Valley State Prison Cycle 7 Medical Inspection Report

Electronic copies of reports published by the Office of the Inspector General are available free in portable document format (PDF) on our website. We also offer an online subscription service. For information on how to subscribe, visit www.oig.ca.gov. For questions concerning the contents of this report, please contact Shaun Spillane, Public Information Officer, at 916-288-4233. Connect with us on social media NOTE: The Office of the Inspector General (the OIG) originally issued its Cycle 7 medical inspection report for Valley State Prison (VSP), on February 20, 2024. In that publication, the OIG rated the overall medical care this institution provided to the incarcerated patient population inadequate. Since the beginning of the fourth cycle of inspections in January 2015, the OIG has performed medical inspections using assessment methodologies that include both clinical case review and compliance testing components. Doing so has allowed our clinicians to provide a holistic assessment of each institution’s medical care on both individual and system levels. Our case review clinicians examine whether providers used sound medical judgment in the course of caring for a patient. In addition, our compliance nurse inspectors collect data in response to compliance- and performance-related questions as established in the OIG’s medical inspection tool. This tool is designed to aid our inspectors in analyzing how effectively each institution adheres to the California Department of Corrections and Rehabilitation’s own Health Care Department Operations Manual. Since the start of Cycle 4, the OIG has reported its findings by holistically interpreting results derived from these two sides of the process: case review observations and interviews, and compliance testing. By analyzing these collective results, the OIG’s clinicians would determine a final overall rating for each institution, along with separate overall ratings for, potentially, up to 15 indicators. As communicated to both California Correctional Health Care Services and the department on April 19, 2024, after careful consideration, the OIG has updated the manner in which it reports its medical inspection findings by bifurcating the ratings for case review and compliance testing. Specifically, beginning with Cycle 7, instead of providing a single aggregated overall rating for the institution under review, the OIG will now report two overall ratings: one assessing the clinical quality of care provided at the institution and another assessing the institution’s compliance with the department’s own policies. Moreover, the reports will present separate ratings for each institution’s individual case review assessments and compliance testing results across each of the 15 indicators reviewed during the inspection. While neither the processes nor the factors for consideration in the case review or compliance methodologies will change, separating the ratings from each half of our methodology will provide a clearer understanding of the OIG’s findings for each institution by more transparently highlighting areas in which the institution is succeeding and areas in which the institution could improve. Therefore, the OIG has revised the Cycle 7 medical inspection report for VSP—originally published in February 2024—and reissues it herewith under the bifurcated rating format. In addition, future medical inspection reports will continue to report the OIG’s findings under this bifurcated rating format to best promote transparency, clarity, and greater understanding of the OIG’s findings. Amarik K. Singh Inspector General Valley State Prison | ii (This page left blank for reproduction purposes.) Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | iii Contents Illustrations iv Introduction 1 Summary: Ratings and Scores 3 Medical Inspection Results 5 Deficiencies Identified During Case Review 5 Case Review Results 5 Compliance Testing Results 6 Institution-Specific Metrics 7 Population-Based Metrics 9 HEDIS Results 9 Recommendations 11 Indicators 14 Access to Care 14 Diagnostic Services 20 Emergency Services 25 Health Information Management 29 Health Care Environment 35 Transfers 45 Medication Management 52 Preventive Services 61 Nursing Performance 64 Provider Performance 70 Specialized Medical Housing 75 Specialty Services 80 Administrative Operations 86 Appendix A: Methodology 91 Case Reviews 92 Compliance Testing 95 Indicator Ratings and the Overall Medical Quality Rating 96 Appendix B: Case Review Data 97 Appendix C: Compliance Sampling Methodology 101 California Correctional Health Care Services’ Response 109 February 16, 2024, OIG Response to February 13, 2024, Letter Regarding VSP Report 110 Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | iv Illustrations Tables 1. VSP Summary Table: Case Review Ratings and Policy Compliance Scores 4 2. VSP Master Registry Data as of January 2023 7 3. VSP Health Care Staffing Resources as of January 2023 8 4. VSP Results Compared With State HEDIS Scores 10 5. Access to Care 17 6. Other Tests Related to Access to Care 18 7. Diagnostic Services 23 8. Health Information Management 32 9. Other Tests Related to Health Information Management 33 10. Health Care Environment 43 11. Transfers 49 12. Other Tests Related to Transfers 50 13. Medication Management 58 14. Other Tests Related to Medication Management 59 15. Preventive Services 62 16. Specialized Medical Housing 78 17. Specialty Services 83 18. Other Tests Related to Specialty Services 84 19. Administrative Operations 88 A–1. Case Review Definitions 92 B–1. VSP Case Review Sample Sets 97 B–2. VSP Case Review Chronic Care Diagnoses 98 B–3. VSP Case Review Events by Program 99 B–4. VSP Case Review Sample Summary 99 Figures A–1. Inspection Indicator Review Distribution for VSP 91 A–2. Case Review Testing 94 A–3. Compliance Sampling Methodology 95 Photographs 1. Shaded Outdoor Waiting Area With Mist Cooling System 35 2. Indoor Waiting Area 36 3. Cluttered Examination Room 37 4. Unsecured Confidential Medical Records 37 5. OHU Medication Cart Found in Disrepair 38 6. Expired Medical Supplies Dated December 2022 38 7. Expired Medical Supplies Dated November 2022 38 8. Staff’s Personal Food Item Stored With Medical Supplies 39 9. Inaccurate Glucometer Daily Quality Control Log and Out-of-Range Results Without Action Taken by Staff 39 10. Staff Did Not Take Proper Action When Glucometer Quality Control Results Were Out of Range 40 11. Expired EMRB Supply Dated December 2022 40 12. Medical Supplies Stored Directly on the Floor 41 Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 1 Introduction Pursuant to California Penal Code section 6126 et seq., the Office of the Inspector General (the OIG) is responsible for periodically reviewing and reporting on the delivery of the ongoing medical care provided to incarcerated people1 in the California Department of Corrections and Rehabilitation (the department).2 In Cycle 7, the OIG continues to apply the same assessment methodologies used in Cycle 6, including clinical case review and compliance testing. Together, these methods assess the institution’s medical care on both individual and system levels by providing an accurate assessment of how the institution’s health care systems function regarding patients with the highest medical risk, who tend to access services at the highest rate. Through these methods, the OIG evaluates the performance of the institution in providing sustainable, adequate care. We continue to review institutional care using 15 indicators as in prior cycles.3 Using each of these indicators, our compliance inspectors collect data in answer to compliance- and performance-related questions as established in the medical inspection tool (MIT). In addition, our clinicians complete document reviews of individual cases and also perform on-site inspections, which include interviews with staff. The OIG determines a total compliance score for each applicable indicator and considers the MIT scores in the overall conclusion of the institution’s compliance performance. In conducting in-depth quality-focused reviews of randomized cases, our case review clinicians examine whether health care staff used sound medical judgment in the course of caring for a patient. In the event we find errors, we determine whether such errors were clinically significant or led to a significantly increased risk of harm to the patient. At the same time, our clinicians consider whether institutional medical processes led to identifying and correcting individual or system errors, and we examine whether the institution’s medical system mitigated the error. The OIG rates each applicable indicator proficient, adequate, or inadequate, and considers each rating in the overall conclusion of the institution’s health care performance. In contrast to Cycle 6, the OIG will provide individual clinical case review ratings and compliance testing scores in Cycle 7, rather than aggregate all findings into a single overall institution rating. This change will clarify the distinctions between these differing quality measures and the results of each assessment. 1 In this report, we use the terms patient and patients to refer to incarcerated people. 2 The OIG’s medical inspections are not designed to resolve questions about the constitutionality of care, and the OIG explicitly makes no determination regarding the constitutionality of care that the department provides to its population. 3 In addition to our own compliance testing and case reviews, the OIG continues to offer selected Healthcare Effectiveness Data and Information Set (HEDIS) measures for comparison purposes. Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 2 As we did during Cycle 6, our office continues to inspect both those institutions remaining under federal receivership and those delegated back to the department. There is no difference in the standards used for assessing a delegated institution versus an institution not yet delegated. At the time of the Cycle 7 inspection of Valley State Prison, the institution had been delegated back to the department by the receiver. We completed our seventh inspection of the institution, and this report presents our assessment of the health care provided at this institution during the inspection period from June 2022 to November 2022.4 4 Samples are obtained per case review methodology shared with stakeholders in prior cycles. The case reviews include death reviews that occurred between January 2022 and July 2022, emergency cardiopulmonary resuscitation (CPR) reviews between February 2022 and June 2022, and transfer reviews between May 2022 and September 2022. Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 3 Summary: Ratings and Scores We completed the Cycle 7 inspection of VSP in April 2023. OIG inspectors monitored the institution’s delivery of medical care that occurred between June 2022 and November 2022. The OIG rated the case review The OIG rated the compliance component of the overall health care component of the overall health care quality at VSP adequate. quality at VSP inadequate. The OIG clinicians (a team of physicians and nurse consultants) reviewed 45 cases, which contained 811 patient-related events. They performed quality control reviews; their subsequent collective deliberations ensured consistency, accuracy, and thoroughness. Our OIG clinicians acknowledged institutional structures that catch and resolve mistakes that may occur throughout the delivery of care. After examining the medical records, our clinicians completed a follow-up on-site inspection in April 2023 to verify their initial findings. The OIG physicians rated the quality of care for 20 comprehensive case reviews. Of these 20 cases, our physicians rated none proficient, 14 adequate, and six inadequate. Our physicians found no adverse deficiencies during this inspection. To test the institution’s policy compliance, our compliance inspectors (a team of registered nurses) monitored the institution’s compliance with its medical policies by answering a standardized set of questions that measure specific elements of health care delivery. Our compliance inspectors examined 379 patient records and 1,137 data points, and used the data to answer 91 policy questions. In addition, we observed VSP’s processes during an on-site inspection in January 2023. The OIG then considered the results from both case review and compliance testing, and drew overall conclusions, which we report in 13 health care indicators.5 5 The indicators for Reception Center and Prenatal and Postpartum Care did not apply to VSP. Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 4 We list the individual indicators and ratings applicable for this institution in Table 1 below. Table 1. VSP Summary Table: Case Review Ratings and Policy Compliance Scores Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 5 Medical Inspection Results Deficiencies Identified During Case Review Deficiencies are medical errors that increase the risk of patient harm. Deficiencies can be minor or significant, depending on the severity of the deficiency. An adverse event occurs when the deficiency caused harm to the patient. All major health care organizations identify and track adverse events. We identify deficiencies and adverse events to highlight concerns regarding the provision of care and for the benefit of the institution’s quality improvement program to provide an impetus for improvement.6 The OIG did not find any adverse events at VSP during the Cycle 7 inspection. Case Review Results OIG case reviewers (a team of physicians and nurse consultants) assessed 10 of the 13 indicators applicable to VSP. Of these 10 indicators, OIG clinicians rated one proficient, seven adequate, and two inadequate. The OIG physicians also rated the overall adequacy of care for each of the 20 detailed case reviews they conducted. Of these 20 cases, none was proficient, 14 were adequate, and six were inadequate. In the 811 events reviewed, we identified 268 deficiencies, 44 of which the OIG clinicians considered to be of such magnitude that, if left unaddressed, would likely contribute to patient harm. Our clinicians found the following strengths at VSP: • Staff provided excellent overall access to providers and nurses. • Staff provided excellent overall access to specialty services. • Staff provided good emergency response and assessments. Our clinicians found the following weaknesses at VSP: • The providers did not consistently review medical records regularly and thoroughly, or consistently document their medical care. • The providers did not consistently review test results and communicate the results to the patients timely. • The staff did not consistently forward specialty reports to the physician. 6 For a further discussion of an adverse event, see Table A–1. Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 6 Compliance Testing Results Our compliance inspectors assessed 10 of the 13 indicators applicable to VSP. Of these 10 indicators, our compliance inspectors rated two proficient, one adequate, and seven inadequate. We tested policy compliance in Health Care Environment, Preventive Services, and Administrative Operations as these indicators do not have a case review component. VSP showed a high rate of policy compliance in the following areas: • Nurses reviewed health care services request forms and conducted face-to- face encounters within required time frames. In addition, VSP housing units contained adequate supplies of health care request forms. • Patients returning from outside community hospitals or specialty service appointments saw their primary care providers within the specified time frames. • Medical staff performed well in scanning specialty service reports, community hospital discharge reports, and requests for health care services into patients’ electronic medical records within required time frames. VSP showed a low rate of policy compliance in the following areas: • Medical clinics had multiple medical supplies that were expired. • Health care staff did not follow hand hygiene precautions before or after patient encounters, and during medication administration. • Nurses did not regularly inspect emergency response bags and treatment carts. • Patients did not always receive their chronic care medications within required time frames. In addition, VSP maintained poor medication continuity for patients returning from hospitalizations, for patients admitted to specialized medical housing, and for patients transferring into and laying over at VSP. • Staff did not perform well in timely providing preapproved specialty services for patients who transferred into the institution. • Staff performed poorly in retrieving specialty service reports, and providers did not always review these reports within the required time frame. Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 7 Institution-Specific Metrics Valley State Prison (VSP) is located in Chowchilla and houses primarily Level II General Population incarcerated people and those requiring sensitive needs yard (SNY) placements. VSP is designated as a basic care institution, providing general medical care through its five medical clinics which handle nonurgent requests for medical services. Patients needing urgent or emergent care are treated in its triage and treatment area (TTA). Additional services are provided in the outpatient housing unit (OHU), through special services, and via telemedicine. VSP provides care to patients in the mental health delivery system at the Enhanced Outpatient Program (EOP) and serves as a reentry hub for incarcerated persons for needs-based rehabilitative services.7 In January 2023, the Health Care Services Master Registry showed that VSP had a total population of 2,971. A breakdown of the medical risk level of the VSP population as determined by the department is set forth in Table 2 below.8 Table 2. VSP Master Registry Data as of January 2023 7 As of July 18, 2023, the department reported on its public tracker that 85% of VSP’s incarcerated population was fully vaccinated while 76% of VSP’s staff was fully vaccinated. For more information, see the department’s statistics on its website page titled Population COVID‑19 Tracking. 