Valley State Prison Cycle 6 Medical Inspection Report

Roy W. Wesley, Inspector General Bryan B. Beyer, Chief Deputy Inspector General OFFICE of the OIG INSPECTOR GENERAL Independent Prison Oversight August 2020 Cycle 6 Medical Inspection Report Valley State Prison 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 916-255-1131. Return to Contents Valley State Prison iii Contents Introduction 1 Summary 3 Overall Rating: Adequate 3 Medical Inspection Results 7 Deficiencies Identified During Case Review 7 Case Review Results 7 Compliance Testing Results 8 Population-Based Metrics 9 HEDIS Results 9 Recommendations 11 Indicators 13 Access to Care 13 Diagnostic Services 18 Emergency Services 21 Health Information Management 24 Health Care Environment 29 Transfers 34 Medication Management 39 Preventive Services 46 Nursing Performance 47 Provider Performance 51 Specialized Medical Housing 55 Specialty Services 58 Administrative Operations 63 Appendix A: Methodology 65 Case Reviews 66 Compliance Testing 69 Indicator Ratings and the Overall Medical Quality Rating 70 Appendix B: Case Review Data 71 Appendix C: Compliance Sampling Methodology 74 California Correctional Health Care Services’ Response 81 Report Issued: August 2020 Office of the Inspector General, State of California Return to Contents iv Cycle 6 Medical Inspection Report Illustrations Tables 1. VSP Summary Table 3 2. VSP Policy Compliance Scores 4 3. VSP Master Registry Data as of April 2019 5 4. VSP Health Care Staffing Resources as of April 2019 6 5. VSP Results Compared With State HEDIS Scores 10 6. Access to Care 16 7. Other Tests Related to Access to Care 17 8. Diagnostic Services 20 9. Health Information Management 27 10. Other Tests Related to Health Information Management 28 11. Health Care Environment 33 12. Transfers 37 13. Other Tests Related to Transfers 38 14. Medication Management 44 15. Other Tests Related to Medication Management 45 16. Preventive Services 46 17. Specialized Medical Housing 57 18. Specialty Services 61 19. Other Tests Related to Specialty Services 62 20. Administrative Operations 64 A–1. Case Review Definitions 66 B–1. Case Review Sample Sets 71 B–2. Case Review Chronic Care Diagnoses 72 B–3. Case Review Events by Program 73 B–4. Case Review Sample Summary 73 Figures A–1. Inspection Indicator Review Distribution for VSP 65 A–2. Case Review Testing 68 A–3. Compliance Sampling Methodology 69 Photographs 1. Shaded Outdoor Waiting Area With a Mist Cooling System 29 2. Indoor Waiting Area With Open Seating 30 3. Examination Table With Insufficient Space for a Patient to Lie Down 30 4. Expired Medical Supplies Dated December 2018 31 5. Torn Sterile Packaging 31 Cover: Rod of Asclepius courtesy of Thomas Shafee Office of the Inspector General, State of California Inspection Period: September 2018 – April 2019 Return to Contents Valley State Prison 1 Introduction Pursuant to California Penal Code section 6126 et seq., the Office of the Inspector General (OIG) is responsible for periodically reviewing and reporting on the delivery of the ongoing medical care provided to incarcerated persons in the California Department of Corrections and Rehabilitation (the department).1 In Cycle 6, the OIG continues to apply the same assessment methodologies used in Cycle 5, including clinical case review and compliance testing. These methods provide 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. This information helps to assess the performance of the institution in providing sustainable, adequate care.2 We continue to review institutional care using 15 indicators, as in prior cycles. 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).3We determine a total compliance score for each applicable indicator and consider the MIT scores in the overall conclusion of the institution’s performance. In addition, our clinicians complete document reviews of individual cases and also perform on-site inspections, which include interviews with staff. In reviewing the cases, our clinicians examine whether providers 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.4 At the same time, our clinicians examine whether the institution’s medical system mitigated the error. The OIG rates the indicators as proficient, adequate, or inadequate. 1. 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 the department provides to its population. 2. 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. 3. The department regularly updates its policies. The OIG updates our policy-compliance testing to reflect the department’s updates and changes. 4. If we learn of a patient needing immediate care, we notify the institution’s chief executive officer. Report Issued: August 2020 Office of the Inspector General, State of California Return to Contents 2 Cycle 6 Medical Inspection Report The OIG has adjusted Cycle 6 reporting in two ways. First, commencing with this reporting period, we interpret compliance and case review results together, providing a more holistic assessment of the care; and, second, we consider whether institutional medical processes lead to identifying and correcting provider or system errors. The review assesses the institution’s medical care on both system and provider levels. As we did during Cycle 5, our office is continuing 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 6 inspection of Valley State Prison (VSP), the receiver had delegated this institution back to the department. We completed our sixth inspection of VSP, and this report presents our assessment of the health care provided at that institution during the inspection period between September 2018 and April 2019.5 Notably, our report of VSP was not impacted by the novel coronavirus disease pandemic (COVID-19). The data we obtained for VSP predates COVID-19, so neither case review nor compliance testing were affected. Similarly, the on-site regional nurse review was not impacted by COVID-19. VSP is located in Chowchilla, houses primarily Level II General Population incarcerated persons 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. 5. Samples are obtained per the case review methodology shared with stakeholders in prior cycles. The case reviews include death reviews that occurred between April 2018 and February 2019, emergency cardiopulmonary resuscitation (CPR) reviews between May 2018 and January 2019, transfer reviews between August 2018 and February 2019, and correctional treatment center (CTC) reviews between August 2018 and February 2019. Office of the Inspector General, State of California Inspection Period: September 2018 – April 2019 Return to Contents Valley State Prison 3 Summary We completed the Cycle 6 inspection of Valley State Prison (VSP) in August 2019. OIG inspectors Overall monitored the institution’s delivery of medical care that occurred between September 2018 and April 2019. Rating The OIG rated the overall quality of health care at Adequate VSP as adequate. We list the individual indicators and ratings applicable for this institution in Table 1 below. Table 1. VSP Summary Table Ratings Proficient Adequate Inadequate Cycle 6 Ratings Change Since Health Care Indicators Case Review Compliance Overall Cycle 5 * Access to Care Diagnostic Services Emergency Services N/A Health Information Management Health Care Environment N/A Transfers Medication Management Prenatal and Postpartum Care N/A N/A N/A N/A Preventive Services N/A Nursing Performance N/A Provider Performance N/A Reception Center N/A N/A N/A N/A Specialized Medical Housing Specialty Services Administrative Operations † N/A * The symbols in this column correspond to changes that occurred in indicator ratings between the medical inspections conducted during Cycle 5 and Cycle 6. The equals sign means there was no change in the rating. The single arrow means the rating rose or fell one level, and the double arrow means the rating rose or fell two levels (green, from inadequate to proficient; pink, from proficient to inadequate). † Administrative Operations is a secondary indicator and is not considered when rating the institution’s overall medical quality. Source: The Office of the Inspector General medical inspection results. Report Issued: August 2020 Office of the Inspector General, State of California Return to Contents 4 Cycle 6 Medical Inspection Report 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 364 patient records and 1,002 data points and observed VSP’s processes during an on-site inspection in April 2019. They used the data to answer 88 policy questions. Table 2 below lists VSP’s average scores from Cycles 4, 5, and 6. OIG case review clinicians (a team of physicians and nurse consultants) reviewed 57 cases, which contained 1,083 patient-related events. After examining the medical records, our clinicians conducted a follow- up on-site inspection in June 2019 to verify their initial findings. Of the 1,083 individual health care events, the OIG clinicians identified Table 2. VSP Policy Compliance Scores Scoring Ranges 100% – 85% 84% – 75% 74% – 0 Medical Average Score Inspection Tool (MIT) Policy Compliance Category Cycle 4 Cycle 5 Cycle 6 1 Access to Care 66% 82% 92% 2 Diagnostic Services 81% 76% 63% 4 Health Information Management 57% 82% 76% 5 Health Care Environment 59% 82% 69% 6 Transfers 80% 89% 66% 7 Medication Management 73% 70% 70% 8 Prenatal and Postpartum Care N/A N/A N/A 9 Preventive Services 66% 76% 73% 12 Reception Center N/A N/A N/A 13 Specialized Medical Housing 94% 63% 83% 14 Specialty Services 84% 84% 89% 15 Administrative Operations 58% 83% 83% * In Cycle 4, there were two secondary (administrative) indicators, and this score reflects the average of those two scores. In Cycle 5 and moving forward, the two indicators were merged into one, with only one score as the result. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: September 2018 – April 2019 Return to Contents Valley State Prison 5 295 deficiencies. However, only 36 of these deficiencies were of such a magnitude that our clinicians felt they resulted in potential significant risk of harm to patients. The OIG physicians rated the quality of care for 25 comprehensive case reviews. Of these 25 cases, our clinicians rated 21 adequate and four inadequate. Our clinicians found no adverse events during this inspection. The OIG then considered the results from both case review and compliance testing, and drew overall conclusions, which we report in the 13 health care indicators.6 Multiple OIG physicians and nurses performed quality control reviews; their subsequent collective deliberations ensured consistency, accuracy, and thoroughness. Our clinicians acknowledged institutional structures that catch and resolve mistakes which may occur throughout the delivery of care. As noted above, we listed the individual indicators and ratings applicable for this institution in Table 1, the VSP Summary Table. In April 2019, the Health Care Services Master Registry showed that VSP had a total population of 3,080. A breakdown of the medical risk level of the VSP population as determined by the department is set forth in Table 3 below. Table 3. VSP Master Registry Data as of April 2019 Medical Risk Level Number of Patients Percentage High 1 108 3.5% High 2 298 9.7% Medium 1,611 52.3% Low 1,063 34.5% Total 3,080 100.0% Source: Cycle 6 medical inspection preinspection questionnaire staffing matrix received on April 1, 2019, from Valley State Prison. 6. The indicators for Reception Center and Prenatal Care do not apply to VSP. Report Issued: August 2020 Office of the Inspector General, State of California Return to Contents 6 Cycle 6 Medical Inspection Report Based on staffing data the OIG obtained from California Correctional Health Care Services (CCHCS), as identified in Table 4 below, VSP had 2.5 vacant nurse supervisor positions, and five vacant nurse positions. At the time of the OIG’s inspection, VSP had one primary care provider, one nursing supervisor, and four nursing staff on extended leave. Table 4. VSP Health Care Staffing Resources as of April 2019 Executive Primary Care Nursing Nursing Positions Leadership * Providers Supervisors Staff † Total Authorized Positions 6 7 10.5 107.7 131.2 Filled by Civil Service 6 8 8 102.6 124.6 Vacant 0 0 2.5 5.1 7.6 Percentage Filled by Civil Service 100% 114% 76.2% 95.3% 95.0% Filled by Telemedicine 0 3 0 0 3 Percentage Filled by Telemedicine 0 42.86% 0 0 2.3% Filled by Registry 0 1 0 6 7 Percentage Filled by Registry 0 14.3% 0 5.6% 5.3% Total Filled Positions 6 12 8 108.6 134.6 Total Percentage Filled 100% 171.4% 76.2% 100.8% 102.6% Appointments in Last 12 Months 0 2 0 22.6 24.6 Redirected Staff 0 0 0 0 0 Staff on Extended Leave ‡ 0 1 1 4 6 Adjusted Total: Filled Positions 6 11 7 104.6 128.6 Adjusted Total: Filled Positions 100% 157.1% 66.7% 97.1% 98.0% * Executive Leadership includes the Chief Physician and Surgeon. † Nursing Staff includes Senior Psychiatric Technician and Psychiatric Technician. ‡ In Authorized Positions. Note: The OIG does not independently validate staffing data received from the department. Source: Cycle 6 medical inspection preinspection questionnaire staffing matrix received on July 30, 2019, from Valley State Prison. Office of the Inspector General, State of California Inspection Period: September 2018 – April 2019 Return to Contents Valley State Prison 7 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.7 Our inspectors did not find any adverse events at VSP during the Cycle 6 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 25 detailed case reviews they conducted. Of these 25 cases, 21 were adequate and four were inadequate. In the 1,083 events reviewed, there were 293 deficiencies, 36 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: • The institution provided excellent overall access to providers and nurses. • Medical staff evaluated patients efficiently and appropriately in emergency medical situations. • The physician managers established a culture of collaboration and communication. VSP’s providers felt well supported and reported high morale. Our clinicians found VSP could improve in the following areas: • VSP providers should review records more reliably and thoroughly, along with consistently documenting their medical care. • VSP staff should retrieve specialty reports on time. Staff should reliably retrieve the physician discharge summary for patients who received care at off-site hospitals and emergency rooms. Providers should also sign specialty reports on time. 7. For a further discussion of an adverse event, see Table A–1. Report Issued: August 2020 Office of the Inspector General, State of California Return to Contents 8 Cycle 6 Medical Inspection Report • VSP nurses should dependably relay stat laboratory results to the providers timely, preventing potential delays in care. • Nurses should complete more thorough initial assessments for newly arrived patients who transferred into the institution. • Nurses and providers should review hospital discharge recommendations thoroughly, preventing errors in the hospital return process. • VSP should improve medication processes, such as newly prescribed medications, chronic care medication continuity, hospital discharge medications, and medication continuity for patients transferring into the institution. 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, three adequate, and five inadequate. In the Health Care Environment, Preventive Services, and Administrative Operations indicators, we tested policy compliance only, because how the institution performed in these indicators usually does not significantly affect the institution’s overall quality of patient care. VSP demonstrated a high rate of policy compliance in the following areas: • Nurses received and reviewed sick call request forms and conducted face-to-face evaluations within the required time frames. In addition, there were enough supplies of sick call request forms in the VSP housing units. • VSP patients experienced timely chronic care appointments and nurse-to-provider referrals. Patients returning from specialty consultations saw their primary care providers promptly. • The institution completed high-priority and routine-specialty services within the required time frames. VSP demonstrated a low rate of policy compliance in the following areas: • Providers often did not review radiology and laboratory reports within the required time frames. Providers often communicated diagnostic results late, and patient letters were often missing key elements required by departmental policy. • Patients did not always receive their chronic care medications timely. There was poor medication continuity for patients who transferred into VSP. • Health care staff did not always follow universal hand hygiene precautions. • Nursing staff did not regularly inspect or inventory emergency medical response bags. Office of the Inspector General, State of California Inspection Period: September 2018 – April 2019 Return to Contents 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 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 6. Likewise, Kaiser (commercial plan) no longer publishes HEDIS scores, but the OIG obtained Kaiser Medi-Cal HEDIS scores through the California Department of Health Care Services’ Medi‑Cal Managed Care Technical Report 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. VSP’s results compared favorably with those found in State health plans for diabetic care measures. We list the five HEDIS measures in Table 5. 