San Quentin State Prison Medical Inspection Results Cycle 1

SAN QUENTIN STATE PRISON MEDICAL INSPECTION RESULTS BUREAU OF AUDITS AND INVESTIGATIONS OFFICE OF THE INSPECTOR GENERAL DAVID R. SHAW INSPECTOR GENERAL STATE OF CALIFORNIA December 2009 Contents Executive Summary ......................................................................................… 1 Introduction …................................................................................................… 3 Background …....................................................................................… 3 About the Institution …......................................................................… 4 Objectives, Scope, and Methodology ….............................................. 4 Medical Inspection Results ….......................................................................… 7 California Prison Health Care Receivership Corporation's Response …............................................................................. 30 Office of the Inspector General's Comments on the Receiver's Response …....................................................................... 34 Executive Summary An April 2001 class action lawsuit filed by inmates represented by the Prison Law Office alleged that the state provided constitutionally inadequate medical care at California state prisons in violation of inmates’ constitutional rights. And, in October 2005, the U.S. Northern District Court of California declared that California’s delivery system for prison medical care was “broken beyond repair” and still not meeting constitutional standards. As a result, the federal court imposed a receivership to raise the delivery of medical care to constitutional standards. To evaluate and monitor the progress of medical care delivery to inmates, the receiver requested, and the Office of the Inspector General (OIG) agreed, to establish an objective, clinically appropriate, and metric-oriented medical program to annually inspect the delivery of medical care at each state prison. In August 2009, we inspected San Quentin State Prison (SQ). Our medical Overall inspection encompassed 19 components of medical delivery and comprised 153 Score questions. The questions are weighted based on their importance to the delivery 68.2% of medical care to inmates. SQ received 68.2 percent of the total weighted points possible. The following summary table lists the components we inspected in order of importance (highest to lowest), with the institution’s score and the definitions of each inspection component. The detailed medical inspection results, with the questions for each component, begin on page 7 of this report. While we are committed to helping each institution achieve a higher level of medical care, it is not our intent to determine the percentage score needed by an institution to meet constitutional standards—that is a legal matter for the federal court to determine. Executive Summary Table Component Weighted Score Definition Chronic Care 64.6% Examines how well the prison provided care and medication to inmates with specific chronic care conditions, which are those that affect (or have the potential to affect) an inmate's functioning and long-term prognosis for more than six months. Our inspection tests the following chronic care conditions: asthma, Coumadin therapy, diabetes, HIV (Human Immunodeficiency Virus), and hypertension. Clinical Services 46.6% Evaluates the inmate's access to primary health care services and focuses on inmates who recently received services from any of the prison's facility or administrative segregation unit clinics. This component evaluates sick call processes (doctor or nurse line), medication management, and nursing. Health Screening 76.5% Focuses on the prison's process for screening new inmates upon arrival to the institution for health care conditions that require treatment and monitoring, as well as ensuring inmates' continuity of care. Specialty Services 58.0% Focuses on the prison's process for approving, denying, and scheduling services that are outside the specialties of the prison's medical staff. Common examples of these services include physical therapy, oncology services, podiatry consultations, and neurology services. Urgent Services 62.9% Addresses the care provided by the institution to inmates before and after they were sent to a community hospital. Emergency Services 78.3% Examines how well the prison responded to medical emergencies. Specifically, we focused on "man down" or "woman down" situations. Further, questions determine the adequacy of medical and staff response to a "man down" or "woman down" emergency drill. Bureau of Audits and Investigations Page 1 Office of the Inspector General State of California Component Weighted Score Definition Prenatal Care/Childbirth/ N/A Focuses on the prenatal and post-delivery medical care provided to pregnant inmates. Not Post-delivery applicable at men's institutions. Diagnostic Services 69.4% Addresses the timeliness of radiology (x-ray) and laboratory services and whether the prison followed up on clinically significant results. Access to Health Care 53.9% Addresses the prison's effectiveness in filing, storing, and retrieving medical records and Information medical-related information. Outpatient Housing Unit 83.3% Determines whether the prison followed department policies and procedures when placing inmates in the outpatient housing unit. This component also evaluates whether the placement provided the inmate with adequate care and whether the physician's plan addressed the placement diagnosis. Internal Reviews 68.8% Focuses on the frequency of meetings held by the prison's Quality Management Committee (QMC) and Emergency Medical Response Review Committee (EMRRC) and whether key staff attended the meetings, the number of medical appeals filed, and the prison's death review process. Inmate Transfers 100.0% Focuses on inmates pending transfer to determine whether the sending institution documented medication and medical conditions to assist the receiving institution in providing continuity of care. Clinic Operations 100.0% Addresses the general operational aspects of the prison's facility clinics. Generally, the questions in this component relate to the overall cleanliness of the clinics, privacy afforded to inmates during nonemergency visits, use of priority ducats (slip of paper the inmate carries for scheduled medical appointments), and availability of health care request forms. Preventive Services 48.7% Focuses on inmate cancer screening, tuberculosis evaluation, and influenza immunizations. Pharmacy Services 86.2% Addresses whether the prison's pharmacy complies with various operational policies, such as conducting periodic inventory counts, maintaining the currency of medications in its crash carts and after-hours medication supplies, and having valid permits. In addition, this component also addresses whether the pharmacy has an effective process for screening medication orders for potential adverse reactions/interactions. Other Services 85.0% Examines additional areas that are not captured in the other components. The areas evaluated in this component include the prison's provision of therapeutic diets, its handling of inmates who display poor hygiene, and the availability of the current version of the department's Inmate Medical Services Policies and Procedures. Inmate Hunger Strikes 53.7% Examines medical staff's monitoring of inmates participating in hunger strikes. Chemical Agent 89.4% Addresses the prison's process of handling inmates who may be predisposed to an adverse Contraindications outcome from calculated uses of force (cell extractions) involving Oleoresin Capsicum (OC), which is commonly referred to as "pepper spray." For example, this might occur if the