inspector General State of California • The OIG inspected electronic medical record files for 25 patients who were admitted to a community hospital and then returned to the institution. RJD providers reviewed 21 of 25 patients’ hospital discharge reports (84 percent) within three calendar days of the patient’s discharge. One patient’s report was reviewed three days late, and for three other patients, OIG clinicians found no evidence that providers ever reviewed their reports (MIT 4.007). • Medical records staff timely scanned medication administration records (MARs) into patients’ electronic medical records in 15 of 20 samples tested (75 percent). Five MARs were scanned from one to 12 days late (MIT 4.005). The institution performed in the proficient range on the following test: • The institution timely scanned 13 of 14 sampled non-dictated progress notes, patients’ initial health screening forms, and requests for health care services into patients’ electronic medical records (93 percent). One non-dictated progress note was scanned one day late (MIT 4.001). Richard J. Donovan Correctional Facility, Cycle 5 Medical Inspection Page 23 Office of the Inspector General State of California 5 — HEALTH CARE ENVIRONMENT This indicator addresses the general operational aspects of the Case Review Rating: institution’s clinics, including certain elements of infection control Not Applicable and sanitation, medical supplies and equipment management, the Compliance Score: availability of both auditory and visual privacy for patient visits, and Inadequate (62.6%) the sufficiency of facility infrastructure to conduct comprehensive medical examinations. Rating of this component is based entirely on Overall Rating: the compliance testing results from the visual observations inspectors Inadequate make at the institution during their onsite visit. This indicator is evaluated entirely by compliance testing. There is no case review portion. Compliance Testing Results The institution received an inadequate compliance score of 62.6 percent in the Health Care Environment indicator, and showed room for improvement on the following seven tests: • The non-clinic bulk medical supply storage areas did not meet the supply management process or support the needs of the medical health care program, resulting in a score of zero for RJD on this test. Medical supplies with specific temperature requirements were stored in a warehouse that was not equipped with a way to monitor the room temperature in order to avoid excessive temperatures and to stay within the manufacturers’ medication storage guidelines (MIT 5.106). • Only 5 of the 12 clinics inspected followed adequate medical supply storage and management protocols (42 percent). In seven clinics, the following deficiencies were identified: germicidal disposable cloths were stored with medical supplies (Figure 1), medical supplies were not orderly or clearly identifiable, and staff stored personal items in the Figure 1: Germicidal cloths stored with medical supplies medical supply area. Staff expressed concern about inadequate replenishment of medical supplies. Medical supplies were stored beyond the manufacturers’ guidelines (MIT 5.107). • RJD clinicians followed good hand hygiene practices in only 6 of the 13 clinics tested (46 percent). At seven clinic locations, clinicians failed to wash their hands before or after patient contact or before applying gloves (MIT 5.104). Richard J. Donovan Correctional Facility, Cycle 5 Medical Inspection Page 24 Office of the Inspector General State of California • Only 6 of the 13 clinic exam rooms observed (46 percent) had appropriate space, configuration, supplies, and equipment to allow clinicians to perform proper clinical examinations. Five clinic exam rooms did not provide auditory or visual privacy for patients who were examined without the use of a portable screen and were triaged near other patients being examined. One other clinic exam room had disorganized supplies, not clearly labeled. In another clinic exam room, Figure 2: Impeded access to the exam table clinicians had impeded access to the exam table (Figure 2) (MIT 5.110). • Inspectors examined emergency response bags (EMRBs) to determine if they were inspected daily, inventoried monthly, and contained all essential items. EMRBs were compliant in 6 of the 11 clinic locations they were stored (55 percent). At five clinic locations, EMRBs had one of more of the following deficiencies: EMRB logs were missing entries from staff verifying compartments were sealed and intact, the portable oxygen valve was detached and not readily available, and crash carts did not have the minimum level of medical supplies (MIT 5.111). • The clinic common areas at 8 of the 13 clinics (62 percent) had an environment conducive to providing medical services. The triage and vital signs stations were located too close to each other in three clinics, which compromised patients’ auditory privacy. Two other clinic common areas located outside were not shaded to protect patients waiting for appointments (MIT 5.109). • Nine of the 13 clinic locations (69 percent) met compliance requirements for essential core medical equipment and supplies. The remaining four clinics were missing one or more of the following items: medication refrigerator, properly calibrated nebulization unit, and properly calibrated electrocardiogram (EKG) (MIT 5.108). The institution scored in the adequate range on the following test: • Out of 13 clinics examined, 11were appropriately disinfected, cleaned, and sanitary (85 percent). In two clinics, the cleaning logs did not indicate that cleaning had been completed (MIT 5.101). Richard J. Donovan Correctional Facility, Cycle 5 Medical Inspection Page 25 Office of the Inspector General State of California RJD received proficient scores on the following tests: • Health care staff at all 13 applicable clinics followed proper protocols to mitigate exposure to blood-borne pathogens and contaminated waste (MIT 5.105). • In 12 of the 13 clinics inspected (92 percent), clinical health care staff ensured reusable invasive and non-invasive medical equipment was properly sterilized or disinfected. In one clinic, staff did not always replace the exam table paper between patient encounters (MIT 5.102). • Out of 13 clinics, 12 had operable sinks and adequate hand hygiene supplies (92 percent). One clinic’s patient restroom did not have sufficient quantities of hand hygiene supplies, such as disposable hand towels (MIT 5.103). Non-Scored Results • The OIG gathered information to determine if the institution’s physical infrastructure was maintained in a manner that supported health care management’s ability to provide timely or adequate health care. When OIG inspectors interviewed health care managers, they did not identify any significant concerns. At the time of the OIG’s medical inspection, several infrastructure projects at RJD were underway. The institution was in the process of increasing medical clinics in four yards, building a new pharmacy and a dialysis unit, and increasing the space and renovating central health services. These projects began in the summer 2015 and were expected to be completed by the end of fall 2018 (MIT 5.999). Richard J. Donovan Correctional Facility, Cycle 5 Medical Inspection Page 26 Office of the Inspector General State of California 6 — INTER- AND INTRA-SYSTEM TRANSFERS This indicator focuses on the management of patients’ medical needs Case Review Rating: and continuity of patient care during the inter- and intra-system Adequate transfer process. The patients reviewed for this indicator include Compliance Score: those received from, as well as those transferring out to, other CDCR Adequate (78.0%) institutions. The OIG review includes evaluation of the institution’s ability to provide and document health screening assessments, Overall Rating: initiation of relevant referrals based on patient needs, and the Adequate continuity of medication delivery to patients arriving from another institution. For those patients, the OIG clinicians also review the timely completion of pending health appointments, tests, and requests for specialty services. For patients who transfer out of the institution, the OIG evaluates the ability of the institution to document transfer information that includes pre-existing health conditions, pending appointments, tests and requests for specialty services, medication transfer packages, and medication administration prior to transfer. The OIG clinicians also evaluate the care provided to patients returning to the institution from an outside hospital and check to ensure appropriate implementation of the hospital assessment and treatment plans. Case Review Results The OIG clinicians reviewed 58 inter- and intra-system transfer events, including information from both the sending and receiving institutions. These included 45 hospitalizations and outside emergency room events, each of which resulted in a transfer back to the institution. There were five deficiencies identified, one of which was significant (case 3). Transfers In The OIG clinicians reviewed nine transfer-in events for five patients. The institution’s nurses provided adequate care for patients transferring into RJD. For example, one patient arrived without his inhaler and RJD staff supplied him a replacement from the Omnicell (an automated medication storage unit). RJD staff appropriately referred patients to medical and mental health providers and patients were seen timely. Patients received their medications without a lapse in continuity and patients who arrived late in the evening received prescribed evening medications without missing scheduled doses. Transfers Out The OIG clinicians reviewed four patients who were transferred out of the facility. While there were no significant deficiencies, there were minor deficiencies identified when nurses did not document pertinent transfer information. • In case 34, the nurse did not document that new dentures had been ordered or that the patient had been receiving antifungal treatment for coccidioidomycosis (Valley Fever). Richard J. Donovan Correctional Facility, Cycle 5 Medical Inspection Page 27 Office of the Inspector General State of California Hospitalizations Patients returning from hospitalizations are some of the highest-risk encounters due to two factors. First, these patients are generally hospitalized for a severe illness or injury. Second, they are at risk due to potential lapses in care that can occur during any transfer. There was only one significant deficiency identified out of the 45 hospitalizations the OIG clinicians reviewed: • In case 3, the patient was transferred to a community hospital ED for chest pain and was not evaluated by a provider until seven days after returning to RJD. Furthermore, the patient’s hospital report was not available for review because institution staff did not retrieve the report until more than one month later. Clinician Onsite Inspection The institution had experienced TTA and receiving and release (R&R) nurses who were knowledgeable in both their patient care areas and clinical roles. The nurses reported no major communication barriers with nursing supervisors, providers, or custody officers regarding patient care needs. Case Review Conclusion The RJD clinical nursing team performed well with inter- and intra-system transfers. The majority of the deficiencies identified were minor. Patients transferring into RJD received their medications timely and were seen by the providers and specialists as scheduled. The OIG clinicians rated this indicator adequate. Compliance Testing Results The institution obtained an adequate score of 78.0 percent in the Inter- and Intra-System Transfers indicator, receiving proficient scores of 100 percent on the following two tests: • Nursing staff timely completed the assessment and disposition sections of the screening form for all five sampled patients (MIT 6.002). • The OIG inspected the transfer packages of two patients who were transferring out of the institution to determine whether the packages included required medications and support documentation. Both patients’ transfer packages were compliant (MIT 6.101). The institution scored within the adequate range in the following test: • The OIG tested five patients who transferred into RJD from other CDCR institutions to determine whether they received a complete initial health screening from nursing staff on the day they arrived. Nursing staff timely prepared all five screening forms, but neglected to answer all applicable screening questions for one patient, resulting in a score of 80 percent (MIT 6.001). Richard J. Donovan Correctional Facility, Cycle 5 Medical Inspection Page 28 Office of the Inspector General State of California The institution showed room for improvement on the following two tests: • Of the five sampled patients who transferred into RJD, four had existing medication orders upon arrival. Only two of the four patients (50 percent) received their medications timely. Two patients incurred medication interruptions; one patient missed two dosing periods of his medication, and another patient’s refusal of his medication was not properly documented (MIT 6.003). • Inspectors sampled 20 patients who transferred out of RJD to other CDCR institutions to determine whether the institution listed their scheduled specialty service appointments on the health care transfer form. RJD nursing staff properly included the scheduled appointments on the transfer forms for only 12 of the 20 sampled patients (60 percent). For eight patients, nursing staff did not document all ordered specialty service appointments (MIT 6.004). Richard J. Donovan Correctional Facility, Cycle 5 Medical Inspection Page 29 Office of the Inspector General State of California 7 — PHARMACYAND MEDICATION MANAGEMENT This indicator is an evaluation of the institution’s ability to provide Case Review Rating: appropriate pharmaceutical administration and security Inadequate management, encompassing the process from the written Compliance Score: prescription to the administration of the medication. By combining Inadequate (67.7%) both a quantitative compliance test with case review analysis, this assessment identifies issues in various stages of the medication Overall Rating: management process, including ordering and prescribing, Inadequate transcribing and verifying, dispensing and delivering, administering, and documenting and reporting. Because effective medication management is affected by numerous entities across various departments, this assessment considers internal review and approval processes, pharmacy, nursing, health information systems, custody processes, and actions taken by the prescriber, staff, and patient. 