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 outscored in four of the five diabetic measures. The institution scored lower than Kaiser Southern California (Medi-Cal) in eye examinations. Immunizations Statewide comparative data were not available for immunization measures; however, we include these data for informational purposes. VSP had a 71 percent immunization rate for adults 18 to 64 years old, and a 97 percent immunization rate for adults 65 years of age and older. The pneumococcal vaccination rate was 90 percent. Report Issued: August 2020 Office of the Inspector General, State of California Return to Contents 10 Cycle 6 Medical Inspection Report Table 5. VSP Results Compared With State HEDIS Scores California California VSP Kaiser Kaiser California NorCal SoCal Cycle 6 Medi-Cal Medi-Cal Medi-Cal HEDIS Measure Results * 2018 † 2018 † 2018 † HbA1c Screening 100% 87% 95% 95% Poor HbA1c Control (> 9.0%) ‡,§ 6% 35% 24% 19% HbA1c Control (< 8.0%) ‡ 86% 54% 63% 71% Blood Pressure Control (< 140/90) ‡ 92% 66% 76% 85% Eye Examinations 76% 61% 75% 84% Influenza – Adults (18 – 64) 71% – – – Influenza – Adults (65 +) 97% – – – Pneumococcal – Adults (65 +) 90% – – – Colorectal Cancer Screening 93% – – – Notes and Sources * Unless otherwise stated, data were collected in April 2019 by reviewing medical records from a sample of VSP’s population of applicable patients. These random statistical sample sizes were based on a 95 percent confidence level with a 15 percent maximum margin of error. † HEDIS Medi-Cal data were obtained from the California Department of Health Care Services publication titled, Medi-Cal Managed Care External Quality Review Technical Report, dated July 1, 2017 – June 30, 2018 (published April 2019). ‡ For this indicator, the entire applicable VSP population was tested. § For this measure only, a lower score is better. Source: Institution information provided by the California Department of Corrections and Rehabilitation. Health Care plan data obtained from the CCHCS Master Registry. Office of the Inspector General, State of California Inspection Period: September 2018 – April 2019 Return to Contents Valley State Prison 11 Recommendations As a result of our assessment of VSP’s performance, we offer the following recommendations to the department: • The chief medical executive CME should audit and address providers’ late reviews of diagnostic reports. • The CNE should audit stat laboratory results to encourage nurses to timely notify providers of the stat results. • The CME and the chief physician and surgeon (CP&S) should improve the monitoring of provider care to ensure the providers are reviewing records thoroughly and documenting all their medical decisions. • The CME and the chief nursing executive (CNE) should regularly perform audits of patients returning from off-site hospitals to improve staff’s retrieval of physician discharge summaries and to encourage providers and nurses to review discharge records thoroughly. • The CNE and nursing supervisors should improve the inventory process to ensure emergency medical response bags (EMRBs) are properly maintained. • Medical staff should be retrained and reminded to follow universal hand hygiene precautions. Implementing random spot checks may help with compliance. • The CNE should monitor the performance of reception and receiving (R&R) nurses to ensure that complete nursing assessments and proper interventions for newly arrived patients occur. Implementing an electronic alert to encourage the completion of electronic health records system (EHRS) electronic nursing assessment forms may help. • VSP medical leadership should examine and modify the institution’s medication processes to ensure timely and appropriate medication administration. Report Issued: August 2020 Office of the Inspector General, State of California Return to Contents 12 Cycle 6 Medical Inspection Report (This page left blank for reproduction purposes.) Office of the Inspector General, State of California Inspection Period: September 2018 – April 2019 Return to Contents Valley State Prison 13 Access to Care Overall Rating In this indicator, OIG inspectors evaluated the institution’s ability to Proficient provide patients with timely clinical appointments. Our inspectors reviewed the scheduling and appointment timeliness for newly arrived Case Review patients, sick calls, and nurse follow-ups. We examined referrals Rating to primary care providers, provider follow-ups, and specialists. Proficient Furthermore, we evaluated the follow-up appointments for patients who received specialty care or returned from an off-site hospitalization Compliance Score Results Overview Proficient (92%) VSP provided excellent access to care in most clinical areas, including access to clinic providers, outpatient housing unit (OHU) providers, nurses, and specialty services. The institution also did well with follow-up after triage and treatment area (TTA) visits and demonstrated acceptable access for patients requiring follow-up appointments after returning from a hospital or off-site specialist. Access for patients (especially high-risk patients) who recently transferred into VSP needed improvement, as these patients were frequently not scheduled for their initial provider intake appointments on time. Nonetheless, the institution performed very well in most areas, resulting in a proficient rating for this indicator. Case Review Results The OIG clinicians reviewed 314 provider, nurse, specialty, and hospital events that required the institution to generate appointments. They identified 18 opportunities for improvement relating to this indicator, only two of which were significant. Access to Clinic Providers Access to clinic providers is an integral part of patient care in health care delivery. Failure to ensure provider appointment availability can cause lapses in care. VSP performed exceptionally well with access to providers in both case review and compliance testing. Compliance testing found chronic care follow-up occurred on time (MIT 1.001, 92%). When sick call nurses referred their patients to a provider, the provider saw patients timely (MIT 1.005, 87%). When providers ordered follow-ups for sick call conditions, staff scheduled patients timely (MIT 1.006, 100%). Our clinicians found two minor and two significant opportunities for improvement in this area. The significant errors occurred when nurses placed incorrect follow-up orders in the electronic health record system (EHRS).8 8. Significant events occurred in cases 18 and 36. Report Issued: August 2020 Office of the Inspector General, State of California Return to Contents 14 Cycle 6 Medical Inspection Report Access to Specialized Medical Housing Providers VSP performed extremely well with access in the OHU. When staff admitted patients to the OHU, providers examined the patients promptly. Providers evaluated and recorded progress notes within the appropriate time frames. (MIT 13.003, 90%). Case review testing did not find any deficiencies regarding access to OHU providers. Access to Clinic Nurses The institution’s nurses provided excellent access for nurse sick calls and provider-to-nurse referrals. Our case reviewers did not identify any opportunities for improvement related to clinic nurse access. Compliance testing also showed excellent sick call access. Nurses consistently reviewed sick call requests the same day they collected them (MIT 1.003, 100%) and evaluated their patients with sick call symptoms within one business day (MIT 1.004, 100%). Access to Specialty Services Compliance testing showed excellent specialty access for both high-priority (MIT 14.001, 100%) and routine-priority (MIT 14.007, 100%) referrals. When the specialist requested a follow-up appointment, the institution scheduled the requested follow-up appointments timely (MIT 14.003, 90%, and MIT 14.009, 75%). Case review testing confirmed this good performance. Our clinicians found four minor delays in access to specialty care9and one significant error in the case reviews: • In case 22, the patient returned to VSP from a brief stay at another institution. The institution did not reconcile the oral maxillofacial surgery follow-up appointment order, and it was not scheduled as ordered. Although the patient did not suffer any complications, the failure to follow policy was significant. We also discuss this error in the Specialty Services indicator. Provider Follow‑Up After Specialty Service VSP performed sufficiently in ensuring patients saw their providers after specialty appointments. Although proficient overall, compliance testing showed VSP still had room for improvement in this area (MIT 1.008, 82%). Case review testing found one opportunity for improvement: • In case 27, the oncologist evaluated the patient for prostate cancer and requested a seven-day oncology follow-up. Due to an error in scheduling a follow-up appointment with the primary provider after the specialty consultation, the patient saw his provider 10 days later, and missed his specialist-recommended follow-up appointment. This case had many delays in care coordination that resulted in a six-month delay for the patient’s prostate cancer treatment. 9. Minor delays in cases 18, 19, 26, and 27. Office of the Inspector General, State of California Inspection Period: September 2018 – April 2019 Return to Contents Valley State Prison 15 Follow‑up After Hospitalization Providers usually saw their patients promptly after patients returned from an off-site hospital. Compliance testing showed minor problems in this area (MIT 1.007, 90%). Case review testing showed issues with patients returning from a hospital. More details are available in the Transfers indicator. Follow‑up After Urgent or Emergent Care (TTA) VSP providers saw their patients promptly after they received urgent or emergent care in the TTA. We found only three minor opportunities for improvement, which were not clinically significant.10 Follow‑up After Transferring Into the Institution VSP performed poorly with ensuring provider access for patients who recently transferred into the institution. Although compliance testing showed 80 percent of the sampled patients saw a provider on time (MIT 1.002), only two of the five high-risk patients (40%) saw a provider on time. It is essential that the institution provide access to providers to high-risk patients. Case review analysis also revealed delays in two of the eight cases in which patients transferred into the institution. Please see the Transfers indicator for additional details. Clinician On‑Site Inspection Our clinicians attended provider meetings and morning huddles in which staff reviewed patients who received overnight care, were hospitalized, or were scheduled for off-site specialty care. Staff discussed and scheduled patients with any urgent needs during these meetings. VSP managers reported their recent difficulty with provider availability; one of their providers was on extended sick leave, and another provider was on vacation. The CME also presented data showing that VSP’s patient population was at 145 percent of the institution’s capacity. Furthermore, 14 percent of the patients carried a high-risk classification. Although the CME maintained that the large numbers of patients with significant medical needs negatively affected VSP’s ability to provide access to care, our inspectors did not find these problems in this inspection. Recommendations We offer no specific recommendations for this indicator. 10. Minor deficiencies occurred in case 23 and twice in case 22. Report Issued: August 2020 Office of the Inspector General, State of California Return to Contents 16 Cycle 6 Medical Inspection Report Compliance Testing Results Table 6. Access to Care Scored Answer Compliance Questions Yes No N/A Yes % Chronic care follow-up appointments: Was the patient’s most recent chronic care visit within the health care guideline’s maximum allowable interval or within the ordered time frame, whichever is 23 2 0 92% shorter? (1.001) * For endorsed patients received from another CDCR institution: Based on the patient’s clinical risk level during the initial health screening, was the patient seen by the clinician within the required time frame? 20 5 0 80% (1.002) * Clinical appointments: Did a registered nurse review the patient’s request for service the same day it was received? (1.003) * 30 0 0 100% Clinical appointments: Did the registered nurse complete a face-to- face visit within one business day after the CDCR Form 7362 was 30 0 0 100% reviewed? (1.004) * Clinical appointments: If the registered nurse determined a referral to a primary care provider was necessary, was the patient seen within the maximum allowable time or the ordered time frame, whichever is the 13 2 15 87% shorter? (1.005) * Sick call follow-up appointments: If the primary care provider ordered a follow-up sick call appointment, did it take place within the time 8 0 22 100% frame specified? (1.006) * Upon the patient’s discharge from the community hospital: Did the patient receive a follow-up appointment within the required time 19 2 4 90% frame? (1.007) * Specialty service follow-up appointments: Did the clinician follow-up visits occur within required time frames? (1.008) * ,† 23 5 2 82% Clinical appointments: Do patients have a standardized process to obtain and submit health care services request forms? (1.101) 6 0 0 100% Overall percentage (MIT 1): 92% * The OIG clinicians considered these compliance tests along with their case review findings when determining the quality rating for this indicator. † CCHCS changed its specialty policies in April 2019, removing the requirement for primary care physician follow-up visits following specialty services. As a result, we tested MIT 1.008 only for high- priority specialty services or when staff ordered follow-ups. The OIG continued to test the clinical appropriateness of specialty follow-ups through its case review testing. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: September 2018 – April 2019 Return to Contents Valley State Prison 17 Table 7. Other Tests Related to Access to Care Scored Answer Compliance Questions Yes No N/A Yes % For patients received from a county jail: If, during the assessment, the nurse referred the patient to a provider, was the patient seen within the N/A N/A N/A N/A required time frame? (12.003) * For patients received from a county jail: Did the patient receive a history and physical by a primary care provider within seven calendar N/A N/A N/A N/A days? (12.004) * For CTC and SNF only (effective 4/2019, include OHU): Was a written history and physical examination completed within the required time N/A N/A N/A N/A frame? (13.002) * For OHU, CTC, SNF, and Hospice (applicable only for samples prior to 4/2019): Did the primary care provider complete the Subjective, Objective, 9 1 0 90% Assessment, and Plan notes on the patient at the minimum intervals required for the type of facility where the patient was treated? (13.003) * ,† Did the patient receive the high-priority specialty service within 14 calendar days of the primary care provider order or the Physician 15 0 0 100% Request for Service? (14.001) * Did the patient receive the subsequent follow-up to the high-priority specialty service appointment as ordered by the primary care provider? 9 1 5 90% (14.003) * Did the patient receive the medium-priority specialty service within 15-45 calendar days of the primary care provider order or the Physician N/A N/A N/A N/A Request for Service? (14.004) * Did the patient receive the subsequent follow-up to the medium- priority specialty service appointment as ordered by the primary care N/A N/A N/A N/A provider? (14.006) * Did the patient receive the routine-priority specialty service within 90 calendar days of the primary care provider order or Physician 15 0 0 100% Request for Service? (14.007) * Did the patient receive the subsequent follow-up to the routine-priority specialty service appointment as ordered by the primary care provider? 3 1 11 75% (14.009) * * The OIG clinicians considered these compliance tests along with their case review findings when determining the quality rating for this indicator. † CCHCS changed its policies and removed mandatory minimum rounding intervals for patients located in specialized medical housing. After April 2, 2019, MIT 13.003 only applied to CTCs that still had state-mandated rounding intervals. OIG case reviewers continued to test the clinical appropriateness of provider follow-ups within specialized medical housing units through case reviews. Source: The Office of the Inspector General medical inspection results. Report Issued: August 2020 Office of the Inspector General, State of California Return to Contents 18 Cycle 6 Medical Inspection Report Diagnostic Services Overall Rating In this indicator, OIG inspectors evaluated the institution’s ability Adequate to timely complete radiology, laboratory, and pathology tests. Our inspectors determined whether the institution properly retrieved the Case Review resultant reports and whether providers reviewed the results correctly. Rating In addition, in Cycle 6, we examined the institution’s ability to timely Adequate complete and review stat (immediate) laboratory tests. Compliance Results Overview Score Inadequate VSP performed well in test completion with only a few opportunities (63%) for improvement noted in this inspection. For example, nurses did not communicate stat results to providers timely, and providers often failed to sign test results timely or send results letters to their patients. These errors were usually not clinically significant; therefore, the OIG rated this indicator adequate. Case Review Results Our clinicians reviewed 181 diagnostic events and identified 11 opportunities for improvement, all of which were minor.11 Of the 11 opportunities for improvement, only one was due to a delay in diagnostic testing. Ten other opportunities for improvement were related to health information management. Test Completion As in Cycle 5, the institution continued its excellent performance completing laboratory (MIT 2.004, 100%) and radiology (MIT 2.001, 100%) services within required time frames. Case review testing also showed excellent performance, as our clinicians identified only one delay: • In case 22, the provider ordered a blood test to be performed on a specific date; however, the diagnostics team drew the laboratory test two days late. The delay was not clinically significant and did not affect the patient’s care. VSP had trouble processing stat laboratory tests on time (MIT 2.007, 60%). When the nurses received these results, they often failed to notify the provider timely (MIT 2.008, 20%). Case reviewers evaluated three cases with stat laboratory events and did not note any deficiencies.12 Health Information VSP staff retrieved laboratory and diagnostic test reports promptly and sent them to the providers for review. However, compliance 11. We noted instances in cases 1, 16, 18, 20, 21, twice in 22, and four times in 11. 