inmate has asthma. Staffing Levels and 95.0% Examines the prison's medical staffing levels and training provided. Training Nursing Policy 70.0% Determines whether the prison maintains written policies and procedures for the safe and effective provision of quality nursing care. The questions in this component also determine whether nursing staff review their duty statements and whether supervisors periodically review the work of nurses to ensure they properly follow established nursing protocols. Overall Score 68.2% Bureau of Audits and Investigations Page 2 Office of the Inspector General State of California Introduction Under the authority of California Penal Code section 6126, which assigns the Office of the Inspector General (OIG) responsibility for oversight of the California Department of Corrections and Rehabilitation, and at the request of the federal receiver, the OIG developed a comprehensive inspection program to evaluate the delivery of medical care at each of the California Department of Corrections and Rehabilitation’s 33 adult prisons. In August 2009, we inspected San Quentin State Prison (SQ). Our medical inspection encompassed 19 components of medical delivery and comprised 153 questions. To help readers understand the medical risk associated with certain components of medical delivery—which pose a greater risk to an inmate- patient—we developed a weighting system and assigned points to each question. Consequently, we assigned more total points to more critical components, such as chronic care, clinical services, and health screening. We assigned fewer total points to less critical components, such as inmate hunger strikes, staffing levels and training, and chemical agent contraindications. (For a detailed description of the weighting system, see Objectives, Scope, and Methodology on the next page.) Background In April 2001, inmates represented by the Prison Law Office filed a class action lawsuit, known as Plata v. Schwarzenegger. The lawsuit alleged that the state provided constitutionally inadequate medical care at California state prisons in violation of inmates’ constitutional rights. In June 2002, the parties entered into a Stipulation for Injunctive Relief, and the state agreed to implement over several years comprehensive new medical care policies and procedures at all institutions. Nevertheless, the U.S. Northern District Court of California declared in October 2005 that California’s delivery system for prison medical care was “broken beyond repair” and still not meeting constitutional standards. Thus, the federal court imposed a receivership to raise the delivery of medical care to constitutional standards. In essence, the court ordered the receiver to manage the state’s delivery of medical care and restructure day-to-day operations to develop and sustain a system that provides constitutionally adequate medical care to inmates. The court stated that it would remove the receiver and return control to the state once the system is stable and provides for constitutionally adequate medical care. To evaluate and monitor the progress of medical care delivery to inmates, the receiver requested that the OIG establish an objective, clinically appropriate, and metric-oriented medical inspection program. Toward that end, the Inspector General agreed to inspect annually each state prison until the state’s delivery of medical care to inmates meets constitutional standards. We are committed to helping each institution achieve a higher level of medical care, but it is up to the federal court to determine the percentage score necessary for an institution to meet constitutional standards. Bureau of Audits and Investigations Page 3 Office of the Inspector General State of California About the Institution San Quentin is California's oldest correctional institution. San Quentin includes a reception center for new commitments, a parole violator unit, general population units, and a minimum security work crew. San Quentin also houses all of the state's condemned male inmates. As of December 16, 2009, the California Department of Corrections and Rehabilitation (CDCR) reported that San Quentin had custody over 4,955 male inmates, including 2,568 reception center inmates and 622 inmates condemned to death. San Quentin runs seven medical clinics where staff handle non-urgent requests for medical services. San Quentin also treats inmates needing urgent or emergency care in its triage and treatment area (TTA). According to information provided by the institution, San Quentin's vacancy rate among licensed medical managers, primary care providers, supervisors, and rank and file nurses was 10.7 percent. When medically screening new arrivals at the institution, San Quentin uses local operating procedures that in some ways differ significantly from CDCR's statewide policies. The federal court, the Prison Law Office, and receiver are aware of the different procedures used by San Quentin. Therefore, some of our questions in the Health Screening component were not applicable at San Quentin. Jackie Clark, RN, MBA, serves as the prison's chief executive officer of health care while Elena Tootell, M.D., serves as the prison's chief medical officer. Both are responsible for San Quentin's entire health care program. Objectives, Scope, and Methodology In designing the medical inspection program, we reviewed the California Department of Corrections and Rehabilitation’s policies and procedures, relevant court orders, guidelines developed by the department’s Quality Medical Assurance Team, and guidance developed by the American Correctional Association. We also reviewed professional literature on correctional medical care, consulted with clinical experts, and met with stakeholders from the court, the receiver’s office, the department, and the Prison Law Office to discuss the nature and scope of the inspection program. Based on input from these stakeholders, we developed a medical inspection program that evaluates medical care delivery. Within each of 20 components, we created “yes” or “no” questions designed to gauge performance. To make the inspection results meaningful to both a medical expert and a lay reader, we worked with clinical experts to create a weighting system that factors the relative importance of each component compared to other components. Further, the program considers the relative importance of each question within a component to the other questions in that component. This weighting ensures that more critical components—such as those that pose the greatest medical risk to the inmate-patient—are given more weight compared to those considered less serious. For example, we assign a high number of possible points to the chronic care component because we consider this the most serious of all the components. Conversely, we assign very few points to the nursing policy component because we consider this the least serious inspection component. Each inspection question is weighted and scored. The score is derived from the percentage of “yes” answers for each question from all items sampled. We then multiply the percentage of “yes” answers Bureau of Audits and Investigations Page 4 Office of the Inspector General State of California within a given question by the question’s weight to arrive at a score. The following example shows how this scoring system works. Example Question: Institution X Answers Weighting Points Yes No Yes + No Yes % Possible Received Score % N/A Unk Is the clinical history adequate? 