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 of this indicator. The OIG clinicians evaluated 74 events related to medications and found ten deficiencies, five of which were significant. Significant deficiencies were identified once in case 25, and two times each in cases 17 and 73. Transfers and Medication Continuity The institution performed well with ensuring medication continuity in newly arriving patients. The majority of newly transferred patients from other institutions arrived with their medications. Nurses were diligent in ensuring missing medications were retrieved from the Omnicell and that patients had ample doses of keep-on-person (KOP) medications until an RJD provider was able to evaluate the patient. Provider Notification Nurses informed providers when patients refused medications and when patients did not go to the medication line to receive their medications. Medication Administration RJD medication staff performed poorly with medication administration; OIG clinicians identified four significant deficiencies related to nurse-administered medications: • In case 17, a provider discontinued the patient’s seizure medication; however, nursing staff continued to administer the medication for a week after the provider discontinued the medication. Richard J. Donovan Correctional Facility, Cycle 5 Medical Inspection Page 30 Office of the Inspector General State of California • In case 25, a provider discontinued the patient’s Clopidogrel (blood thinner), but nursing staff continued to administer the medication for three days after the provider discontinued the medication. • In case 73, the patient was anti-coagulated with warfarin (a blood thinning medication) and had a high INR level (a blood test for monitoring the warfarin levels).The high INR level increased the patient’s risk of serious bleeding complications. A provider appropriately placed orders to stop giving the warfarin for two days, and then to restart the medication at a lower dose. Unfortunately, the medication nurses stopped the medication for only one day. On the second day, the nurses resumed giving the warfarin at the higher dose and not the lower dose the provider prescribed. Five days later, the patient developed a diminished mental status and the institution transferred the patient to a community hospital. In the hospital, the patient’s warfarin level had risen to a critically dangerous level. The patient had bled into his brain, and subsequently died. This medication error contributed to the patient’s death and was an adverse event. • In case 73 at another encounter, the patient had a high INR level and the provider decreased the warfarin dose to 2 mg daily; however, after the patient was on the lower level of warfarin for five days, nursing staff inappropriately administered the 3 mg of dose. Health Information Management There was one significant deficiency related to a missing medication administration record (MAR): • In case 17, the patient with insulin dependent diabetes received insulin twice daily as a nurse-administered medication. The patient’s MAR with documentation of his insulin doses was not scanned into his electronic medical record for 13 days. Because the insulin and glucose records were unavailable, providers could not have made an accurate assessment of the diabetes during the period. This deficiency is also discussed in the Health Information Management indicator. Clinician Onsite Inspection During the onsite visit, patient care teams discussed medication issues during the morning huddles. The medication line nurses reported on problems with medications or patient refusals of medications. The provider was informed of medications needing refill to ensure timely renewal of medications. The OIG clinicians held discussions with pharmacy personnel to clarify problems regarding medications that were continued, despite providers’ orders to discontinue. According to pharmacy staff, these deficiencies occurred because provider orders were scanned late in the evening, and there was a power outage, which caused scanning errors, and the orders did not get to the medication nurses. Richard J. Donovan Correctional Facility, Cycle 5 Medical Inspection Page 31 Office of the Inspector General State of California Case Review Conclusion RJD performed poorly with medication administration. The institution had four significant deficiencies related to nurse-administered medications, placing patients at risk of harm, and one medication error contributed to a patient’s death. The OIG clinicians rated the Pharmacy and Medication Management indicator inadequate. Compliance Testing Results The institution received an inadequate compliance score of 67.7 percent in the Pharmacy and Medication Management indicator. For discussion purposes below, this indicator is divided into three sub-indicators: medication administration, observed medication practices and storage controls, and pharmacy protocols. Medication Administration In this sub-indicator, the institution received an inadequate score of 50.6 percent, showing room for improvement in the following areas: • Among 22 sampled patients, only four (18 percent) timely received their chronic care medications. For the other 18 sampled patients, chronic care medications were not received within required time frames, ranging from 1 to 28 days late (MIT 7.001). • RJD ensured that 11 of 25 patients sampled (44 percent) received their medications without interruption when they transferred from one housing unit to another. The 14 remaining patients did not receive their medication at the proper dosing interval; 13 patients received their medications from one to two days late, and one other patient received his medication 21 days late (MIT 7.005). • RJD timely provided hospital discharge medications to only 12 of 25 patients sampled (48 percent). For 13 remaining patients, nursing staff did not timely provide their ordered discharge medications; three patients received ordered medications from one dosing period to three days late, and for ten other patients, there was no evidence that they received their ordered medications (MIT 7.003). • When the OIG sampled ten patients who were in transit to another institution and were temporarily laid over at RJD, only five (50 percent) received their medications without interruption. Five patients did not receive their ordered medications while they were at RJD (MIT 7.006). The institution received a proficient score on the following test: • RJD timely administered or delivered new medication orders to 13 of 14 patients sampled (93 percent). One patient received his medication one day late (MIT 7.002). Richard J. Donovan Correctional Facility, Cycle 5 Medical Inspection Page 32 Office of the Inspector General State of California Observed Medication Practices and Storage Controls In this sub-indicator, the institution received an inadequate score of 66.1 percent, showing areas needing improvement in the following tests: • RJD properly stored non-narcotic medications not requiring refrigeration in 4 of 13 applicable clinic and medication line storage locations (31 percent). In nine locations, one or more of the following deficiencies were observed: the medication area lacked a designated area for return-to-pharmacy medications; external and internal medications were not properly separated when stored; medication rooms and cabinets were unlocked; multiuse medication was not labeled with the date it was opened; medication was stored beyond its expiration date; and Omnicell inventory report did not accurately reflect the physical count of sampled medications (MIT 7.102). • Only three of the nine inspected medication preparation and administration areas demonstrated appropriate administrative controls and protocols (33 percent). In six locations, one or more of the following deficiencies were observed: patients waiting to receive their medications did not have sufficient outdoor cover to protect them from heat or inclement weather (Figure 3); the medication nurse did not ensure patients swallowed direct observation therapy (DOT) medications; and the medication nurse signed the MAR prior to administering Figure 3: Insufficient protection from medications (MIT 7.106). inclement weather • Non-narcotic refrigerated medications were properly stored in 6 of 11 applicable clinics and medication line storage locations (55 percent). In five locations, one or more of the following deficiencies were observed: the medication area lacked a designated area for return-to-pharmacy refrigerated medications; a previously opened antibiotic was found stored beyond the manufacturer’s guideline; an open vial of insulin was stored in the refrigerator without opened date or expiration labels; and a medication refrigerator was found unlocked at the time of the inspection (MIT 7.103). The institution received an adequate score on the following test: • The OIG interviewed nursing staff and inspected medication storage areas at nine applicable clinic and medication line locations to assess security controls over narcotic medications. Nursing staff had strong security controls over narcotic medications at seven locations (78 percent). At two locations, the narcotic mediations logbook was not signed by two Richard J. Donovan Correctional Facility, Cycle 5 Medical Inspection Page 33 Office of the Inspector General State of California nursing staff for a controlled substance inventory during shift changes or immediately updated by the medication nurse after removing narcotic medication from the locker (MIT 7.101). The following two tests received proficient scores: • At all eight of the inspected medication line locations, nursing staff was compliant with proper hand hygiene protocols and employed appropriate administrative controls, as well as followed appropriate protocols during medication preparation (MIT 7.104, 7.105). Pharmacy Protocols In this sub-indicator, the institution received an adequate score of 86.8 percent, comprised of scores received at the institution’s main pharmacy. The institution received proficient scores of 100 percent on the following tests: • In its main pharmacy, the institution followed general security, organization, and cleanliness management protocols; properly stored and monitored non-narcotic medications that required refrigeration; and maintained adequate controls over and properly accounted for narcotic medications (MIT 7.107, 7.109, 7.110). The institution received an adequate score on the following test: • The institution’s pharmacist in charge (PIC) followed the required protocols for 21 of the 25 medication error reports and monthly statistical reports reviewed (84 percent). For three medication error reports, the PIC completed corresponding medication error follow-up reports from one to nine days late. For one other medication error report, which met the criteria for sentinel event, the PIC did not report it to headquarters on the Sentinel Event Reporting Form (MIT 7.111). The institution showed room for improvement in the following area: • In its satellite pharmacy, RJD did not properly store