8 For a definition of medical risk, see CCHCS HCDOM 1.2.14, Appendix 1.9. Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 8 According to staffing data the OIG obtained from California Correctional Health Care Services (CCHCS), as identified in Table 3 below, VSP had no vacant executive leadership positions, 1.5 primary care provider vacancy, no nursing supervisor vacancies, and 8.5 nursing staff vacancies. Table 3. VSP Health Care Staffing Resources as of January 2023 Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 9 Population-Based Metrics In addition to our own compliance testing and case reviews, as noted above, the OIG presents selected measures from the Healthcare Effectiveness Data and Information Set (HEDIS) for comparison purposes. The HEDIS is a set of standardized quantitative performance measures designed by the National Committee for Quality Assurance to ensure that the public has the data it needs to compare the performance of health care plans. Because the Veterans Administration no longer publishes its individual HEDIS scores, we removed them from our comparison for Cycle 7. Likewise, Kaiser (commercial plan) no longer publishes HEDIS scores. However, through the California Department of Health Care Services’ Medi‑Cal Managed Care Technical Report, the OIG obtained California Medi-Cal and Kaiser Medi-Cal HEDIS scores to use in conducting our analysis, and we present them here for comparison. HEDIS Results We considered VSP’s performance with population-based metrics to assess the macroscopic view of the institution’s health care delivery. Currently, only one HEDIS measure is available for review: poor HbA1c control, which measures the percentage of diabetic patients who have poor blood sugar control. VSP’s results compared favorably with those found in State health plans for this measure. We list the applicable HEDIS measures in Table 4. Comprehensive Diabetes Care When compared with statewide Medi-Cal programs—California Medi-Cal, Kaiser Northern California (Medi-Cal), and Kaiser Southern California (Medi-Cal)—VSP’s percentage of patients with poor HbA1c control was significantly lower, indicating very good performance on this measure. Immunizations Statewide comparative data were not available for immunization measures; however, we include these data for informational purposes. VSP had a 67 percent influenza immunization rate for adults 18 to 64 years old and a 90 percent influenza immunization rate for adults 65 years of age and older.9 The pneumococcal vaccination rate was 92 percent.10 Cancer Screening Statewide comparative data were not available for colorectal cancer screening; however, we include these data for informational purposes. VSP had an 81 percent colorectal cancer screening rate. 9 The HEDIS sampling methodology requires a minimum sample of 10 patients to have a reportable result. 10 The pneumococcal vaccines administered are the 13, 15, and 20 valent pneumococcal vaccines (PCV13, PCV15, and PCV20), or 23 valent pneumococcal vaccine (PPSV23), depending on the patient’s medical conditions. For the adult population, the influenza or pneumococcal vaccine may have been administered at a different institution other than where the patient was currently housed during the inspection period. Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 10 Table 4. VSP Results Compared With State HEDIS Scores Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 11 Recommendations As a result of our assessment of VSP’s performance, we offer the following recommendations to the department: Diagnostic Services • Medical leadership should ensure that providers endorse all diagnostic results timely and communicate the results with patients. • The department should consider developing an electronic solution to ensure that providers create patient letters at the time of endorsement and that patient results letters automatically populate accurately with all required elements per CCHCS policy. • Medical leadership should determine the root cause of challenges with untimely collecting, receiving, notifying, and endorsing STAT laboratory results and implement remedial measures as appropriate to ensure they are performed within required time frames. Emergency Services • Medical and nursing leadership should ensure that the Emergency Medical Response Review Committee (EMRRC) thoroughly audits emergency events, identifies all deficiencies, and ensures all required reviewers complete the clinical reviews. Health Information Management • Medical leadership should identify challenges in scanning, labeling, and including medical records in the correct patient’s file, and implement remedial measures as appropriate. • The department should develop an electronic hard stop to not allow staff to complete a report scanning task until the report has been forwarded to the provider for review or endorsement. Health Care Environment • Medical leadership should remind staff to follow universal hand hygiene precautions. Implementing random spot checks could improve compliance. • Executive leadership should consider performing random spot checks to ensure medical supply storage areas, which were located outside the clinics, store medical supplies adequately. • Nursing leadership should direct each clinic nurse supervisor to review the monthly emergency medical response bag (EMRB) and treatment cart logs to ensure these bags and carts are regularly inventoried and sealed. Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 12 Transfers • Nursing leadership should ensure that receiving and release (R&R) nurses confirm that all patients transferring out of the institution have required medications, transfer documents, and assigned durable medical equipment (DME). • Medical, nursing, and pharmacy leadership should ensure that newly arrived patients and patients returning from a hospitalization receive recommended medications to ensure medication continuity. • Nursing leadership should educate R&R nurses to thoroughly complete the initial health screening, including answering all questions and documenting an explanation for each “yes” answer, documenting a complete vital signs check as part of the patient’s initial health screening assessment, and completing the initial health screening form prior to the patient being placed in housing. Medication Management • The institution should consider developing and implementing measures to ensure that staff timely make available and administer medications to patients and that staff document in EHRS as described in CCHCS policy and procedures.11 Preventive Services • Nursing leadership should consider developing and implementing measures to ensure that nursing staff monitor patients who are receiving TB medications according to CCHCS guidelines. • Medical leadership should analyze the challenges related to the untimely provision of preventative vaccines and implement remedial measures as warranted. Nursing Performance • Nursing leadership should ensure that thorough assessments are completed for all face-to-face encounters. Provider Performance • Medical leadership should ascertain causative factors in the untimely provider review of test results. Medical leadership should implement remedial measures as appropriate. • Medical leadership should remind providers to fully document their co- consultations with nurses in the EHRS. 11 EHRS is the initialism for the department’s electronic health record system. Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 13 • Medical leadership should consider reminding providers to review the blood- sugar levels from finger-stick tests of diabetic patients at each appointment. Specialized Medical Housing • The institution should consider determining and evaluating causative factors related to the untimely provisions of medications and implement remedial measures as appropriate. • Nursing leadership should provide training to the OHU nurses about the institution’s local operating procedures for the call light communication system. Specialty Services • Medical leadership should identify the root cause(s) of untimely completion of subsequent, specialty follow-up appointments for high-priority and medium-priority services, and implement remedial measures as appropriate. • Medical leadership should identify the root cause(s) of untimely completion of transfer patients’ specialty appointments and implement remedial measures as appropriate. • Medical leadership should ascertain the challenges in the untimely receipt of specialty reports and the untimely provider review of these reports and implement remedial measures as appropriate. Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 14 Access to Care In this indicator, OIG inspectors evaluated the institution’s performance in providing patients with timely clinical appointments. Our inspectors reviewed scheduling and appointment timeliness for newly arrived patients, sick calls, and nurse follow-up appointments. We examined referrals to primary care providers, provider follow-ups, and specialists. Furthermore, we evaluated the follow-up appointments for patients who received specialty care or returned from an off-site hospitalization. Ratings and Results Overview Case Review Rating Compliance Rating and Score Proficient Proficient (91.9%) Similar to Cycle 6, case review found VSP performed excellently in providing access to care for patients in Cycle 7. Overall, providers and nurses evaluated patients timely when appointments were requested. We identified a few examples in which patients did not receive their specialty and diagnostic testing appointments within the specified time frame. Considering all factors, the OIG rated the case review component of this indicator proficient. Compliance testing showed VSP performed excellently in reviewing patient sick call requests, completing face-to-face encounters, and providing provider follow-up appointments after returning from hospitalization. VSP demonstrated good performance in delivering provider follow-ups for patients transferring into the institution, patients with chronic care conditions, and patients returning from specialty services. Factoring all the information, the OIG rated the compliance testing component of this indicator proficient. Case Review and Compliance Testing Results OIG clinicians reviewed 164 provider, nursing, urgent or emergent, specialty, and hospital events that required the institution to generate appointments. We identified two deficiencies relating to Access to Care, neither of which was significant.12 Access to Care Providers VSP performed well in providing access to provider appointments. Compliance testing showed good access to chronic care follow-up appointments (MIT 1.001, 84.0%) and nursing to primary care provider referral appointments (MIT 1.005, 90.0%). Case review clinicians found no deficiencies in the scheduling of provider appointments. Due to movement restrictions related to the COVID-19 pandemic, we considered most providers’ chart reviews for nonurgent, low- or medium-risk chronic care appointments 12 Deficiencies occurred in cases 10 and 16. Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 15 in patients who had stable chronic conditions as acceptable alternatives to face-to-face or telephonic appointments. Access to Specialized Medical Housing Providers VSP provided sufficient access to specialized medical housing providers. The compliance testing determined that providers completed a written history and physical examination within the required time frame for most of the review period (MIT 13.002, 77.8%). The case review clinicians found no deficiencies related to access to specialized medical housing providers. Access to Clinic Nurses VSP performed excellently in access to nurse sick calls and provider-to-nurse referrals. Compliance testing found that nurses always triaged sick call requests the same day they received them (MIT 1.003, 100%), and performed face-to-face appointments timely (MIT 1.004, 100%). Our clinicians assessed 48 nursing sick call requests and identified no deficiencies related to clinic nurse access. Access to Specialty Services VSP performed well in referrals to specialty services. Compliance testing determined there was a good completion rate of high-priority (MIT 14.001, 86.7%), medium-priority (MIT 14.004, 86.7%), routine-priority (MIT 14.007, 86.7%), and subsequent follow-up to routine-priority (MIT 14.009, 88.9%) appointments. In contrast, compliance testing found that patients did not receive subsequent specialty follow-up appointments within the specified time frames for high-priority (MIT 14.003, 57.1%) and medium-priority (MIT 14.006, 50.0%) services. Case review clinicians found most specialty appointments took place within requested time frames; we identified only two deficiencies, both of which were not considered significant.13 Follow-Up After Specialty Services Compliance testing revealed that 85.0 percent of provider appointments, after specialty services, occurred within required time frames (MIT 1.008). Case review did not identify any deficiencies related to provider follow-up after specialty services. Follow-Up After Hospitalization VSP provided excellent access to provider follow-up appointments for patients who were discharged from a community hospital (MIT 1.007, 100%). Case review did not identify any deficiencies related to provider follow-up after hospitalization. 13 Deficiencies occurred in cases 10 and 16. Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 16 Follow-Up After Urgent or Emergent Care (TTA) Providers always saw their patients following a triage and treatment area (TTA) event as requested. OIG clinicians assessed 25 TTA events and identified no delays in provider follow-up appointments. Follow-Up After Transferring Into VSP Compliance testing showed sufficient access to intake appointments for newly arrived patients (MIT 1.002, 76.0%). Case reviewers did not find any deficiencies in this area; however, we only reviewed five cases in which patients transferred from another institution. Clinician On-Site Inspection VSP had four main clinics: A, B, C, and D, and each clinic had two providers. Clinics A, C, and D were staffed with one telemedicine and one on-site provider. Clinic B was staffed with two on-site providers. At the time of the on-site inspection, Clinic B was temporarily housed in the infirmary area while renovation of the permanent clinic space was nearing completion. All the clinics were staffed with registered nurses (RNs), licensed vocational nurses (LVNs), and medical assistants (Mas). In addition to the provider line, staff members all had their own lines. Mas reported that their providers had no current backlogs. The OIG clinicians attended morning huddles, which were well attended by the patient care team and staff. The morning huddles lasted about 15 minutes and were satisfactorily organized. OIG clinicians met with the scheduling supervisor who reported that the institution had four office technician vacancies during the case review period and that three providers were out on long-term sick leave (ranging from three to six months). In addition, the scheduling supervisor provided a local operating policy for scheduling and access to care that was in place during the case review period and stated it was similar to the policy from CCHCS. The scheduling supervisor also mentioned that, while it was challenging to adhere to the policy, as directions sometimes were changed daily, providers accepted the changes. Compliance Testing Results Compliance On-Site Inspection and Discussion Patients had access to health care services request forms in all six housing units inspected (MIT 1.101, 100%). Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 17 Compliance Testing Results Table 5. Access to Care Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 18 Table 6. Other Tests Related to Access to Care Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 19 Recommendations The OIG offers no recommendations for this indicator. Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 20 Diagnostic Services In this indicator, OIG inspectors evaluated the institution’s performance in timely completing radiology, laboratory, and pathology tests. Our inspectors determined whether the institution properly retrieved the resultant reports and whether providers reviewed the results correctly. In addition, in Cycle 7, we examined the institution’s performance in timely completing and reviewing immediate (STAT) laboratory tests. Ratings and Results Overview Case Review Rating Compliance Rating and Score Adequate Inadequate (58.1%) Case review found VSP usually completed diagnostic testing timely. However, VSP did not always perform STAT (immediate) or routine lab work on time. In addition, case review found improvement needed with the providers’ performance in timely laboratory review and completing patient test result notification letters. After reviewing all aspects, the OIG rated the case review component of this indicator adequate. Compliance testing showed VSP performed poorly in providing and notifying patients of STAT laboratory results and generating patient test result notification letters with all required key elements. In contrast, the institution performed very well in reviewing and endorsing diagnostic test results and providing laboratory services. In addition, staff performed well in providing radiology services, retrieving, reviewing, and endorsing pathology reports. On balance, the OIG rated the compliance testing component of this indicator inadequate. Case Review and Compliance Testing Results The OIG clinicians reviewed 214 diagnostic-related events and found 93 deficiencies, eight of which were significant.14 Of the 93 deficiencies, 84 were related to health information management, and nine were related to the noncompletion or delayed completion of ordered tests.15 Most of the deficiencies were due to patient notification letters either missing some of the required elements or not being sent to patients at all. Although the case reviewers identified a high number of these deficiencies, we determined that these deficiencies did not significantly increase the risk of harm to patients. 14 Deficiencies occurred in cases 1, 2, 6–17, 19, 20, 22, 23, 43, 44, and 45. Significant deficiencies occurred in cases 1, 8, 10, and 16. 