40 10 50 80% 20 16 80.0% 0 0 If the institution receives 40 “yes” answers and 10 “no” answers, the percentage of “yes” answers to this question equals 80 percent. We calculate the number of points the institution would receive by multiplying the “yes” percent of 80 by the number of possible points for this question, which is 20, to arrive at 16 points. To arrive at the total score, we add the points received for each question and then for each program component. Finally, we calculate the institution’s overall score by dividing the sum of the points received by the sum of the points possible. We do not include in the institution’s overall score the weight for questions that are not applicable or, in some cases, where a lack of documentation would result in numerous “no” answers for one deviation from policy (unknown). For instance, an institution may not be able to provide documentation that its Emergency Medical Response Review Committee met for a particular month. Therefore, when we evaluate whether meeting minutes document monthly meetings for a particular month, the institution would receive a “no” answer for that question. However, when we evaluate whether the meeting minutes document the warden’s attendance at the meeting, the answer would be “unknown” so that the institution’s score is not penalized twice for the same reason, not documenting the meeting. To evaluate the institution’s delivery of medical care, we obtained various electronic data files maintained by the institution for inmate medical scheduling and tracking, pharmacy, and census data. We used these electronic data files only to identify random samples of inmates receiving or requiring specific medical services. We then reviewed the medical file for each inmate in our sample. We did not rely on the medical care information contained in these electronic data files. Our medical inspection at SQ encompassed 19 of the 20 components of medical delivery. One of the components was not applicable during the period inspected. In total, we reviewed 204 inmate medical files, which are referred to as unit health records. In addition, we reviewed staffing level reports, medical appeals summaries, nursing policies and procedures, summaries of medical drills and emergencies, minutes from Quality Management Committee and Emergency Medical Response Review Committee hearings, and assorted manual logs or tracking worksheets related to medical care delivery. We also conducted a live medical emergency drill and evaluated the adequacy of the responding staff’s actions. Finally, we interviewed medical and custody staff members about the delivery of medical care to inmates, and we observed day-to-day medical delivery at the institution. We do not test the care provided in the licensed hospitals or correctional treatment centers because they are subject to inspections and oversight by other regulatory agencies. Bureau of Audits and Investigations Page 5 Office of the Inspector General State of California Consistent with our agreement with the receiver, our report only addresses the conditions found related to the medical care criteria. We do not discuss the causes of noncompliance, nor do we make specific recommendations in this report. However, if we learn of an inmate-patient who needs immediate care, we notify the health care manager and request a status report. Moreover, if we learn of significant departures from community standards, we may report such departures to the institution’s health care manager or the receiver’s office. Because these matters involve confidential medical information protected by state and federal privacy laws, specific details related to these cases are not included in our report. For ease of reference, following is a table of abbreviations used in the remainder of this report. Abbreviations used in this report AED Automatic External Defibrillator BLS Basic Life Support CMO Chief Medical Officer CTC Correctional Treatment Center CTQ Confined to Quarters ERRC Emergency Response Review Committee FTF Face-to-Face GACH General Acute Care Hospital HCM Health Care Manager INH Isoniazid (antituberculous medication) LVN Licensed Vocational Nurse MOD Medical Officer of the Day OB Obstetrician OC Oleoresin Capsicum (pepper spray) OHU Outpatient Housing Unit OIG Office of the Inspector General PCP Primary Care Provider QMC Quality Management Committee RN Registered Nurse SOAPE Subjective, Objective, Assessment, Plan, Education SRN Supervising Registered Nurse TB Tuberculosis TTA Triage and Treatment Area UHR Unit Health Record UM Utilization Management Bureau of Audits and Investigations Page 6 Office of the Inspector General State of California OFFICE OF THE INSPECTOR GENERAL SAN QUENTIN STATE PRISON Overall Score: MEDICAL INSPECTION RESULTS 68.2% 08/10/2009 – 08/13/2009 Answers Weighting Points Questions Not Answered Component Page Yes No Yes + No Yes % Points Possible Points Received Score % Not Applicable Unknown Chronic Care 8 143 80 223 64.1% 133 85.9 64.6% 0 2 Clinical Services 9 121 164 285 42.5% 95 44.3 46.6% 74 88 Health Screening 11 110 29 139 79.1% 60 45.9 76.5% 334 17 Specialty Services 13 58 33 91 63.7% 71 41.2 58.0% 50 3 Urgent Services 14 94 59 153 61.4% 52 32.7 62.9% 45 2 Emergency Services 15 40 10 50 80.0% 58 45.4 78.3% 0 0 Diagnostic Services 17 36 17 53 67.9% 52 36.1 69.4% 12 0 Access to Health Care Information 18 5 3 8 62.5% 51 27.5 53.9% 0 0 Outpatient Housing Unit 19 60 11 71 84.5% 48 40.0 83.3% 11 0 Internal Reviews 20 29 5 34 85.3% 40 27.5 68.8% 0 0 Inmate Transfers 21 15 0 15 100.0% 22 22.0 100.0% 10 0 Clinic Operations 22 28 0 28 100.0% 33 33.0 100.0% 0 0 Preventive Services 23 14 18 32 43.8% 30 14.6 48.7% 0 0 Pharmacy Services 24 8 3 11 72.7% 29 25.0 86.2% 0 0 Other Services 25 6 1 7 85.7% 10 8.5 85.0% 2 0 Inmate Hunger Strikes 26 8 7 15 53.3% 19 10.2 53.7% 0 0 Chemical Agent Contraindications 27 10 1 11 90.9% 17 15.2 89.4% 1 0 Staffing Levels and Training 28 7 1 8 87.5% 16 15.2 95.0% 1 0 Nursing Policy 29 10 5 15 66.7% 14 9.8 70.0% 0 0 Totals 802 447 1249 64.2% 850 580 68.2% 540 112 Bureau of Audits and Investigations Page 7 Office of the Inspector General State of California Answers Weighting Points Reference Chronic Care Number Yes No Yes + No Yes % Possible Received Score % N/A Unk 03.076 Was the inmate's most recent chronic care visit within the time frame 21 4 25 84.0% 10 8.4 84.0% 0 0 required by the degree of control of the inmate's condition based on his or her prior visit? 03.077 Were key elements on Forms 7419 (Chronic Care Follow-Up Visit) and 18 7 25 72.0% 10 7.2 72.0% 0 0 7392 (Primary Care Flow Sheet) filled out completely for the inmate's two most recent visits? 03.082 Did the institution document that it provided the inmate with health care 3 22 25 12.0% 12 1.4 12.0% 0 0 education? 03.175 Did the inmate receive his or her prescribed chronic care medications during 2 23 25 8.0% 18 1.4 8.0% 0 0 the most recent three-month period or did the institution follow departmental policy if the inmate refused to pick up or show up for his or her medications? 03.235 Is the clinical history adequate? 17 8 25 68.0% 18 12.2 68.0% 0 0 03.236 Is the focused clinical examination adequate? 19 6 25 76.0% 19 14.4 76.0% 0 0 03.237 Is the assessment adequate? 22 2 24 91.7% 19 17.4 91.7% 0 1 03.238 Is the plan adequate and consistent with the degree of control based on the 22 2 24 91.7% 19 17.4 91.7% 0 1 chronic care program intervention and follow up requirements? 03.262 Is the inmate's Problem List complete and filed accurately in the inmate's 19 6 25 76.0% 8 6.1 76.0% 0 0 unit health record (UHR)? Components Subtotals: 143 80 223 64.1% 133 85.9 64.6% 0 2 Bureau of Audits and Investigations Page 8 Office of the Inspector General State of California Answers Weighting Points Reference Clinical Services Number Yes No Yes + No Yes % Possible Received Score % N/A Unk 01.024 RN FTF Documentation: Did the inmate's request for health care get 4 31 35 11.4% 4 0.5 11.4% 0 0 reviewed the same day it was received? 