non-refrigerated medication. Inspectors found medications that were not stored in their original container. As a result, the institution scored 50 percent for this test (MIT 7.108). Richard J. Donovan Correctional Facility, Cycle 5 Medical Inspection Page 34 Office of the Inspector General State of California Non-Scored Tests • In addition to testing reported medication errors, OIG inspectors follow up on any significant medication errors found during compliance testing to determine whether the errors were properly identified and reported. The OIG provides those results for information purposes only; however, at RJD, the OIG found no applicable severe medication errors in compliance testing (MIT 7.998). • The OIG tested patients housed in isolation units to determine if they had immediate access to their prescribed KOP rescue inhalers and nitroglycerin medications. All ten of the sampled patients had access to their rescue inhalers or nitroglycerin medications (MIT 7.999). Richard J. Donovan Correctional Facility, Cycle 5 Medical Inspection Page 35 Office of the Inspector General State of California 8 — PRENATALAND POST-DELIVERY SERVICES This indicator evaluates the institution’s capacity to provide timely Case Review Rating: and appropriate prenatal, delivery, and postnatal services to Not Applicable pregnant patients. This includes the ordering and monitoring of Compliance Score: indicated screening tests, follow-up visits, referrals to higher levels Not Applicable of care, e.g., high-risk obstetrics clinic, when necessary, and Overall Rating: postnatal follow-up. Not Applicable Because RJD was a male-only institution, this indicator did not apply. Richard J. Donovan Correctional Facility, Cycle 5 Medical Inspection Page 36 Office of the Inspector General State of California 9 — PREVENTIVE SERVICES This indicator assesses whether various preventive medical Case Review Rating: services are offered or provided to patients. These include cancer Not Applicable screenings, tuberculosis screenings, and influenza and chronic Compliance Score: care immunizations. This indicator also assesses whether certain Inadequate institutions take preventive actions to relocate patients identified (69.7%) 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 69.7 percent and inadequate scores on the following tests: • The institution received a score of zero for monitoring of patients receiving tuberculosis (TB) medications. For all nine of the patients sampled, the institution either failed to complete monitoring at all required intervals or failed to timely scan the monitoring forms into the patient’s electronic medical record (MIT 9.002). • RJD performed poorly in administration of patients’ TB medications. Only five of the nine patients sampled (56 percent) who were on TB medications, received all the required doses of medications. Four patients did not receive their TB medications as ordered; three patients received their medications from one to 22 days late, and one patient received one dose of TB medications after the provider discontinued the medication (MIT 9.001). The institution performed in the adequate range on the following test: • The OIG tested whether RJD offered patients who suffered from chronic care conditions immunizations and vaccinations for influenza, pneumonia, and hepatitis; 13 of 17 sampled patients (76 percent) received all vaccinations at the required intervals. For three patients, there was no medical record evidence that they received or refused required immunizations and vaccinations (MIT 9.008). RJD received proficient scores on the following three tests: • All 25 patients sampled timely received or were offered influenza vaccinations during the most recent influenza season (MIT 9.004). Richard J. Donovan Correctional Facility, Cycle 5 Medical Inspection Page 37 Office of the Inspector General State of California • RJD offered colorectal cancer screenings to 24 of 25 sampled patients (96 percent) subject to the annual screening requirement (over the age of 50). For one patient, there was no medical record evidence that health care staff offered a colorectal cancer screening within the prior year or that the patient had a normal colonoscopy within the last ten years (MIT 9.005). • RJD timely and accurately screened 27 of 30 sampled patients (90 percent) for TB within the prior year; for three patients, the history section of their TB screening form was not completed properly (MIT 9.003). Richard J. Donovan Correctional Facility, Cycle 5 Medical Inspection Page 38 Office of the Inspector General State of California 10 — QUALITY OF NURSING PERFORMANCE The Quality of Nursing Performance indicator is a qualitative Case Review Rating: evaluation of the institution’s nursing services. The evaluation is Adequate completed entirely by OIG nursing clinicians within the case review Compliance Score: process and does not have a score under the OIG compliance testing Not Applicable component. Case reviews include face-to-face encounters and Overall Rating: indirect activities performed by nursing staff on behalf of the Adequate patient. Review of nursing performance includes all nursing services performed on site, such outpatient, inpatient, urgent/emergent, patient transfers, care coordination, and medication management. The key focus areas for evaluation of nursing care include appropriateness and timeliness of patient triage and assessment, identification and prioritization of health care needs, use of the nursing process to implement interventions, and accurate, thorough, and legible documentation. Although nursing services provided in specialized medical housing units are reported in the Specialized Medical Housing indicator, and those provided in the TTA or related to emergency medical responses are reported in the Emergency Services indicator, all areas of nursing services are summarized in this Quality of Nursing Performance indicator. Case Review Results The OIG clinicians reviewed 321 nursing encounters, of which 169 were outpatient nursing encounters. Most outpatient nursing encounters were sick call requests, walk-in visits, and follow-up visits. There were 61 deficiencies identified related to nursing performance, 4 of which were significant. Significant deficiencies were identified once each in cases 15 and 51, and twice in case 16. The OIG clinicians rated the Quality of Nursing Performance indicator adequate. Nursing Assessment A major part of providing adequate nursing care involves the quality of nursing assessments, which includes both the subjective (patient interview) and the objective (evaluation and observation) portions. The majority of nurses consistently included both subjective and objective nursing assessments with patients. The deficiencies that were identified in nursing assessments were primarily for incomplete assessments and did not significantly contribute to patient harm; nurses did not ask patients to describe their symptoms, or did not complete a physical examination. See also Specialized Medical Housing for description of inpatient deficiencies. Nursing Intervention Nursing interventions are based on appropriate nursing assessments and include nursing actions, treatments, and referrals to help patients reach their health care goals and alleviate illness and injury conditions. Although most nursing interventions were satisfactory, the cases reviewed revealed the following two significant deficiencies. Richard J. Donovan Correctional Facility, Cycle 5 Medical Inspection Page 39 Office of the Inspector General State of California • In case 15, the patient had critically high blood glucose, and nursing staff did not inform a provider per parameters specified by the provider’s orders. • In case 16, the nurses did not check the patient’s blood pressure or blood glucose level as ordered. Additionally, nurses often did not complete refusal of treatment forms when the patient refused to have his blood glucose checked. Nursing Documentation Nursing documentation was adequate, and for outpatient care, it was comprehensive and addressed the specific needs of the patient. However, case review identified several patterns of minor nursing documentation deficiencies. For example, some nurses did not document the reasons for not administering medications, or document patients’ pain intensity levels. Sick Call The OIG clinicians reviewed 74 sick call nursing encounters. Generally, nurses triaged sick call requests promptly, assessed the patient timely, and provided appropriate care. The deficiencies identified were not significant, but did reflect a pattern of practice by some nurses that did not adhere to CCHCS policy. The policy requires patients with routine medical complaints be assessed and evaluated the day after the request is reviewed, patients with more serious complaints be seen immediately, and patients with urgent complaints be seen the same day. • In case 51, the patient had numbness and weakness in his leg, and was not assessed by a nurse until three days after the sick call request was reviewed. At that time, the patient was transferred out to a community hospital emergency room for a higher level of care. Care Management The role of the nurse primary care manager includes assessing patients, initiating appropriate interventions that support goals in the patient’s treatment plan, and monitoring patients with chronic health needs and those at increased risk for developing serious health complications. Nurse care managers took an active role in patient care management. They prepared patients, two or three visits in advance, for outpatient procedures and surgeries. The patient education included the importance of the patient not eating or drinking the night before, the predicted recovery and rehabilitation process, and what to expect regarding the procedure. The OIG review of nursing notes for wellness visits and sick call follow-up visits found that nurses adequately intervened for patients for commonplace problems. Examples of these included providing reading glasses when a patient lost his eyeglasses or replacing broken wheelchair parts. Richard J. Donovan Correctional Facility, Cycle 5 Medical Inspection Page 40 Office of the Inspector General State of California Urgent/Emergent Nurses’ performance in the TTA was satisfactory. Minor issues in documentation and nursing assessment were identified in the cases reviewed. Post Hospital Returns OIG clinicians reviewed 45 patient returns following community hospital visits. Patients returning to the institution after hospital discharge were assessed by a TTA nurse and received appropriate nursing assessment and follow-up referrals. TTA nurses reconciled discharge recommendations for the patient from the hospital with the institution’s provider, and most patients received their recommended medications and treatments upon returning to the institution. While the cases reviewed by the OIG clinicians did not demonstrate problems with medication continuity after hospital return, there were severe problems in this area in the cases examined during the OIG compliance testing. This is discussed further in the Inter- and Intra-System Transfers indicator. Out-to-Medical Return and Specialty Care The OIG clinicians reviewed 17 nursing encounters for patients who had returned to the institution from their specialty pre-scheduled appointments and hospital admissions. Nurses assessed these returning patients in the TTA. When a provider was not present in the TTA, nurses appropriately contacted the on-call provider for hospital discharge and specialty consultation recommendations. This is discussed further in the Specialty Services indicator. Specialized Medical Housing The CTC nurses provided satisfactory nursing care services, which is discussed in more detail in the Specialized Medical Housing indicator. Transfers and Reception Center The OIG reviewed 14 patient encounters for transfers in and out of the institution and found the care provided during the transfer process satisfactory. The Inter- and Intra-System Transfers indicator provides more details on these encounters. Medication Administration Nurses performed poorly in medication administration. This performance is discussed in more detail in the Pharmacy and Medication Management indicator. Richard J. Donovan Correctional Facility, Cycle 5 Medical Inspection Page 41 Office of the Inspector General State of California Clinician Onsite Inspection The director of nursing services and chief medical executive met with the OIG clinicians and answered all questions related to patient care and nursing operations. The OIG clinicians also interviewed nurses from utilization management, specialty services, telemedicine, and receiving and release and found RJD nurses were knowledgeable about their clinical positions. All nurses were cross-trained for various positions and felt comfortable covering nursing staff vacancies. Nurses in outpatient clinic settings