15 Deficiencies related to health information management occurred in cases 1, 2, 6–16, 19, 20, and 43–45. Deficiencies related to noncompletion or delayed completion of ordered tests occurred in cases 6, 8, 10, 17, 19, 22, and 23. Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 21 Test Completion VSP had a mixed performance in the timely completion of tests. Compliance testing showed very good performance completing radiology services (MIT 2.001, 80.0%) and laboratory services (MIT 2.004, 90.0%) within required time frames, but poor performance with completing STAT laboratory services (MIT 2.007, 30.0%). Case reviewers found only one significant deficiency related to test completion as described in the following case: • In case 8, the provider ordered the coagulation laboratory test to be performed as soon as possible; however, the laboratory specimen was collected more than a day later. Health Information Management VSP had a mixed performance in managing the results of diagnostic tests. Compliance testing showed that providers performed very well in endorsing both radiology (MIT 2.002, 90.0%) and laboratory (MIT 2.005, 90.0%) results. In contrast, the case reviewers identified seven significant deficiencies related to late endorsement of test results.16 The following are two examples of severe deficiencies: • In case 8, the provider reviewed the coagulation test results 47 days after the results were available. • In case 10, the provider reviewed the proBNP laboratory test result 24 days after the results were available.17 The institution performed sufficiently in pathology report retrieval (MIT 2.010, 80.0%) and provider review of pathology reports (MIT 2.011, 77.8%). However, the providers only occasionally acknowledged, or nursing staff only intermittently notified providers of, STAT test results within required time frames (MIT 2.008, 40.0%). Similarly, the providers sometimes endorsed STAT laboratory test results timely (MIT 2.009, 70.0%). The case reviewers did not identify any deficiencies related to STAT or pathology test result retrieval or provider review. Compliance testing revealed that VSP providers performed poorly in communicating results to the patients. Providers sporadically communicated results from radiology studies (MIT 2.003, 20.0%) and laboratory studies (MIT 2.006, 30.0%), and never communicated results from pathology studies (MIT 2.012, zero) within the required time frames. Case review found 68 deficiencies related to provider communication of test results in the form of incomplete letters or letters not sent to the patient.18 Additional discussion can be found under the Health Information Management indicator. 16 Significant deficiencies occurred in cases 1, 8, 10, and 16. 17 The laboratory test, proBNP, is used to diagnose and evaluate congestive heart failure. 18 We identified deficiencies with patient notification letters in cases 1, 2, 6, 8–12, 14–16, 19, 20, 43, 44, and 45. None of these deficiencies were considered significant. Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 22 Clinician On-Site Inspection The OIG clinicians interviewed the senior laboratory assistant and the correctional health services administrator (CHSA) who stated that, during the case review period, the institution classified all laboratory work as urgent or emergent. This meant laboratory tests were drawn on a modified program because of COVID-19 protocols. In addition, the CHSA and senior laboratory assistant reported that the institution had staff shortages due to COVID-19-related long-term sick leave among these staff members. VSP did not have a centralized laboratory draw area as each clinic had a laboratory draw station. The senior laboratory assistant, CHSA, and clinic staff all cited this was a benefit, especially in yards with a high number of EOP patients who could not mix with the general population patients. VSP offered routine X-rays, computed tomography (CT) scans, and ultrasounds on site.19 Providers reported no issues with obtaining routine laboratory and on-site imaging studies. When asked about the availability of STAT labs, most providers indicated they had seldom ordered STAT labs and had not experienced any roadblocks to the timely completion of STAT laboratory tests when the need had arisen. 19 A CT scan is a computed, or computerized, tomography imaging scan. Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 23 Compliance Testing Results Table 7. Diagnostic Services Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 24 Recommendations • Medical leadership should ensure that providers endorse all diagnostic results timely and communicate the results with patients. • The department should consider developing an electronic solution to ensure that providers create patient letters at the time of endorsement and that patient results letters automatically populate accurately with all required elements per CCHCS policy. • Medical leadership should determine the root cause of challenges with untimely collecting, receiving, notifying, and endorsing STAT laboratory results and implement remedial measures as appropriate to ensure they are performed within required time frames. Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 25 Emergency Services In this indicator, OIG clinicians evaluated the quality of emergency medical care. Our clinicians reviewed emergency medical services by examining the timeliness and appropriateness of clinical decisions made during medical emergencies. Our evaluation included examining the emergency medical response, cardiopulmonary resuscitation (CPR) quality, triage and treatment area (TTA) care, provider performance, and nursing performance. Our clinicians also evaluated the Emergency Medical Response Review Committee’s (EMRRC) performance in identifying problems with its emergency services. The OIG assessed the institution’s emergency services mainly through case review. Ratings and Results Overview Case Review Rating Compliance Rating and Score Adequate Not Applicable VSP provided emergency care comparable to that rendered in Cycle 6. Nursing staff responded immediately to emergencies and frequently performed good patient assessments, interventions, and documentation. For patients who required CPR, custody and nursing staff worked together to initiate CPR and call 9-1-1. We identified opportunities for improvement with EMRRC. Overall, VSP medical and nursing staff provided good emergency care; therefore, the OIG rated this indicator adequate. Case Review Results We reviewed 25 urgent or emergent events and found 20 emergency care deficiencies. Of these 20 deficiencies, six were significant.20 Emergency Medical Response Generally, VSP provided very good emergency care. Health care and custody staff responded immediately to medical emergencies throughout the institution. They initiated CPR, activated emergency medical services, and notified the TTA staff as required. Cardiopulmonary Resuscitation Quality VSP performed well in this area. Our OIG clinicians reviewed five cases in which patients required CPR.21 Custody and nursing staff initiated CPR without delay, as well as notified emergency medical services and the TTA staff as required. We identified three deficiencies, none of which was significant. The deficiencies were related to lack of AED 20 We reviewed the following cases with urgent or emergent events: 1–7, 9, 13–15, 18–21, and 23. Deficiencies occurred in cases 1, 4, 5, 7, 9, 13, 18, 19, and 23. Cases 1, 9, and 18 had significant deficiencies. 21 Patients required CPR in cases 3–7. Deficiencies occurred in cases 4, 5, and 7. Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 26 documentation, time-line and documentation discrepancies, and Narcan administration.22 However, these deficiencies did not affect overall patient care. Provider Performance Providers generally performed well in urgent, emergent situations, and after-hours care. They usually made accurate diagnoses and completed documentation. However, we identified seven deficiencies related to emergency care.23 The following are examples of significant deficiencies, all of which occurred in case 9. • The provider documented that the patient’s blood pressure was low and heart rate was elevated within the setting of an elevated INR.24 These findings could have suggested blood loss. In addition, the patient was receiving a medication (carvedilol) that lowers the blood pressure and heart rate. The provider should have considered adjusting the carvedilol or expediting the work-up for blood loss. • The provider urgently evaluated the patient for symptomatic low blood pressure. The patient was of advanced age and had a recent elevated coagulation test result, but had been discharged back to housing after receiving intravenous fluids. The provider attributed the low blood pressure reading to an irregular heart rhythm, but did not consider blood loss as a cause for the patient’s symptoms. In addition, the patient’s blood pressure medication was continued at a higher dosage, which placed the patient at risk for further episodes of low blood pressure. • The provider saw the patient for repeated episodes of low blood pressure, but did not adjust the blood pressure medication. Nursing Performance First medical responders and TTA nurses mostly performed good assessments, intervened, and notified the providers as required. Of the 20 deficiencies, six were related to nursing performance.25 The following are examples of significant deficiencies: • In case 1, the patient with a history of stroke, hypertension, and diabetes had stroke-like symptoms, but the records indicated a 53-minute delay in calling 9-1-1. In addition, the nurse did not check the patient’s blood-sugar level by performing a point-of-care glucose test. Point-of-care glucose testing is an accepted standard of care for patients who present with stroke-like symptoms. • In case 18, a medical emergency was called for a patient who complained of chest pain, a rapid heart rate, and palpitations. Records indicated the nurse placed the AED on the patient 19 minutes after the notification, instead of 22 The lack of AED documentation included times of defibrillation and response to defibrillation. 23 Deficiencies occurred in cases 9, 13, and 23. Case 9 had significant deficiencies. 24 The INR is a laboratory test to measure the body’s blood clotting mechanism. This test is used to monitor the effectiveness of blood thinning medications such as warfarin. 25 Nursing performance deficiencies occurred in cases 1, 4, 5, 18, and 19. Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 27 immediately. A fast heart rate can progress rapidly and become life threatening without immediate intervention. During our on-site inspection, VSP agreed with these deficiencies and provided training to staff. Nursing Documentation First medical responders and TTA nurses mostly performed adequate documentation. We did not identify any significant documentation deficiencies.26 The following are examples of deficiencies identified: 1) no order was documented for oxygen administration, and 2) documentation did not identify the provider arrival time in the TTA, the time of defibrillation, or the patient’s response to defibrillation. Emergency Medical Response Review Committee EMRRC met monthly, usually identified deficiencies, and provided staff training. Our clinicians reviewed 10 emergency events.27 Examples of deficiencies not identified during the EMRRC or supervisor review include the following types: delay in applying the AED, lack of provider documentation for a patient sent to the hospital, and lack of chief nurse executive (CNE) and chief medical executive (CME) review of events.28 Similarly, compliance testing revealed incomplete checklists, missing entries, untimely review of incidents, and missing clinical review by the supervising registered nurse II (SRN II), CME, or CNE (MIT 15.003, 50.0%). This is an opportunity for improvement. Clinician On-Site Inspection During our on-site inspection to the TTA, we interviewed the nursing staff. They reported the TTA has two beds and is staffed with two RNs on each watch except on Mondays. On first watch, the TTA was staffed with three RNs. On weekends, the TTA was assigned a third RN on second watch. This RN collected the sick calls, triaged them, and evaluated patients with urgent complaints. The TTA had a provider who covered the TTA and the OHU, Monday through Friday. On-call providers covered after-hour periods and on holidays. The staff expressed nursing morale was low due to the prevailing short-staffing situation. Nursing staff reported their supervisor was available, made rounds daily on second watch, and communicated information with the TTA staff via email. The staff reported they did not have any Issues with supplies or pharmacy and found custody staff to be helpful. They maintained a well-supplied Omnicell (automated drug delivery system) with medications. The TTA had three emergency vehicles, one of which was out for repair. 26 Documentation deficiencies occurred in cases 1, 4, 18, and 19. 27 We reviewed emergency events in cases 1, 3–7, 13, and 18–20. We identified deficiencies in cases 1, 4, 13, 18, and 19. 28 The EMRRC or supervisors did not identify deficiencies for emergency events in cases 1, 4, 13, 18, and 19. Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 28 Recommendations • Medical and nursing leadership should ensure that the EMRRC thoroughly audits emergency events, identifies all deficiencies, and ensures all required reviewers complete the clinical reviews. Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 29 Health Information Management In this indicator, OIG inspectors evaluated the flow of health information, a crucial link in high-quality medical care delivery. Our inspectors examined whether the institution retrieved and scanned critical health information (progress notes, diagnostic reports, specialist reports, and hospital discharge reports) into the medical record in a timely manner. Our inspectors also tested whether clinicians adequately reviewed and endorsed those reports. In addition, our inspectors checked whether staff labeled and organized documents in the medical record correctly. Ratings and Results Overview Case Review Rating Compliance Rating and Score Inadequate Proficient (87.0%) Case review found VSP needed improvement in managing health information. Staff did not always timely scan hospital records and specialty records into the EHRS or properly forward them to the providers for review. Some providers endorsed laboratory results very late. In addition, some providers did not send or sent incomplete patient rest result notification letters. After careful consideration, the OIG rated the case review component of this indicator inadequate. Compared with Cycle 6, compliance testing showed VSP performed excellently in scanning patient sick call requests and scanning specialty documents. In addition, the staff exceptionally retrieved, scanned, and endorsed hospital records. However, staff needs to improve in scanning medical records in the correct patient files. Taking all results into consideration, the OIG rated the compliance testing component of this indicator proficient. Case Review and Compliance Testing Results We reviewed 811 events and found 103 deficiencies related to health information management, 14 of which were significant.29 Hospital Discharge Reports VSP staff timely retrieved hospital discharge records, scanned them into the EHRS, and reviewed them within the required time frames (MIT 4.003, 100%). Our clinicians reviewed 10 off-site emergency department and hospital encounters and identified four deficiencies.30 The following are examples of significant deficiencies: 29 Deficiencies occurred in cases 1, 2, 6–6, 18–23, and 43–45. Cases 1, 8, 10, 13, 14, 16, 18, and 21 had significant deficiencies. 30 Deficiencies occurred in cases 13, 14, 18, and 21. Cases 13, 18, and 21 had significant deficiencies. Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 30 • In case 13, the provider endorsed the emergency room report 36 days after it was available in the EHRS. • In case 18, health information management (HIM) staff scanned hospital documentation into the EHRS but did not forward the documentation to the provider for review or endorsement. • In case 21, the HIM staff scanned the patient’s emergency department records into the EHRS but did not send the report to the provider for review. Specialty Reports VSP did not consistently perform well in managing specialty reports. Compliance testing showed excellent retrieval of specialty reports (MIT 4.002, 93.6%), but fair to poor performance in provider endorsement of high-priority (MIT 14.002, 71.4%), medium- priority (MIT 14.005, 46.7%), and routine-priority (MIT 14.008, 71.4%) specialty reports. Our clinicians reviewed 60 specialty reports and identified 12 deficiencies.31 Six deficiencies were due to the providers endorsing the specialty reports outside policy time frames, three were due to delayed or mislabeled scans, and three reports were not properly forwarded to the provider for review. The following are examples of two significant deficiencies: • In case 10, HIM staff scanned an echocardiogram report into the EHRS; however, HIM staff did not forward the report to the provider for review. • In case 14, HIM staff scanned a nephrology consultation report into the EHRS; however, HIM staff did not forward the report to the provider for review. We also discuss these findings in the Specialty Services indicator. Diagnostic Reports VSP had a mixed performance with managing diagnostic reports. Compliance testing showed a pattern of the late endorsement of STAT results (MIT 2.008, 40.0%). The providers also performed poorly with timely communicating pathology results to patients (MIT 2.012, zero), but reviewed the pathology reports mostly on time (MIT 2.011, 77.8%). Case reviewers identified 68 deficiencies related to incomplete (56) or missing (12) patient result letters, which, taken together, accounted for most of the diagnostic health information management deficiencies.32 OIG clinicians also identified a minor pattern of significant deficiencies related to late provider endorsement of diagnostic results.33 Please refer to the Diagnostic Services indicator for a further detailed discussion. 