01.025 RN FTF Documentation: Did the RN complete the face-to-face (FTF) triage 12 23 35 34.3% 6 2.1 34.3% 0 0 within one (1) business day after the Form 7362 was reviewed? For 12 of the 35 inmates' requests for medical care that we reviewed, we found that not only did San Quentin R.N.'s not conduct face-to-face triages within one business day, according to documentation reviewed by our inspectors, they did not complete the triages at all. 01.246 Did documentation indicate that the RN reviewed all of the inmate's 20 2 22 90.9% 5 4.5 90.9% 1 12 complaints listed on Form 7362 (Health Care Services Request Form)? 01.157 RN FTF Documentation: Did the RN's subjective note address the nature 7 15 22 31.8% 7 2.2 31.8% 1 12 and history of the inmates primary complaint? 01.159 RN FTF Documentation: Did the RN's objective note include vital signs and 11 11 22 50.0% 6 3.0 50.0% 1 12 a focused physical examination, and did it adequately address the problems noted in the subjective note? 01.244 RN FTF Documentation: Did the RN's objective note include allergies, 4 18 22 18.2% 3 0.5 18.2% 1 12 weight, current medication, and where appropriate, medication compliance? 01.158 RN FTF Documentation: Did the RN's assessment provide conclusions 6 16 22 27.3% 6 1.6 27.3% 1 12 based on subjective and objective data, were the conclusions formulated as patient problems, and did it contain applicable nursing diagnoses? 01.162 RN FTF Documentation: Did the RN's plan include an adequate strategy to 22 0 22 100.0% 7 7.0 100.0% 1 12 address the problems identified during the FTF triage? 01.163 RN FTF Documentation: Did the RN's education/instruction adequately 14 8 22 63.6% 5 3.2 63.6% 1 12 address the problems identified during the FTF triage? 01.027 If the RN determined a referral to a primary care physician (PCP) was 5 4 9 55.6% 8 4.4 55.6% 26 0 necessary, was the inmate seen within the timelines specified by the RN during the FTF triage? Bureau of Audits and Investigations Page 9 Office of the Inspector General State of California Answers Weighting Points Reference Clinical Services Number Yes No Yes + No Yes % Possible Received Score % N/A Unk 01.247 Sick Call Follow-up: If the provider ordered a follow-up sick call 4 4 8 50.0% 7 3.5 50.0% 27 0 appointment, did it take place within the time frame specified? 01.124 Sick Call Medication: Did the institution administer or deliver prescription 7 25 32 21.9% 6 1.3 21.9% 3 0 medications (new orders) to the inmate within specified time frames? 15.234 Are clinic response bags audited daily and do they contain essential items? 1 1 2 50.0% 5 2.5 50.0% 0 0 21.278 For inmates seen in the TTA, was there adequate prior management of pre- 4 6 10 40.0% 20 8.0 40.0% 11 4 existing medical conditions related to the reason for the TTA visit? Components Subtotals: 121 164 285 42.5% 95 44.3 46.6% 74 88 Bureau of Audits and Investigations Page 10 Office of the Inspector General State of California Answers Weighting Points Reference Health Screening Number Yes No Yes + No Yes % Possible Received Score % N/A Unk 02.016 Did the institution complete the initial health screening on the same day the 27 3 30 90.0% 9 8.1 90.0% 0 0 inmate arrived at the institution? 02.017 If yes was answered to any of the questions on the initial health screening 0 0 0 0.0% 0 0.0 0.0% 30 0 form(s), did the RN provide an assessment and disposition on the date of arrival? 02.018 If, during the assessment, the RN referred the inmate to a clinician, was the 11 7 18 61.1% 8 4.9 61.1% 11 1 inmate seen within the time frame? 02.021 Reception center: Did the inmate receive a complete history and physical by 19 1 20 95.0% 5 4.8 95.0% 10 0 a Nurse Practitioner, Physician Assistant, or a Physician and Surgeon within 14 calendar days of arrival? 02.211 Reception center history and physical: Is the "History of Present Illness" 0 0 0 0.0% 0 0.0 0.0% 20 0 section of Form 7206 (History and Physical Examination) complete and appropriate to the chief complaint(s), if any? 02.212 Reception center history and physical: Are the "Past History" and "Past 0 0 0 0.0% 0 0.0 0.0% 20 0 Medical History" sections of Form 7206 (History and Physical Examination) complete? 02.215 Reception center history and physical: Is the "Review Systems" section of 0 0 0 0.0% 0 0.0 0.0% 20 0 Form 7206 (History and Physical Examination) complete? 02.213 Reception center history and physical: Is the "Family and Social History" 0 0 0 0.0% 0 0.0 0.0% 20 0 section of Form 7206 (History and Physical Examination) complete? 02.216 Reception center history and physical: Is the "Physical Examination" 0 0 0 0.0% 0 0.0 0.0% 20 0 section of Form 7206 (History and Physical Examination) complete and appropriate to the history and review of systems? 02.217 Reception center history and physical: Is the "Diagnosis/Impression" section 0 0 0 0.0% 0 0.0 0.0% 20 0 of Form 7206 (History and Physical Examination) appropriate to the history and physical examination? Bureau of Audits and Investigations Page 11 Office of the Inspector General State of California Answers Weighting Points Reference Health Screening Number Yes No Yes + No Yes % Possible Received Score % N/A Unk 02.218 Reception center history and physical: Is the "Plan of Action" section of 0 0 0 0.0% 0 0.0 0.0% 20 0 Form 7206 (History and Physical Examination) appropriate to the "Diagnosis/Impression" section of the form? 02.219 Reception center history and physical: Has required intake testing been 17 3 20 85.0% 4 3.4 85.0% 0 0 ordered? 02.020 Did the LVN/RN adequately document the tuberculin test or a review of 24 1 25 96.0% 6 5.8 96.0% 5 0 signs and symptoms if the inmate had a previous positive tuberculin test? 02.015 Was a review of symptoms completed if the inmate's tuberculin test was 5 0 5 100.0% 7 7.0 100.0% 25 0 positive, and were the results reviewed by the infection control nurse? 02.022 Reception center: If the primary care provider (PCP) indicated the inmate 0 0 0 0.0% 0 0.0 0.0% 30 0 required a special diet, did the PCP refer the inmate to a registered dietician? 02.128 If the inmate had an existing medication order upon arrival at the institution, 4 13 17 23.5% 8 1.9 23.5% 13 0 did the inmate receive the medications by the next calendar day, or did a physician explain why the medications were not to be continued? 02.007 Non-reception center: Does the health care transfer information form 2 0 2 100.0% 7 7.0 100.0% 20 8 indicate that it was reviewed and signed by licensed health care staff within one calendar day of the inmate's arrival at the institution? 02.014 Non-reception center: If the inmate was scheduled for a specialty 0 0 0 0.0% 0 0.0 0.0% 22 8 appointment at the sending institution, did the receiving institution schedule the appointment within 30 days of the original appointment date? 02.111 Non-reception center: Did the inmate receive medical accommodations 1 1 2 50.0% 6 3.0 50.0% 28 0 upon arrival, if applicable? Components Subtotals: 110 29 139 79.1% 60 45.9 76.5% 334 17 Bureau of Audits and Investigations Page 12 Office of the Inspector General State of California Answers Weighting Points Reference Specialty Services Number Yes No Yes + No Yes % Possible Received Score % N/A Unk 07.037 Did the institution approve or deny the PCP's request for specialty services 20 2 22 90.9% 8 7.3 90.9% 0 0 within the specified time frames? 07.038 Did the PCP see the inmate between the date the PCP ordered the service 0 11 11 0.0% 8 0.0 0.0% 11 0 and the date the inmate received it, in accordance with specified time frames? 07.035 Did the inmate receive the specialty service within specified time frames? 11 6 17 64.7% 9 5.8 64.7% 5 0 07.090 Physical therapy services: Did the physical therapist assess the inmate and 2 0 2 100.0% 8 8.0 100.0% 20 0 document the treatment plan and treatment provided to the inmate? 07.043 Did the PCP review the consultant's report and see the inmate for a follow- 3 10 13 23.1% 9 2.1 23.1% 9 0 up appointment after the specialty services consultation within specified time frames? 