actively participated in the primary care team morning huddles along with providers, sick call nurses, medication line nurses, mental health staff, schedulers, and other care team members. During the OIG visit, the huddle content was comprehensive and allowed time for meaningful discussion. Schedulers reported add-ons to the day’s clinic schedule including patients for follow-up in nurse lines, and the utilization management nurse reported on the patients returning after hospital discharge. Each of the huddle’s participants contributed to the discussion by providing short, factual reports related to their specific area of responsibility. The OIG clinicians also visited clinics in each yard of the institution and found the nurse staffing was appropriate for the patient needs. Some yard clinics had two nurses depending on the patient population. Nursing staff reported no major barriers to initiating communication with nursing supervisors, providers, or custody officers regarding patient care needs. Nurses were enthusiastic about their assignments and working conditions. Case Review Conclusion The OIG clinicians rated the Quality of Nursing Performance indicator adequate. Outpatient nursing care demonstrated a timely and appropriate nurse triage. Significant nursing deficiencies were isolated and did not display a pattern of inadequate nursing practices. Richard J. Donovan Correctional Facility, Cycle 5 Medical Inspection Page 42 Office of the Inspector General State of California 11 — QUALITY OF PROVIDER PERFORMANCE In this indicator, the OIG physicians provide a qualitative evaluation Case Review Rating: of the adequacy of provider care at the institution. Appropriate Adequate evaluation, diagnosis, and management plans are reviewed for Compliance Score: programs including, but not limited to, nursing sick call, chronic Not Applicable care programs, TTA, specialized medical housing, and specialty Overall Rating: services. The assessment of provider care is performed entirely by Adequate OIG physicians. There is no compliance testing component associated with this quality indicator. Case Review Results The OIG clinicians reviewed 258 medical provider encounters and identified 29 deficiencies related to provider performance, 9 of which were significant. Significant deficiencies were identified once each in cases 6, 9, 12, 13, 15, 16, 22, and twice in case 23. The OIG clinicians rated the Quality of Provider Performance indicator adequate. Assessment and Decision-Making In most cases, providers made appropriate assessments and sound medical plans; however, there were three significant deficiencies: • In case 16, the patient, with no history of hypertension, had elevated blood pressure (166/99 mmHg) and tachycardia (rapid heart rate) of 112 beats per minute. The provider inappropriately released the patient back to his housing without monitoring him further or scheduling a prompt follow-up visit, placing the patient at risk of harm. Furthermore, the provider suspected the abnormal vital signs were from substance abuse, but failed to order a drug-screening test. • In case 23, a provider started the patient on a diuretic, but did not monitor the patient’s potassium level, which is often changed by this medication. A significant change in the potassium level, if not managed, could have led to an unstable heart rhythm. • Also in case 23, the patient was admitted to the CTC with acute encephalopathy (confusion) for close monitoring. A provider reviewed the lab results, but did not address the patient’s severely abnormal thyroid level. An underactive thyroid could have been the cause or could have contributed to the encephalopathy. Emergency Care Providers at RJD made appropriate triage decisions when patients needed emergency care in the TTA and were available to the TTA nursing staff for consultation. Provider performance in this area is further discussed in the Emergency Services indicator. Richard J. Donovan Correctional Facility, Cycle 5 Medical Inspection Page 43 Office of the Inspector General State of California Hospital Return RJD providers properly signed hospital discharge summaries and addressed all recommendations timely. Chronic Care Chronic care performance was adequate and the providers demonstrated good care in regard to hypertension, asthma, hepatitis C infection, and cardiovascular disease. The providers’ thorough documentation demonstrated sound assessments and plans; however, there was one significant deficiency: • In case 12, a provider reviewed laboratory results including cholesterol levels. These results, combined with the patient’s other risk factors, placed him at an elevated risk of heart disease or stroke. At the patient’s risk level, medical guidelines recommend a specific type of cholesterol medication, but the provider did not prescribe it. The management of diabetes was generally adequate; however, three significant deficiencies were identified: • In case 9, the patient with acute leukemia had a low white blood cell count and was susceptible to infection. On four occasions, the patient’s lab results showed elevated blood glucose levels, suggesting diabetes, which the providers did not address. Without treatment to lower the blood glucose levels, the patient was at an even higher risk of infection. • In case 15, the patient had poorly controlled diabetes with elevated hemoglobin, HbA1c (a blood test to indicate the average level of blood sugar over the past two to three months), and elevated fasting and before meal blood glucose levels. On multiple occasions, the providers did not review the patient’s glucose log and did not adjust insulin doses as indicated. The poor diabetes control placed the patient at an increased risk for diabetic complications. • In case 22, the patient had poorly controlled diabetes but refused to be placed on insulin. The provider did not prescribe a second oral medication and ordered an inappropriately lengthy follow-up visit. Furthermore, the patient had worsening kidney function, but the provider failed to recheck the kidney function tests. Finally, the provider kept the patient on a pain medication that could have further worsened the patient’s kidney function. The institution had an effective warfarin clinic, which managed patients on anticoagulants. The pharmacist and the providers worked together to appropriately monitor the blood tests that measure warfarin levels and to adjust the warfarin dosages. Richard J. Donovan Correctional Facility, Cycle 5 Medical Inspection Page 44 Office of the Inspector General State of California Specialty Services RJD providers appropriately referred patients for specialty services and timely reviewed specialty reports. Providers properly signed-off the reports and addressed the specialist recommendations timely. However, one significant deficiency was identified: • In case 13, the dermatologist performed a biopsy on the patient’s skin and recommended the patient have surgery if the biopsy revealed cancer. The biopsy results showed the patient had skin cancer, but the providers did not address the problem on subsequent visits with the patient. Health Information Management RJD providers usually documented outpatient and TTA encounters on the same day, and most provider progress notes were dictated or legibly written. Clinician Onsite Inspection During the OIG inspection, the institution had two and a half provider vacancies. Providers were enthusiastic about their work and were generally satisfied with diagnostic and specialty services, as well as nursing services. To ensure continuity of care, each provider was primarily assigned to one clinic. RJD providers led productive morning huddles that were well attended by nurses, the psychologist, the care coordinator, custody, and other medical staff. Providers averaged three on-call assignments per month. The day after a provider was on call, the provider was given a lighter clinic schedule. The chief medical executive (CME) and the chief physician and surgeon were committed to patient care and quality improvement. The institution developed a workbook to assist patients living with chronic pain. The providers were supportive of the CME and expressed general job satisfaction with their positions, and morale at RJD was good. Case Review Conclusion The institution’s providers delivered good care. Of the 25 cases the OIG physicians reviewed, 24 were adequate, and only one was inadequate. The OIG clinicians rated the Quality of Provider Performance indicator adequate. Richard J. Donovan Correctional Facility, Cycle 5 Medical Inspection Page 45 Office of the Inspector General State of California 12 — RECEPTION CENTER ARRIVALS This indicator focuses on the management of medical needs and Case Review Rating: continuity of care for patients arriving from outside the CDCR Not Applicable system. The OIG review includes evaluation of the ability of the Compliance Score: institution to provide and document initial health screenings, Not Applicable initial health assessments, continuity of medications, and Overall Rating: completion of required screening tests; address and provide Not Applicable significant accommodations for disabilities and health care appliance needs; and identify health care conditions needing treatment and monitoring. The patients reviewed for reception center cases are those received from non-CDCR facilities, such as county jails. Because RJD did not have a reception center, this indicator did not apply. Richard J. Donovan Correctional Facility, Cycle 5 Medical Inspection Page 46 Office of the Inspector General State of California 13 — SPECIALIZED MEDICAL HOUSING This indicator addresses whether the institution follows appropriate Case Review Rating: policies and procedures when admitting patients to onsite inpatient Adequate facilities, including completion of timely nursing and provider Compliance Score: assessments. The chart review assesses all aspects of medical care Adequate related to these housing units, including quality of provider and (85.0%) nursing care. RJD’s only specialized medical housing unit is the Overall Rating: Correctional Treatment Center (CTC). Adequate Case Review Results The CTC had 20 medical beds, 15 mental health beds, a safety cell, and restraint rooms. There were two negative pressure rooms to house contagious patients with suspected respiratory infections. The OIG clinicians reviewed 114 provider and nursing CTC encounters and identified 12 deficiencies, 2 of which were considered significant (cases 9 and 23). The CTC provided 24-hour skilled nursing care for treatment and rehabilitation after surgery, pain management, administration of intravenous medications, and end-of-life care. Provider Performance The CTC providers timely examined their patients, addressed the specialists’ recommendations, and generally made appropriate medical decisions. The OIG clinicians reviewed 27 provider encounters in the CTC and found five deficiencies, two of which were significant. The deficiencies are also discussed in the Quality of Provider Performance indicator. • In case 9, the patient had acute leukemia with leukopenia (low white blood cell count) which made the patient susceptible to infection. On four occasions, labs showed elevated blood glucose levels (from 167 to 238 mg/dL). However, the providers did not address the elevated blood glucose levels, suggestive of diabetes. Leaving this elevated blood glucose untreated placed this patient at risk for infection. • In case 23, the patient with acute encephalopathy (confusion) was admitted to the CTC for close monitoring. A provider reviewed the patient’s laboratory test results but failed to address an elevated thyroid-stimulating hormone (TSH level of 74.08 mIU/L) which revealed inadequate treatment of the patient’s thyroid condition. This condition may have contributed to the encephalopathy. Nursing Performance There were no significant deficiencies in CTC nursing care at RJD. Richard J. Donovan Correctional Facility, Cycle 5 Medical Inspection Page 47 Office of the Inspector General State of California Clinician Onsite Inspection During the onsite visit, the CTC was well staffed. One physician was assigned as the primary CTC provider to ensure continuity of care. Three RNs were in the CTC at all times. An LVN, a certified nursing assistant (CNA), and support staff to assist nurses with patient care were available during the day. Morale in the CTC was high. Nurses reported being part of a good team with other nurses, mental health workers, and custody staff. They felt supported by nursing administrators, whom they were able to communicate with openly and freely about work-related issues. Nurses explained they were excited about the upcoming expansion and renovation of medical facilities at RJD and were anxious to move into the new clinical space. Case Review Conclusion Nursing and provider care in the CTC was adequate; the OIG clinicians rated the Specialized