12. Stat laboratory events were observed in cases 11, 21, and 22. Office of the Inspector General, State of California Inspection Period: September 2018 – April 2019 Return to Contents Valley State Prison 19 testing showed providers often did not sign the radiology reports (MIT 2.002, 60%) or laboratory reports (MIT 2.005, 70%) on time, nor send letters notifying patients of their results timely. In case review testing, our clinicians also found that providers did not always sign the laboratory reports or send patient notifications timely. We found five occurrences in which the provider did not endorse the reports on time. This occurred in cases 20, 22, and the following cases: • In case 16, the provider did not sign the laboratory results. • In case 18, the provider waited six days after notification to sign a test result. • In case 21, the provider waited 12 days after notification to sign a test result. Upon further analysis, our clinicians determined these errors were not clinically significant. In each of the examples listed, the providers reviewed the laboratory tests with the patient at subsequent appointments and made appropriate clinical decisions. Compliance testing found that the institution retrieved pathology reports timely (MIT 2.010, 90%) and that VSP providers signed the reports on time (MIT 2.011, 90%). However, providers did not send results letters to patients within the required time frames (MIT 2.012, 0%). When our clinicians analyzed this finding further, they confirmed that while the VSP providers failed to send results letters to their patients, providers discussed the results with their patients at subsequent appointments. Therefore, the pathology report processing errors were not clinically significant. Clinician On‑Site Inspection During our on-site inspection, we interviewed VSP’s leaders and staff regarding our review findings. In response, all interviewed providers reported excellent laboratory and radiology ancillary services at VSP. They also reported diagnostic tests were completed on time. Laboratory staff reported that they tracked all tests from the time of the order until the time the providers reviewed the results, and if results were returned from an outside laboratory or hospital, staff scanned the results into the EHRS and routed them to the providers. The chief physician and surgeon (CP&S) explained that he regularly monitored all VSP providers’ electronic inboxes to ensure they were reviewing results. Recommendations The CME should audit and address providers’ late reviews of diagnostic reports. The CNE should audit stat laboratory results to encourage nurses to timely notify providers of the stat results. Report Issued: August 2020 Office of the Inspector General, State of California Return to Contents 20 Cycle 6 Medical Inspection Report Compliance Testing Results Table 8. Diagnostic Services Scored Answer Compliance Questions Yes No N/A Yes % Radiology: Was the radiology service provided within the time frame specified in the health care provider’s order? (2.001) * 10 0 0 100% Radiology: Did the ordering health care provider review and endorse the radiology report within specified time frames? (2.002) * 6 4 0 60% Radiology: Did the ordering health care provider communicate the results of the radiology study to the patient within specified time 7 3 0 70% frames? (2.003) Laboratory: Was the laboratory service provided within the time frame specified in the health care provider’s order? (2.004) * 10 0 0 100% Laboratory: Did the health care provider review and endorse the laboratory report within specified time frames? (2.005) * 7 3 0 70% Laboratory: Did the health care provider communicate the results of the laboratory test to the patient within specified time frames? (2.006) 0 10 0 0 Laboratory: Did the institution collect the STAT laboratory test and receive the results within the required time frames? (2.007) * 6 4 0 60% Laboratory: Did the nursing staff notify the health care provider within one (1) hour from receiving the STAT laboratory results? (2.008) * 2 8 0 20% Laboratory: Did the health care provider endorse the STAT laboratory results within the required time frames? (2.009) 10 0 0 100% Pathology: Did the institution receive the final pathology report within the required time frames? (2.010) * 9 1 0 90% Pathology: Did the health care provider review and endorse the pathology report within specified time frames? (2.011) * 9 1 0 90% Pathology: Did the health care provider communicate the results of the pathology study to the patient within specified time frames? 0 10 0 0 (2.012) Overall percentage (MIT 2): 63% * The OIG clinicians considered these compliance tests along with their case review findings when determining the quality rating for this indicator. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: September 2018 – April 2019 Return to Contents Valley State Prison 21 Emergency Services Overall In this indicator, OIG clinicians evaluated the quality of emergency Rating Adequate 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 Case Review the emergency medical response, cardiopulmonary resuscitation (CPR) Rating quality, TTA care, provider performance, and nursing performance. Adequate Our clinicians also evaluated the Emergency Medical Response Review Committee’s (EMRRC) ability to identify problems with its emergency Compliance services. The OIG assessed the institution’s emergency services Score through case review only; we did not perform compliance testing for (N/A) this indicator. Results Overview VSP provided adequate emergency care. Staff gave prompt care for patients who overdosed on narcotics. VSP almost always responded timely and performed life-saving measures for patients requiring urgent or emergent care. However, staff sometimes had difficulty recognizing the signs and symptoms of stroke during this inspection, and the institution’s nurses could improve their accuracy when recording their emergency care. Overall, the institution provided sufficient emergency services, resulting in an adequate rating for this indicator. Case Review Results Our clinicians reviewed urgent and emergent events and found 34 opportunities for improvement, three of which were significant.13 Emergency Medical Response Our clinicians reviewed 40 emergency medical events that required responses from first medical responders. VSP staff responded promptly to emergencies throughout the institution; staff gave first aid and began resuscitation promptly. However, we identified deficiencies in the following two cases: • In case 1, the patient complained of general weakness and dizziness. The first medical responders noted the patient had slurred speech and numbness of his left arm. The patient reported he had a history of silent stroke. The nurses did not recognize the signs and symptoms of a possible stroke, did not call 9-1-1 immediately, and did not contact a provider until more than 30 minutes later. This was a significant delay because stroke patients require immediate, time-sensitive treatment. Although ultimately the patient did not have a stroke, the failure to follow clinical protocol was significant. 13. Urgent and emergent events were noted in cases 1, 2, 3, 4, 6, 7, 8, 9, 10, 15, 21, 22, and 23; significant opportunities for improvement occurred in cases 1, 3, and 23. Report Issued: August 2020 Office of the Inspector General, State of California Return to Contents 22 Cycle 6 Medical Inspection Report • In case 3, the patient, who had recently undergone open heart surgery, was taken to the TTA for recurrent chest pain. The TTA nurse should have started the nursing chest pain protocol. This error resulted in a treatment delay of more than 30 minutes. Although the patient did not have a heart attack, there was a failure to follow chest pain protocol. Case reviewers also found nursing documentation errors, such as inaccurate emergency time lines and missing vital signs. These errors did not significantly affect the quality of emergency care. Cardiopulmonary Resuscitation (CPR) Quality The OIG clinicians reviewed three cases in which staff performed CPR. In all three cases, custody and medical staff worked collaboratively to provide quality care.14 In one of the three cases, custody officers started CPR. Patients overdosed on opioids in two of the three cases, and nurses promptly administered Narcan (an opioid antidote). However, there were inaccuracies in the documentation of emergency time lines and medication administration. Provider Performance VSP providers performed well for most patients in urgent or emergent situations. Providers made accurate assessments and sound triage decisions. Nonetheless, our case review clinicians found an opportunity for improvement in the following example: • In case 2, the patient developed high blood pressure associated with left arm numbness, weakness, and pain. The TTA provider did not consider the possibility of stroke. The patient was sent to a community hospital immediately for high blood pressure. Although the patient did not have a stroke, the provider’s failure to consider the possibility of a stroke was clinically significant. Nursing Performance Our clinicians found occasional problems with assessments and interventions in several cases and the following examples:15 • In case 21, the patient went to the TTA for weakness and dizziness. The TTA nurse administered anti-nausea medication, but failed to document patient reassessment. Although there was no adverse outcome, the failure to follow the nursing standard of care was significant. • In case 22, the patient went to the TTA on two occasions for right foot pain. Two different TTA nurses did not assess the patient’s foot. Although the errors did not affect the outcome for 14. CPR was performed in cases 6, 7, and 8. 15. Nursing performance: cases 1, 3, 21, 22, and 23. Office of the Inspector General, State of California Inspection Period: September 2018 – April 2019 Return to Contents Valley State Prison 23 this patient, the failure to assess the patient’s primary complaint fell below the standard of nursing care. • Also, in case 22, the patient had chest pain. The nurse did not follow the provider’s orders of frequent monitoring of vital signs and neurological status checks. The TTA nurse also did not follow the order to administer intravenous (IV) fluids. Although these errors did not affect the outcome for this patient, the failure to follow orders is a serious lapse in nursing standards. • In case 23, the medication nurse informed the TTA nurse that the patient complained of abdominal pain. The TTA nurse only advised the patient to submit a sick call request without examining the patient’s abdomen. The error exposed the patient to severe risk of harm. The patient collapsed the next day and required hospitalization and surgical consultation. Nursing Documentation VSP nurses did not always document their care correctly. We identified several areas to improve documentation, as follows: • In cases 6, 21, 22, and 23, the nurses failed to record vital signs. • In cases 1, 7, 9, 22, and 23, the nurses documented incorrect time lines of emergency care. • In cases 4, 6, and 7, the nurses did not accurately document the administration of a medication. Emergency Medical Response Review Committee (EMRRC) The institution’s EMRRC met monthly to review emergency response cases. The EMRRC performed well and correctly identified the same quality issues that we identified. Clinician On‑Site Inspection The TTA is located in a central medical building at the institution along with numerous other medical services. The TTA maintained two beds and one additional overflow bed in an adjacent room. Two emergency transport vehicles were available for emergency response throughout the institution. According to VSP staff, they respond to an average of eight urgent or emergent situations daily. Nurse managers reported that they adequately staffed the TTA, reviewed staff members’ emergency responses, and provided training to improve performance. The nurse instructor reported that the most recent emergency drill scenario centered on a stroke patient. Recommendations We offer no specific recommendations for this indicator. Report Issued: August 2020 Office of the Inspector General, State of California Return to Contents 24 Cycle 6 Medical Inspection Report Health Information Management Overall Rating In this indicator, OIG inspectors evaluated the flow of health Adequate information, a crucial link in high-quality medical care delivery. Our inspectors examined whether the institution retrieved and scanned Case Review critical health information (progress notes, diagnostic reports, specialist Rating reports, and hospital-discharge reports) into the medical record in a Adequate timely manner. Our inspectors also tested whether clinicians adequately reviewed and endorsed those reports. In addition, our inspectors checked Compliance if staff labeled and organized documents in the medical record correctly. Score Adequate Results Overview (76%) VSP performed capably with health information management. Hospital discharge reports were retrieved and endorsed timely. Although compliance testing showed good performance for specialty report handling, case review clinicians identified opportunities for improvement. Nurses did not consistently notify providers of stat results timely; however, the providers acted upon the results. Staff duplicated and mislabeled documents in the EHRS. Despite these errors, case reviewers found that these issues were rarely clinically significant. Overall, these factors resulted in an adequate rating for this indicator. Case Review Results The OIG clinicians reviewed 1,094 events and found 51 opportunities for improvement related to health information management, of which only three were significant.16 Hospital Discharge Reports VSP staff usually retrieved and scanned hospital and discharge records timely (MIT 4.003, 95%). The hospital discharge reports contained key elements and were reviewed by the provider timely (MIT 4.005. 80%). In case review analysis, our clinicians identified problems retrieving physician discharge summaries in cases 3, 28, and in the following case: • In case 23, the patient had a lymph node biopsy in the hospital. The provider recognized the biopsy report was unavailable and requested the result several times. VSP staff did not retrieve the pathology report until one month after the provider’s initial request. Although the biopsy result was benign, the retrieval was delayed. In the above three cases, the delays were not clinically significant. Providers also reviewed and signed the summaries late in cases 3, 22, and 23. Although the providers signed the reports late, they were aware of the recommendations and made appropriate medical decisions. Please 16. Opportunities for improvement were noted in cases 1, 2, 3, 7, 8, 9, 10, 11, 12, 14, 15, 16, 18, 19, 20, 21, 22, 23, 25, 26, 27, and 28; and were significant in cases 23 and 27. Office of the Inspector General, State of California Inspection Period: September 2018 – April 2019 Return to Contents Valley State Prison 25 refer to the Transfers indicator for additional details regarding hospital discharge reports. Specialty Reports In compliance testing, VSP scored well with specialty report retrieval (MIT 4.002, 90%) and obtaining provider signatures for high-priority and routine-priority specialty reports (MIT 14.002, 93%, and MIT 14.008, 80%). Despite these high scores, our case reviewers found that VSP staff had difficulty retrieving, scanning, and signing specialty reports. Of the 51 opportunities for improvements case reviewers found in this indicator, 28 were related to specialty report processing.17 The following specialty report handling errors illustrate how VSP’s specialty report retrieval system affected patient care: • In case 27, the medically complex patient had two different cancers under the care of four different specialists. One specialist requested imaging tests to care for the patient properly. VSP staff did not to forward the results of the requested imaging tests to the specialist. This error contributed to a delay in cancer treatment because the specialist could not make proper treatment decisions without the test results. • Also, in case 27, on a different occasion, VSP staff overlooked retrieving a consultation report from the medical oncologist. This error also contributed to a six-month delay in prostate cancer treatment. For additional details regarding VSP’s specialty report processing, please refer to the Specialty Services indicator. Diagnostic Reports Overall, VSP performed adequately with diagnostic reports, apart from notifying providers of stat laboratory reports. Please refer to the Diagnostic Services indicator for a detailed discussion of these issues. Compliance testing showed nurses often did not notify the ordering provider promptly after the stat result became available for review (MIT 2.008, 20%). Compliance testing found that the providers usually reviewed and signed pathology reports timely (MIT 2.011, 90%); however, the providers did not send letters to their patients to notify them of the results (MIT 2.012, 0%). These errors were not clinically significant because VSP providers mitigated the errors by discussing the diagnostic results with their patients at subsequent clinic appointments. 