07.260 Was the institution's denial of the PCP's request for specialty services 2 0 2 100.0% 9 9.0 100.0% 0 3 consistent with the "medical necessity" requirement? 07.259 Was there adequate documentation of the reason for the denial of specialty 3 2 5 60.0% 5 3.0 60.0% 0 0 services? 07.270 Did the specialty provider provide timely findings and recommendations or 17 0 17 100.0% 6 6.0 100.0% 5 0 did an RN document that he or she called the specialty provider to ascertain the findings and recommendations? 07.261 Is the institution scheduling high-priority (urgent) specialty services within 0 2 2 0.0% 9 0.0 0.0% 0 0 14 days? Components Subtotals: 58 33 91 63.7% 71 41.2 58.0% 50 3 Bureau of Audits and Investigations Page 13 Office of the Inspector General State of California Answers Weighting Points Reference Urgent Services Number Yes No Yes + No Yes % Possible Received Score % N/A Unk 21.248 Upon the inmate's discharge from the community hospital, did the triage 13 12 25 52.0% 7 3.6 52.0% 0 0 and treatment area (TTA) registered nurse document that he or she reviewed the inmate's discharge plan and completed a face-to-face assessment of the inmate? 21.250 Upon the inmate's discharge from the community hospital, did the inmate's 18 7 25 72.0% 7 5.0 72.0% 0 0 Primary Care Provider (PCP) provide orders for appropriate housing for the inmate? 21.251 Upon the inmate's discharge from the community hospital, did the 0 0 0 0.0% 0 0.0 0.0% 25 0 Registered Nurse intervene if the inmate was housed in an area that was inappropriate for nursing care based on the primary care provider's (PCP) housing orders? 21.249 Upon the inmate's discharge from the community hospital, did the inmate 12 13 25 48.0% 7 3.4 48.0% 0 0 receive a follow-up appointment with his or her primary care provider (PCP) within five calendar days of discharge? 21.281 Upon the inmate's discharge from a community hospital, did the institution 1 14 15 6.7% 6 0.4 6.7% 9 1 administer or deliver all prescribed medications to the inmate within specified time frames? 21.275 Was the documentation of the clinical care provided in the TTA adequate? 17 8 25 68.0% 10 6.8 68.0% 0 0 21.276 While the patient was in the TTA, was the clinical care rendered by the 19 5 24 79.2% 7 5.5 79.2% 0 1 attending provider adequate and timely? 21.279 For patients managed by telephone consultation alone, was the provider's 14 0 14 100.0% 8 8.0 100.0% 11 0 decision not to come to the TTA appropriate? Components Subtotals: 94 59 153 61.4% 52 32.7 62.9% 45 2 Bureau of Audits and Investigations Page 14 Office of the Inspector General State of California Answers Weighting Points Reference Emergency Services Number Yes No Yes + No Yes % Possible Received Score % N/A Unk 08.183 Was the medical emergency responder notified of the medical emergency 5 0 5 100.0% 5 5.0 100.0% 0 0 without delay? 08.241 Did the first responder provide adequate basic life support (BLS) prior to 3 2 5 60.0% 6 3.6 60.0% 0 0 medical staff arriving? 08.184 Did the medical emergency responder arrive at the location of the medical 4 1 5 80.0% 4 3.2 80.0% 0 0 emergency within five (5) minutes of initial notification? 08.185 Did the medical emergency responder use proper equipment to address the 5 0 5 100.0% 7 7.0 100.0% 0 0 emergency and was adequate medical care provided within the scope of his or her license? 08.242 Did licensed health care staff call 911 without unnecessary delay after a life- 3 2 5 60.0% 6 3.6 60.0% 0 0 threatening condition was identified by a licensed health care provider or peace officer? 08.187 Did the institution provide adequate preparation for the ambulance's arrival, 5 0 5 100.0% 4 4.0 100.0% 0 0 access to the inmate, and departure? 08.186 Were both the first responder (if peace officer or licensed health care staff) 5 0 5 100.0% 4 4.0 100.0% 0 0 and the medical emergency responder basic life support (BLS) certified at the time of the incident? 08.222 Were the findings of the institution's Emergency Response Review 0 5 5 0.0% 7 0.0 0.0% 0 0 Committee (ERRC) supported by the documentation and completed within 30 days? 15.240 Emergency Medical Response Drill: Did the responding officer activate the 1 0 1 100.0% 2 2.0 100.0% 0 0 emergency response system by providing the pertinent information to the relevant parties, immediately and without delay? 15.255 Emergency Medical Response Drill: Did the responding officer carry and 1 0 1 100.0% 1 1.0 100.0% 0 0 use the proper equipment (protective shield or micro-mask, gloves) required by the department? Bureau of Audits and Investigations Page 15 Office of the Inspector General State of California Answers Weighting Points Reference Emergency Services Number Yes No Yes + No Yes % Possible Received Score % N/A Unk 15.256 Emergency Medical Response Drill: Did the responding officer properly 1 0 1 100.0% 1 1.0 100.0% 0 0 perform an assessment on the patient for responsiveness? 15.257 Emergency Medical Response Drill: Did the responding officer properly 1 0 1 100.0% 2 2.0 100.0% 0 0 perform CPR? 15.258 Emergency Medical Response Drill: Did the responding officer begin CPR 1 0 1 100.0% 2 2.0 100.0% 0 0 without unecessary delay? 15.282 Emergency Medical Response Drill: Did medical staff arrive on scene in 1 0 1 100.0% 2 2.0 100.0% 0 0 five minutes or less? 15.283 Emergency Medical Response Drill: Did the emergency medical responders 1 0 1 100.0% 1 1.0 100.0% 0 0 arrive with proper equipment (ER bag, bag-valve-mask, AED)? 15.284 Emergency Medical Response Drill: Did the responding officer provide 1 0 1 100.0% 1 1.0 100.0% 0 0 accurate information to responding medical staff? 15.285 Emergency Medical Response Drill: Did emergency medical responders 1 0 1 100.0% 1 1.0 100.0% 0 0 continue basic life support? 15.287 Emergency Medical Response Drill: Was 911 called without unnecessary 1 0 1 100.0% 2 2.0 100.0% 0 0 delay? Components Subtotals: 40 10 50 80.0% 58 45.4 78.3% 0 0 Bureau of Audits and Investigations Page 16 Office of the Inspector General State of California Answers Weighting Points Reference Diagnostic Services Number Yes No Yes + No Yes % Possible Received Score % N/A Unk 06.049 Radiology order: Was the radiology service provided within the time frame 5 0 5 100.0% 7 7.0 100.0% 0 0 specified in the physician's order? 06.245 Radiology order: Was the diagnostic report received by the institution 5 0 5 100.0% 8 8.0 100.0% 0 0 within 14 days? 06.200 Radiology order: Did the primary care provider (PCP) review the diagnostic 0 5 5 0.0% 7 0.0 0.0% 0 0 report and initiate written notice to the inmate within two (2) business days of the date the institution received the diagnostic reports? 06.188 All laboratory orders: Was the specimen collected within the applicable time 10 0 10 100.0% 6 6.0 100.0% 0 0 frames of the physician's order? 06.191 All diagnostic services: Did the PCP document the clinically significant 8 1 9 88.9% 7 6.2 88.9% 6 0 diagnostic test results on Form 7230 (Interdisciplinary Progress Notes)? 06.263 All diagnostic services: Did the PCP adequately manage clinically 8 1 9 88.9% 10 8.9 88.9% 6 0 significant test results? 06.202 All laboratory orders: Did the PCP review the diagnostic reports and initiate 0 10 10 0.0% 7 0.0 0.0% 0 0 written notice to the inmate within two (2) business days of the date the institution received the diagnostic reports? Components Subtotals: 36 17 53 67.9% 52 36.1 69.4% 12 0 Bureau of Audits and Investigations Page 17 Office of the Inspector General State of California Answers Weighting Points Reference Access to Health Care Information Number Yes No Yes + No Yes % Possible Received Score % N/A Unk 19.150 Is the medical records office current with its loose filing? 