Medical Housing indicator adequate. Compliance Testing Results The institution received an adequate compliance score of 85.0 percent. RJD scored in the proficient range on the following three tests: • For all ten patients sampled, nursing staff timely completed an initial health assessment on the day the patient was admitted to the CTC (MIT 13.001). • Inspectors tested the working order of call buttons in CTC patient rooms and found all working properly. According to staff, clinicians and custody officers were able to expeditiously access patients’ locked rooms when emergent events occurred (MIT 13.101). • OIG inspectors sampled ten patients who were admitted to the CTC to determine if providers completed the required history and physical examination within 24 hours of the patient’s admission. For nine of the ten patients sampled (90 percent), the history and physical examination was timely completed. For one patient, there was no evidence found in the electronic medical record that a history and physical was completed (MIT 13.002). RJD scored in the inadequate range on the following test: • The OIG tested whether providers completed their Subjective, Objective, Assessment, Plan, and Education (SOAPE) notes at required three-day intervals for patients in the CTC. Providers completed timely SOAPE notes for only five of the ten sampled patients (50 percent). Two patients’ SOAPE notes were completed one and two days late. For three other patients, there was no evidence found in their electronic medical records that the required SOAPE notes were completed (MIT 13.003). Richard J. Donovan Correctional Facility, Cycle 5 Medical Inspection Page 48 Office of the Inspector General State of California 14 — SPECIALTY SERVICES This indicator focuses on specialist care from the time a request for Case Review Rating: services or physician’s order for specialist care is completed to the Proficient 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, (79.5%) including course of care when specialist recommendations were not Overall Rating: ordered, and whether the results of specialists’ reports are Adequate communicated to the patients. For specialty services denied by the institution, the OIG determines whether the denials are timely and appropriate, and whether the patient is updated on the plan of care. For this indicator, the OIG’s case review and compliance review processes yielded different results, with the case review giving a proficient rating and the compliance review resulting in an adequate score. The OIG’s internal review process considered those factors that led to both results and ultimately rated this indicator adequate. The factor that warranted the lower rating was that compliance review found that patients did not always receive high-priority specialty appointments, and RJD providers did not always review the corresponding high-priority reports timely. In addition, the institution did not always receive specialty reports within required time frames. Case Review Results The OIG clinicians reviewed 148 events related to specialty services, which included 121 specialty consultations and procedures and 27 nursing encounters. There were three deficiencies identified in this indicator, of which two were considered significant (cases 13 and 15). Case review rated this indicator proficient. Access to Specialty Services Specialty appointments are integral aspects of specialty services, and the OIG clinicians found that most specialty appointments occurred within the requested time frame. Nursing Performance RJD nursing care was adequate in out-to-medical-return assessments, interventions, and documentation; however, there was one minor deficiency. • In case 23, the patient returned from offsite radiation therapy. Nursing staff did not document the patient’s condition before discharging the patient back to housing. Richard J. Donovan Correctional Facility, Cycle 5 Medical Inspection Page 49 Office of the Inspector General State of California Provider Performance Providers referred patients to specialists appropriately and addressed most of the specialists’ recommendations. This performance is also discussed in the Quality of Provider Performance indicator. Health Information Management RJD staff retrieved and scanned most specialty reports into the electronic medical record within required time frames. Only one significant deficiency was identified: • In case 15, the patient underwent a sleep study, but the report from the study was not timely retrieved or scanned into the patient’s electronic medical record. Two weeks later a provider evaluated the patient, but the report was not available. Clinician Onsite Inspection The institution’s specialty service staff was assigned to coordinate offsite, onsite, and telemedicine specialty services. They scheduled specialty appointments and made necessary orders and referrals. Specialty services staff offsite worked closely with custody staff to ensure patients were taken to all offsite specialty appointments. Case Review Conclusion Most specialty appointments were met and specialty reports were timely retrieved and scanned; therefore, the OIG clinicians rated the Specialty Services indicator proficient. Compliance Testing Results The institution received an adequate compliance score of 79.5 percent in the Specialty Services indicator, and received a proficient score on the following two tests: • Providers timely received and reviewed the routine specialists’ reports for 14 of the 15 patients sampled (93 percent). One patient’s report was reviewed four days late (MIT 14.004). • For 13 of the 15 patients sampled (87 percent), routine specialty service appointments occurred within 90 calendar days of the provider’s order. Two patients’ appointments occurred 8 and 22 days late (MIT 14.003). RJD performed in the adequate range on the following tests: • RJD timely denied providers’ specialty service requests for 17 of 20 patients sampled (85 percent). Three denials for specialty services were from two to four days late (MIT 14.006). Richard J. Donovan Correctional Facility, Cycle 5 Medical Inspection Page 50 Office of the Inspector General State of California • When patients are approved or scheduled for specialty services at one institution and then are transferred to another institution, policy requires the receiving institution reschedule and provide the patient’s appointment within the required time frame. At RJD, 16 of the 20 patients sampled who transferred into RJD received their specialty service appointment timely (80 percent). Four patients never received their pending specialty service appointment or received it late: one patient never received his specialty service appointment; one patient had two appointments that were 7 and 33 days late, and a third appointment that never occurred; one patient had one appointment that was 15 days late and two other appointments that never occurred; and one patient had an appointment that was 35 days late (MIT 14.005). The institution showed room for improvement on the following tests: • Providers timely received and reviewed the specialists’ reports for 9 of the 14 applicable sampled patients (64 percent). For one patient, the provider reviewed the specialist’s report one day late. For one other patient, the specialist’s report was received one day late. For three other patients, the specialty service reports were received 7, 18, and 19 days late (MIT 14.002). • For 11 of the 15 patients sampled (73 percent), high-priority specialty service appointments occurred within 14 days of the provider’s order. Four patients received their specialty service appointments 5, 8, 12, and 59 days late (MIT 14.001). • Among 19 applicable patients sampled who had a specialty service denied by RJD’s health care management, 14 (74 percent) received timely notification of the denied service, including the provider meeting with the patient within 30 days to discuss alternate treatment strategies. One patient received notification of his denied service five days late. Four other patients never received notification (MIT 14.007). Richard J. Donovan Correctional Facility, Cycle 5 Medical Inspection Page 51 Office of the Inspector General State of California 15 — ADMINISTRATIVE OPERATIONS (SECONDARY) This indicator focuses on the institution’s administrative health care Case Review Rating: oversight functions. The OIG evaluates whether the institution Not Applicable promptly processes patient medical appeals and addresses all Compliance Score: appealed issues. Inspectors also verify that the institution follows Proficient reporting requirements for adverse/sentinel events and inmate (92.3%) deaths. The OIG verifies that the Emergency Medical Response Overall Rating: Review Committee (EMRRC) performs required reviews and that Proficient staff perform required emergency response drills. Inspectors also assess whether the Quality Management Committee (QMC) meets regularly and adequately addresses program performance. For those institutions with licensed facilities, inspectors also verify that required committee meetings are held. In addition, OIG examines whether the institution adequately manages its health care staffing resources by evaluating whether job performance reviews are completed as required; specified staff possess current, valid credentials and professional licenses or certifications; nursing staff receive new employee orientation training and annual competency testing; and clinical and custody staff have current medical emergency response certifications. The Administrative Operations indicator is a secondary indicator, and, therefore, was not relied on for the overall score for the institution. Compliance Testing Results The institution received a proficient compliance score of 92.3 percent in the Administrative Operations indicator, with several tests yielding proficient scores of 100 percent, as follows: • The institution promptly processed all inmate medical appeals in each of the most recent 12 months (MIT 15.001). • RJD’s QMC met monthly, evaluated program performance, and took action when management identified areas for improvement opportunities, and took adequate steps to ensure the accuracy of its Dashboard data reporting (MIT 15.003, 15.004). • The OIG inspected incident package documentation for 12 emergency medical responses reviewed by RJD’s EMRRC during the prior six-month period; all the sampled packages complied with CCHCS policy (MIT 15.005). • Inspectors reviewed the last 12 months of RJD’s local governing body (LGB) meeting minutes and determined that the LGB met at least quarterly and exercised responsibility for the quality management of patient heath care each quarter, as documented in the meeting minutes. As a result, RJD scored 100 percent on this test (MIT 15.006). • Based on a sample of ten second-level medical appeals, the institution’s responses addressed all the patients’ appealed issues (MIT 15.102). Richard J. Donovan Correctional Facility, Cycle 5 Medical Inspection Page 52 Office of the Inspector General State of California • All ten nurses sampled were current with their clinical competency validations (MIT 15.105). • The OIG reviewed performance evaluation packets for all ten of RJD’s providers, and the institution met all performance review requirements for its providers (MIT 15.106). • All providers at the institution were current with their professional licenses. Similarly, all nursing staff and the PIC were current with their professional licenses and certification requirements (MIT 15.107, 15.109). • All active duty providers and nurses were current with their emergency response certifications (MIT 15.108). • All pharmacy staff and providers who prescribed controlled substances had current United States Drug Enforcement Administration registrations (MIT 15.110). • All nursing staff hired within the most recent year timely received new employee orientation training (MIT 15.111). The institution showed room for improvement on the following two tests: • The OIG inspected records for five nurses from February 2017 to determine if their nursing supervisors properly completed monthly performance reviews. Inspectors identified the following deficiencies among four of five of the nurses’ monthly nursing reviews, for a result of 20 percent (MIT 15.104). The supervising nurse did not complete the required number of reviews for two nurses; o The supervising nurse did not discuss review findings with four nurses on a monthly o basis. • Inspectors reviewed drill packages for three medical emergency response drills conducted in the prior quarter. Only two of the three drill packages were properly completed, resulting in a score of 67 percent for this test. In one drill package, there was no indication that custody participated in the emergency response drill (MIT 15.101). Non-Scored Results • The OIG gathered non-scored data regarding the completion of death review reports by