17. Delayed retrieval or no retrieval occurred in cases 3, 9, 11, 18, 23, 25, 26, and 27; and either late or no endorsement was noted in cases 7, 9, 10, 12, 15, 19, 21, 22, 23, 25, 26, and 27. Report Issued: August 2020 Office of the Inspector General, State of California Return to Contents 26 Cycle 6 Medical Inspection Report Urgent and Emergent Records Frequently, VSP nurses did not correctly record their emergency care. Providers recorded their emergency care sufficiently, including their off-site telephone encounters. Although nurses could improve their documentation in this area, the problems were not clinically significant. Please refer to the Emergency Services indicator for additional information regarding emergency care documentation. Scanning Performance Although VSP generally scanned documents timely, our inspectors found numerous errors in the scanning process. Compliance testing showed that these errors occurred often (MIT 4.004, 21%). Case review testing identified the most common errors were duplicate and mislabeled documents, though none were clinically significant.18 Clinician On‑Site Inspection At the on-site inspection, our case reviewers met with VSP’s medical managers, health information management supervisors, providers, nurses, and ancillary staff. The CME acknowledged that the institution had difficulty retrieving specialty reports and produced a tracking log of the specialty reports discussed in the daily provider meetings. The health records supervisor reported it was difficult obtaining specific specialty reports from the contracted speech therapist, so VSP contacted the vendor multiple times and escalated the issue to the contract department of CCHCS headquarters. According to medical staff, once VSP began using a different specialty vendor, the problems were resolved. Recommendations The chief medical executive (CME) and the chief physician and surgeon (CP&S) should improve the monitoring of provider care to ensure the providers are reviewing records thoroughly and documenting all their medical decisions. The CME and the chief nursing executive (CNE) should regularly perform audits of patients returning from off-site hospitals to improve staff’s retrieval of physician discharge summaries and to encourage providers and nurses to review discharge records thoroughly. The CME should audit and address providers’ late reviews of diagnostic reports. 18. Duplicate documents were found in cases 2, 11, 14, 22, 23, and 27; and mislabeled documents in cases 1, 9, 11, 16, and 18. Office of the Inspector General, State of California Inspection Period: September 2018 – April 2019 Return to Contents Valley State Prison 27 Compliance Testing Results Table 9. Health Information Management Scored Answer Compliance Questions Yes No N/A Yes % Are health care service request forms scanned into the patient’s electronic health record within three calendar days of the encounter 19 1 10 95% date? (4.001) Are specialty documents scanned into the patient’s electronic health 18 2 10 90% record within five calendar days of the encounter date? (4.002) * Are community hospital discharge documents scanned into the patient’s electronic health record within three calendar days of 19 1 5 95% hospital discharge? (4.003) * During the inspection, were medical records properly scanned, 5 19 0 21% labeled, and included in the correct patients’ files? (4.004) * For patients discharged from a community hospital: Did the preliminary or final hospital discharge report include key elements 20 5 0 80% and did a provider review the report within five calendar days of discharge? (4.005) * Overall percentage (MIT 4): 76% * The OIG clinicians considered these compliance tests along with their case review findings when determining the quality rating for this indicator. Source: The Office of the Inspector General medical inspection results. Report Issued: August 2020 Office of the Inspector General, State of California Return to Contents 28 Cycle 6 Medical Inspection Report Table 10. Other Tests Related to Health Information Management Scored Answer Compliance Questions Yes No N/A Yes % Laboratory: Did the nursing staff notify the health care provider within 2 8 0 20% one (1) hour from receiving the STAT laboratory results? (2.008) * Pathology: Did the health care provider review and endorse the 9 1 0 90% pathology report within specified time frames? (2.011) * Pathology: Did the health care provider communicate the results of the 0 10 0 0 pathology study to the patient within specified time frames? (2.012) Did the institution receive and did the primary care provider review the high-priority specialty service consultant report within the required time 14 1 0 93% frame? (14.002) * Did the institution receive and did the primary care provider review the medium-priority specialty service consultant report within the required N/A N/A N/A N/A time frame? (14.005) * Did the institution receive and did the primary care provider review the routine-priority specialty service consultant report within the required 12 3 0 80% time frame? (14.008) * * The OIG clinicians considered these compliance tests along with their case review findings when determining the quality rating for this indicator. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: September 2018 – April 2019 Return to Contents Valley State Prison 29 Health Care Environment Overall In this indicator, OIG compliance inspectors tested the clinics’ waiting Rating areas, infection control, sanitation procedures, medical supplies, Inadequate equipment management, and examination rooms. Inspectors also tested the clinics’ ability to maintain auditory and visual privacy for clinical Case Review encounters. Compliance inspectors asked the institution’s health care Rating administrators to comment on their facility’s infrastructure and its (N/A) ability to support health care operations. The OIG rated this indicator solely on the compliance score, using the same scoring thresholds as in Compliance the Cycle 4 and Cycle 5 medical inspections. Our case review clinicians Score Inadequate typically do not rate this indicator. (69%) Compliance Testing Results For this indicator, VSP’s performance declined compared with its performance in Cycle 5. Waiting areas were adequate, core medical equipment was available, and proper sanitation and sterilization procedures were followed. However, improvement was needed in other aspects of VSP’s health care environment. Some examination rooms lacked enough space for examination and lacked visual privacy. In a few clinics, our compliance inspectors found improperly labeled and expired medical supplies. Emergency medical response bags (EMRBs) were not properly sealed or inventoried. Medical supply storage areas located outside the medical clinics did not store medical supplies adequately. Lastly, VSP staff did not regularly wash their hands when examining their patients or when applying gloves. These factors resulted in a rating of inadequate. Outdoor Waiting Areas Our compliance inspectors examined outdoor patient waiting areas. Health care custody staff reported that the existing waiting areas (Photo 1, left) had enough seating capacity, ample protection from inclement weather, and an operational misting system for use during extreme heat conditions. Photo 1. Shaded outdoor waiting area with a mist cooling system (photographed on 4/23/19). Report Issued: August 2020 Office of the Inspector General, State of California Return to Contents 30 Cycle 6 Medical Inspection Report Indoor Waiting Areas Inside the medical clinics, there was enough seating capacity for patients waiting for their appointments (Photo 2, left). In addition to the main waiting room, there were three additional adjacent rooms for patient overflow. Although there were several patients standing in the main waiting room, the patients explained they preferred standing in the main waiting room instead of sitting in the adjacent waiting rooms. Photo 2. Indoor waiting area with open seating (photographed on 4/22/19). Clinic Environment All nine applicable clinics had environments conducive for medical care. Our inspectors found reasonable auditory privacy, appropriate waiting areas, good wheelchair accessibility, and ample workspace (MIT 5.109, 100%). Of the nine examination rooms observed, five had sufficient space, configuration, supplies, and equipment, permitting VSP clinicians to perform proper clinical examinations. The remaining four examination rooms had one or more of the following opportunities for improvement: insufficient space; examination table placement preventing patients from lying down fully (Photo 3, right); lack of visual Photo 3. Examination table with insufficient space for a patient to lie down (photographed on 4/25/19). privacy, or unsecured confidential medical records (MIT 5.110, 56%). Office of the Inspector General, State of California Inspection Period: September 2018 – April 2019 Return to Contents Valley State Prison 31 Clinic Supplies Six of the nine observed clinics followed adequate medical supply storage and management protocols. In three other clinics, inspectors found improperly labeled medical supplies, and one of the three clinics had expired medical supplies (Photo 4, right) (MIT 5.107, 67%). All nine clinics met requirements for essential core medical equipment and supplies (MIT 5.108, 100%). Our inspectors examined seven EMRBs to determine if they contained all essential items. They checked if staff inspected the bags daily and inventoried them monthly. Only one of the seven EMRBs passed the compliance test. For the other Photo 4. Expired medical supplies dated December 2018 six EMRBs, staff failed to seal the (photographed on 4/22/19). EMRBs’ compartments or ensure they were intact, or had not inventoried the EMRBs in the previous 30 days (MIT 5.111, 14%). Medical Supply Management None of the medical supply storage areas located outside the medical clinics (e.g., warehouse, Conex containers, etc.) stored medical supplies adequately. Our inspectors also found medical supplies with torn sterile packaging (Photo 5, left) (MIT 5.106, 0%). According to the CEO, the institution was in the process of transferring bulk items from the Conex containers to the warehouse. Furthermore, health care managers expressed no concerns about the medical supply chain or their communication with the Photo 5. Torn sterile packaging (photographed on 4/22/19). main warehouse. Report Issued: August 2020 Office of the Inspector General, State of California Return to Contents 32 Cycle 6 Medical Inspection Report Infection Control and Sanitation Staff appropriately cleaned, sanitized, and disinfected all nine clinics (MIT 5.101, 100%). Staff in eight of nine clinics properly sterilized or disinfected medical equipment. In the other clinic, when describing their daily protocol, staff did not discuss disinfecting the examination table prior to their shift (MIT 5.102, 89%). Our inspectors found operating sinks and hand hygiene supplies in the examination rooms of all nine clinics (MIT 5.103, 100%). Our inspectors observed patient encounters in eight clinics and found that VSP staff followed good hand hygiene practices in three clinics. In five other clinics, VSP staff failed to wash their hands before or after examining their patients or before applying gloves (MIT 5.104, 38%). Health care staff in all clinics followed proper protocols to mitigate exposure to blood-borne pathogens and contaminated waste (MIT 5.105, 100%). Physical Infrastructure At the time of the compliance inspection, VSP was renovating and adding clinic space to four clinics. These projects began in 2015, and management estimated they would be complete by winter 2020. During our interview, VSP’s health care management and the CEO explained that staff were caring for yard clinic patients in the infirmary clinic while the yard clinic was under renovation. The CEO was concerned that his staff was rendering too many services (including yard clinic, TTA, specialty clinic, and physical therapy) in the infirmary clinic but did not believe the extra foot traffic had compromised patient care (MIT 5.999). Recommendations The CNE and nursing supervisors should improve the inventory process to ensure EMRBs are properly maintained. Medical staff should be retrained and reminded to follow universal hand hygiene precautions. Implementing random spot checks may help with compliance. Office of the Inspector General, State of California Inspection Period: September 2018 – April 2019 Return to Contents Valley State Prison 33 Compliance Testing Results Table 11. Health Care Environment Scored Answer Compliance Questions Yes No N/A Yes % Infection control: Are clinical health care areas appropriately 9 0 0 100% disinfected, cleaned, and sanitary? (5.101) Infection control: Do clinical health care areas ensure that reusable invasive and noninvasive medical equipment is properly sterilized or 8 1 0 89% disinfected as warranted? (5.102) Infection control: Do clinical health care areas contain operable sinks 9 0 0 100% and sufficient quantities of hygiene supplies? (5.103) Infection control: Does clinical health care staff adhere to universal 3 5 1 38% hand hygiene precautions? (5.104) Infection control: Do clinical health care areas control exposure to 9 0 0 100% blood-borne pathogens and contaminated waste? (5.105) Warehouse, conex, and other nonclinic storage areas: Does the medical supply management process adequately support the needs 0 1 0 0 of the medical health care program? (5.106) Clinical areas: Does each clinic follow adequate protocols for 6 3 0 67% managing and storing bulk medical supplies? (5.107) Clinical areas: Do clinic common areas and exam rooms have 9 0 0 100% essential core medical equipment and supplies? (5.108) Clinical areas: Are the environments in the common clinic areas 9 0 0 100% conducive to providing medical services? (5.109) Clinical areas: Are the environments in the clinic exam rooms 5 4 0 56% conducive to providing medical services? (5.110) Clinical areas: Are emergency medical response bags and emergency crash carts inspected and inventoried within required time frames, 1 6 2 14% and do they contain essential items? (5.111) Does the institution’s health care management believe that all clinical This is a nonscored test. Please areas have physical plant infrastructures that are sufficient to provide see the indicator for discussion adequate health care services? (5.999) of this test. Overall percentage (MIT 5): 69% * The OIG clinicians considered these compliance tests along with their case review findings when determining the quality rating for this indicator. Source: The Office of the Inspector General medical inspection results. Report Issued: August 2020 Office of the Inspector General, State of California Return to Contents 34 Cycle 6 Medical Inspection Report Transfers Overall Rating In this indicator, OIG inspectors examined the transfer process for Inadequate those patients who transferred into the institution, as well as for those who transferred to other institutions. For newly arrived patients, our Case Review inspectors assessed the quality of health screenings and the continuity Rating of provider appointments, specialist referrals, diagnostic tests, and Inadequate medications. For patients who transferred out of the institution, inspectors checked whether staff reviewed patient medical records and Compliance determined the patient’s need for medical holds. They also assessed if Score staff transferred patients with their medical equipment and gave correct Inadequate medications before patients left. In addition, our inspectors evaluated the (66%) ability of staff to communicate vital health transfer information, such as preexisting health conditions, pending appointments, tests, and specialty referrals; and inspectors confirmed if staff sent complete medication transfer packages to the receiving institution. For patients who returned from off-site hospitals or emergency rooms, inspectors reviewed whether staff appropriately implemented the recommended treatment plans, administered necessary medications, and scheduled appropriate follow-up appointments. Results Overview VSP revealed multiple opportunities for improvement in this indicator. For patients returning from an off-site hospital, our inspectors identified several important issues, including: lack of medication continuity, incorrect retrieval