31 Specialty health information management deficiencies occurred in cases 9, 10, 13–15, 18, 22, 23, and 44. Significant deficiencies occurred in cases 10 and 14. 32 Deficiencies occurred in cases 1, 2, 6, 8–12, 14–16, 19, 20, and 43–45. No significant deficiencies occurred. Deficiencies related to incomplete patient notification letters in cases 1, 2, 6, 8–12, 14–16, 19, 20, 44, and 45. Deficiencies related to missing patient notification letters occurred in cases 1, 8, 9, and 43. 33 Deficiencies occurred in cases 1, 7–10, 13, 16, and 44. Seven significant deficiencies occurred in cases 1, 8, 10, and 16. Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 31 Urgent and Emergent Records OIG clinicians reviewed 25 emergency care events and found nurses and providers recorded these events well. The providers also recorded their emergency care sufficiently, including off-site telephone encounters and no deficiencies were identified. The Emergency Services indicator provides additional details. Scanning Performance VSP had a mixed performance with the scanning process. While compliance testing found the institution occasionally properly labeled, scanned, and filed documents (MIT 4.004, 41.7%), the case reviewers identified only four deficiencies. None of these deficiencies was considered significant.34 Clinician On-Site Inspection We discussed health information management (HIM) processes with the health records technician (HRT) supervisor who described the process of retrieving off-site reports. The HRT supervisor acknowledged some difficulty in obtaining reports from one community hospital. However, the HIM staff was able to establish a contact for medical records procurement the week before the OIG’s on-site inspection. Concerning specialty reports, the HRT supervisor reported the specialty department had an office technician (OT) who tracked specialty appointments and would try to obtain the report for the institution. We discussed the process of ensuring timely provider review of reports and results with the HRT supervisor during the HIM meeting. We also discussed the process with the senior laboratory assistant and the correctional health services administrator during the diagnostic services meeting. The HRT supervisor reported that HIM staff ran a provider deficiency report weekly and emailed the providers, a process that had been in place for approximately six years. The HRT supervisor noted the medical leadership had recently asked the HIM staff to run the report twice a week. Even so, we identified multiple deficiencies with providers’ nonendorsements as described above. The HRT supervisor reported that HIM staffing was down. HIM was staffed for four HRTs and two and a half office assistants (OAs), but presently has three HRTs and one OA. OIG clinicians discussed patient notification letters with providers and medical assistants. Medical assistants usually printed out the letters and prepared them for patient distribution. They reported most patients did not pick up the letters and often requested the results to be emailed to them instead. 34 Deficiencies occurred in cases 2, 7, and 15. Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 32 Compliance Testing Results Table 8. Health Information Management Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 33 Table 9. Other Tests Related to Health Information Management Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 34 Recommendations • Medical leadership should identify challenges in scanning, labeling, and including medical records in the correct patient’s file, and implement remedial measures as appropriate. • The department should develop an electronic hard stop to not allow staff to complete a report scanning task until the report has been forwarded to the provider for review or endorsement. Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 35 Health Care Environment In this indicator, OIG compliance inspectors tested clinics’ waiting areas, infection control, sanitation procedures, medical supplies, equipment management, and examination rooms. Inspectors also tested clinics’ performance in maintaining auditory and visual privacy for clinical encounters. Compliance inspectors asked the institution’s health care administrators to comment on their facility’s infrastructure and its ability to support health care operations. The OIG rated this indicator solely on the compliance score. Our case review clinicians do not rate this indicator. Ratings and Results Overview Case Review Rating Compliance Rating and Score Not Applicable Inadequate (43.0%) In this cycle, VSP performed poorly in this indicator. Medical supplies storage areas in and outside of the clinics either contained expired medical supplies or medical supplies were directly stored on the floor. Emergency medical response bag (EMRB) logs were missing staff verification, inventory was not performed, or the bags stored expired medical supplies. Several clinics did not meet the requirements for essential core medical equipment and supplies. Finally, staff did not regularly sanitize their hands before and after examining patients. These factors resulted in an inadequate rating for this indicator. Compliance Testing Results Outdoor Waiting Areas We examined outdoor patient waiting areas. Health care and custody staff reported existing waiting areas had enough seating capacity, ample protection from inclement weather, and an operational misting system for use during extreme heat conditions (see Photo 1). Indoor Waiting Areas We inspected indoor waiting areas. Health care and custody staff reported existing waiting areas had sufficient seating capacity (see Photo 1. Shaded outdoor waiting area with mist cooling system Photo 2, next page). During our (photographed on 1-20-23). inspection, we did not observe overcrowding in any of the clinics’ indoor waiting areas. Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 36 Photo 2. Indoor waiting area (photographed on 1-17-23). Clinic Environment All clinic environments were excellently conducive to medical care; they provided reasonable auditory privacy, appropriate waiting areas, wheelchair accessibility, and nonexamination room workspace (MIT 5.109, 100%). Of the eight clinics we observed, three contained appropriate space, configuration, supplies, and equipment to allow their clinicians to perform proper clinical examinations (MIT 5.110, 37.5%). The remaining five clinics had one or more of the following deficiencies: staff reported that, although they could provide service to patients simultaneously and use privacy curtains, the examination room gurneys were too close to each other, which prevented auditory privacy during clinical examination; physical therapy equipment had a torn vinyl cover; examination rooms contained unidentified or inaccurately labeled examination room supplies; the examination room was unorganized or cluttered (see Photo 3, next page); examination room cabinets and desk were not free of trash (a food wrapper and a drink can, and unsanitized medical equipment); and an examination room had unsecured confidential medical records (see Photo 4, next page). Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 37 Photo 3. Cluttered examination room (photographed on 1-18-23). Photo 4. Unsecured confidential medical records (photographed on 1-18-23). Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 38 In addition to the above findings, our compliance inspectors observed the following notable findings in the clinic during their on-site inspection: • The OHU clinic’s medication cart was in disrepair (see Photo 5). Staff reported the cart had been damaged for several months. OHU staff had not reported the issue nor filed a work order to replace or repair the broken medication cart. Photo 5. OHU medication cart found in disrepair (photographed on 1-19-23). Clinic Supplies None of the nine clinics followed adequate medical supply storage and management protocols (MIT 5.107, zero). We found one or more of the following deficiencies in nine clinics: medical supplies that were expired, unidentified, or disorganized (see Photo 6 and Photo 7); cleaning materials stored with medical supplies; staff members’ personal items and food stored with medical supplies (see Photo 8, next page); bulk-food items stored long-term in the supply storage room location; and compromised sterile medical supply packaging. Photo 6. Expired medical supplies dated December 2022 (photographed on 1-19-23). Photo 7. Expired medical supplies dated November 2022 (photographed on 1-19- 23). Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 39 Photo 8. Staff’s personal food item stored with medical supplies (photographed on 1-18-23). Only two of the nine clinics met the requirements for essential core medical equipment and supplies (MIT 5.108, 22.2%). The remaining seven clinics lacked medical supplies or had nonfunctional equipment. The missing items included an oto-ophthalmoscope, a biohazard receptacle bin or bag, a nebulizer, and lubricating jelly. The staff had not properly calibrated an oto-ophthalmoscope, vital signs machine, an overhead light, a weight scale, and a nebulizer. We found several nonfunctional oto- ophthalmoscopes. VSP staff either did not always document daily performance checks of the automated external defibrillator (AED) or did not complete the defibrillator performance test log documentations within the past 30 days. In addition, daily glucometer quality control logs in several clinics were either inaccurate or incomplete (see Photo 9). Photo 9. Inaccurate glucometer daily quality In addition to the above findings, our control log and out-of-range results without compliance inspectors observed the following action taken by staff (photographed on 1-20-23). notable findings in several clinics during their on-site inspection: • Staff did not document having taken any action when the glucometer quality control results were beyond the range of what is acceptable (see Photo 9, this page, and Photo 10, next page). Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 40 Photo 10. Staff did not take proper action when glucometer quality control results were out of range (photographed on 1-18-23). We examined EMRBs to determine whether they contained all essential items. We checked whether staff inspected the bags daily and inventoried them monthly. None of the seven EMRBs passed our test (MIT 5.111, zero). We found one or more of the following deficiencies: staff failed to ensure the EMRBs’ compartments were sealed and intact; staff had not inventoried EMRBs when the seal tags were replaced; and medical supplies stored in EMRBs were expired or the original packaging was compromised (see Photo 11). The TTA staff did not properly perform an inventory of the treatment cart, and the treatment cart daily check sheet indicated the cart had missing items that were not replaced as per CCHCS policy. We also found compromised medical supplies stored in the treatment cart. Photo 11. Expired EMRB supply dated December 2022 (photographed on 1-19-23). Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 41 Medical Supply Management None of the medical supply storage areas located outside the medical clinics contained adequately stored medical supplies (MIT 5.106, zero). The warehouse manager did not maintain a temperature log for medical supplies with manufacturer temperature guidelines stored in the Conex box. In addition, we found medical supplies stored directly on the floor (see Photo 12). According to the CEO, the institution did not have any concerns about the medical supplies process. Health care managers and medical warehouse managers expressed no concerns about the medical supply chain or their communication process. Photo 12. Medical supplies stored directly on the floor (photographed on 1-18-23). Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 42 Infection Control and Sanitation Staff appropriately cleaned, sanitized, and disinfected five of nine clinics (MIT 5.101, 55.6%). In four clinics, we found one or both of the following deficiencies: cleaning logs were not maintained, and biohazardous waste was not emptied after each clinic day. Staff in five of seven applicable clinics properly sterilized or disinfected medical equipment (MIT 5.102, 71.4%). In two clinics, examination table disposable paper was not removed and replaced in between patient encounters. We found operating sinks and hand hygiene supplies in the examination rooms in seven of nine clinics (MIT 5.103, 77.8%). In one clinic, patient restrooms lacked disposable hand towels. In another clinic, the examination room lacked disposable hand towels and had a nonfunctional hand dryer. We observed patient encounters in five applicable clinics. In four of the clinics, staff did not wash their hands before or after examining their patients, and before applying gloves (MIT 5.104, 20.0%). Health care staff in eight of nine clinics followed proper protocols to mitigate exposure to blood-borne pathogens and contaminated waste (MIT 5.105, 88.9%). In one clinic, nursing staff did not describe the appropriate disinfection process of medical equipment after exposure to biohazardous waste. Physical Infrastructure We gathered information to determine whether the institution’s physical infrastructure was maintained in a manner that supported health care management’s ability to provide timely, adequate health care. At the time of our inspection, the institution had two infrastructure projects underway, which management staff felt would improve the delivery of care at VSP. These are detailed below: • Project SP 3.1: Expansion of Clinic B, which began December 2013. The project had been delayed due to pending approval from the State Fire Marshall and, at the time of inspection, project completion had been expected by January 2023. • Project SP 3.2: Renovation of Clinic B, which began September 2020. This project had also been delayed due to pending approval from the State Fire Marshall and, at the time of inspection, project completion had been expected by February 2023. Despite the delay of both projects SP 3.1 and SP 3.2 described above, when we interviewed health care managers, they did not have concerns about the facility’s infrastructure or its effect on the staff’s ability to provide adequate health care (MIT 5.999). Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 43 Compliance Testing Results Table 10. Health Care Environment Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 44 Recommendations • Medical leadership should remind staff to follow universal hand hygiene precautions. Implementing random spot checks could improve compliance. • Executive leadership should consider performing random spot checks to ensure medical supply storage areas, which were located outside the clinics, store medical supplies adequately. • Nursing leadership should direct each clinic nurse supervisor to review the monthly emergency medical response bag (EMRB) and treatment cart logs to ensure these bags and carts are regularly inventoried and sealed. Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 45 Transfers In this indicator, OIG inspectors examined the transfer process for those patients who transferred into the institution as well as for those who transferred to other institutions. For newly arrived patients, our inspectors assessed the quality of health care screenings and the continuity of provider appointments, specialist referrals, diagnostic tests, and medications. For patients who transferred out of the institution, inspectors checked whether staff reviewed patient medical records and determined the patient’s need for medical holds. They also assessed whether staff transferred patients with their medical equipment and gave correct medications before patients left. In addition, our inspectors evaluated the performance of staff in communicating vital health transfer information, such as preexisting health conditions, pending appointments, tests, and specialty referrals; and inspectors confirmed whether staff sent complete medication transfer packages to receiving institutions. For patients who returned from off-site hospitals or emergency rooms, inspectors reviewed whether staff appropriately implemented recommended treatment plans, administered necessary medications, and scheduled appropriate follow-up appointments. Ratings and Results Overview Case Review Rating Compliance Rating and Score Adequate Inadequate (56.5%) Case review found VSP’s performance was mixed for this cycle. Case reviewers did not identify any significant deficiencies for the transfer in or the transfer out processes. When patients arrived at VSP, nurses generally completed the nursing screening thoroughly, patients did not have any problems with medication continuity, and provider appointments occurred as required. When patients returned from the hospital or emergency room, nurses completed satisfactory assessments and patients frequently received their medications without interruption. However, we found significant deficiencies with provider performance and HIM. Factoring all the information, OIG rated the case review component of this indicator adequate. Compliance testing showed overall poor performance. VSP scored low in completing initial health screening forms, ensuring medication continuity for newly transferred patients, and ensuring transfer packets for departing patients include the required documents and medications. In contrast, staff performed very well in completing the assessment and disposition sections of the screening process. Factoring all the information, the OIG rated the compliance testing component of this indicator inadequate. Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 46 Case Review and Compliance Testing Results We reviewed 33 events in 17 cases in which patients transferred into or out of the institution or returned from an off-site hospital or emergency room. We identified 17 deficiencies, four of which were significant.35 Transfers In OIG clinicians reviewed 17 events in five cases in which patients transferred into the facility from other institutions. We identified six deficiencies, none of which was significant.36 Our clinicians found that R&R nurses generally completed the nursing screening thoroughly. However, in one case, we identified deficiencies wherein a nurse did not weigh the patient on multiple occasions when he arrived at VSP.37 In two other cases, the nurse did not reassess the patients for elevated heart rates and blood pressure levels.38 R&R nurses performed well for MIT 6.002, scoring 86.4 percent. Nurses frequently completed the assessment and disposition section of the initial health screening form. Compliance testing identified that R&R nurses completed the initial health screening within the required time frame. However, the screening was not completed thoroughly (MIT 6.001, 20.0%). Nurses frequently did not document an explanation when patients answered “yes” to the question asking whether they had ever been treated for mental illness. Our case reviewers identified one deficiency in which the nurse did not request additional information when the patient answered “yes” for significant dental problems and had recently received bad news.39 Both case reviewers and compliance testing found patients who arrived at VSP were seen by the provider within the required time frame (MIT 1.002, 76.0%). Our case reviewers did not identify any deficiencies for timely provider access. For medication continuity, case review and compliance reached different results. Our case reviewers did not identify any problems with medication continuity for patients who arrived at VSP. In contrast, compliance testing resulted in a low score of 69.6 percent (MIT 6.003). Patients who were temporarily housed at VSP intermittently received their medications without interruption (MIT 7.006, 70.0%). For those patients who transferred from one housing unit to another within the facility, VSP performed very well, with patients frequently receiving their medication without disruption (MIT 7.005, 88.0%). 35 We reviewed cases 1, 7, 9, 13, 14, 18–21, 23–29, and 45. Deficiencies occurred in cases 7, 13, 14, 18, 21, 24, 26, and 28, Cases 13, 18, and 21 had significant deficiencies. 36 We reviewed cases 7, 21, and 24–26 for patients who arrived at VSP. Deficiencies occurred in cases 7, 21, 24, and 26. 37 On three occasions, for case 7, the nurse did not weigh the patient. 38 The R&R nurse did not reassess the patients elevated blood pressure or heart rate in cases 7 and 24. 39 In case 26, the nurse did not inquire for additional information. Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 47 Specialty service appointments for patients who arrived at VSP sometimes occurred within required time frames (MIT 14.010, 50.0%), but some appointments were seven to 67 days late. Transfers Out VSP’s transfer-out process had mixed results for compliance and case review. We reviewed 15 events in five cases and identified three deficiencies, none of which was significant.40 The three case review deficiencies related to medication administration and nursing documentation. Our clinicians found one deficiency wherein the patient did not receive his medications prior to transferring out of VSP.41 Compliance testing found that one of two patients tested who transferred out of the institution was not sent with his medications and required documents (MIT 6.101, 50.0%). In addition, one of the patients sampled had one medication with an expired pharmacy label. Hospitalizations Patients returning from an off-site hospitalization or emergency room are at high risk for lapses in care quality. These patients typically experience severe illness or injury. They require more care and place a strain on the institution’s resources. In addition, because these patients have complex medical issues, successful health information transfers are necessary for good quality care. Any transfer lapse can result in serious consequences for these patients. For hospital returns, VSP’s performance resulted in different findings for case review and compliance testing. Our clinicians reviewed 10 events in 10 cases in which patients had returned from an off-site hospitalization or emergency room encounter. We identified seven deficiencies, four of which were significant.42 Nurses completed adequate assessments when patients returned from the hospital or emergency room. Our case reviewers did not identify any significant deficiencies related to nursing performance.43 VSP performed poorly for continuity of hospital recommended medications (MIT 7.003, 23.8%). Please refer to the Medication Management indicator for details. OIG case reviewers identified one deficiency in which the patient did not receive one dose of his chronic care medications.44 Compliance testing showed excellent performance for provider follow-ups (MIT 1.007, 100%), availability, and quality of discharge summaries (MIT 4.003 and MIT 4.005, 100%). 40 We reviewed transfer out events in cases 7, 27–29, and 45. Deficiencies occurred in cases 7 and 28. 41 In case 7 the patient did not receive his medications prior to transferring out of VSP. During our on-site inspection, VSP agreed with our findings. 42 Patients returned from a hospitalization or emergency room encounter in cases 1, 9, 13, 14, 18–21, 23, and 45. Deficiencies occurred in cases 13, 14, 18, and 21. Cases 13, 18, and 21 had significant deficiencies. 43 Case 18 had one nursing deficiency in which the nurse did not weigh the patient upon the patient’s return from a hospitalization. 44 In case 14, the patient did not receive an evening dose of his medications, Apixaban, which prevents blood clots, and Aripiprazole, a psychiatric medication. Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 48 On the other hand, case reviewers cited four HIM deficiencies, three of which were significant. Please refer to the Health Information Management indicator for further discussion on cases 13, 18, and 21. Although compliance testing was excellent for provider follow-ups, our clinicians identified the following significant provider deficiency: • In case 18, the provider saw the patient to follow-up on the patient’s hospitalization for dysrhythmia, cardiac arrest, and automatic implantable cardioverter defibrillator (AICD) placement.45 Per the hospital discharge summary, a sleep study was recommended to further evaluate the patient for the presence of obstructive sleep apnea (OSA). Untreated OSA has the potential for causing dysrhythmias. However, the provider did not order the sleep study, thus increasing the risk for recurrence and potentially fatal dysrhythmias. In addition, the provider did not address the patient’s obesity as recommended by the hospitalist, which is a risk factor for OSA. Clinician On-Site Inspection The R&R nurse we interviewed was familiar with the transfer process and reported no issues with supplies, equipment, or the pharmacy. We were informed the administrative staff are receptive, and their relationship with custody staff is good. Second and third watches have one RN assigned to them. The TTA nurse performs transfer duties on first watch as needed. On average, six patients arrive at VSP and three transfer out of VSP daily. The R&R nurse informed us the institution rarely has issues with transfers. On the occasions when medications or durable medical equipment are missing, items are replaced immediately. We also interviewed the SRN covering for the R&R SRN. She informed us the administration has an open-door policy, nursing has a good relationship with custody staff, and no supply issues exist. 45 Dysrhythmia is a medical condition with an abnormal heart rhythm. Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 49 Compliance Testing Results Table 11. Transfers Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 50 Table 12. Other Tests Related to Transfers Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 51 Recommendations • Nursing leadership should ensure that R&R nurses confirm that all patients transferring out of the institution have required medications, transfer documents, and assigned DME. • Medical, nursing, and pharmacy leadership should ensure that newly arrived patients and patients returning from a hospitalization receive recommended medications to ensure medication continuity. • Nursing leadership should educate R&R nurses to thoroughly complete the initial health screening, including answering all questions and documenting an explanation for each “yes” answer, documenting a complete vital signs check as part of the patient’s initial health screening assessment, and completing the initial health screening form prior to the patient being placed in housing. Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 52 Medication Management In this indicator, OIG inspectors evaluated the institution’s performance in administering prescription medications on time and without interruption. The inspectors examined this process from the time a provider prescribed medication until the nurse administered the medication to the patient. When rating this indicator, the OIG strongly considered the compliance test results, which tested medication processes to a much greater degree than case review testing. In addition to examining medication administration, our compliance inspectors also tested many other processes, including medication handling, storage, error reporting, and other pharmacy processes. Ratings and Results Overview Case Review Rating Compliance Rating and Score Adequate Inadequate (57.0%) VSP had a mixed performance with case review. Overall, VSP had slightly a smaller number of deficiencies this cycle compared to Cycle 6. We found nurses generally administered medications timely as ordered and performance was acceptable in hospital discharge, specialized medical housing, transfers, and new medications. However, we identified opportunities for improvement for chronic medication continuity. Factoring all the information, OIG rated the case review component of this indicator adequate. Compliance testing showed VSP needed improvement in this indicator. VSP scored low in providing patients with chronic care medications, newly prescribed medications as ordered, and hospital discharge medications, including for patients temporarily housed at the institution. Conversely, VSP performed well in providing medication continuity for patients transferring within the institution, and performed exceptionally in employing general security and storing medications in its main pharmacy. On balance, the OIG rated the compliance testing component of this indicator inadequate. Case Review and Compliance Testing Results We reviewed 140 events in 28 cases related to medications and found 24 medication deficiencies, four of which were significant.46 New Medication Prescriptions For new medication availability, Compliance testing found the institution’s performance needed improvement with a score of 52.0 percent (MIT 7.002) because new medications were not available within the required time frame. Specifically, compliance results showed 12 out of 25 patients sampled received medications one to four days late. 46 We reviewed cases 1, 2, 6–24, 26–29, and 43–45. Deficiencies occurred in cases 1, 2, 6, 7, 11, 14, 15, and 20–22. Significant deficiencies occurred in cases 1 and 22. Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 53 Examples of medications received late included those for cholesterol, diabetes, and urinary concerns. Our clinicians found four deficiencies indicating a pattern of late administration of newly ordered medications.47 Three examples follow: • In case 15, the patient complained of severe ear pain. The provider ordered ibuprofen; however, the patient received the new medication one day late. • In case 21, the provider discontinued the diltiazem prescription and ordered a new cardiac antiarrhythmic medication, Flecainide, for the patient to start taking the same day.48 However, the patient did not receive the medication until the following morning. • In case 22, the provider ordered the new keep-on-person (KOP) medication, polycarbophil.49 However, the patient received the medication ten days late. Chronic Medication Continuity During this review period, VSP performed poorly with chronic medication continuity. Compliance testing showed VSP had difficulty ensuring medication continuity for patients with chronic conditions. Patients did not receive their chronic care medications timely (MIT 7.001, zero). This score of zero resulted from the pharmacy not filling and dispensing KOP medications timely. Our clinicians also found cases in which chronic medications were not received timely or at all.50 The following are examples of significant deficiencies: • In case 1, during the month of June 2022, the patient did not receive his KOP chronic care medications for blood pressure (Amlodipine and Losartan) and aspirin. The medications were ordered as automatic refills; however, the medication administration record (MAR) documentation stated, “not done, task duplication” for all three medications. • Also in case 1, during the month of July 2022, the patient did not receive his chronic care KOP medications for aspirin and blood pressure (hydrochlorothiazide) as ordered. Both medications were ordered as automatic refill types. • In case 22, during the month of July 2022, the patient received his chronic care KOP medications for blood pressure, cholesterol, and blood thinning six to eight days late. 47 Patients received newly ordered medications late in cases 11, 15, 21, and 22. 48 Flecainide is a medication used to treat abnormal heart rhythms. 49 KOP means “keep on person” and refers to medications in which a patient can keep and self-administer according to the directions provided. Polycarbophil is a bulk-forming laxative that increases the amount of water in a patient’s stools to help make the stools softer and easier to pass. 50 Patients did not receive chronic care medications timely or did not received medications in cases 1, 2, 6, 7, 11, 14, 20, and 22 with multiple occurrences in most of these cases. Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 54 Hospital Discharge Medications Overall, VSP performed poorly in patients receiving their discharge medications upon return from an off-site hospitalization or emergency room encounter (MIT 7.003, 23.8%). Most medications were one to three days late with one exception in which the medication was 60 days late. Our clinicians reviewed 10 hospitalization events in 10 cases and found VSP’s performance was acceptable.51 Please refer to the Transfers indicator for additional details. Specialized Medical Housing Medications Case review and compliance testing had mixed results. Compliance testing indicated the institution needs improvement at 55.6 percent (MIT 13.003). Although patients received their medications as ordered, the low score was due to the pharmacy not filling and dispensing the medications timely. In contrast, case reviewers did not identify any medication deficiencies. Transfer Medications Case review showed better results for transfer medications compared with the findings from compliance testing.52 Our compliance testing indicated when patients arrived at VSP, they did not always receive their medications without interruption. However, when patients transferred among housing units within the facility, they frequently received medications without disruption. Additional information is discussed in the Transfers indicator. Medication Administration Our clinicians found nurses generally administered medications timely as ordered.53 VSP performed very well in administering TB medications (MIT 9.001, 88.9%). However, nurses sporadically performed weekly monitoring of patients who were prescribed TB medications (MIT 9.002, 33.3%). Side effects from TB medications can be harmful to the liver; therefore, timely patient monitoring is important. Clinician On-Site Inspection Medication LVNs attend daily clinic huddles via teleconference if they are unable to attend in person, and they communicate patient medication issues with the providers via email. We interviewed several medication nurses, and they were familiar with medication- related processes such as KOP medications, patient refusals, and the transfer process. The LVN staff reported that, for KOP medications, ducats are sent to patients to pick up their medications via the institution ducat system as opposed to the previous process of 51 Case 14 had a deficiency related to hospitalization medication where the patient did not receive an evening dose of an anticoagulant medication (Apixaban). 52 Transfer cases 7 and 21 had two deficiencies related to medication management. One deficiency was related to missing documentation on the medication administration record. In the other case, the patient did not receive his morning dose of psychiatric medications prior to transferring out of VSP. 53 Deficiencies related to medication administration occurred in cases 11 and 20. Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 55 handwritten ducats.54 The new process allows ducats to be tracked and ensures patient notification. The Omnicell was primarily used to store narcotics. The medication LVNs informed us they mostly received medications timely from the pharmacy. At times, they experienced issues with scanning medications and needed to create entries manually. Overall, nurses reported their communication with the pharmacy was good, and they did not have any equipment or supply issues. Medication nurses also explained their role as emergency responders to us. They had the required equipment for responding to medical emergencies. Medication nurses reported they believed nursing morale was fair, they could communicate concerns to their supervisors, and they had a good rapport with custody staff. Compliance Testing Results Medication Practices and Storage Controls The institution adequately stored and secured narcotic medications in eight of nine applicable clinics and medication line locations (MIT 7.101, 88.9%). In one location, narcotic medications were not properly securely stored as required by CCHCS policy. VSP appropriately stored and secured nonnarcotic medications in two of 10 clinic and medication line locations (MIT 7.102, 20.0%). In eight locations, we observed one or more of the following deficiencies: the medication storage cabinet and cart was disorganized; the medication area lacked a clearly labeled designated area for nonrefrigerated or refrigerated medications identified for return to the pharmacy; nurses did not maintain unissued medication in its original labeled packaging; and medications were not properly securely stored as required by CCHCS policy. Staff kept medications protected from physical, chemical, and temperature contamination in three of the 10 clinics and medication line locations (MIT 7.103, 30.0%). In seven locations, we found one or more of the following deficiencies in which staff did not do the following: consistently record the room and refrigerator temperatures; store oral and topical medications separately; or separate medications from disinfectants. In addition, the medication refrigerator was unsanitary. Staff successfully stored valid and unexpired medications in six of the 10 applicable medication line locations (MIT 7.104, 60.0%). In four locations, we found one or more of the following deficiencies: medication nurses did not label multiple-use medication as required by CCHCS policy; medication was stored beyond the expiration date; and a medication was stored beyond the labeled use date. Nurses exercised proper hand hygiene and contamination control protocols in one of six applicable locations (MIT 7.105, 16.7%). In five locations, some nurses neglected to wash 54 A ducat is a pass that allows patients to move in an institution. Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 56 or sanitize their hands before donning gloves, before each subsequent regloving, or to resanitize their hands and change gloves when gloves were compromised. Staff in five of six applicable medication preparation and administration areas demonstrated appropriate administrative controls and protocols (MIT 7.106, 83.3%). In one location, the medication nurses did not describe the process they followed when reconciling newly received medication and the MAR against the corresponding physician’s order. Staff in three of six applicable medication areas used appropriate administrative controls and protocols when distributing medications to patients (MIT 7.107, 50.0%). In one location, medication nurses did not reliably observe patients while they swallowed direct observation therapy medications. In another location, we observed a medication nurse did not follow the CCHCS care guide when administering Suboxone medication. In the remaining location, we observed some medication nurses did not properly disinfect the vial’s port prior to withdrawing medication during insulin administration. Pharmacy Protocols VSP followed general security, organization, and cleanliness management protocols for nonrefrigerated and refrigerated medications stored in its pharmacy (MITs 7.108, 7.109, and 7.110, 100%). The pharmacist-in-charge (PIC) did not adequately manage narcotic medications stored in VSP’s pharmacy. The PIC incorrectly reviewed monthly inventories of controlled substances in the institution’s clinic and medication storage locations. Specifically, the PIC and the pharmacist did not complete several medication area inspection checklists (CDCR Form 7477). These errors resulted in a score of zero for this test (MIT 7.111). We examined 21 medication error reports. The PIC timely or correctly processed 18 of these 21 reports (MIT 7.112, 85.7%). For three reports, we found one or more of the following deficiencies due to the PIC not appropriately documenting the following: the reason why the patient and provider were not notified of the error; where the error occurred within the pharmacy process; or the recommended changes to correct the errors or prevent them from occurring in the future. In addition, the PIC could provide no evidence that the pharmacy follow-up review had been performed within the required time frame. Nonscored Tests In addition to testing the institution’s self-reported medication errors, our inspectors also followed up on any significant medication errors found during compliance testing. We did not score this test; we provide these results for informational purposes only. At VSP, the OIG did not find any applicable medication errors (MIT 7.998). The OIG interviewed patients in the restricted housing units to determine whether they had immediate access to their prescribed rescue medications. One of three applicable patients interviewed indicated they did not have access to their rescue medications. The patient verbalized that the medication was taken away and placed in their property when transferred to the restrictive housing unit five days ago. The patient reported that he notified medical staff the previous day, requesting a replacement. We promptly notified Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 57 the CEO of this concern, and health care management immediately reissued a replacement rescue inhaler to the patient (MIT 7.999). Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 58 Compliance Testing Results Table 13. Medication Management Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 59 Table 14. Other Tests Related to Medication Management Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 60 Recommendations • The institution should consider developing and implementing measures to ensure that staff timely make available and administer medications to patients and that staff document in EHRS as described in CCHCS policy and procedures. Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 61 Preventive Services In this indicator, OIG compliance inspectors tested whether the institution offered or provided cancer screenings, tuberculosis (TB) screenings, influenza vaccines, and other immunizations. If the department designated the institution as being at high risk for coccidioidomycosis (Valley Fever), we tested the institution’s performance in transferring out patients quickly. The OIG rated this indicator solely according to the compliance score. Our case review clinicians do not rate this indicator. Ratings and Results Overview Case Review Rating Compliance Rating and Score Not Applicable Inadequate (72.8%) VSP had a mixed performance in preventive services. Staff performed well in administering TB medications, screening patients annually for TB, offering patients an influenza vaccine for the most recent influenza season, and offering colorectal cancer screening for patients from ages 45 through 75. However, VSP rarely monitored patients taking prescribed TB medications and rarely offered required immunizations to chronic care patients. The OIG rated this indicator inadequate. Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 62 Compliance Testing Results Table 15. Preventive Services Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 63 Recommendations • Nursing leadership should consider developing and implementing measures to ensure that nursing staff monitor patients who are receiving TB medications according to CCHCS guidelines. • Medical leadership should analyze the challenges related to the untimely provision of preventative vaccines and implement remedial measures as warranted. Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 64 Nursing Performance In this indicator, the OIG clinicians evaluated the quality of care delivered by the institution’s nurses, including registered nurses (RN), licensed vocational nurses (LVN), psychiatric technicians (PT), certified nursing assistants (CNA), and medical assistants (MA). Our clinicians evaluated nurses’ performance in making timely and appropriate assessments and interventions. We also evaluated the institution’s nurses’ documentation for accuracy and thoroughness. Clinicians reviewed nursing performance across many clinical settings and processes, including sick call, outpatient care, care coordination and management, emergency services, specialized medical housing, hospitalizations, transfers, specialty services, and medication management. The OIG assessed nursing care through case review only and performed no compliance testing for this indicator. When summarizing nursing performance, our clinicians understand that nurses perform numerous aspects of medical care. As such, specific nursing quality issues are discussed in other indicators, such as Emergency Services, Specialty Services, and Specialized Medical Housing. Ratings and Results Overview Case Review Rating Compliance Rating and Score Adequate Not Applicable Similar to Cycle 6, VSP nurses overall delivered good nursing care with fewer nursing performance deficiencies. Nurses frequently performed good assessments, intervened timely, and documented as required. However, we identified an opportunity for improvement in the outpatient clinic area: the nursing assessments should be more thorough. Taking all factors into consideration, the OIG rated this indicator adequate. Case Review Results We reviewed 179 nursing encounters in 44 cases. Of the 179 nursing encounters, 91 occurred in the outpatient setting. We identified 45 nursing performance deficiencies, two of which were significant.55 Outpatient Nursing Assessment and Interventions A critical component of nursing care is the quality of nursing assessment, which includes both subjective (patient interviews) and objective (observation and examination) elements. Overall, nurses completed thorough assessments and provided care by intervening timely and appropriately. However, completing thorough assessments is an opportunity for improvement for the outpatient clinic nurses. Our clinicians reviewed 47 sick call requests and identified 21 deficiencies, none of which was significant.56 Clinic 55 We reviewed nursing encounters in cases 1–7, 9–11, and 13–45. Deficiencies occurred in cases 1, 2, 4, 5, 7, 13– 16, 18, 19, 21, 23, 24, 26, 28, 34, 35, 38, 39, 41, 44, and 45. Cases 1 and 18 had significant deficiencies. 56 We reviewed sick call request in cases 2, 11, 13–16, 18, 19, 21, 23, and 30–42. Deficiencies occurred in cases 2, 13–16, 18, 19, 21, 34, 35, 38, 39 and 41. Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 65 nurses frequently performed timely face-to-face triage. They generally provided interventions timely and performed good documentation.57 However, we identified a pattern of deficiencies for incomplete assessments.58 Examples include the following cases: • In case 18, the patient submitted a sick call request reporting that he was experiencing short-term memory loss, a sharp pain in his buttocks that went down his leg, and waking every night feeling his heart quivering, a situation that was continually worsening. o The nurse did not further inquire about any of the patient’s complaints. The patient reported that he was compliant with his medications, but that he had been experiencing recent short- term memory loss and heart quivering. The concern regarding the recent memory changes would have been related to the patient remembering to take his KOP heart medications. The nurse should have had the patient bring his medications to the clinic to check whether he had been taking the medications as ordered. o The nurse also should have asked the patient if he had experienced such symptoms as shortness of breath, dizziness, or chest pain with the episodes of his heart quivering. o Regarding the pain radiating from the buttocks down the leg, the nurse did not assess the patient’s gait, inquire about recent injuries, or determine if the pain was on the right or the left side. o The nurse should have co-consulted with a provider or scheduled a provider follow-up regarding the patient’s multiple complaints. o The nurse did not provide patient education for this encounter. • In case 34, the patient submitted a sick call request reporting he was continuing to have chest and stomach pain every couple of days. He had stated, “I’m having them now.” He also reported frequent urination. o The nurse triaged the sick call at 7:30 a.m. and evaluated the patient at 9:30 a.m., two hours later. The nurse should have contacted the building’s custody staff and instructed them to call a medical emergency if the patient were experiencing chest and stomach pain. o The nurse evaluated the patient in the clinic, but did not perform a thorough assessment. The nurse also did not assess the patient for bowel sounds, his last bowel movement, and his last meal. 57 Sick call intervention deficiencies occurred in cases 14, 18, and 34. Sick call documentation deficiencies occurred in case 15, 16, 21, and 38. 58 Sick call nursing assessment deficiencies occurred in cases 2, 13, 14, 18, 19, 21, 24, 35, 38, and 39. Multiple deficiencies occurred in cases 2, 18, and 21. Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 66 o The patient had multiple complaints including chest pain, stomach pain, and urinary symptoms. The nurse should have co- consulted with a provider. Outpatient Nursing Documentation Complete and accurate nursing documentation is an essential component of patient care. Without proper documentation, health care staff can overlook changes in patients’ conditions. Although we identified a few documentation deficiencies, nurses mostly completed thorough and accurate documentation. Wound Care OIG clinicians reviewed two cases in which nursing staff provided wound care. We did not identify any deficiencies.59 Case Management OIG clinicians reviewed three cases in which patients were evaluated by a care manager.60 We did not identify any deficiencies. The clinic RNs were the care managers. LVNs performed care coordinator duties that included distributing DME, performing screenings and immunizations, and obtaining orders for laboratory results. Emergency Services Overall, nurses provided good emergency medical care. We reviewed 25 urgent or emergent events and identified six deficiencies related to nursing performance, two of which were significant. Please refer to the Emergency Services indicator for further discussion. Hospital Returns We reviewed 10 events in which patients returned from off-site hospitals or emergency rooms. The nurses performed good nursing assessments, which we detailed further in the Transfers indicator. Transfers Nursing performance for transfers was acceptable. Nurses completed timely assessments and initiated appointments within appropriate time frames. However, for patients arriving at VSP, the screening was not always complete. We reviewed nine cases involving transfer-in and transfer-out processes. Please refer to the Transfers indicator for further details. Specialized Medical Housing SMH nursing performance was adequate. We reviewed three cases with a total of 51 OHU events, 20 of which were nursing events. Of the nine deficiencies identified, 59 We reviewed wound care in cases 23 and 43. 60 A care manager evaluated patients in cases 14, 17, and 21. Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 67 four were related to nursing performance. We did not identify any significant deficiencies. For further details, please refer to the Specialized Medical Housing indicator. Specialty Services Specialty services nursing care was adequate. We reviewed 17 nursing events in eight cases in which patients returned to the institution after specialty procedures or consultations. We identified two deficiencies, neither of which was significant. Nurses mostly performed good assessments, reviewed specialty reports, and communicated with providers as required. Please refer to the Specialty Services indicator for additional details. Medication Management Nursing medication management at VSP was acceptable. Our clinicians reviewed 140 events related to medication management and identified 24 deficiencies, four of which were significant. Nurses generally administered medications as ordered and timely. Please refer to the Medication Management indicator for additional details. Clinician On-Site Inspection During our on-site inspection, we interviewed VSP nursing leadership and staff, and we inspected outpatient clinics, medications rooms, the TTA, the R&R, and the OHU. The acting CNE had been in the position for two weeks. Clinic nurses informed us they did not have any backlog RN or PCP appointments at the time of our inspection. The number of patients seen daily by clinic RNs varied from clinic to clinic. One of the clinic RNs on average evaluated 15 to 20 patients daily. In addition to the scheduled patient appointments, the nurse lines had patients added to the line daily, which included walk-in patients. Clinic nursing staff reported receiving supplies timely. One of the SRNs informed us that, a week before our inspection, the facility had initiated a new supply process which entailed organizing the supply storage areas and ordering supplies electronically. The SRN discussed recent process improvements. She informed us that adding a third LVN to the medication line had reduced patient wait times and increased medication compliance. Another yard experienced a supply shortage for suboxone. To resolve this issue, the pharmacy had increased the number of bins with suboxone doses in the Omnicell. Additional improvement projects included clarifying institution policies on 1) circumstances when an RN should co-consult with a provider, and 2) correctly entering orders. VSP had also implemented a project to identify causes of long provider appointment line wait times and solutions to reduce those waits. We also interviewed nursing instructors, who shared they have all the tools and resources they needed to provide staff training except for a designated training space. Nursing instructors were accessible to nursing staff daily to answer questions. Some of these instructors’ other duties included onboarding new staff, creating curriculums, collaborating with supervisors for one-on-one training, and participating in committees. Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 68 At the time of our inspection, they were providing new staff orientation to 11 new staff members, which included RN, LVN, and MA staff. Overall, the VSP nursing staff expressed that nursing morale was fair, and that they had good communication with their supervisors, the pharmacy, and custody staff. Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 69 Recommendations • Nursing leadership should ensure that thorough assessments are completed for all face-to-face encounters. Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 70 Provider Performance In this indicator, OIG case review clinicians evaluated the quality of care delivered by the institution’s providers: physicians, physician assistants, and nurse practitioners. Our clinicians assessed the institution’s providers’ performance in evaluating, diagnosing, and managing their patients properly. We examined provider performance across several clinical settings and programs, including sick call, emergency services, outpatient care, chronic care, specialty services, intake, transfers, hospitalizations, and specialized medical housing. We assessed provider care through case review only and performed no compliance testing for this indicator. Ratings and Results Overview Case Review Rating Compliance Rating and Score Inadequate Not Applicable VSP providers struggled with consistently delivering good care. Although providers made accurate assessments and appropriate treatment plans at times, we found opportunities for improvement in several important areas. VSP’s providers repeatedly did not review their patients’ medical records sufficiently, document their medical care, or address significant or abnormal test results timely. After careful consideration of all these factors, the OIG rated this indicator inadequate. Case Review Results The OIG clinicians reviewed 113 medical provider encounters and identified 78 deficiencies related to provider performance, 22 of which were significant.61 In addition, our clinicians examined the quality of care in 20 comprehensive case reviews. Of these 20 cases, we found 14 adequate and six inadequate.62 Outpatient Assessment and Decision-Making Providers generally made appropriate assessments and sound decisions for their patients. They mostly took good histories, formulated differential diagnoses, ordered appropriate tests, provided care with the correct diagnosis, and referred patients to proper specialists when needed. However, our clinicians identified 21 significant deficiencies related to poor assessments and decision-making.63 These severe deficiencies were found only in the six inadequate cases. The deficiencies listed below illustrate poor decision-making: • In case 6, the provider evaluated the patient to discuss adding an angiotensin converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) medication due to the patient’s history of diabetes and hypertension. The 61 Deficiencies occurred in cases 1, 6, 8–14, 16, 17–21, 23, 31, 33, and 42–45. Cases 6, 8, 9, 13, 18, and 20 had significant deficiencies. 62 Cases 6, 8, 9, 13, 18, and 20 were rated inadequate. 63 Significant deficiencies in assessments and decision-making occurred in cases 6, 8, 9, 13, 18, and 20. Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 71 provider documented that the patient had an allergy to lisinopril, an ACEI, but did not document what the allergic reaction was. The provider ordered an ARB, but did not order the appropriate follow-up laboratory tests. Serum potassium and creatinine laboratory testing levels should be checked on patients taking ARB due to the risk of high potassium and acute kidney problems while taking this medication. • In case 9, the nurse notified the provider of abnormal STAT complete blood count results; however, the provider did not intervene for the abnormal result. • Also in case 9, the provider evaluated the patient for repeated episodes of low blood pressure, but did not adjust the dosage of the blood pressure medication.64 Emergency Care Providers usually managed patients in the TTA with urgent or emergent conditions appropriately. In addition, providers were available for consultation with TTA staff. We identified seven deficiencies related to emergency care,65 which were discussed further in the Emergency Services indicator. Specialized Medical Housing Providers generally delivered good care in the OHU. We further discuss specialized medical housing provider performance in the Specialized Medical Housing indicator. Specialty Services Providers appropriately referred patients for specialty consultation when needed. When specialists made recommendations, providers usually followed the recommendations appropriately and reviewed specialty reports timely. We identified only one deficiency in case 14, which was not significant, related to the provider not ordering a specialty recommended laboratory test. Outpatient Review of Records Providers did not consistently review medical records carefully. We found deficiencies related to the provider not reviewing medication records and blood-sugar levels from finger-stick tests. We identified 10 deficiencies in cases related to poor or no review of medical records.66 The following are examples of significant deficiencies: • In case 9, the provider sent a patient notification letter stating test results were “Normal or No Change.” However, the chest X-ray showed an enlarged heart and possible lung fibrosis, neither of which was normal. 64 The blood pressure medication, a beta-blocker, can lower the blood pressure and heart rate. 65 Deficiencies occurred in cases 9, 13, and 23. Case 9 had significant deficiencies. 66 Deficiencies occurred in cases 9, 13, 16, 18, 20, and 21. Cases 9, 13, and 20 had significant deficiencies. Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 72 • In case 13, the provider evaluated the patient after an emergency room encounter for a urinary tract infection. However, the provider did not address the elevated blood-sugar levels from finger-stick tests, which can contribute to urinary tract infections. • In case 20, the provider reordered the patient’s additional dose of an antiseizure medication, but then canceled this order and erroneously stated the order was a “Duplicate Order.” Consequently, the patient did not receive the full dosage of antiseizure medication and was at an increased risk of breakthrough seizures. • Moreover, in case 20, the provider saw the patient for a chronic care appointment, documented that the patient was taking an increased dose of antiseizure medication twice weekly, and ordered a laboratory test to check for the antiseizure medication blood level. However, the provider did not thoroughly review the MAR to see the patient was no longer receiving the increased dosage of antiseizure medication after the provider had canceled this order the previous month. Patient Notification Letter Providers did not always send patient notification letters to patients. When they did, letters did not always contain the four elements required by policy. After providers interpret laboratory results, they are responsible for notifying patients of the laboratory results and of the necessary next steps. We found these types of deficiencies in 13 of the 20 detailed cases we reviewed.67 Further discussion can be found in the Health and Information Management indicator. Chronic Care In many instances, providers appropriately managed patients’ chronic health conditions. However, we identified deficiencies related to poor review of records and decision- making.68 We discuss these instances of untimely review of coagulation studies and blood-sugar levels from finger-stick tests, and inappropriate management of diabetes, hypertension, and seizure disorder above. Further discussion of chronic care management of coagulation studies can be found in the Diagnostic Services indicator. Documentation Quality Documentation is important because it shows the provider’s thought-process during clinical decision-making. When contacted by nurses, providers did not always document the interactions. In 10 of the 45 cases we reviewed, our clinicians found 12 undocumented 67 Cases 1, 2, 6, 8–12, 14–16, 19, and 20 had deficiencies related to incomplete or missing patient notification letters. 68 Deficiencies occurred in cases 1, 6, 8–14, 20. Cases 6, 8, 9, 13, and 20 had significant deficiencies. Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 73 interactions and one deficiency related to poor documentation.69 In 10 of the undocumented interactions, the provider was co-consulted by the nurse.70 Provider Continuity Provider continuity was generally good, with most providers attending to patients on one yard for long periods of time and, in some cases, for years. Most patients were usually seen by their primary care provider. Clinician On-Site Inspection The OIG clinicians observed the weekly provider meeting, which was attended by both in-clinic providers in person and telemedicine providers remotely. The physician on-call gave a report on significant overnight issues. The medical team discussed specific patient care plans and general medical practice updates. OIG clinicians also attended population management meetings wherein medical staff discussed individual patient needs, and at which providers appeared to know their patients well. The OIG physician met with the CME and the chief physician and surgeon (CP&S) separately, and discussed the institution’s vacancy rate. VSP did not have any vacancies at the time of our on-site inspection, but two providers were out on long-term sick leave, and another provider was due to retire imminently. In addition, the OIG physician was unable to meet with most of the providers who generated the most severe deficiencies. Five of the eight providers were either no longer working for CCHCS or on long-term sick leave. Another challenge to provider care that the institution’s medical leadership identified was specialty physicians who were aging and retiring, which resulted in reduced access to specialty care providers. However, the CME and CP&S reported no difficulty in hiring and retaining providers despite not being able to offer a 15 percent pay differential. They cited VSP’s proximity to Highway 99 and the institution’s reputation for being well- organized as reasons for experiencing success in retaining providers. When asked about their morale and the relationship with medical leadership, providers consistently reported high morale and having very good relationships with their CME and CP&S. Providers reported their medical leadership had an “open door policy” and regularly met providers in their clinics and attended huddles. OIG clinicians attended the OHU huddle and witnessed a code blue alert call come in from the adjacent TTA. Although the dedicated OHU/TTA physician left to attend to this alert, the CP&S was already on scene. The CME also reported the CP&S had previously stepped in to see patients to assist line physicians. 69 Documentation deficiencies were identified in cases 11, 13, 14, 18, 19, 21, 23, 31, 33, and 42. 70 The nurse co-consulted the provider in cases 11, 14, 18, 21, 23, 31, 33, and 42. Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 74 Recommendations • Medical leadership should ascertain causative factors in the untimely provider review of test results. Medical leadership should implement remedial measures as appropriate. • Medical leadership should remind providers to fully document their co- consultations with nurses in the EHRS. • Medical leadership should consider reminding providers to review the blood- sugar levels from finger-stick tests of diabetic patients at each appointment. Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 75 Specialized Medical Housing In this indicator, OIG inspectors evaluated the quality of care in the specialized medical housing units. We evaluated the performance of the medical staff in assessing, monitoring, and intervening for medically complex patients requiring close medical supervision. Our inspectors also evaluated the timeliness and quality of provider and nursing intake assessments and care plans. We assessed staff members’ performance in responding promptly when patients’ conditions deteriorated and looked for good communication when staff consulted with one another while providing continuity of care. Our clinicians also interpreted relevant compliance results and incorporated them into this indicator. At the time of our inspection, VSP’s specialized medical housing consisted of an outpatient housing unit (OHU). Ratings and Results Overview Case Review Rating Compliance Rating and Score Adequate Inadequate (55.6%) Case review found both OHU providers and OHU nurses provided sufficient patient care. Providers generally evaluated patients timely and completed assessments as required. Similarly, nurses mostly performed thorough admission patient assessments, communicated with the providers, and documented as required. We did not identify any deficiencies for medication management in the SMH. Taking all factors into consideration, the OIG rated the case review component of this indicator adequate. Compared with Cycle 6, compliance testing showed VSP needs improvement in specialized medical housing. Staff performed well in completing initial assessments, and fairly in completing history and physical examinations within required timeframes. However, newly admitted patients to specialized medical housing received poor medication continuity. Factoring all the information, the OIG rated the compliance testing component of this indicator inadequate. Case Review and Compliance Testing Results We reviewed 51 events in three OHU cases that included 16 provider events and 20 nursing events. Due to the frequency of nursing and provider contacts in the specialized medical housing, we bundled up to two weeks of patient care into a single event. We identified nine deficiencies, none of which was significant.71 Provider Performance Providers generally delivered adequate care. Compliance testing showed that providers completed most admission history and physical examinations without delay (MIT 13.002, 77.8%). Our clinicians found providers generally made appropriate assessments and decisions, reviewed medical records thoroughly, and addressed specialists’ 71 We reviewed OHU cases 43–45. Deficiencies occurred in cases 43–45. Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 76 recommendations timely. We identified five deficiencies related to incomplete assessments and questionable decision-making, none of which was significant.72 Nursing Performance SMH nurses provided good patient care. They frequently performed thorough assessments, intervened timely, and documented as required. They performed rounds every shift, ensured patient safety, and notified the provider as needed. Compliance testing showed SMH nurses performed very well in completing initial nursing assessments timely (MIT 13.001, 88.9%). However, case reviewers identified deficiencies in which the nurses did not perform the following: assess vital signs for a patient who returned from an outside appointment, perform a genitourinary assessment, and inquire about the patient’s last bowel movement during an admission assessment, provide patient education on the nurse call light, and perform PICC line dressing changes as ordered.73 Medication Administration Case review and compliance testing showed different results. Our clinicians did not identify any deficiencies for medication management in the SMH. However, compliance testing found the institution needs improvement with timely providing medications to the patients on admission to SMH (MIT 13.003, 55.6%). The low score resulted from pharmacy not timely filling and dispensing medications. We discuss these concerns in the Medication Management indicator. Clinician On-Site Inspection During the on-site inspection, 18 of the OHU beds were occupied. The OHU had 20 medical beds and a dedicated provider who was present for the morning huddle. The huddle was well organized, had good attendance, and started on time. During the huddle, the provider left briefly to tend to a medical emergency in the TTA as the OHU provider also covers the TTA. Two RNs are assigned to the OHU on second watch and one LVN is assigned to the first and third watches. Nurses conduct daily rounds on patients and record them on a paper log. To communicate patient care needs between shifts, nursing staff give verbal reports as well as paper copies of reports describing events that happened during the shift. Nursing staff reported that the OHU did not have any issues with supplies, equipment, or the pharmacy. They reported their supervisor was available, and custody staff was helpful. Despite that assessment, OHU nursing staff stated nursing morale was only fair. However, they reported being short of staff and that they were often redirected to perform other assignments, which could have been the reason. 72 Deficiencies occurred in cases 43–45. 73 Assessment and education deficiencies occurred in cases 43–45. A PICC is a peripherally inserted central catheter, which is used to provide intravenous access and administer fluids and medication. Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 77 Compliance Testing Results Compliance On-Site Inspection and Discussion At the time of our on-site inspection, the OHU had a nonfunctional call light communication system (MIT 13.101, N/A).74 Although the institution had a local operating procedure in the event the call light system was not working, the OHU nurse whom we interviewed was not aware this local operating procedure existed, which meant the nurse did not perform a safety check for all patients admitted into the OHU (MIT 13.102, zero). 74 Unlike the inpatient units that are governed by Title 22, the OHU is not required to have a call light communicating system. Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 78 Compliance Testing Results Table 16. Specialized Medical Housing Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 79 Recommendations • The institution should consider determining and evaluating causative factors related to the untimely provisions of medications and implement remedial measures as appropriate. • Nursing leadership should provide training to the OHU nurses about the institution’s local operating procedures for the call light communication system. Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 80 Specialty Services In this indicator, OIG inspectors evaluated the quality of specialty services. The OIG clinicians focused on the institution’s performance in providing needed specialty care. Our clinicians also examined specialty appointment scheduling, providers’ specialty referrals, and medical staff’s retrieval, review, and implementation of any specialty recommendations. Ratings and Results Overview Case Review Rating Compliance Rating and Score Adequate Inadequate (69.8%) Case review found VSP performed well in specialty services. VSP provided excellent specialty services access, providers always evaluated patients timely for specialty follow- up appointments, and nurses usually assessed patients appropriately following specialty appointments. However, we found instances of untimely report retrieval and provider report review. Considering these aspects of care, on balance, the OIG rated the case review component of this indicator adequate. Compared with Cycle 6, compliance testing showed VSP needs improvement in this indicator. VSP’s performance was satisfactory for providing high-priority, medium- priority, and routine-priority services. However, compliance testing resulted in low scores for providing preapproved specialty services and subsequent follow-up appointments for high-priority and medium-priority specialty services. Staff also needs improvement in communicating denied requests for specialty services. Factoring all the information, the OIG rated the compliance testing component of this indicator inadequate. Case Review and Compliance Testing Results The OIG clinicians reviewed 81 events related to this indicator, which included 60 specialty consultations and procedures, and 17 nursing encounters. There were 16 deficiencies in this category, four of which were considered significant.75 Access to Specialty Services VSP’s access to specialists varied. Compliance testing showed the institution provided timely high-priority (MIT 14.001), medium-priority (MIT 14.004), and routine-priority (MIT 14.007) specialty appointments, all at a rate of 86.7 percent. Similarly, compliance testing found the institution provided timely subsequent follow-up routine-priority specialty appointments (MIT 14.009, 88.9%). However, VSP struggled with providing subsequent follow-up specialty appointments for high-priority (MIT 14.003, 57.1%) and medium-priority (MIT 14.006, 50.0%) requests within the required time frame. VSP only 75 Deficiencies occurred in cases 9, 10, 13–15, 16, 18, 22, 23, 43, and 44. Cases 10 and 14 had significant deficiencies. Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 81 ensured specialty access for patients who transferred into the institution with a preapproved specialty request at a rate of 50.0 percent (MIT 14.010). Case reviewers found two deficiencies with specialty access, neither of which was considered significant.76 Provider Performance Providers generally ordered appropriate specialty consults and followed specialty recommendations. We found six deficiencies related to untimely provider endorsement with one significant deficiency as illustrated below:77 • In case 14, the HIM staff scanned the consultation report into the EHRS. However, the provider endorsed the report 10 days later. Nursing Performance We reviewed 17 nursing events in eight cases in which patients returned to the institution after specialty procedures and consultations. Overall, nurses frequently performed good assessments, reviewed specialty reports, communicated with the provider as necessary, and documented as required. We did not identify any significant deficiencies. Deficiencies we did identify were related to assessments.78 Health Information Management Compliance testing showed providers struggled with the timely review of specialty reports for routine-priority (MIT 14.008, 71.4%), medium-priority (MIT 14.005, 46.7%), and high-priority (MIT 14.002, 71.4%) services. However, VSP scanned specialty reports into the EHRS in a timely manner (MIT 4.002, 93.6%). Case review found some minor deficiency patterns in specialty HIM. There were 12 HIM deficiencies of different types: three were delayed or mislabeled scans, three were not properly forwarded to the provider for review, and six were endorsed by the provider late.79 Further discussion is located under the Health Information Management indicator. Clinician On-Site Inspection We discussed specialty HIM processes with VSP’s health records technician (HRT) supervisor and nursing supervisors. The HRT supervisor reported the utilization management (UM) nurse or specialty office technicians dropped off reports from off-site specialty appointments to the HIM department. HIM staff, in turn, scanned the off-site reports into the EHRS and routed them to providers for review. We met with two SRNs who were filling in for the specialty nurse to discuss specialty services care. They reported the area had lost on-site gastroenterology services and was also having difficulty securing dietary consultation services due to a backlog. The closure of one community hospital had also affected the institution’s ability to provide specialty 76 Deficiencies occurred in cases 10 and 16. 77 Deficiencies occurred in cases 13, 14, 18, 22, 23, and 44. Case 14 had a significant deficiency. 78 We reviewed the following specialty cases for nursing encounters: 10, 14, 18, 21–23, 43, and 44. Deficiencies occurred in cases 23 and 43. 79 Deficiencies occurred in cases 9, 10, 13–15, 18, 22, 23, and 44. Cases 10 and 14 had significant deficiencies. Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 82 care. When asked about who in their area tracked request for service (RFS) and specialty follow-up appointments, they informed us that VSP used an internal tracking system in Microsoft Excel software. Upon the patient’s return from an off-site specialty appointment, the TTA nurse reviewed the recommendations and communicated via EHRS with the specialty nurse and the patient care team about the recommendations. The medical team would then discuss the specialty return patient during the morning huddle and place orders under the direction of the provider. Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 83 Compliance Testing Results Table 17. Specialty Services Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 84 Table 18. Other Tests Related to Specialty Services Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 85 Recommendations • Medical leadership should identify the root cause(s) of untimely completion of subsequent, specialty follow-up appointments for high-priority and medium-priority services, and implement remedial measures as appropriate. • Medical leadership should identify the root cause(s) of untimely completion of transfer patients’ specialty appointments and implement remedial measures as appropriate. • Medical leadership should ascertain the challenges in the untimely receipt of specialty reports and the untimely provider review of these reports and implement remedial measures as appropriate. Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 86 Administrative Operations In this indicator, OIG compliance inspectors evaluated health care administrative processes. Our inspectors examined the timeliness of the medical grievance process and checked whether the institution followed reporting requirements for adverse or sentinel events and patient deaths. Inspectors checked whether the Emergency Medical Response Review Committee (EMRRC) met and reviewed incident packages. We investigated and determined whether the institution conducted required emergency response drills. Inspectors also assessed whether the Quality Management Committee (QMC) met regularly and addressed program performance adequately. In addition, our inspectors determined whether the institution provided training and job performance reviews for its employees. We checked whether staff possessed current, valid professional licenses, certifications, and credentials. The OIG rated this indicator solely based on the compliance score. Our case review clinicians do not rate this indicator. Ratings and Results Overview Case Review Rating Compliance Rating and Score Not Applicable Adequate (77.6%) VSP’s performance was mixed in this indicator. The institution scored well in several applicable tests, such as maintaining valid licensure and competency requirements. However, the institution could improve in several areas. The Emergency Medical Response Review Committee (EMRRC) either did not complete event checklists or did not complete the review timely. In addition, the institution did not conduct live medical emergency response drills and had incomplete documentation. The nurse educator did not ensure nurses who administered medication had completed their annual competency testing in a timely manner. Physician managers did not always complete probationary and annual performance appraisals in a timely manner. These findings are set forth in the table below. We rated this indicator adequate. Compliance Testing Results Nonscored Results We reviewed VSP’s root cause analysis (RCA) of reported incidents. During our review period, VSP submitted two reports to the CCHCS Health Care Incident Review Committee (HCIRC). We found that one RCA report remained incomplete and was still awaiting HCIRC approval. The remaining RCA report was granted an extension for completion, but the deadline was beyond the OIG review period; therefore, this RCA was not assessed (MIT 15.001). Our testing period reviewed mortality reports completed both before and after the effective revision date of the CCHCS mortality review policy requirements. Prior to May 2022, we obtained CCHCS Death Review Committee (DRC) reporting data. Three unexpected (Level 1) and two expected (Level 2) deaths occurred during our review period. In our inspection, we found the DRC did not complete any death review reports promptly. The DRC finished four reports 18 to 133 days late and submitted the reports to Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 87 the institution’s CEO 11 to 126 days late. The remaining report was overdue at the time of the OIG’s inspection. Effective May 2022, we obtained CCHCS Mortality Case Review reporting data. At the time of our inspection, for three patients, we found no evidence in the submitted documentation of the Preliminary Mortality Report having been completed. These three reports were overdue at the time of the OIG’s inspection. For the remaining report, the compliance date was beyond the OIG’s review period; therefore, this was not assessed (MIT 15.998). Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 88 Compliance Testing Results Table 19. Administrative Operations Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 89 Recommendations The OIG offers no recommendations for this indicator. Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 90 (This page left blank for reproduction purposes.) Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 91 Appendix A: Methodology In designing the medical inspection program, the OIG met with stakeholders to review CCHCS policies and procedures, relevant court orders, and guidance developed by the American Correctional Association. We 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, the department, the Office of the Attorney General, and the Prison Law Office to discuss the nature and scope of our inspection program. With input from these stakeholders, the OIG developed a medical inspection program that evaluates the delivery of medical care 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. We rate each of the quality indicators applicable to the institution under inspection based on case reviews conducted by our clinicians or compliance tests conducted by our registered nurses. Figure A–1 below depicts the intersection of case review and compliance. Figure A–1. Inspection Indicator Review Distribution for VSP Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 92 Case Reviews The OIG added case reviews to the Cycle 4 medical inspections at the recommendation of its stakeholders, which continues in the Cycle 7 medical inspections. Below, Table A–1 provides important definitions that describe this process. Table A–1. Case Review Definitions Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 93 The OIG eliminates case review selection bias by sampling using a rigid methodology. No case reviewer selects the samples he or she reviews. Because the case reviewers are excluded from sample selection, there is no possibility of selection bias. Instead, nonclinical analysts use a standardized sampling methodology to select most of the case review samples. A randomizer is used when applicable. For most basic institutions, the OIG samples 20 comprehensive physician review cases. For institutions with larger high-risk populations, 25 cases are sampled. For the California Health Care Facility, 30 cases are sampled. Case Review Sampling Methodology We obtain a substantial amount of health care data from the inspected institution and from CCHCS. Our analysts then apply filters to identify clinically complex patients with the highest need for medical services. These filters include patients classified by CCHCS with high medical risk, patients requiring hospitalization or emergency medical services, patients arriving from a county jail, patients transferring to and from other departmental institutions, patients with uncontrolled diabetes or uncontrolled anticoagulation levels, patients requiring specialty services or who died or experienced a sentinel event (unexpected occurrences resulting in high risk of, or actual, death or serious injury), patients requiring specialized medical housing placement, patients requesting medical care through the sick call process, and patients requiring prenatal or postpartum care. After applying filters, analysts follow a predetermined protocol and select samples for clinicians to review. Our physician and nurse reviewers test the samples by performing comprehensive or focused case reviews. Case Review Testing Methodology An OIG physician, a nurse consultant, or both review each case. As the clinicians review medical records, they record pertinent interactions between the patient and the health care system. We refer to these interactions as case review events. Our clinicians also record medical errors, which we refer to as case review deficiencies. Deficiencies can be minor or significant, depending on the severity of the deficiency. If a deficiency caused serious patient harm, we classify the error as an adverse event. On the next page, Figure A–2 depicts the possibilities that can lead to these different events. After the clinician inspectors review all the cases, they analyze the deficiencies, then summarize their findings in one or more of the health care indicators in this report. Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 94 Figure A–2. Case Review Testing Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 95 Compliance Testing Compliance Sampling Methodology Our analysts identify samples for both our case review inspectors and compliance inspectors. Analysts follow a detailed selection methodology. For most compliance questions, we use sample sizes of approximately 25 to 30. Figure A–3 below depicts the relationships and activities of this process. Figure A–3. Compliance Sampling Methodology Compliance Testing Methodology Our inspectors answer a set of predefined medical inspection tool (MIT) questions to determine the institution’s compliance with CCHCS policies and procedures. Our nurse inspectors assign a Yes or a No answer to each scored question. OIG headquarters nurse inspectors review medical records to obtain information, allowing them to answer most of the MIT questions. Our regional nurses visit and inspect each institution. They interview health care staff, observe medical processes, test the facilities and clinics, review employee records, logs, medical grievances, death reports, and other documents, and obtain information regarding plant infrastructure and local operating procedures. Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 96 Scoring Methodology Our compliance team calculates the percentage of all Yes answers for each of the questions applicable to a particular indicator, then averages the scores. The OIG continues to rate these indicators based on the average compliance score using the following descriptors: proficient (85.0 percent or greater), adequate (between 84.9 percent and 75.0 percent), or inadequate (less than 75.0 percent). Indicator Ratings and the Overall Medical Quality Rating The OIG medical inspection unit individually examines all the case review and compliance inspection findings under each specific methodology. We analyze the case review and compliance testing results for each indicator and determine separate overall indicator ratings. After considering all the findings of each of the relevant indicators, our medical inspectors individually determine the institution’s overall case review and compliance ratings. Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 97 Appendix B: Case Review Data Table B–1. VSP Case Review Sample Sets Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 98 Table B–2. VSP Case Review Chronic Care Diagnoses Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 99 Table B–3. VSP Case Review Events by Program Table B–4. VSP Case Review Sample Summary Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 100 (This page left blank for reproduction purposes.) Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 101 Appendix C: Compliance Sampling Methodology Valley State Prison Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 102 Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 103 Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 104 Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 105 Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 106 Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 107 Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 108 (This page left blank for reproduction purposes.) Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 109 California Correctional Health Care Services’ Response Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 110 February 16, 2024, OIG Response to February 13, 2024, Letter Regarding VSP Report Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 111 Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Valley State Prison | 112 Office of the Inspector General, State of California Inspection Period: June 2022 – November 2022 Report Issued: June 2024 Cycle 7 Medical Inspection Report for Valley State Prison OFFICE of the INSPECTOR GENERAL Amarik K. Singh Inspector General Neil Robertson Chief Deputy Inspector General STATE of CALIFORNIA June 2024 OIG