0 1 1 0.0% 9 0.0 0.0% 0 0 19.169 Did medical records staff make unit health records (UHR) available to clinic 2 0 2 100.0% 15 15.0 100.0% 0 0 staff for the inmates ducated for medical appointments the next day? 19.243 Was the institution able to account for the OIG's requested UHR files? 0 1 1 0.0% 12 0.0 0.0% 0 0 19.266 Does the institution properly file inmates' medical information? 1 0 1 100.0% 5 5.0 100.0% 0 0 19.271 While reviewing unit health records (UHR) as part of the OIG's inspection, 1 0 1 100.0% 5 5.0 100.0% 0 0 were the OIGs RN and MD inspectors able to locate all relevant documentation of health care provided to inmates? 19.272 Does the institution promptly file blood pressure logs in unit health records 1 1 2 50.0% 5 2.5 50.0% 0 0 (UHR)? Components Subtotals: 5 3 8 62.5% 51 27.5 53.9% 0 0 Bureau of Audits and Investigations Page 18 Office of the Inspector General State of California Answers Weighting Points Reference Outpatient Housing Unit Number Yes No Yes + No Yes % Possible Received Score % N/A Unk 04.052 Did the RN complete an initial assessment of the inmate on the day of 10 0 10 100.0% 5 5.0 100.0% 0 0 placement? 04.051 Did the primary care provider (PCP) evaluate the inmate within one 8 2 10 80.0% 5 4.0 80.0% 0 0 calendar day after placement? 04.053 While the inmate was placed in the OHU, did the PCP complete the 1 0 1 100.0% 4 4.0 100.0% 9 0 Subjective, Objective, Assessment, Plan and Education (SOAPE) at a minimum of every 14 days? 04.054 Did the utilization management (UM) nurse assess the inmate within one 0 8 8 0.0% 4 0.0 0.0% 2 0 week of the inmate's placement and every 30 days thereafter? 04.112 Was the PCP's initial evaluation adequate for the problem(s) requiring OHU 10 0 10 100.0% 5 5.0 100.0% 0 0 placement? 04.230 Was the PCP's initial assessment (or diagnoses) appropriate for the findings 10 0 10 100.0% 5 5.0 100.0% 0 0 in the initial evaluation? 04.056 Did the PCP's plan adequately address the initial assessment? 10 0 10 100.0% 5 5.0 100.0% 0 0 04.208 Was the level of care available in the OHU appropriate to the patient's 10 0 10 100.0% 9 9.0 100.0% 0 0 clinical presentation? 15.103 In the outpatient housing unit (OHU), are patient call buttons operational or 0 1 1 0.0% 3 0.0 0.0% 0 0 does medical staff make rounds every 30 minutes? 15.225 Does the OHU use disinfectant daily in common patient areas? 1 0 1 100.0% 3 3.0 100.0% 0 0 Components Subtotals: 60 11 71 84.5% 48 40.0 83.3% 11 0 Bureau of Audits and Investigations Page 19 Office of the Inspector General State of California Answers Weighting Points Reference Internal Reviews Number Yes No Yes + No Yes % Possible Received Score % N/A Unk 17.221 Did the institution complete a medical emergency response drill for each 0 1 1 0.0% 5 0.0 0.0% 0 0 watch and include participation from each medical facility during the most recent full quarter? 17.174 Did the institution promptly process inmate medical appeals during the most 0 1 1 0.0% 5 0.0 0.0% 0 0 recent 12 months? 17.136 For each death sampled, did the institution complete the death review 5 0 5 100.0% 5 5.0 100.0% 0 0 process? 17.132 Do the Emergency Response Review Committee (ERRC) meeting minutes 6 0 6 100.0% 5 5.0 100.0% 0 0 document monthly meetings for the last six (6) months? 17.138 Do the Emergency Response Review Committee (ERRC) meeting minutes 3 3 6 50.0% 5 2.5 50.0% 0 0 document the warden's (or his or her designee's) attendance? 17.118 Do the Quality Management Committee (QMC) meeting minutes document 6 0 6 100.0% 5 5.0 100.0% 0 0 monthly meetings for the last six (6) months? 17.119 Did the Quality Management Committee (QMC) report its findings to the 6 0 6 100.0% 5 5.0 100.0% 0 0 HCM/CMO each of the last six (6) meetings? 17.135 Did the last three Quality Management Committee (QMC) meeting minutes 3 0 3 100.0% 5 5.0 100.0% 0 0 reflect findings and strategies for improvement? Components Subtotals: 29 5 34 85.3% 40 27.5 68.8% 0 0 Bureau of Audits and Investigations Page 20 Office of the Inspector General State of California Answers Weighting Points Reference Inmate Transfers Number Yes No Yes + No Yes % Possible Received Score % N/A Unk 05.108 Did Receiving and Release have the inmate's UHR and transfer envelope? 5 0 5 100.0% 7 7.0 100.0% 0 0 05.109 If the inmate was scheduled for any upcoming specialty services, were the 0 0 0 0.0% 0 0.0 0.0% 5 0 services noted on Form 7371 (Health Care Transfer Information)? 05.110 Do all appropriate forms in the transfer envelope identify all medications 0 0 0 0.0% 0 0.0 0.0% 5 0 ordered by the physician, and are the medications in the transfer envelope? 05.171 Did an RN accurately complete all applicable sections of Form 7371 5 0 5 100.0% 7 7.0 100.0% 0 0 (Health Care Transfer Information) based on the inmate's UHR? 05.172 Did the Health Records Department maintain a copy of the inmate's Form 5 0 5 100.0% 8 8.0 100.0% 0 0 7371 (Health Care Transfer Information) and Form 7231A (Outpatient Medication Administration Record) when the inmate transferred? Components Subtotals: 15 0 15 100.0% 22 22.0 100.0% 10 0 Bureau of Audits and Investigations Page 21 Office of the Inspector General State of California Answers Weighting Points Reference Clinic Operations Number Yes No Yes + No Yes % Possible Received Score % N/A Unk 14.023 Does the institution make the Form 7362 (Health Care Services Request 7 0 7 100.0% 4 4.0 100.0% 0 0 Form) available to inmates? 14.164 Are areas available to ensure privacy during RN face-to-face assessments 2 0 2 100.0% 3 3.0 100.0% 0 0 and doctors' examinations for non-emergencies? 14.166 Was the medication stored in a sealed container if food was present in the 2 0 2 100.0% 2 2.0 100.0% 0 0 clinic refrigerator? 14.131 Do medication nurses understand that medication is to be administered by 2 0 2 100.0% 4 4.0 100.0% 0 0 the same licensed staff member who prepares it and on the same day? 14.106 Does clinical staff wash their hands (either with soap or hand sanitizer) or 4 0 4 100.0% 4 4.0 100.0% 0 0 change gloves between patients? 14.033 Does the institution have an adequate process to ensure inmates who are 2 0 2 100.0% 4 4.0 100.0% 0 0 moved to a new cell still receive their medical ducats? 14.032 Does medical staff understand the institution's priority ducat process? 2 0 2 100.0% 2 2.0 100.0% 0 0 14.160 Does the institution have a process to identify, review, and address urgent 2 0 2 100.0% 4 4.0 100.0% 0 0 appointments if a doctor's line is canceled? 14.029 Does medical staff in the facility clinic know which inmates are on modified 2 0 2 100.0% 4 4.0 100.0% 0 0 program or confined to quarters (CTQ) and does staff have an adequate process to ensure those inmates receive their medication? 14.165 Are the clinic floors, waiting room chairs, and equipment cleaned with a 3 0 3 100.0% 2 2.0 100.0% 0 0 disinfectant daily? Components Subtotals: 28 0 28 100.0% 33 33.0 100.0% 0 0 Bureau of Audits and Investigations Page 22 Office of the Inspector General State of California Answers Weighting Points Reference Preventive Services Number Yes No Yes + No Yes % Possible Received Score % N/A Unk 10.228 Inmates prescribed INH: Did the institution properly administer the 1 4 5 20.0% 6 1.2 20.0% 0 0 medication to the inmate? 10.232 Inmates prescribed INH: Did the institution monitor the inmate monthly for 0 5 5 0.0% 6 0.0 0.0% 0 0 the most recent three months he or she was on the medication? 10.229 Inmates with TB code 34: Was the inmate evaluated for signs and symptoms 2 0 2 100.0% 7 7.0 100.0% 0 0 of TB within the previous 12 months? 10.086 All inmates age 66 or older: Did the inmate receive an influenza vaccination 9 1 10 90.0% 6 5.4 90.0% 0 0 within the previous 12 months or was the inmate's refusal documented? 