of physician discharge summaries, lack of careful review of hospital discharge records, and delayed posthospital follow-up appointments. For patients transferring into the institution we found incomplete initial nurse health screenings, intermittently delayed initial intake provider appointments, medication continuity lapses for chronic care patients, and delayed specialty referrals due to the transfer. VSP performed adequately for patients transferring to other institutions. These factors resulted in an inadequate rating for this indicator. Case Review Results The OIG clinicians reviewed cases in which patients transferred into or out of the institution, or returned from an off-site hospital or emergency room. Case reviewers identified 28 opportunities for improvement in VSP’s hospital return processes. Transfers In Compliance testing showed reception and receiving (R&R) nurses scored poorly when performing the initial health screening (MIT 6.001, 8%). Analysis of the compliance data showed that while the nurses completed the screening forms on time, they rarely complete the forms thoroughly. Office of the Inspector General, State of California Inspection Period: September 2018 – April 2019 Return to Contents Valley State Prison 35 Our case review clinicians found nine deficiencies19 in this process related to insufficient nursing assessment and intervention in the following four cases: • In case 58, the R&R nurses did not obtain a full set of vital signs as part of the initial health screening. The OHU nurse obtained vital signs upon admission. This minor error did not affect the patient’s care. • In case 22, the patient complained of pain upon arrival at VSP. The R&R nurse did not administer the patient’s prescribed pain medication. • In cases 31 and 32, the R&R nurses did not recognize that diabetes was a risk factor for valley fever. Compliance testing showed poor medication continuity for newly arrived patients (MIT 6.003, 68%). Case review testing also found delays in medication delivery; however, our clinicians determined most of these delays were not clinically significant. VSP generally provided good access to primary care providers when patients transferred into the institution (MIT 1.002, 80%); however, only two of the five high-risk patients (40%) saw their provider timely. Case review testing also found room for improvement in this area: • In case 1, the patient was receiving cancer treatment when he transferred to VSP. This high-risk patient was not seen by the primary care provider within seven days. Compliance testing showed VSP had difficulty scheduling timely specialty appointments for patients who transferred into the institution with preapproved specialty referrals (MIT 14.010, 65%). Transfers Out VSP’s transfer-out process was adequate. Compliance testing found that most transfer medication packets were complete (MIT 6.101, 86%). While our clinicians found the performance adequate in this area, we found opportunities for improvement: • In case 33, the nurse did not document a pending esophago- gastroduodenoscopy (EGD)20 appointment in the transfer information notes. Although there was no delay in care, this did not follow policy. • In case 34, the nurse did not obtain the diabetic patient’s morning blood sugar level before transferring him out, resulting in the patient’s exposure to significant risk of harm. • In cases 22, 33, and 34, the R&R nurses did not check patients’ vital signs before the patients transferred out of VSP. 19. Cases 1, 22, 31, 32, and 58. 20. The esophagogastroduodenoscopy (EGD) is a procedure in which the physician inserts a camera scope into the mouth and advances to the small intestine to examine the esophagus, stomach, and the first portion of the small intestine. Report Issued: August 2020 Office of the Inspector General, State of California Return to Contents 36 Cycle 6 Medical Inspection Report Hospitalizations Patients returning from an off-site hospitalization or an emergency room may have experienced severe illness or injury. These patients often have complex medical issues and are especially susceptible to lapses in care. Even seemingly small lapses in care for these patients can result in serious consequences. Compliance testing found an acceptable continuity of hospital- recommended medications (MIT 7.003, 75%) and good provider follow- ups after patients returned from a community hospital (MIT 1.007, 90%). Case reviewers found room for improvement with VSP’s hospital- return performance. Our clinicians reviewed 26 hospital or emergency department returns and identified 15 opportunities for improvement, four of which were significant.21 In the case reviews, staff did not always assess their patients, review hospital records, or intervene correctly: • In case 1, the nurse and the provider did not follow hospital discharge medication recommendations to stop a blood pressure medication. As a result, the patient had low blood pressure. • In case 2, the nurse incorrectly entered a five-day provider follow-up order. The nurse transposed the start and end dates. • In case 3, the provider did not order daily aspirin and did not request follow-up with the specialist as recommended by the hospitalist. This case is also discussed in the Specialized Medical Housing indicator. • In case 22, the nurse did not order the provider hospital follow- up within five days as required by policy. Compliance testing found that staff retrieved discharge documents timely (MIT 4.003, 95%) and retrieved physician discharge summaries 80 percent of the time (MIT 4.005). Case review testing confirmed compliance results.22 Providers also reviewed and signed the summaries late in cases 3, 22, and 23. Please refer to the Health Information Management indicator for additional details. Clinician On‑Site Inspection Our clinicians met with the nurse managers at VSP to discuss some of the case review findings. They agreed with the opportunities for improvement we identified, and indicated they would provide additional education and training for their staff. Compliance On‑Site Inspection Our compliance inspectors examined the contents of the transfer packets for all patients transferring out of the institution. In one transfer packet, 21. These occurred in cases 1, 2, 3, 21, 22, 23, and 28, with significant deficiencies noted in cases 1, 3, 22, and 23. 22. Retrieved discharge documents were late in cases 3, 23, and 28. Office of the Inspector General, State of California Inspection Period: September 2018 – April 2019 Return to Contents Valley State Prison 37 inspectors found one expired medication. VSP staff immediately removed the expired medication. In addition, our inspectors checked patients who were transferring with durable medical equipment and found all patients possessed this equipment at the time of transfer. Recommendations The CNE should monitor the performance of R&R nurses to ensure that complete nursing assessments and proper interventions for newly arrived patients occur. Implementing an electronic alert to encourage the completion of EHRS electronic nursing assessment forms may help. Compliance Testing Results Table 12. Transfers Scored Answer Compliance Questions Yes No N/A Yes % For endorsed patients received from another CDCR institution or COCF: Did nursing staff complete the initial health screening and 2 23 0 8% answer all screening questions within the required time frame? (6.001) * For endorsed patients received from another CDCR institution or COCF: When required, did the RN complete the assessment and disposition section of the initial health screening form; refer the 25 0 0 100% patient to the TTA if TB signs and symptoms were present; and sign and date the form on the same day staff completed the health screening? (6.002) For endorsed patients received from another CDCR institution or COCF: If the patient had an existing medication order upon arrival, 13 6 6 68% were medications administered or delivered without interruption? (6.003) * For patients transferred out of the facility: Do medication transfer packages include required medications along with the corresponding 6 1 2 86% transfer packet required documents? (6.101) * Overall percentage (MIT 6): 66% * The OIG clinicians considered these compliance tests along with their case review findings when determining the quality rating for this indicator. Source: The Office of the Inspector General medical inspection results. Report Issued: August 2020 Office of the Inspector General, State of California Return to Contents 38 Cycle 6 Medical Inspection Report Table 13. Other Tests Related to Transfers Scored Answer Compliance Questions Yes No N/A Yes % For endorsed patients received from another CDCR institution: Based on the patient’s clinical risk level during the initial health screening, was the 20 5 0 80% patient seen by the clinician within the required time frame? (1.002) * Upon the patient’s discharge from the community hospital: Did the patient receive a follow-up appointment with a primary care provider 19 2 4 90% within the required time frame? (1.007) * Are community hospital discharge documents scanned into the patient’s electronic health record within three calendar days of hospital 19 1 5 95% discharge? (4.003) * For patients discharged from a community hospital: Did the preliminary or final hospital discharge report include key elements and did a 20 5 0 80% provider review the report within five calendar days of discharge? (4.005) * Upon the patient’s discharge from a community hospital: Were all ordered medications administered, made available, or delivered to the 15 5 5 75% patient within required time frames? (7.003) * Upon the patient’s transfer from one housing unit to another: Were 23 2 0 92% medications continued without interruption? (7.005) * For patients en route who lay over at the institution: If the temporarily housed patient had an existing medication order, were medications N/A N/A N/A N/A administered or delivered without interruption? (7.006) * For endorsed patients received from another CDCR institution: If the patient was approved for a specialty services appointment at the 13 7 0 65% sending institution, was the appointment scheduled at the receiving institution within the required time frames? (14.010) * * The OIG clinicians considered these compliance tests along with their case review findings when determining the quality rating for this indicator. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: September 2018 – April 2019 Return to Contents Valley State Prison 39 Medication Management Overall In this indicator, OIG inspectors evaluated the institution’s ability to Rating administer prescription medications on time and without interruption. Inadequate The inspectors examined this process from the time a provider prescribed medication until the nurse administered the medication to Case Review the patient. When rating this indicator, the OIG strongly considered Rating the compliance test results, which tested medication processes to a Inadequate much greater degree than case review testing. In addition to examining medication administration, our compliance inspectors also tested many Compliance other processes, including medication handling, storage, error reporting, Score Inadequate and other pharmacy processes. (70%) Results Overview As in Cycle 5, VSP continued to struggle in this indicator. For Cycle 6, our inspectors identified the following medication processes that showed significant room for improvement: the timely provision of newly prescribed medications, the continuity of chronic care medications, medications for patients transferring into VSP, and the monitoring of patients taking TB medications. On the other hand, we found the following VSP medication processes adequate: the continuity of medications for patients admitted to the OHU, the transfer of patients to other institutions with appropriate medications, and the administration of TB medications. Taking these factors into consideration, along with compliance testing, the OIG rated this indicator inadequate. Case Review Results Our clinicians reviewed 163 events within 49 cases related to medications and found 34 opportunities for improvement, two of which were significant.23 New Medication Prescriptions Our clinicians found that staff occasionally did not administer new medications at times specified by the prescription. Compliance testing revealed that patients received their new medications 76 percent of the time (MIT 7.002). For 19 sampled patients, 13 received their medications on time. Five patients received their medications between one and four days late, and for one other patient, nursing staff administered his medications incorrectly. In case review testing, our clinicians also found a pattern of new medications administered late in cases 7, 10, 23, 28, and in the following cases:24 23. Significant deficiencies were noted in cases 16 and 19. 24. Medication was late in cases 1, 7, 23, 28, and the dose was inaccurate in case 10. Report Issued: August 2020 Office of the Inspector General, State of California Return to Contents 40 Cycle 6 Medical Inspection Report • In case 1, the patient received two different prostate medications late. Although these delays were not clinically significant, they did not follow policy. • In case 15, the patient had an eye injury, and the provider prescribed eye drops to treat swelling and infection. The patient received the eye drops one to two days late. This delay increased the patient’s risk of infection and eye damage. • In case 18, the provider ordered medications for acid reflux and pain. The patient received his medications one and five days late. These delays were not clinically significant. • In case 19, the provider prescribed a new medication for the patient’s acid-damaged esophagus, but the patient never received the medication. This increased the risk of esophageal damage, including abdominal pain and ulcers. During the on- site inspection, the institution did not provide evidence that the pharmacy dispensed or delivered the medication. Chronic Medication Continuity VSP had difficulty ensuring medication continuity for patients with chronic conditions. Compliance testing showed low compliance in this area (MIT 7.001, 13%). Case review testing also identified issues with medication continuity in cases 15, 22, 28, and in the following cases: • In case 13, the patient did not receive his blood pressure and diabetes medications for one month. This lapse increased the patient’s risk of poor diabetes and blood pressure control. • In case 16, the provider failed to renew the patient’s prescription for chronic acid reflux. At the on-site inspection, the pharmacist reported the medication should have shown up in the automated huddle agenda. However, staff showed the medication was not listed in the huddle agenda. The institution did not provide documentation that the nurse notified the physician about the expired medication. • In case 17, the provider prescribed the patient nitroglycerin for ongoing chest pains. When the patient ran out of this medication, the nurse sent the refill request to the wrong message pool. As a result, the patient did not get his nitroglycerin for three weeks. Hospital Discharge Medications Compliance testing found sufficient medication continuity for 15 of 20 patients who returned from a community hospital (MIT 7.003, 75%). Case review testing showed similar performance. Please refer to the Transfers indicator for additional details. Specialized Medical Housing Medications Patients in the OHU usually received their medications on time. Although compliance testing showed some delays in this area Office of the Inspector General, State of California Inspection Period: September 2018 – April 2019 Return to Contents Valley State Prison 41 (MIT 13.004, 50%), our clinicians found those delays were not clinically significant because most were fewer than two hours. In case review testing, clinicians also found minor, nonclinically significant delays. In the six OHU case reviews, two patients received their medications one to two days late.25 Transfer Medications VSP did not adequately ensure medication continuity for patients transferring into the institution. Compliance testing showed patients received their prescribed medications timely upon arriving to VSP from another institution in only 13 of the 19 samples tested (MIT 6.003, 68%). For patients transferring out of VSP, staff performed well with medication continuity. Our clinicians did not find any opportunities for improvement in the cases we reviewed. Compliance testing also showed good completion of medication transfer packets (MIT 6.101, 86%). Our compliance testing also showed VSP performed well with medication continuity for patients transferring from one housing unit to another (MIT 7.005, 92%). Out of 25 patients sampled, 23 patients received their medications without interruption when they transferred from one housing unit to another. For additional details, please refer to the Transfers indicator. Medication Administration Our clinicians found that VSP nurses often administered medications timely and properly. However, case reviewers identified several types of nurse medication administration errors in this inspection. The institution can use the following examples for quality improvement: • In case 2, the nurse did not review the patient’s medical record and administered an influenza vaccine twice. Although this did not impact patient care, this was below the nursing standards of care. • In case 10, nurses administered the patient’s antiviral medication four times a day instead of the prescribed five times a day. This increased the risk of the patient losing his eyesight due to a viral infection of the eye. Although this error did not have a clinical effect, this was below the nursing standards of care. • In case 22, the nurse did not administer the patient’s chronic medications on several occasions. The patient missed doses of his cholesterol, asthma, and diabetes medication. Although these errors were not clinically significant, this was below the nursing standards of care. Compliance testing examined how VSP staff administered and monitored patients taking tuberculosis (TB) medications and found nurses correctly administered TB medications as prescribed (MIT 9.001, 100%). 