CCHCS’s Death Review Committee (DRC). The DRC did not timely complete its death review summary for any of the ten deaths that occurred at RJD during the OIG’s inspection period. The DRC was required to complete its death review summary report within 60 days from the date of death for the Level 1 death and within 30 days from the date of death for the Level 2 deaths; a Level 1 death is an unexpected death and a Level 2 death is an Richard J. Donovan Correctional Facility, Cycle 5 Medical Inspection Page 53 Office of the Inspector General State of California expected death. The reports should then have been submitted to the institution’s chief executive officer (CEO) within seven calendar days thereafter, so that any needed corrective action may be promptly pursued. RJD was not compliant with the CCHCS policy regarding the review and reporting of inmate deaths. For five of the ten deaths, the DRC submitted the death review summary reports to RJD’s CEO from one to 16 days late. The other five did not have a Death Review Summary completed at the time of the inspection (MIT 15.998). • RJD’s health care staffing resources are discussed in the About the Institution section on page 2 (MIT 15.999). Richard J. Donovan Correctional Facility, Cycle 5 Medical Inspection Page 54 Office of the Inspector General State of California RECOMMENDATIONS No specific recommendations. Richard J. Donovan Correctional Facility, Cycle 5 Medical Inspection Page 55 Office of the Inspector General State of California POPULATION-BASED METRICS The compliance testing and the case reviews give an accurate assessment of how the institution’s health care systems are functioning with regard to the patients with the highest risk and utilization. This information is vital to assess the capacity of the institution to provide sustainable, adequate care. However, one significant limitation of the case review methodology is that it does not give a clear assessment of how the institution performs for the entire population. For better insight into this performance, the OIG has turned to population-based metrics. For comparative purposes, the OIG has selected several Healthcare Effectiveness Data and Information Set (HEDIS) measures for disease management to gauge the institution’s effectiveness in outpatient health care, especially chronic disease management. The Healthcare Effectiveness Data and Information Set is a set of standardized performance measures developed by the National Committee for Quality Assurance with input from over 300 organizations representing every sector of the nation’s health care industry. It is used by over 90 percent of the nation’s health plans as well as many leading employers and regulators. It was designed to ensure that the public (including employers, the Centers for Medicare and Medicaid Services, and researchers) has the information it needs to accurately compare the performance of health care plans. Healthcare Effectiveness Data and Information Set data is often used to produce health plan report cards, analyze quality improvement activities, and create performance benchmarks. Methodology For population-based metrics, the OIG used a subset of HEDIS measures applicable to the CDCR patient population. Selection of the measures was based on the availability, reliability, and feasibility of the data required for performing the measurement. The OIG collected data utilizing various information sources, including the eUHR, the Master Registry (maintained by CCHCS), as well as a random sample of patient records analyzed and abstracted by trained personnel. Data obtained from the CCHCS Master Registry and Diabetic Registry was not independently validated by the OIG and is presumed to be accurate. For some measures, the OIG used the entire population rather than statistically random samples. While the OIG is not a certified HEDIS compliance auditor, the OIG uses similar methods to ensure that measures are comparable to those published by other organizations. Comparison of Population-Based Metrics For Richard J. Donovan Correctional Facility, nine HEDIS measures were selected and are listed in the following Richard J. Donovan Correctional Facility 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 5 Medical Inspection Page 56 Office of the Inspector General State of California Results of Population-Based Metrics Comparison Comprehensive Diabetes Care For chronic care management, the OIG chose measures related to the management of diabetes. Diabetes is the most complex common chronic disease requiring a high level of intervention on the part of the health care system in order to produce optimal results. RJD performed very well with its management of diabetes compared to most state and national plans. When compared statewide, RJD outperformed Medi-Cal scores in all five diabetic measures. When compared to Kaiser Permanente, RJD also outperformed Kaiser in three of the five diabetic measures, but scored lower than Kaiser North and South regions, in diabetic blood pressure control and diabetic eye exams. When compared nationally, RJD outperformed Medicaid and commercial health plans in all five measures, and outperformed Medicare in four of five measures, with Medicare performing better than RJD in diabetic eye exams. Finally, RJD outperformed the U.S. Department of Veterans Affairs (VA) in all diabetic measures with the exception of diabetic eye exams for which RJD scored 26 percentage points lower than the VA. However, 28 percent of the sampled RJD patients refused the eye exam. The number of refusals negatively affected the institution’s score in this measure. Immunizations Comparative data for immunizations was only fully available for the VA and partially available for Kaiser, commercial plans, Medicaid, and Medicare. With respect to administering influenza vaccinations to younger adults, RJD scored higher than all health plans. In addition, RJD outperformed both Medicare and the VA for influenza vaccinations for older adults. When administering pneumococcal vaccines to older adults, RJD scored higher than Medicare but slightly lower than the VA. Cancer Screening With respect to colorectal cancer screening, RJD scored higher than all health care plans, statewide and national. Summary RJD’s population-based metrics performance reflected an adequate chronic care program, and is comparable to the other health care plans reviewed. The institution may improve its scores for diabetic eye exams by reducing patient refusals through educating patients on the benefits of this preventive service. Richard J. Donovan Correctional Facility, Cycle 5 Medical Inspection Page 57 Office of the Inspector General State of California RJD Results Compared to State and National HEDIS Scores California National HEDIS RJD Kaiser HEDIS HEDIS Clinical Measures HEDIS (No. Kaiser HEDIS Com- HEDIS VA Cycle 5 Medi-Cal CA) (So.CA) Medicaid mercial Medicare Average Results1 20152 20163 20163 20164 20164 20164 20155 Comprehensive Diabetes Care HbA1c Testing (Monitoring) 100% 86% 94% 94% 86% 90% 93% 98% Poor HbA1c Control (>9.0%)6, 7 12% 39% 20% 23% 45% 34% 27% 19% HbA1c Control (<8.0%)6 77% 49% 70% 63% 46% 55% 63% - Blood Pressure Control (<140/90) 78% 63% 83% 83% 59% 60% 62% 74% Eye Exams 63% 53% 68% 81% 53% 54% 69% 89% Immunizations Influenza Shots - Adults (18–64) 67% - 56% 57% 39% 48% - 55% Influenza Shots - Adults (65+) 82% - - - - - 72% 76% Immunizations: Pneumococcal 87% - - - - - 71% 93% Cancer Screening Colorectal Cancer Screening 90% - 79% 82% - 63% 67% 82% 1. Unless otherwise stated, data was collected in April 2017 by reviewing medical records from a sample of RJD’s with a 15 percent maximum margin of error. 2. HEDIS Medi-Cal data was obtained from the California Department of Health Care Services 2015 HEDIS Aggregate Report for Medi-Cal Managed Care. 3. Data was obtained from Kaiser Permanente November 2016 reports for the Northern and Southern California regions. 4. National HEDIS data for Medicaid, commercial plans, and Medicare was obtained from the 2016 State of Health Care Quality Report, available on the NCQA website: www.ncqa.org. The results for commercial plans were based on data received from various health maintenance organizations. 5. The Department of Veterans Affairs (VA) data was obtained from the VA’s website, www.va.gov. For the Immunizations: Pneumococcal measure only, the data was obtained from the VHA Facility Quality and Safety Report - Fiscal Year 2012 Data. 6. For this indicator, the entire applicable 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 5 Medical Inspection Page 58 Office of the Inspector General State of California APPENDIX A — COMPLIANCE TEST RESULTS Richard J. Donovan Correctional Facility Range of Summary Scores: 62.41% - 92.29% Indicator Compliance Score (Yes %) 1–Access to Care 85.93% 2–Diagnostic Services 70.00% 3–Emergency Services Not Applicable 4–Health Information Management (Medical Records) 62.41% 5–Health Care Environment 62.59% 6–Inter- and Intra-System Transfers 78.00% 7–Pharmacy and Medication Management 67.72% 8–Prenatal and Post-Delivery Services Not Applicable 9–Preventive Services 69.67% 10–Quality of Nursing Performance Not Applicable 11–Quality of Provider Performance Not Applicable 12–Reception Center Arrivals Not Applicable 13–Specialized Medical Housing (OHU, CTC, SNF, Hospice) 85.00% 14–Specialty Services 79.47% 15–Administrative Operations 92.29% Richard J. Donovan Correctional Facility, Cycle 5 Medical Inspection Page 59 Office of the Inspector General State of California Scored Answers Yes Reference + 1–Access to Care Number Yes No No Yes % N/A Chronic care follow-up appointments: Was the patient’s most recent chronic care visit within the health care guideline’s 1.001 21 4 25 84.00% 0 maximum allowable interval or within the ordered time frame, whichever is shorter? For endorsed patients received from another CDCR institution: If 1.002 the nurse referred the patient to a provider during the initial health 4 1 5 80.00% 0 screening, was the patient seen within the required time frame? Clinical appointments: Did a registered nurse review the patient’s 1.003 45 0 45 100% 0 request for service the same day it was received? Clinical appointments: Did the registered nurse complete a 1.004 face-to-face visit within one business day after the CDCR Form 45 0 45 100% 0 7362 was reviewed? Clinical appointments: If the registered nurse determined a referral to a primary care provider was necessary, was the patient 1.005 11 5 16 68.75% 29 seen within the maximum allowable time or the ordered time frame, whichever is the shorter? Sick call follow-up appointments: If the primary care provider 1.006 ordered a follow-up sick call appointment, did it take place within 7 2 9 77.78% 36 the time frame specified? Upon the patient’s discharge from the community hospital: Did 1.007 the patient receive a follow-up appointment within the required 21 3 24 87.50% 1 time frame? Specialty service follow-up appointments: Do specialty service 1.008 primary care physician follow-up visits occur within required time 23 2 25 92.00% 5 frames? Clinical appointments: Do patients have a standardized process to 1.101 5 1 6 83.33% 0 obtain and submit health care services request forms? Overall percentage: 85.93% Richard J. Donovan Correctional Facility, Cycle 5 Medical Inspection Page 60 Office of the Inspector General State of California Scored Answers Yes Reference + 2–Diagnostic Services Number Yes No No Yes % N/A Radiology: Was the radiology service provided within the time 2.001 10 0 10 100% 0 frame specified in the provider’s order? Radiology: Did the primary care provider review and initial the 2.002 0 10 10 0.00% 0 diagnostic report within specified time frames? Radiology: Did the primary care provider communicate the results 2.003 7 3 10 70.00% 0 of the diagnostic study to the patient within specified time frames? Laboratory: Was the laboratory service provided within the time 2.004 7 2 9 77.78% 1 frame specified in the provider’s order? Laboratory: Did the primary care provider review and initial the 2.005 9 1 10 90.00% 0 diagnostic report within specified time frames? Laboratory: Did the primary care provider communicate the 2.006 results of the diagnostic study to the patient within specified time 9 1 10 90.00% 0 frames? Pathology: Did the institution receive the final diagnostic report 2.007 8 2 10 80.00% 0 within the required time frames? Pathology: Did the primary care provider review and initial the 2.008 9 0 9 100% 1 diagnostic report within specified time frames? Pathology: Did the primary care provider communicate the results 2.009 2 7 9 22.22% 1 of the diagnostic study to the patient within specified time frames? Overall percentage: 70.00% 3–Emergency Services This indicator is evaluated only by case review clinicians. There is no compliance testing component. Richard J. Donovan Correctional Facility, Cycle 5 Medical Inspection Page 61 Office of the Inspector