10.085 Male inmates age 51 or older: Did the inmate receive a fecal occult blood 2 8 10 20.0% 5 1.0 20.0% 0 0 test (FOBT) within the previous 12 months or was the inmate's refusal documented? Components Subtotals: 14 18 32 43.8% 30 14.6 48.7% 0 0 Bureau of Audits and Investigations Page 23 Office of the Inspector General State of California Answers Weighting Points Reference Pharmacy Services Number Yes No Yes + No Yes % Possible Received Score % N/A Unk 13.139 Does the institution conspicuously post a valid permit in its pharmacies? 1 0 1 100.0% 2 2.0 100.0% 0 0 13.141 Does the institution properly maintain its emergency crash cart 0 2 2 0.0% 2 0.0 0.0% 0 0 medications? 13.252 Does the institution properly maintain medications in its after-hours 0 1 1 0.0% 2 0.0 0.0% 0 0 medication supply(ies)? 13.253 Does the institution conduct monthly inspections of its emergency cart and 3 0 3 100.0% 1 1.0 100.0% 0 0 after-hours medication supply(ies)? 13.142 Is the Pharmacist in Charge's license current? 1 0 1 100.0% 5 5.0 100.0% 0 0 13.144 Does the institution have information to ensure that medications are 1 0 1 100.0% 6 6.0 100.0% 0 0 prescribed by licensed health-care providers lawfully authorized to do so? 13.145 Does the pharmacist in charge have an effective process for screening new 1 0 1 100.0% 7 7.0 100.0% 0 0 medication orders for potential adverse reactions? 13.148 Does the pharmacist in charge monitor the quantity of medications on hand, 1 0 1 100.0% 4 4.0 100.0% 0 0 and does the pharmacy conduct an annual inventory to ensure that the quantity of medications in the system matches the quantity of medications on hand? Components Subtotals: 8 3 11 72.7% 29 25.0 86.2% 0 0 Bureau of Audits and Investigations Page 24 Office of the Inspector General State of California Answers Weighting Points Reference Other Services Number Yes No Yes + No Yes % Possible Received Score % N/A Unk 15.059 Did the institution properly provide therapeutic diets to inmates? 0 0 0 0.0% 0 0.0 0.0% 1 0 15.058 If the institution does not offer therapeutic diets, does staff know the 1 0 1 100.0% 3 3.0 100.0% 0 0 department's procedures for transferring inmates who are determined to require a therapeutic diet? 15.134 Did the institution properly respond to all active cases of TB discovered in 0 0 0 0.0% 0 0.0 0.0% 1 0 the last six months? 15.265 Is the most current version of the CDCR Health Services Policies and 1 1 2 50.0% 3 1.5 50.0% 0 0 Procedures available in the institution's law library? 20.092 Hygiene Intervention: Did custody staff understand the department's 4 0 4 100.0% 4 4.0 100.0% 0 0 policies and procedures for identifying and evaluating inmates displaying inappropriate hygiene management? Components Subtotals: 6 1 7 85.7% 10 8.5 85.0% 2 0 Bureau of Audits and Investigations Page 25 Office of the Inspector General State of California Answers Weighting Points Reference Inmate Hunger Strikes Number Yes No Yes + No Yes % Possible Received Score % N/A Unk 11.097 Did the RN conduct a face-to-face triage of the inmate within two (2) 4 1 5 80.0% 6 4.8 80.0% 0 0 business days of receipt of the Form 128-B and document the inmate's reasons for the hunger strike, most recent recorded weight, current weight, vital signs, and physical condition? 11.099 After the first 48 hours, did an RN or PCP complete daily assessments 1 4 5 20.0% 6 1.2 20.0% 0 0 documenting the inmate's weight, physical condition, emotional condition, vital signs, and hydration status? 11.100 After the first 72 hours, did a physician perform a physical examination and 3 2 5 60.0% 7 4.2 60.0% 0 0 order a metabolic panel and a urinalysis of the inmate? Components Subtotals: 8 7 15 53.3% 19 10.2 53.7% 0 0 Bureau of Audits and Investigations Page 26 Office of the Inspector General State of California Answers Weighting Points Reference Chemical Agent Contraindications Number Yes No Yes + No Yes % Possible Received Score % N/A Unk 12.062 Did the institution document that it consulted with an RN or primary care 4 1 5 80.0% 9 7.2 80.0% 1 0 provider (PCP) before a calculated use of OC? 12.064 Did the institution record how it decontaminated the inmate and did it 6 0 6 100.0% 8 8.0 100.0% 0 0 follow the decontamination policy? Components Subtotals: 10 1 11 90.9% 17 15.2 89.4% 1 0 Bureau of Audits and Investigations Page 27 Office of the Inspector General State of California Answers Weighting Points Reference Staffing Levels and Training Number Yes No Yes + No Yes % Possible Received Score % N/A Unk 18.002 Information purposes only: Calculate the institution's average vacancy 0 0 0 0.0% 0 0.0 0.0% 1 0 percentages, the number of health care staff starting within six (6) months of the OIG visit, and the number of health care staff hired from the registry. The institution provided vacancy statistics within four licensed medical staffing groups: (1) management; (2) primary care providers; (3) supervision; and (4) rank and file nursing. Total number of filled positions: 114.98 Total number of vacancies: 13.81 Total number of positions: 128.79 Vacancy percentage: 10.72% Number of staff hired within last six months: 12 Total number of registry staff: 38 18.004 Did the institution have a registered nurse (RN) available on site 24 hours a 1 0 1 100.0% 4 4.0 100.0% 0 0 day, seven days a week, for emergency care? 18.005 Did the institution have a physician on site, a physician on call, or an MOD 1 0 1 100.0% 4 4.0 100.0% 0 0 available 24 hours a day, seven days a week, for the last 30 days? 18.006 Does the institution's orientation program for all newly hired nursing staff 1 0 1 100.0% 4 4.0 100.0% 0 0 include a module for sick call protocols that require face-to-face triage? 18.001 Are licensed health care staff current with their certifications and did they 4 1 5 80.0% 4 3.2 80.0% 0 0 attend required training? Components Subtotals: 7 1 8 87.5% 16 15.2 95.0% 1 0 Bureau of Audits and Investigations Page 28 Office of the Inspector General State of California Answers Weighting Points Reference Nursing Policy Number Yes No Yes + No Yes % Possible Received Score % N/A Unk 16.231 Does the institution ensure that nursing staff review their duty statements? 4 1 5 80.0% 5 4.0 80.0% 0 0 16.154 Does the institution have written nursing policies and procedures that 5 0 5 100.0% 5 5.0 100.0% 0 0 adhere to the department's guidelines? 16.254 Does the institution's supervising registered nurse (SRN) conduct periodic 1 4 5 20.0% 4 0.8 20.0% 0 0 reviews of nursing staff? Components Subtotals: 10 5 15 66.7% 14 9.8 70.0% 0 0 Bureau of Audits and Investigations Page 29 Office of the Inspector General State of California California Prison Health Care Receivership Corporation's Response Bureau of Audits and Investigations Page 30 Office of the Inspector General State of California STATE OF CALIFORNIA J. Clark Kelso, Receiver PRISON HEALTH CARE SERVICES December 23, 2009 David R. Shaw, Inspector General Office ofthe Inspector General P.O. Box 348780 Sacramento, CA 95834-8780 Dear Mr. Shaw, The purpose of this letter is to inform you that the Office of the Receiver has reviewed the draft report of the Office of the Inspector General's (OIG) Medical Inspection Results (MIR) for the August, 2009 inspection of San Quentin State Prison (SQ). At this time, we would like to address the following conditions raised as a result ofthe MIR. Outpatient Housing Unit (OHU): Reference Number 04.054 The OIG found SQ's utilization management (UM) nurse did not assess inmates within one week of placement and every 30 days thereafter. This finding is accepted with regard to the standard of care required by the Inmate Medical Standard Policy and Procedure (IMSP&P) manual. However, the institution indicates their documentation shows patients in the OHU are seen and evaluated daily by the OHU Primary Care Physician (PCP) and the OHU Primary Care Team (pCT), which also includes anRN. Thislevel ofcareexceedstherequirement ofthe IMSP&P. Chronic Care: Reference Number 03.236 The OIG found the institution did