25. Cases 23 and 57. Report Issued: August 2020 Office of the Inspector General, State of California Return to Contents 42 Cycle 6 Medical Inspection Report However, nurses routinely failed to monitor these patients correctly (MIT 9.002, 0%). Monitoring for side effects of TB medications is important because these medications can be very harmful to a patient’s liver. Clinician On‑Site Inspection OIG clinicians interviewed nurses and observed them during medication administration. The nurses were familiar with processes for medication renewals, new prescriptions, transfer medications, and administering “keep on person” (KOP) medications timely. The medication nurses attended the clinic huddles and informed the providers of expiring medications. Our clinicians also met with pharmacy and nursing staff to discuss our case review findings. In response, the pharmacist in charge (PIC) explained that VSP was implementing a “pharmacy correctional clinic” model, where each clinic will have an Omnicell (automated medication storage and dispensing cabinet). According to the PIC, this will improve storage and access to medications, enabling VSP to provide continuous medication availability, 24 hours per day, seven days per week. With this implementation, the PIC predicted that VSP will receive a higher rating in this indicator in Cycle 7. Compliance Testing Results Medication Practices and Storage Controls The institution failed to store and secure narcotic medications correctly in the seven applicable clinic and medication line locations we tested. In all seven locations, our inspectors identified one or more of the following opportunities for improvement: two licensed nurses did not counter- sign the logbook for narcotics during the inventory count; nurses did not update the logbook when they administered narcotic medications; and nurses did not record in the logbook the administration date, time, patient identification number, and reason for disposal of narcotics (MIT 7.101, 0%). VSP appropriately stored and secured nonnarcotic medications in all eight applicable clinic and medication line locations (MIT 7.102, 100%). Staff properly protected medications from physical, chemical, and temperature contamination in seven of the eight clinic and medication line locations. Staff separated the storage of oral and topical medications for one location (MIT 7.103, 88%). Staff successfully stored valid, unexpired medications in six of the eight applicable clinic and medication line locations. In one clinic, nurses did not label the multiple- use medication with the date it was opened,26 and in another clinic, 26. On May 2019, the department changed the policy regarding multiple-use medication labeling to require listing the expiration date instead of the opening date. Office of the Inspector General, State of California Inspection Period: September 2018 – April 2019 Return to Contents Valley State Prison 43 nurses generally stored multiple-use refrigerated medication according to the manufacturers’ guidelines (MIT 7.104, 75%). Medication nurses exercised proper hand hygiene and contamination control protocols at four of six locations. In two locations, some nurses neglected to wash or sanitize their hands before subsequent regloving (MIT 7.105, 67%). Medication nurses at three of the six inspected medication line locations employed appropriate administrative controls and followed protocols during medication preparation. In two locations, nursing staff did not explain their process for reconciling new medications received from the pharmacy with the physician’s order. At another location, nurses improperly opened the original packages before issuing the medications to the patients. Inspectors found loose medications in the medication carts; these medications were contaminated and would require disposal (MIT 7.106, 50%). Staff in five of six medication preparation and administration locations demonstrated appropriate administrative controls and protocols (MIT 7.107, 83%). In one location, a medication nurse did not appropriately administer medication as ordered by the provider. Pharmacy Protocols VSP’s pharmacy followed general security, organization, and cleanliness management protocols (MIT 7.108, 100%). The pharmacy properly stored nonrefrigerated medication (MIT 7.109, 100%). We found one example of an expired medication in the pharmacy refrigerator (MIT 7.110, 0%). The PIC correctly accounted for narcotic medications stored in VSP’s pharmacy (MIT 7.111, 100%). Inspectors examined 14 medication error reports and found the PIC processed all reports timely (MIT 7.112, 100%). Nonscored Tests In addition to testing the institution’s self-reported medication errors, OIG inspectors also followed up on any significant medication errors found during compliance testing. We do not score this test; these results are provided for informational purposes only. We did not find any applicable medication errors for VSP (MIT 7.998). In the VSP administration segregation unit, we interviewed the one applicable patient and determined the patient had access to his rescue medications (MIT 7.999). Recommendations VSP medical leadership should examine and modify the institution’s medication processes to ensure timely and appropriate medication administration. Report Issued: August 2020 Office of the Inspector General, State of California Return to Contents 44 Cycle 6 Medical Inspection Report Table 14. Medication Management Scored Answer Compliance Questions Yes No N/A Yes % Did the patient receive all chronic care medications within the required time frames or did the institution follow departmental policy for refusals or 3 20 2 13% no-shows? (7.001) * Did health care staff administer, make available, or deliver new order 19 6 0 76% prescription medications to the patient within the required time frames? (7.002) Upon the patient’s discharge from a community hospital: Were all ordered medications administered, made available, or delivered to the patient within 15 5 5 75% required time frames? (7.003) * For patients received from a county jail: Were all medications ordered by the institution’s reception center provider administered, made available, or N/A N/A N/A N/A delivered to the patient within the required time frames? (7.004) * Upon the patient’s transfer from one housing unit to another: Were 23 2 0 92% medications continued without interruption? (7.005) * For patients en route who lay over at the institution: If the temporarily housed patient had an existing medication order, were medications administered or N/A N/A N/A N/A delivered without interruption? (7.006) * All clinical and medication line storage areas for narcotic medications: Does the institution employ strong medication security controls over narcotic 0 7 3 0 medications assigned to its storage areas? (7.101) All clinical and medication line storage areas for nonnarcotic medications: Does the institution properly secure and store nonnarcotic medications in the 8 0 2 100% assigned storage areas? (7.102) All clinical and medication line storage areas for nonnarcotic medications: Does the institution keep nonnarcotic medication storage locations free of 7 1 2 88% contamination in the assigned storage areas? (7.103) All clinical and medication line storage areas for nonnarcotic medications: Does the institution safely store nonnarcotic medications that have yet to expire in 6 2 2 75% the assigned storage areas? (7.104) Medication preparation and administration areas: Do nursing staff employ and follow hand hygiene contamination control protocols during medication 4 2 4 67% preparation and medication administration processes? (7.105) Medication preparation and administration areas: Does the institution employ appropriate administrative controls and protocols when preparing medications 3 3 4 50% for patients? (7.106) Medication preparation and administration areas: Does the institution employ appropriate administrative controls and protocols when administering 5 1 4 83% medications to patients? (7.107) Pharmacy: Does the institution employ and follow general security, organization, and cleanliness management protocols in its main and remote 1 0 0 100% pharmacies? (7.108) Pharmacy: Does the institution’s pharmacy properly store nonrefrigerated 1 0 0 100% medications? (7.109) Pharmacy: Does the institution’s pharmacy properly store refrigerated or frozen 0 1 0 0 medications? (7.110) Pharmacy: Does the institution’s pharmacy properly account for narcotic 1 0 0 100% medications? (7.111) Pharmacy: Does the institution follow key medication error reporting 14 0 0 100% protocols? (7.112) Pharmacy: For Information Purposes Only: During compliance testing, did the This is a nonscored test. Please OIG find that medication errors were properly identified and reported by the see the indicator for discussion of institution? (7.998) this test. Pharmacy: For Information Purposes Only: Do patients in isolation housing This is a nonscored test. Please units have immediate access to their KOP prescribed rescue inhalers and see the indicator for discussion of nitroglycerin medications? (7.999) this test. Overall percentage (MIT 7): 70% * The OIG clinicians considered these compliance tests along with their case review findings when determining the quality rating for this indicator. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: September 2018 – April 2019 Return to Contents Valley State Prison 45 Table 15. Other Tests Related to Medication Management Scored Answer Compliance Questions Yes No N/A Yes % For endorsed patients received from another CDCR institution or COCF: If the patient had an existing medication order upon arrival, 13 6 6 68% were medications administered or delivered without interruption? (6.003) * For patients transferred out of the facility: Do medication transfer packages include required medications along with the corresponding 6 1 2 86% transfer-packet required documents? (6.101) * Patients prescribed TB medication: Did the institution administer the 8 0 0 100% medication to the patient as prescribed? (9.001) * Patients prescribed TB medication: Did the institution monitor the patient per policy for the most recent three months he or she was on 0 8 0 0 the medication? (9.002) * Upon the patient’s admission to specialized medical housing: Were all medications ordered, made available, and administered to the patient 5 5 0 50% within required time frames? (13.004) * * The OIG clinicians considered these compliance tests along with their case review findings when determining the quality rating for this indicator. Source: The Office of the Inspector General medical inspection results. Report Issued: August 2020 Office of the Inspector General, State of California Return to Contents 46 Cycle 6 Medical Inspection Report Preventive Services Overall Rating In this indicator, OIG compliance inspectors tested whether the Inadequate institution offered or provided cancer screenings, tuberculosis (TB) screenings, influenza vaccines, and other immunizations. Case Review If the department designated the institution as high risk for Rating coccidioidomycosis (valley fever), our inspectors tested the institution’s (N/A) ability to transfer patients out quickly. The OIG rated this indicator solely based on the compliance score, using the same scoring thresholds Compliance as in the Cycle 4 and Cycle 5 medical inspections. Our case review Score clinicians do not rate this indicator. Inadequate (73%) Recommendations We offer no specific recommendations for this indicator. Compliance Testing Results Table 16. Preventive Services Scored Answer Compliance Questions Yes No N/A Yes % Patients prescribed TB medication: Did the institution administer the 8 0 0 100% medication to the patient as prescribed? (9.001) Patients prescribed TB medication: Did the institution monitor the patient per policy for the most recent three months he or she was on 0 8 0 0 the medication? (9.002) Annual TB screening: Was the patient screened for TB within the last 15 10 0 60% year? (9.003) Were all patients offered an influenza vaccination for the most recent 25 0 0 100% influenza season? (9.004) All patients from the age of 50 through the age of 75: Was the 24 1 0 96% patient offered colorectal cancer screening? (9.005) Female patients from the age of 50 through the age of 74: Was the N/A N/A N/A N/A patient offered a mammogram in compliance with policy? (9.006) Female patients from the age of 21 through the age of 65: Was N/A N/A N/A N/A patient offered a pap smear in compliance with policy? (9.007) Are required immunizations being offered for chronic care patients? 10 2 13 83% (9.008) Are patients at the highest risk of coccidioidomycosis (valley fever) N/A N/A N/A N/A infection transferred out of the facility in a timely manner? (9.009) Overall percentage (MIT 9): 73% * The OIG clinicians considered these compliance tests along with their case review findings when determining the quality rating for this indicator. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: September 2018 – April 2019 Return to Contents Valley State Prison 47 Nursing Performance Overall In this indicator, the OIG clinicians evaluated the quality of care Rating delivered by the institution’s nurses, including registered nurses (RNs), Adequate licensed vocational nurses (LVNs), psychiatric technicians (PTs), and certified nursing assistants (CNAs). Our clinicians evaluated nurses’ Case Review ability to make timely and appropriate assessments and interventions. Rating We also evaluated the institution’s nurses’ documentation for accuracy Adequate and thoroughness. Clinicians reviewed nursing performance in many clinical settings and processes, including sick call, outpatient care, care Compliance coordination and management, emergency services, specialized medical Score housing, hospitalizations, transfers, specialty services, and medication (N/A) management. The OIG assessed nursing care through case review only and performed no compliance testing for this indicator. When summarizing overall 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. Results Overview VSP nurses provided good nursing care, as noted in Cycle 5. However, our clinicians identified opportunities for improvement in some several areas of the nursing process described in the subcategories below. These nursing process errors did not place patients at significant risk of harm. Considering all these factors, the OIG clinicians rated this indicator adequate. Case Review Results The OIG clinicians reviewed 284 nursing encounters in 56 cases. Of the nursing encounters reviewed, 122 were in the outpatient setting. Case reviewers identified 104 nursing performance opportunities for improvement, eight of which were significant.27 Nursing Assessment and Intervention A critical component of nursing care is the quality of nursing assessment, which includes both subjective (patient interview) and objective (observation and examination) elements. Another essential factor for quality nursing care is nursing intervention. Although VSP nurses made appropriate assessments and interventions, at times they did not review their patients’ medical records properly and did not perform thorough assessments. Fortunately, these errors were minor and did not significantly affect patient care. The following two deficiencies are examples: 27. Significant deficiencies occurred in cases 1, 3, 16, 19, 22, 23, and 44. Report Issued: August 2020 Office of the Inspector General, State of California Return to Contents 48 Cycle 6 Medical Inspection Report • In case 16, the nurse noted on several occasions that the patient was compliant with all his medications. However, the patient periodically refused his asthma medication and medicated eye drops. The nurses did not properly review the patient’s medical record to identify the refusals and did not counsel the patient concerning medication compliance. • In case 19, the patient had a lower-extremity infection. On multiple occasions, the nurses did not assess the patient’s affected area appropriately, including assessing the patient’s gait, pedal pulses, or skin temperature. VSP nurses did not always intervene appropriately for their patients. The most commonly identified error was that nurses periodically failed to address their patients’ symptoms. These oversights occurred in cases 2, 8, 16, 22, 23, 44, 45, and the following case: • In case 17, the nurses did not inform the provider when the patient had high blood pressure readings. On another occasion, the patient submitted a sick call request for severe back and lower extremity pain, but the nurse did not examine the patient on the same day. Although these errors did not harm the patient, they fell below nursing standards of care. Nursing Documentation Without proper documentation, health