General State of California Scored Answers Yes Reference + 4–Health Information Management Number Yes No No Yes % N/A Are non-dictated healthcare documents (provider progress notes) 4.001 13 1 14 92.86% 0 scanned within 3 calendar days of the patient encounter date? Are dictated/transcribed documents scanned into the patient’s 4.002 electronic health record within five calendar days of the encounter 12 8 20 60.00% 0 date? Are High-Priority specialty notes (either a Form 7243 or other 4.003 scanned consulting report) scanned within the required time 8 12 20 40.00% 0 frame? Are community hospital discharge documents scanned into the 4.004 patient’s electronic health record within three calendar days of 17 3 20 85.00% 0 hospital discharge? Are medication administration records (MARs) scanned into the 4.005 15 5 20 75.00% 0 patient’s electronic health record within the required time frames? During the inspection, were medical records properly scanned, 4.006 0 24 24 0.00% 0 labeled, and included in the correct patients’ files? For patients discharged from a community hospital: Did the preliminary hospital discharge report include key elements and 4.007 21 4 25 84.00% 0 did a primary care provider review the report within three calendar days of discharge? Overall percentage: 62.41% Richard J. Donovan Correctional Facility, Cycle 5 Medical Inspection Page 62 Office of the Inspector General State of California Scored Answers Yes Reference + 5–Health Care Environment Number Yes No No Yes % N/A Are clinical health care areas appropriately disinfected, cleaned 5.101 11 2 13 84.62% 0 and sanitary? Do clinical health care areas ensure that reusable invasive and 5.102 non-invasive medical equipment is properly sterilized or 12 1 13 92.31% 0 disinfected as warranted? Do clinical health care areas contain operable sinks and sufficient 5.103 12 1 13 92.31% 0 quantities of hygiene supplies? Does clinical health care staff adhere to universal hand hygiene 5.104 6 7 13 46.15% 0 precautions? Do clinical health care areas control exposure to blood-borne 5.105 13 0 13 100% 0 pathogens and contaminated waste? Warehouse, Conex and other non-clinic storage areas: Does the 5.106 medical supply management process adequately support the needs 0 1 1 0.00% 0 of the medical health care program? Does each clinic follow adequate protocols for managing and 5.107 5 7 12 41.67% 1 storing bulk medical supplies? Do clinic common areas and exam rooms have essential core 5.108 9 4 13 69.23% 0 medical equipment and supplies? Do clinic common areas have an adequate environment conducive 5.109 8 5 13 61.54% 0 to providing medical services? Do clinic exam rooms have an adequate environment conducive 5.110 6 7 13 46.15% 0 to providing medical services? Emergency response bags: Are TTA and clinic emergency 5.111 medical response bags inspected daily and inventoried monthly, 6 5 11 54.55% 2 and do they contain essential items? Overall percentage: 62.59% Richard J. Donovan Correctional Facility, Cycle 5 Medical Inspection Page 63 Office of the Inspector General State of California Scored Answers Yes Reference + 6–Inter- and Intra-System Transfers Number Yes No No Yes % N/A For endorsed patients received from another CDCR institution or COCF: Did nursing staff complete the initial health screening and 6.001 4 1 5 80.00% 0 answer all screening questions on the same day the patient arrived at the institution? For endorsed patients received from another CDCR institution or COCF: When required, did the RN complete the assessment and disposition section of the health screening form; refer the patient 6.002 5 0 5 100% 0 to the TTA, if TB signs and symptoms were present; and sign and date the form on the same day staff completed the health screening? For endorsed patients received from another CDCR institution or COCF: If the patient had an existing medication order upon 6.003 2 2 4 50.00% 1 arrival, were medications administered or delivered without interruption? For patients transferred out of the facility: Were scheduled 6.004 specialty service appointments identified on the patient’s health 12 8 20 60.00% 0 care transfer information form? For patients transferred out of the facility: Do medication transfer 6.101 packages include required medications along with the 2 0 2 100% 0 corresponding transfer packet required documents? Overall percentage: 78.00% Richard J. Donovan Correctional Facility, Cycle 5 Medical Inspection Page 64 Office of the Inspector General State of California Scored Answers 7–Pharmacy and Medication Yes Reference + Management Number Yes No No Yes % N/A Did the patient receive all chronic care medications within the 7.001 required time frames or did the institution follow departmental 4 18 22 18.18% 3 policy for refusals or no-shows? Did health care staff administer, make available, or deliver new 7.002 order prescription medications to the patient within the required 13 1 14 92.86% 0 time frames? Upon the patient’s discharge from a community hospital: Were all 7.003 ordered medications administered, made available, or delivered to 12 13 25 48.00% 0 the patient within required time frames? For patients received from a county jail: Were all medications ordered by the institution’s reception center provider 7.004 Not Applicable administered, made available, or delivered to the patient within the required time frames? Upon the patient’s transfer from one housing unit to another: 7.005 11 14 25 44.00% 0 Were medications continued without interruption? For patients en route who lay over at the institution: If the 7.006 temporarily housed patient had an existing medication order, were 5 5 10 50.00% 0 medications administered or delivered without interruption? All clinical and medication line storage areas for narcotic 7.101 medications: Does the Institution employ strong medication 7 2 9 77.78% 4 security over narcotic medications assigned to its clinical areas? All clinical and medication line storage areas for non-narcotic medications: Does the Institution properly store non-narcotic 7.102 4 9 13 30.77% 0 medications that do not require refrigeration in assigned clinical areas? All clinical and medication line storage areas for non-narcotic 7.103 medications: Does the institution properly store non-narcotic 6 5 11 54.55% 2 medications that require refrigeration in assigned clinical areas? Medication preparation and administration areas: Do nursing staff employ and follow hand hygiene contamination control protocols 7.104 8 0 8 100% 5 during medication preparation and medication administration processes? Medication preparation and administration areas: Does the 7.105 institution employ appropriate administrative controls and 8 0 8 100% 5 protocols when preparing medications for patients? Medication preparation and administration areas: Does the 7.106 Institution employ appropriate administrative controls and 3 6 9 33.33% 4 protocols when distributing medications to patients? Pharmacy: Does the institution employ and follow general 7.107 security, organization, and cleanliness management protocols in 2 0 2 100% 0 its main and satellite pharmacies? Richard J. Donovan Correctional Facility, Cycle 5 Medical Inspection Page 65 Office of the Inspector General State of California Scored Answers 7–Pharmacy and Medication Yes Reference + Management Number Yes No No Yes % N/A Pharmacy: Does the institution’s pharmacy properly store 7.108 1 1 2 50.00% 0 non-refrigerated medications? Pharmacy: Does the institution’s pharmacy properly store 7.109 2 0 2 100% 0 refrigerated or frozen medications? Pharmacy: Does the institution’s pharmacy properly account for 7.110 2 0 2 100% 0 narcotic medications? Does the institution follow key medication error reporting 7.111 21 4 25 84.00% 0 protocols? Overall percentage: 67.72% 8–Prenatal and Post-Delivery Services The institution has no female patients, so this indicator is not applicable. Richard J. Donovan Correctional Facility, Cycle 5 Medical Inspection Page 66 Office of the Inspector General State of California Scored Answers Yes Reference + 9–Preventive Services Number Yes No No Yes % N/A Patients prescribed TB medication: Did the institution administer 9.001 5 4 9 55.56% 0 the medication to the patient as prescribed? Patients prescribed TB medication: Did the institution monitor the 9.002 patient monthly for the most recent three months he or she was on 0 9 9 0.00% 0 the medication? Annual TB Screening: Was the patient screened for TB within the 9.003 27 3 30 90.00% 0 last year? Were all patients offered an influenza vaccination for the most 9.004 25 0 25 100% 0 recent influenza season? All patients from the age of 50 - 75: Was the patient offered 9.005 24 1 25 96.00% 0 colorectal cancer screening? Female patients from the age of 50 through the age of 74: Was the 9.006 Not Applicable patient offered a mammogram in compliance with policy? Female patients from the age of 21 through the age of 65: Was 9.007 Not Applicable patient offered a pap smear in compliance with policy? Are required immunizations being offered for chronic care 9.008 13 4 17 76.47% 8 patients? Are patients at the highest risk of coccidioidomycosis (valley 9.009 Not Applicable fever) infection transferred out of the facility in a timely manner? Overall percentage: 69.67% 10–Quality of Nursing Performance This indicator is evaluated only by case review clinicians. There is no compliance testing component. 11–Quality of Provider Performance This indicator is evaluated only by case review clinicians. There is no compliance testing component. Richard J. Donovan Correctional Facility, Cycle 5 Medical Inspection Page 67 Office of the Inspector General State of California 12–Reception Center Arrivals The institution has no reception center, so this indicator is not applicable. Scored Answers Yes Reference + 13–Specialized Medical Housing Number Yes No No Yes % N/A For OHU, CTC, and SNF: Did the registered nurse complete an 13.001 initial assessment of the patient on the day of admission, or within 10 0 10 100% 0 eight hours of admission to CMF’s Hospice? For CTC and SNF only: Was a written history and physical 13.002 9 1 10 90.00% 0 examination completed within the required time frame? For OHU, CTC, SNF, and Hospice: Did the primary care provider complete the Subjective, Objective, Assessment, Plan, and 13.003 5 5 10 50.00% 0 Education (SOAPE) notes on the patient at the minimum intervals required for the type of facility where the patient was treated? For OHU and CTC Only: Do inpatient areas either have properly working call systems in its OHU & CTC or are 30-minute patient 13.101 1 0 1 100% 0 welfare checks performed; and do medical staff have reasonably unimpeded access to enter patient’s cells? Overall percentage: 85.00% Richard J. Donovan Correctional Facility, Cycle 5 Medical Inspection Page 68 Office of the Inspector General State of California Scored Answers Yes Reference + 14–Specialty Services Number Yes No No Yes % N/A Did the patient receive the high priority specialty service within 14.001 14 calendar days of the primary care provider order or the 11 4 15 73.33% 0 Physician Request for Service? Did the primary care provider review the high priority specialty 14.002 9 5 14 64.29% 1 service consultant report within the required time frame? Did the patient receive the routine specialty service within 90 14.003 calendar days of the primary care provider order or Physician 13 2 15 86.67% 0 Request for Service? Did the primary care provider review the routine specialty service 14.004 14 1 15 93.33% 0 consultant report within the required time frame? For endorsed patients received from another CDCR institution: If the patient was approved for a specialty services appointment at 14.005 16 4 20 80.00% 0 the sending institution, was the appointment scheduled at the receiving institution within the required time frames? Did the institution deny the primary care provider request for 14.006 17 3 20 85.00% 0 specialty services within required time frames? Following the denial of a request for specialty services, was the 14.007 14 5 19 73.68% 1 patient informed of the denial within the required time frame? Overall percentage: 79.47% Richard J. Donovan Correctional Facility, Cycle 5 Medical Inspection Page 69 Office of the Inspector General State of California Scored Answers Yes Reference 15–Administrative Operations + Number Yes No No Yes % N/A Did the institution promptly process inmate medical appeals 15.001 12 0 12 100% 0 during the most recent 12 months? Does the institution follow adverse / sentinel event reporting 15.002 Not Applicable requirements? Did the institution Quality Management Committee (QMC) meet at least monthly to evaluate program performance, and did the 15.003 6 0 6 100% 0 QMC take action when improvement opportunities were identified? Did the institution’s Quality Management Committee (QMC) or 15.004 other forum take steps to ensure the accuracy of its Dashboard 1 0 1 100% 0 data reporting? Does the Emergency Medical Response Review Committee 15.005 perform timely incident package reviews that include the use of 12 0 12 100% 0 required review documents? For institutions with licensed care facilities: Does the Local Governing Body (LGB), or its equivalent, meet quarterly and 15.006 4 0 4 100% 0 exercise its overall responsibilities for the quality management of patient health care? Did the institution complete a medical emergency response drill 15.101 for each watch and include participation of health care and 2 1 3 66.67% 0 custody staff during the most recent full quarter? Did the institution’s second level medical appeal response address 15.102 10 0 10 100% 0 all of the patient’s appealed issues? Did the institution’s medical staff review and submit the initial 15.103 9 1 10 90.00% 0 inmate death report to the Death Review Unit in a timely manner? Does the institution’s Supervising Registered Nurse conduct 15.104 1 4 5 20.00% 0 periodic reviews of nursing staff? Are nursing staff who administer medications current on their 15.105 10 0 10 100% 0 clinical competency validation? 