not provide an adequate focused clinical examination, specifically as related to patient-inmates prescribed the medication Coumadin. The OIG guidance document states that the exam for all patients on Coumadin should include a "skin and mucus membranes" exam noting "bleeding, petechiae, and ecchymoses". The State's guidance documentation, the IMSP&P, does not address this issue. Therefore, San Quentin's procedure for certain patients on Coumadin is to "document pertinent positives" as the community standard. It is their belief that some patients on Coumadin do not require documentation of a normal skin and mucus membrane exam. Clinical Services: Reference Number 21.278 and 21.249 The OIG determined there was inadequate prior management of specific pre-existing medical conditions and that patient-inmates did not receive follow-up appointments with his or her PCP within five calendar days of discharge from a community hospital. SQ staff contends that patient-inmates were provided frequent and thorough primary care, in accordance with departmental policies and constitutional standards. Further, the institution asserts that some inmates were admitted to the OHU, (a temporary housing unit) immediately upon return from a community hospital and in the OHU patient-inmates were evaluated and treated by the OHU PCP. Upon return to their housing units, patient-inmates were seen in follow-up appointments by their housing unit PCPs. P.O. Box 4038· Sacramento, CA 95812-4038 David R. Shaw, Inspector General December 23, 2009 Page 2 Specialty Services: Reference Number 07.043 The OIG found the patient-inmates were not seen within the specified timeframes outlined in Chapter 8, section III, A ofthe IMSP&P. SQ asserts the services they provided were within required timeframes in accordance with their own local operating procedures as well as Chapter 8, section III E, of the IMSP&P. Both sections of the IMSP&P provide different acceptable timeframes for follow-up. The OIG's guidance measurement allows for a shorter follow-up timetable than that utilized by SQ. In addition to the items identified above, the OIG draft report contains other findings with a low reported rate of compliance. A number of findings are being addressed by statewide initiatives or other resources designed to achieve a constitutional level of health care. For those items that are not addressed by a statewide initiative, California Prison Health Care Services (CPHCS) staffwill work with the institution to develop a Corrective Action Plan (CAP). Once a CAP is submitted and approved, CPHCS staff will monitor and follow-up on any corrective action identified. Thank you for preparing the report. Your efforts have advanced our mutual objective of ensuring transparency and accountability in the CPHCS operations. Should you have any questions or concerns, please contact Theresa Kimura-Yip, Deputy Director, Policy and Program Compliance Branch at (916) 327-1205. Sincerely, P -lJ../h JJOtAi1 Y-E~L~:~recQ BRENDA EPPERL Policy, Planning and Evaluation Services California Prison Health Care Services cc: 1. Clark Kelso, Receiver Elaine Bush, ChiefDeputy, Office ofthe Receiver Dwight W. Winslow, M.D., Chief Medical Officer (A), Medical Services Starr Babcock, Special Assistant to the Court Kenneth Martin, Northern Regional Administrator Renee Kanan, M.D., Northern Regional Medical Director Jane Robinson, Northern Regional ChiefNurse Executive Jackie Clark, Health Care Manager, San Quentin Elaine Tootell, (CMO), Chief Medical Officer, San Quentin Steve Fama, Attorney, Prison Law Office Nancy Faszer, Deputy Inspector General In-Charge Bernie Fernandez, Deputy Inspector General Senior Rob Hughes, Deputy Inspector General Johnny Hui, ChiefofInternal Audit, CPHCS David R. Shaw, Inspector General December 23, 2009 Page 3 Theresa Kimura-Yip, Deputy Director, Policy and Program Compliance Branch Olga Durette, Health Program Manager II, Program Compliance Section Office of the Inspector General’s Comments on the Receiver’s Response Outpatient Housing Unit – Reference Number 04.054 The receiver’s response accepts the OIG finding that the San Quentin patients in the Outpatient Housing Unit reviewed by the OIG were not assessed by the utilization management nurse within timeframes required by department policy. This was true for all eight of the applicable files reviewed. Therefore, the score for this question is unchanged. Chronic Care - Reference Number 03.236 The receiver’s response asserts that the community standard does not specifically require medical providers to document skin and mucus membrane exams when conditions are normal (i.e. no bleeding, petechiae, or ecchymoses). The OIG agrees that the community standard may not require documentation of normal skin exam results for inmate patients on Coumadin at a recently documented sub-therapeutic level. However, the OIG’s understanding is that the community standard calls for documentation of both pertinent positives and negatives. In the case of fully anti-coagulated patients this includes evidence, or lack thereof, of bleeding or bruising. Without such documentation, medical providers in subsequent examinations do not have adequate information regarding the patient’s condition during that prior visit. Clinical Services – Reference Number 21.278 The receiver’s response asserts that the inmate patients were provided with frequent and thorough primary care prior to their going to the treatment and triage area (TTA), in accordance with departmental policies and constitutional standards. The OIG concurs that some of the inmate patients included in our review received adequate prior care. Our original inspection identified seven inmates that had not received adequate prior care. At the request of the receiver we re-evaluated the conclusion for four of the seven inmate patients, discussed our findings with them, and reviewed additional documentation provided by the receiver’s office. Based on that review and discussion, staff from the OIG and receiver’s office jointly concluded that one of the four inmate patients received adequate prior care. Our results were changed to reflect that conclusion. Urgent Services – Reference Number 21.249 The receiver’s response asserts that patients returning to the prison from an outside hospital, who were placed in the outpatient housing unit (OHU), received appropriate follow-up medical care. Bureau of Audits and Investigations Page 34 Office of the Inspector General State of California In the OIG’s review of the sampled inmate patients, we noted those who were provided follow- up care in the OHU and gave the institution credit for successfully meeting the criteria in those cases. As the institution’s score already includes credit for those inmates provided follow-up care in the OHU, the score for this question is unchanged. Specialty Services – Reference Number 07.043 The receiver’s response identifies an inconsistency in the Inmate Medical Standards Policy and Procedures’ (IMSP&P) acceptable timeframes for follow-up of specialty services. The response further asserts that follow-up services were provided in accordance with San Quentin’s local operating procedures and with the longer timeframe identified in IMSP&P. Based on those factors the receiver believes that San Quentin is in compliance. The OIG agrees that there is a conflict in the IMSP&P. However, the shorter timeframe that the OIG uses as the criteria is also supported by IMSP&P and was agreed to by both the receiver’s office and the plaintiffs’ attorneys when the inspection protocols were developed. Further, the OIG has consistently applied this criterion in all prior inspections. Therefore, the score for this question is unchanged. Bureau of Audits and Investigations Page 35 Office of the Inspector General State of California