care staff can overlook changes in a patient’s condition or transmit incomplete or inaccurate information. Poor documentation increases the risk of lapses in care. In most areas, VSP nurses recorded their care acceptably. However, our case reviewers found opportunities for improvement in emergency services, such as time-line discrepancies and incomplete documentation.28 These errors were not clinically significant. Nursing Sick Call Our clinicians reviewed 83 sick call requests. The clinic nurse saw an average of eight patients per day, and staff reported no nurse appointment backlog. VSP nurses usually reviewed sick call requests the same day they received them and performed timely evaluations for symptomatic patients. Most nurses followed the appropriate nursing protocols. However, clinic nurses intermittently made incomplete evaluations. Although these errors did not affect the overall care that the patients received, they were below nursing standards of care. VSP nurse managers should use the following examples for training purposes: 28. Opportunities for improvement were observed in cases 1, 3, 4, 6, 7, 9, 21, and 23. Office of the Inspector General, State of California Inspection Period: September 2018 – April 2019 Return to Contents Valley State Prison 49 • In case 18, the patient complained of severe ear pain, itchiness, and ankle pain. The nurse did not evaluate the patient’s hearing, describe the appearance of the patient’s eardrum, nor evaluate the patient’s gait. • In case 53, the patient complained of arthritis pain while walking and difficulty standing up from a sitting position. The patient did not have pain on the day of the face-to-face appointment. The nurse did not assess the patient’s gait nor lower-extremity strength. Care Coordination VSP managers assigned one LVN care coordinator to each clinic. The care coordinators provided education regarding chronic care conditions, performed tuberculosis (TB) screenings, and issued medical supplies. Our clinicians did not identify any problems in this area during this inspection. Wound Care Our clinicians did not identify any wound care errors. The nurses performed wound care consistent with the providers’ orders. Emergency Services The nurses responded promptly to medical emergencies. Nurses in the TTA appropriately assessed and intervened for their patients. However, nurses demonstrated poor documentation in this area, as detailed in the Emergency Services indicator. Transfers R&R nurses often did not categorize diabetic patients with elevated risk for valley fever and sometimes did not check vital signs before patients transferred to another institution. The TTA nurses did not always properly review or inform the provider of hospital recommendations. Please refer to the Transfers indicator for further details. Specialized Medical Housing The nurses in the OHU made timely and suitable nursing assessments. The Specialized Medical Housing indicator has additional details. Specialty Services VSP nurses provided good care for patients returning from off-site specialty and telemedicine appointments. Please refer to the Specialty Services indicator for additional discussion. Report Issued: August 2020 Office of the Inspector General, State of California Return to Contents 50 Cycle 6 Medical Inspection Report Medication Management The nurses administered medications timely and as ordered. The Medication Management indicator provides further information. Clinician On‑Site Inspection We spoke with nurses in several clinical areas, including the TTA, OHU, R&R, specialty, utilization management, outpatient clinics, and medication areas. Our clinicians attended a well-coordinated clinic huddle, where the provider conveyed pertinent information from the morning provider meeting to the clinic staff. The clinic staff were familiar with their patients. The clinicians discussed the case review findings with nurse managers, who acknowledged the findings and were training the nurses. Nurse managers reported that they held “town hall” educational meetings. The CNE was knowledgeable and well-versed regarding nursing issues. Recommendations We offer no specific recommendations for this indicator. Office of the Inspector General, State of California Inspection Period: September 2018 – April 2019 Return to Contents Valley State Prison 51 Provider Performance Overall In this indicator, OIG case review clinicians evaluated the quality of Rating care the institution’s providers (physicians, physician assistants, and Adequate nurse practitioners) delivered. Our clinicians assessed the institution’s providers’ ability to evaluate, diagnose, and manage their patients Case Review properly. We examined provider performance across several clinical Rating settings and programs, including sick call, emergency services, Adequate outpatient care, chronic care, specialty services, intake, transfers, hospitalizations, and specialized medical housing. The OIG assessed Compliance provider care through case review only and performed no compliance Score testing for this indicator. (N/A) Results Overview VSP providers usually delivered good patient care and made accurate assessments and appropriate decisions. At the on-site inspection, the institution’s providers reported high morale. While provider performance was rated adequate overall, the OIG physicians found some opportunities for improvement in several important areas. VSP’s providers often did not review their patients’ medical records sufficiently and repeatedly did not document their medical care. Fortunately, these errors were not widespread and they usually did not result in increased risk of patient harm. These factors resulted in an adequate rating for this indicator. Case Review Results In 25 comprehensive case reviews, our physicians reviewed 225 face- to-face provider encounters and found one or more provider errors in 62 encounters. We found a total of 84 provider opportunities for improvement, 21 of which were significant. Assessment and Decision‑Making In most cases, VSP providers made good assessments and decisions, diagnosed illnesses correctly, made appropriate follow-up appointments, ordered suitable tests, and referred their patients to the proper specialists. However, case reviewers identified occasionally questionable decision-making and found opportunities for improvement in cases 3, 15, and in the following case: • In case 10, the provider prescribed an unnecessary blood thinner. The patient did not need the blood thinner because he had a biological heart valve. By prescribing the medication, the provider unnecessarily increased the patient’s risk of bleeding. • Also, in case 10, the provider misdiagnosed the patient with a blood clot in the lungs (pulmonary embolism) and incorrectly continued blood thinner medication. The provider did not order any of the necessary laboratory or imaging tests before the diagnosis of pulmonary embolism. This action unnecessarily increased the patient’s risk of bleeding. While the provider’s Report Issued: August 2020 Office of the Inspector General, State of California Return to Contents 52 Cycle 6 Medical Inspection Report error was significant, the error was internally identified and corrected by the CP&S before patient harm occurred. Review of Records The review of records is a basic and essential component of a provider’s evaluation. This review is especially important if the patient underwent recent testing, saw a specialist, or returned from a higher level of care. Providers also must review records for patients unfamiliar to them. VSP providers demonstrated many opportunities for improvement in this area. In fact, 27 of the 82 provider opportunities for improvement occurred because providers did not sufficiently review their patients’ records. Of the 82 opportunities for improvement, 11 were clinically significant. Providers had errors in reviewing records for patients following hospital return, specialty consultations, diabetes care, and medical procedures.29 The errors affected providers’ diagnoses and treatments. Examples follow: • In case 2, the provider did not recognize a new diagnosis of diabetes on laboratory review. Consequently, the provider failed to treat the patient’s diabetes for the remainder of the review period. • In case 3, the provider did not reconcile the cardiology follow- up order after hospitalization for heart bypass surgery. As a result, the patient did not see the cardiologist timely. On site, the provider agreed that he made the mistake. • In case 9, the provider reviewed imaging studies showing kidney hemorrhagic cysts (blood-filled sacs), but did not order the recommended follow-up studies. Another provider also made the same error a month later. No subsequent provider addressed the patient’s kidney cysts in the review period. • As mentioned previously, in case 10, the provider mistakenly prescribed a blood thinner. The provider did not review the echocardiogram30 carefully to identify that the patient had a biological tissue heart valve and did not need anticoagulation. Emergency Care VSP providers appropriately managed patients with urgent or emergent conditions at the TTA. The providers appropriately examined, diagnosed, and triaged patients with urgent and emergent conditions. Our clinicians found only three minor opportunities for improvement in this area, which is discussed further in the Emergency Services indicator.31 29. Cases 1, 2, 3, 9, 10, 11, 18, 19, 23, 24, and 27. 30. An echocardiogram is a procedure using an ultrasound to show the heart’s anatomy and function. 31. Minor deficiencies were observed in cases 2, 10, and 15. Office of the Inspector General, State of California Inspection Period: September 2018 – April 2019 Return to Contents Valley State Prison 53 Chronic Care By appropriately managing chronic health care conditions, such as diabetes, high blood pressure, and abnormal cholesterol levels, providers decrease their patients’ risk of short- and long-term complications. In most instances, VSP providers appropriately managed their patients’ chronic health conditions. Rare exceptions occurred in case 2 and the following case: • In case 10, clinic providers repeatedly failed to manage the patient’s blood pressure, which resulted in multiple TTA visits. Specialty Services The providers appropriately referred patients for specialty consultations when needed. When specialists made recommendations, providers followed the recommendations correctly. Please refer to the Specialty Services indicator for additional details regarding provider performance in this area. Documentation Quality VSP providers demonstrated many opportunities for improvement when documenting their decisions. Case reviewers found widespread documentation errors.32 Poor documentation affected multiple areas of patient care, including diagnoses, treatments, specialty care, and chronic care. The following are examples of poor documentation: • Providers did not record progress notes in cases 7, 8, 19, and 38. • Providers did not document why they did not follow specialists’ recommendations in cases 1, 15, and 23. • In case 19, multiple providers did not record progress notes when prescribing antibiotics or performing procedures, and did not record an elevated blood pressure reading. Although these lapses did not affect the patient, they fell below standards of care. Provider Continuity Provider staffing at VSP was stable during this inspection period; there was no provider staff turnover. In most cases, VSP providers properly assessed their patients with chronic health conditions and appropriately arranged follow-up appointments. As a result, VSP patients experienced very good provider continuity. However, the following case is the sole exception: • In case 27, four primary care providers and four different specialists evaluated the patient for prostate cancer and a second tumor. The high number of providers involved and the lack of care coordination resulted in delayed appointments and treatment plans. As a result, VSP medical staff did not send the 32. Cases 1, 2, 7, 8, 10, 15, 18, 19, 23, and 38. Report Issued: August 2020 Office of the Inspector General, State of California Return to Contents 54 Cycle 6 Medical Inspection Report patient for his prostate cancer treatment until six months after the initial diagnosis. Clinician On‑Site Inspection VSP held daily provider meetings before the clinic huddles. During the meeting, the on-call provider discussed after-hours patients who were evaluated in the TTA, sent to a higher level of care, or returned from off- site specialist appointments. The care team nurses relayed information concerning hospitalized patients and all patients who had upcoming specialty appointments. Providers discussed any pertinent patient issues. All VSP providers praised their physician managers. The CP&S covered the TTA and OHU during providers’ unexpected absences, and also reassigned providers to different clinics, ensuring appropriate medical care for scheduled patients. Physician managers were available to answer questions. Providers reported high morale and felt supported. Providers said they appreciated the constructive feedback their managers gave them regularly. The physician managers expressed satisfaction with their providers’ performance. The institution employed nine providers: three advanced practitioners and six physicians. Two of the six physicians were telemedicine providers. The physician manager explained that the recent difficulty recruiting on-site physicians led to converting two on-site positions to remote telemedicine positions. According to the CME, all VSP providers delivered high-quality care. Recommendations We offer no specific recommendations for this indicator. Office of the Inspector General, State of California Inspection Period: September 2018 – April 2019 Return to Contents Valley State Prison 55 Specialized Medical Housing Overall In this indicator, OIG inspectors evaluated the quality of care in the Rating Adequate specialized medical housing units. VSP’s only specialized medical housing is an outpatient housing unit (OHU). Our clinicians focused on medical staff’s ability to assess, monitor, and intervene for medically Case Review complex patients requiring close medical supervision. Inspectors Rating evaluated the timeliness and quality of provider and nursing intake Adequate assessments and care plans. We assessed staff’s ability to respond promptly when patients’ conditions deteriorated. Our clinicians looked Compliance for good communication when staff consulted with one another while Score Adequate providing continuity of care. Our clinicians also interpreted relevant compliance results and incorporated them into this indicator. (83%) Results Overview VSP providers and nurses delivered quality care in the OHU. Our clinicians found sporadic opportunities for improvement in this area. Although compliance testing found that OHU staff did not always deliver medications timely, our clinicians determined that the delays did not significantly increase the risk of patient harm. Overall, the OHU staff performed well, resulting in an adequate rating for this indicator. Case Review Results OIG clinicians reviewed six OHU cases, which included 43 provider events and 37 nursing events. Each provider and nursing event can represent up to one month of care. Case reviewers identified 27 opportunities for improvement,33 five of which were significant. All five significant opportunities for improvement occurred in one case (case 3) and were related to provider performance. Provider Performance VSP providers usually delivered good care in the OHU. New patients admitted to the OHU received thorough evaluations. The providers followed up on their patients and reviewed test results appropriately. Compliance testing confirmed VSP providers completed admission history and physical examinations promptly, and evaluated their patients at appropriate intervals (MIT 13.003, 90%). The only significant opportunities for improvements were in case 3. These deficiencies did not show any pattern of performance issues. • In case 3, the patient underwent heart bypass surgery. The provider did not order daily aspirin and the cardiology follow- up appointment. Although the patient did not suffer graft failure, these omissions fell below standards of care. On site, the provider agreed. 