15.106 Are structured clinical performance appraisals completed timely? 12 0 12 100% 0 15.107 Do all providers maintain a current medical license? 15 0 15 100% 0 Are staff current with required medical emergency response 15.108 2 0 2 100% 1 certifications? Are nursing staff and the Pharmacist-in-Charge current with their professional licenses and certifications, and is the pharmacy licensed as a correctional pharmacy by the California State Board 15.109 7 0 7 100% 0 of Pharmacy? Richard J. Donovan Correctional Facility, Cycle 5 Medical Inspection Page 70 Office of the Inspector General State of California Scored Answers Yes Reference 15–Administrative Operations + Number Yes No No Yes % N/A Do the institution’s pharmacy and authorized providers who 15.110 prescribe controlled substances maintain current Drug 2 0 2 100% 0 Enforcement Agency (DEA) registrations? 15.111 Are nursing staff current with required new employee orientation? 1 0 1 100% 0 Overall percentage: 92.29% Richard J. Donovan Correctional Facility, Cycle 5 Medical Inspection Page 71 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 4 Diabetes 3 Emergency Services – CPR 5 Emergency Services – Non-CPR 3 High Risk 5 Hospitalization 4 Intra-System Transfers In 3 Intra-System Transfers Out 3 RN Sick Call 36 Specialty Services 4 73 Richard J. Donovan Correctional Facility, Cycle 5 Medical Inspection Page 72 Office of the Inspector General State of California Table B-2: RJD Chronic Care Diagnoses Diagnosis Total Anemia 9 Anticoagulation 4 Arthritis/Degenerative Joint Disease 9 Asthma 14 COPD 18 Cancer 4 Cardiovascular Disease 16 Chronic Kidney Disease 8 Chronic Pain 21 Cirrhosis/End-Stage Liver Disease 6 Coccidioidomycosis 4 Deep Venous Thrombosis/Pulmonary Embolism 7 Diabetes 16 Gastroesophageal Reflux Disease 21 HIV 3 Hepatitis C 24 Hyperlipidemia 28 Hypertension 46 Mental Health 13 Migraine Headaches 2 Seizure Disorder 9 Sleep Apnea 1 Thyroid Disease 3 286 Richard J. Donovan Correctional Facility, Cycle 5 Medical Inspection Page 73 Office of the Inspector General State of California Table B-3: RJD Event – Program Program Total Diagnostic Services 197 Emergency Care 67 Hospitalization 95 Intra-System Transfers In 9 Intra-System Transfers Out 5 Not Specified 2 Outpatient Care 510 Specialized Medical Housing 114 Specialty Services 253 1,252 Richard J. Donovan Correctional Facility, Cycle 5 Medical Inspection Page 74 Office of the Inspector General State of California Table B-4: RJD Review Sample Summary Total MD Reviews Detailed 25 MD Reviews Focused 1 RN Reviews Detailed 13 RN Reviews Focused 47 Total Reviews 86 Total Unique Cases 73 Overlapping Reviews (MD & RN) 13 Richard J. Donovan Correctional Facility, Cycle 5 Medical Inspection Page 75 Office of the Inspector General State of California APPENDIX C — COMPLIANCE SAMPLING METHODOLOGY RJ Donovan Correctional Facility (RJD) Sample Category Quality (number of Indicator samples) Data Source Filters Access to Care MIT 1.001 Chronic Care Patients Master Registry • Chronic care conditions (at least one condition per patient—any risk level) (25) • Randomize MIT 1.002 Nursing Referrals OIG Q: 6.001 • See Intra-system Transfers (5) MITs 1.003-006 Nursing Sick Call MedSATS • Clinic (each clinic tested) (5 per clinic) • Appointment date (2–9 months) (45) • Randomize MIT 1.007 Returns from OIG Q: 4.007 • See Health Information Management (Medical Community Hospital Records) (returns from community hospital) (25) MIT 1.008 Specialty Services OIG Q: 14.001 & • See Specialty Services Follow-up 14.003 (30) MIT 1.101 Availability of Health OIG onsite • Randomly select one housing unit from each yard Care Services review Request Forms (6) Diagnostic Services MITs 2.001–003 Radiology Radiology Logs • Appointment date (90 days–9 months) • Randomize (10) • Abnormal MITs 2.004–006 Laboratory Quest • Appt. date (90 days–9 months) • Order name (CBC or CMPs only) • Randomize (10) • Abnormal MITs 2.007–009 Pathology InterQual • Appt. date (90 days–9 months) • Service (pathology related) (10) • Randomize Richard J. Donovan Correctional Facility, Cycle 5 Medical Inspection Page 76 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 (14) 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: 4.007 • 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 (24) any tested inmate during OIG compliance review (24 or more = No) MIT 4.007 Returns From Inpatient claims • Date (2–8 months) Community Hospital data • Most recent 6 months provided (within date range) • Rx count • Discharge date • Randomize (each month individually) • First 5 patients from each of the 6 months (if not 5 in a month, supplement from another, as needed) (25) Health Care Environment MIT 5.101-105 Clinical Areas OIG inspector • Identify and inspect all onsite clinical areas. MIT 5.107–111 (13) 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 (5) MIT 6.004 Specialty Services MedSATS • Date of transfer (3–9 months) Send-Outs • Randomize (20) MIT 6.101 Transfers Out OIG inspector • R&R IP transfers with medication (2) onsite review Richard J. Donovan Correctional Facility, Cycle 5 Medical Inspection Page 77 Office of the Inspector General State of California Sample Category Quality (number of Indicator samples) Data Source Filters Pharmacy and Medication Management MIT 7.001 Chronic Care OIG Q: 1.001 See Access to Care Medication • At least one condition per patient—any risk level • Randomize (25) MIT 7.002 New Medication Master Registry • Rx count Orders • Randomize (14) • Ensure no duplication of IPs tested in MIT 7.001 MIT 7.003 Returns from OIG Q: 4.007 • See Health Information Management (Medical Community Hospital Records) (returns from community hospital) (25) MIT 7.004 RC Arrivals – OIG Q: 12.001 • See Reception Center Arrivals Medication Orders (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) (25) • Randomize MIT 7.006 En Route SOMS • Date of transfer (2–8 months) • Sending institution (another CDCR facility) • Randomize (10) • NA/DOT meds MITs 7.101-103 Medication Storage OIG inspector • Identify and inspect clinical & med line areas that Areas onsite review store medications (varies by test) MITs 7.104–106 Medication OIG inspector • Identify and inspect onsite clinical areas that Preparation and onsite review prepare and administer medications Administration Areas (varies by test) MITs 7.107-110 Pharmacy OIG inspector • Identify & inspect all onsite pharmacies (2) onsite review MIT 7.111 Medication Error Monthly • All monthly statistic reports with Level 4 or higher Reporting medication error • Select a total of 5 months (25) reports MIT 7.999 Isolation Unit KOP Onsite active • KOP rescue inhalers & nitroglycerin medications Medications medication for IPs housed in isolation units (10) listing Prenatal and Post-Delivery Services MIT 8.001-007 Recent Deliveries OB Roster • Delivery date (2–12 months) (N/A at this • Most recent deliveries (within date range) institution) or Pregnant Arrivals OB Roster • Arrival date (2–12 months) (N/A at this • Earliest arrivals (within date range) institution) or Richard J. Donovan Correctional Facility, Cycle 5 Medical Inspection Page 78 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) (9) • Randomize MIT 9.003 TB Evaluation, SOMS • Arrival date (at least 1 year prior to inspection) Annual Screening • Birth Month (30) • Randomize MIT 9.004 Influenza SOMS • Arrival date (at least 1 year prior to inspection) Vaccinations • Randomize (25) • Filter out IPs tested in MIT 9.008 MIT 9.005 Colorectal Cancer SOMS • Arrival date (at least 1 year prior to inspection) Screening • Date of birth (51 or older) (25) • Randomize MIT 9.006 Mammogram SOMS • Arrival date (at least 2 yrs prior to inspection) (N/A at this • Date of birth (age 52–74) institution) or • Randomize MIT 9.007 Pap Smear SOMS • Arrival date (at least three yrs prior to inspection) (N/A at this • Date of birth (age 24–53) institution) or • Randomize MIT 9.008 Chronic Care OIG Q: 1.001 • Chronic care conditions (at least 1 condition per Vaccinations IP—any risk level) • Randomize (25) • Condition must require vaccination(s) MIT 9.009 Valley Fever Cocci transfer • Reports from past 2–8 months (number will vary) status report • Institution (N/A at this • Ineligibility date (60 days prior to inspection date) institution) or • All Richard J. Donovan Correctional Facility, Cycle 5 Medical Inspection Page 79 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) (N/A at this • Arrived from (county jail, return from parole, etc.) institution) or • 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 onsite review (all) Specialty Services MITs 14.001–002 High-Priority MedSATS • Approval date (3–9 months) (15) • Randomize MITs 14.003–004 Routine MedSATS • Approval date (3–9 months) • Remove optometry, physical therapy or podiatry (15) • Randomize MIT 14.005 Specialty Services MedSATS • Arrived from (other CDCR institution) Arrivals • Date of transfer (3–9 months) (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 5 Medical Inspection Page 80 Office of the Inspector General State of California Sample Category Quality (number of Indicator samples) Data Source Filters Administrative Operations MIT 15.001 Medical Appeals Monthly medical • Medical appeals (12 months) (all) appeals reports MIT 15.002 Adverse/Sentinel Adverse/sentinel • Adverse/sentinel events (2–8 months) Events events report (0) MITs 15.003–004 QMC Meetings Quality • Meeting minutes (12 months) Management Committee (6) meeting minutes MIT 15.005 EMRRC EMRRC meeting • Monthly meeting minutes (6 months) (12) minutes MIT 15.006 LGB LGB meeting • Quarterly meeting minutes (12 months) (4) minutes MIT 15.101 Medical Emergency Onsite summary • Most recent full quarter Response Drills reports & • Each watch documentation (3) for ER drills MIT 15.102 2nd Level Medical Onsite list of • Medical appeals denied (6 months) Appeals appeals/closed (10) appeals files MIT 15.103 Death Reports Institution-list of • Most recent 10 deaths deaths in prior 12 • Initial death reports (10) months MIT 15.104 RN Review Onsite supervisor • RNs who worked in clinic or emergency setting Evaluations periodic RN six or more days in sampled month reviews • Randomize (5) MIT 15.105 Nursing Staff Onsite nursing • On duty one or more years Validations education files • Nurse administers medications (10) • Randomize MIT 15.106 Provider Annual Onsite • All required performance evaluation documents Evaluation Packets provider (12) evaluation files MIT 15.107 Provider licenses Current provider • Review all listing (at start of (15) inspection) MIT 15.108 Medical Emergency Onsite • All staff Response certification Providers (ACLS) o Certifications tracking logs Nursing (BLS/CPR) o (all) • Custody (CPR/BLS) MIT 15.109 Nursing staff and Onsite tracking • All required licenses and certifications Pharmacist in system, logs, or Charge Professional employee files Licenses and Certifications (all) Richard J. Donovan Correctional Facility, Cycle 5 Medical Inspection Page 81 Office of the Inspector General State of California Sample Category Quality (number of Indicator samples) Data Source Filters Administrative Operations MIT 15.110 Pharmacy and Onsite listing of • All DEA registrations Providers’ Drug provider DEA Enforcement Agency registration #s & (DEA) Registrations pharmacy registration (all) document MIT 15.111 Nursing Staff New Nursing staff • New employees (hired within last 12 months) Employee training logs • Orientations (all) MIT 15.998 Death Review OIG summary • Between 35 business days & 12 months prior Committee log - deaths • CCHCS death reviews (10) Richard J. Donovan Correctional Facility, Cycle 5 Medical Inspection Page 82 Office of the Inspector General State of California CALIFORNIA CORRECTIONAL HEALTH CARE SERVICES’ RESPONSE Richard J. 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