33. These opportunities for improvement occurred in cases 3, 11, 23, 57, and 58. Report Issued: August 2020 Office of the Inspector General, State of California Return to Contents 56 Cycle 6 Medical Inspection Report • Later in case 3, the provider did not review and reorder the patient’s cardiac rehabilitation appointments after hospitalization. Subsequently, the patient did not receive any further cardiac rehabilitation appointments. Nursing Performance OHU nurses performed timely admission assessments. Compliance testing indicated nurses usually completed an initial assessment for patients on the day of admission (MIT 13.001, 90%). Our clinicians found one late admission assessment in the case reviews: • In case 58, the OHU nurse did not obtain a full health history or perform a thorough physical examination until the following day. Although this did not affect the patient’s overall care, the nurse did not follow OHU policy. Most of the time, the OHU nurses checked on patients appropriately, assessed their functional status, and provided care as ordered by the provider. Case reviewers found isolated opportunities for improvement when OHU nurses made incomplete nursing assessments and interventions: • In case 3, the OHU nurse did not complete an assessment when the patient complained of a productive cough. • In case 57, the nurses did not properly monitor the patient’s fluid intake or weight per provider orders. Although this did not affect the patient’s health outcome, this omission fell below nursing standards of care. • In case 58, the nurses did not follow provider orders to obtain the patient’s vital signs every day. Although the patient was clinically stable, this omission fell below nursing standards of care. Medication Administration In case review testing, clinicians found medication administration in the OHU was occasionally delayed: • In case 23, the pharmacy provided the patient’s inflammatory bowel disease medication two days late. Compliance testing showed that VSP had trouble administering medications to patients timely after admitting patients to the OHU (MIT 13.004, 50%). However, when our clinicians analyzed this low score, we determined that the delays in administration were one-hour to one-day late, and the medications were nonessential. Although there was room for improvement in this area, the OHU patients usually received their medications within clinically appropriate time frames. Clinician On‑Site Inspection The OHU had 20 medical beds, and all were in use during the case review on-site inspection. Half the rooms in the OHU could also be Office of the Inspector General, State of California Inspection Period: September 2018 – April 2019 Return to Contents Valley State Prison 57 used as reverse isolation rooms, and all rooms had a working call-light system present. Compliance testing found the call systems in all rooms functioned properly, and staff had unimpeded access to the patient’s rooms (MIT 13.101, 100%). The OHU staff conducted daily morning huddles, during which they discussed patient care, with an emphasis on pending consultations and specialty service appointments. Recommendations We offer no specific recommendations for this indicator. Compliance Testing Results Table 17. Specialized Medical Housing Scored Answer Compliance Questions Yes No N/A Yes % For OHU, CTC, and SNF: Prior to 4/2019: Did the registered nurse complete an initial assessment of the patient on the day of admission, or within eight hours of admission to CMF’s Hospice? 9 1 0 90% Effective 4/2019: Did the registered nurse complete an initial assessment of the patient at the time of admission? (13.001) * For CTC and SNF only (effective 4/2019, include OHU): Was a written history and physical examination completed within the required time N/A N/A N/A N/A frame? (13.002) * For OHU, CTC, SNF, and Hospice (applicable only for samples prior to 4/2019): Did the primary care provider complete the Subjective, Objective, Assessment, and Plan notes on the patient at the 9 1 0 90% minimum intervals required for the type of facility where the patient was treated? (13.003) *, † Upon the patient’s admission to specialized medical housing: Were all medications ordered, made available, and administered to the 5 5 0 50% patient within required time frames? (13.004) * For OHU and CTC only: Do inpatient areas either have properly working call systems in its OHU & CTC or are 30-minute patient 1 0 0 100% welfare checks performed; and do medical staff have reasonably unimpeded access to enter patient’s cells? (13.101) * Overall percentage (MIT 13): 83% * The OIG clinicians considered these compliance tests along with their case review findings when determining the quality rating for this indicator. † CCHCS changed its policies and removed mandatory minimum rounding intervals for patients located in specialized medical housing. After April 2, 2019, MIT 13.003 only applied to CTCs that still have state-mandated rounding intervals. OIG case reviewers continued to test the clinical appropriateness of provider follow-ups within specialized medical housing units through case reviews. Source: The Office of the Inspector General medical inspection results. Report Issued: August 2020 Office of the Inspector General, State of California Return to Contents 58 Cycle 6 Medical Inspection Report Specialty Services Overall Rating In this indicator, OIG inspectors evaluated the quality of specialty Adequate services. The OIG clinicians focused on the institution’s ability to provide needed specialty care. Our clinicians also examined Case Review specialty appointment scheduling, providers’ specialty referrals, Rating and medical staff’s retrieval, review, and implementation of any Adequate specialty recommendations. Compliance Results Overview Score Proficient VSP provided good specialty services and performed well in compliance (89%) testing. Providers referred their patients to specialists appropriately and followed the specialists’ recommendations. Nurses also did well with their assessments and interventions when their patients returned from specialty consultations. VSP provided excellent specialty access for patients already in the institution; yet, they had difficulty providing timely specialty access for patients transferring into the institution with preexisting referrals. In addition, the institution’s staff demonstrated significant problems handling specialty reports; however, these errors did not significantly impact specialty services. This indicator received an adequate rating. Case Review Results OIG clinicians reviewed 143 events related to specialty services, including 111 specialty consultations and procedures, and found 38 opportunities for improvement,34 three of which were significant.35 Most of the opportunities for improvement were related to processing specialty reports. Access to Specialty Services Compliance testing showed VSP had excellent adherence to policy-required time frames for routine-priority (MIT 14.007, 100%) and high-priority (MIT 14.001, 100%) specialty referrals. VSP did not score as well for patients who transferred into the institution with preapproved specialty services; only 13 of 20 sampled patients (MIT 14.010, 65%) received their specialty appointment on time. Our clinicians also found VSP had good specialty access. Although clinicians identified five opportunities for improvement,36 the errors were not common and were unlikely to place patients at significant risk of harm. Clinicians found one specialty referral that lapsed due to the transfer process: 34. This occurred in cases 3, 7, 9, 10, 11, 12, 15, 18, 19, 20, 21, 22, 23, 25, 26, and 27. 35. Significant deficiencies were observed in cases 26 and 27. 36. Opportunities for improvement were noted in cases 18, 19, 22, 26, and 27. Office of the Inspector General, State of California Inspection Period: September 2018 – April 2019 Return to Contents Valley State Prison 59 • In case 22, the patient transferred to another institution, but returned to VSP. The provider did not review and reorder the oral maxillofacial surgery follow-up appointment per policy. Provider Performance VSP providers performed well with specialty care, usually referring their patients to specialists properly. Clinicians identified only one opportunity for improvement in which the provider ordered the specialty referral with the wrong priority: • In case 26, the patient had shoulder surgery, and the orthopedic specialist recommended a referral to physical therapy. The provider inappropriately ordered routine-priority physical therapy instead of urgent-priority, resulting in delayed therapy. This delay contributed to the subsequent finding by the orthopedic surgeon that the patient developed a restricted active range of motion. On site, the provider acknowledged the incorrect order. Overall, providers gave appropriate follow-up care after the specialty consultations. Compliance testing also found that providers usually saw their patients promptly following a specialty appointment (MIT 1.008, 82%). Nursing Performance The majority of VSP nurses made good assessments and interventions for patients returning from off-site and telemedicine specialty appointments. In addition, nurses appropriately informed providers of specialists’ findings and recommendations, obtained orders, and scheduled provider follow-up appointments. Our clinicians reviewed 27 nursing encounters and identified two opportunities for improvement.37 Although the errors were infrequent, VSP should use the following example for improvement purposes: • In case 7, the nurse did not inform the patient of the correct diabetic medication adjustments prior to his colonoscopy. Health Information Management VSP scored high marks with specialty report retrieval (MIT 4.002, 90%) and provider signatures for high-priority and routine-priority specialty reports (MIT 14.002, 93%, and MIT 14.008, 80%). However, clinicians found delays in scanning and retrieval of specialty reports,38 as well as 37. Opportunities for improvement were found in cases 7 and 20. 38. The institution did not timely retrieve or scan specialty reports in cases 3, 9, 11, 18, 22, 23, 25, 26, and 27. Report Issued: August 2020 Office of the Inspector General, State of California Return to Contents 60 Cycle 6 Medical Inspection Report instances of providers not signing specialty reports.39 Please refer to the Health Information Management indicator for additional details. Clinician On‑Site Inspection Our clinicians met with VSP’s medical managers, providers, nurses, and ancillary staff. The specialty and utilization management nurses were familiar with their patient population, as well as with their responsibilities and duties. The nurses attended the morning provider meeting and relayed pertinent updates for the patients. The providers then transmitted this information to the care teams in the morning clinic huddles. The CP&S described the institution’s tracking processes for specialty appointments and the subsequent provider follow-up appointments. Providers reported no barriers when referring their patients to specialists. However, according to the specialty schedulers, some of the nearby specialists stopped serving VSP patients. The schedulers now relied on the larger metropolitan areas for specialty services, but reported limited specialty appointment availability. VSP managers acknowledged the problems the OIG clinicians identified with specialty report handling and reported they had already started training ancillary staff to improve their handling of specialty reports. Recommendations We offer no specific recommendations for this indicator. 39. Providers failed to sign specialty reports in cases 7, 9, 10, 12, 15, 19, 21, 22, 23, 25, 26, and 27. Office of the Inspector General, State of California Inspection Period: September 2018 – April 2019 Return to Contents Valley State Prison 61 Compliance Testing Results Table 18. Specialty Services Scored Answer Compliance Questions Yes No N/A Yes % Did the patient receive the high-priority specialty service within 14 calendar days of the primary care provider order or the Physician 15 0 0 100% Request for Service? (14.001) * Did the institution receive and did the primary care provider review the high-priority specialty service consultant report within the 14 1 0 93% required time frame? (14.002) * Did the patient receive the subsequent follow-up to the high-priority specialty service appointment as ordered by the primary care 9 1 5 90% provider? (14.003) * Did the patient receive the medium-priority specialty service within 15-45 calendar days of the primary care provider order or Physician N/A N/A N/A N/A Request for Service? (14.004) * Did the institution receive and did the primary care provider review the medium-priority specialty service consultant report within the N/A N/A N/A N/A required time frame? (14.005) * Did the patient receive the subsequent follow-up to the medium- priority specialty service appointment as ordered by the primary care N/A N/A N/A N/A provider? (14.006) * Did the patient receive the routine-priority specialty service within 90 calendar days of the primary care provider order or Physician 15 0 0 100% Request for Service? (14.007) * Did the institution receive and did the primary care provider review the routine-priority specialty service consultant report within the 12 3 0 80% required time frame? (14.008) * Did the patient receive the subsequent follow-up to the routine- priority specialty service appointment as ordered by the primary care 3 1 11 75% provider? (14.009) * For endorsed patients received from another CDCR institution: If the patient was approved for a specialty services appointment at the 13 7 0 65% sending institution, was the appointment scheduled at the receiving institution within the required time frames? (14.010) * Did the institution deny the primary care provider’s request for 19 1 0 95% specialty services within required time frames? (14.011) Following the denial of a request for specialty services, was the patient informed of the denial within the required time frame? 19 0 1 100% (14.012) Overall percentage (MIT 14): 89% * The OIG clinicians considered these compliance tests along with their case review findings when determining the quality rating for this indicator. Source: The Office of the Inspector General medical inspection results. Report Issued: August 2020 Office of the Inspector General, State of California Return to Contents 62 Cycle 6 Medical Inspection Report Table 19. Other Tests Related to Specialty Services Scored Answer Compliance Questions Yes No N/A Yes % Specialty service follow-up appointments: Did the clinician follow-up 23 5 2 82% visits occur within required time frames? (1.008) *, † Are specialty documents scanned into the patient’s electronic health 18 2 10 90% record within five calendar days of the encounter date? (4.002) * * The OIG clinicians considered these compliance tests along with their own case review findings when determining the quality rating for this indicator. † CCHCS changed its specialty policies in April 2019, removing the requirement for primary care physician follow-up visits following most specialty services. As a result, we test 1.008 only for high-priority specialty services or when the staff orders PCP or PC RN follow-ups. The OIG continues to test the clinical appropriateness of specialty follow-ups through its case review testing. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: September 2018 – April 2019 Return to Contents Valley State Prison 63 Administrative Operations Overall In this indicator, OIG compliance inspectors evaluated health care Rating administrative processes. Our inspectors examined the timeliness of Adequate the medical grievance process and checked whether the institution followed reporting requirements for adverse or sentinel events and Case Review patient deaths. Inspectors checked whether the Emergency Medical Rating Response Review Committee (EMRRC) met and reviewed incident (N/A) packages. We investigated and determined if the institution conducted the required emergency response drills. Inspectors also assessed whether Compliance the Quality Management Committee (QMC) met regularly and addressed Score Adequate program performance adequately. In addition, the inspectors examined if the institution provided training and job performance reviews for (83%) its employees. They checked whether staff possessed current, valid professional licenses, certifications, and credentials. The OIG rated this indicator solely based on the compliance score, using the same scoring thresholds as in the Cycle 4 and Cycle 5 medical inspections. Our case review clinicians typically do not rate this indicator. Because none of the tests in this indicator affected clinical patient care directly (it is a secondary indicator), the OIG did not consider this indicator’s rating when determining the institution’s overall quality rating. Recommendations We offer no specific recommendations for this indicator. Compliance Testing Results Nonscored Tests We obtained CCHCS Death Review Committee (DRC) reporting records. After a patient dies, the DRC must complete a death review report within 60 calendar days for unexpected deaths and within 30 calendar days for expected deaths. When the DRC completes the death review summary report, it must submit the report to the institution’s CEO within seven calendar days. Two deaths occurred during the inspection review period, one unexpected death and one expected death. The DRC did not complete the death review reports on time. For the expected death, the DRC finished the report 123 days late and did not notify the institution’s CEO of the report. For the unexpected death, the DRC did not complete the final death review report timely, which remained overdue at the end of the inspection period (MIT 15.998). Report Issued: August 2020 Office of the Inspector General, State of California Return to Contents 64 Cycle 6 Medical Inspection Report Compliance Testing Results Table 20. Administrative Operations Scored Answer Compliance Questions Yes No N/A Yes % For health care incidents requiring root cause analysis (RCA): Did the N/A N/A N/A N/A institution meet RCA reporting requirements? (15.001) Did the institution’s Quality Management Committee (QMC) meet 6 0 0 100% monthly? (15.002) For Emergency Medical Response Review Committee (EMRRC) reviewed cases: Did the EMRRC review the cases timely, and did 3 9 0 25% the incident packages the committee reviewed include the required documents? (15.003) For institutions with licensed care facilities: Did the Local Governing Body (LGB) or its equivalent, meet quarterly and discuss local N/A N/A N/A N/A operating procedures and any applicable policies? (15.004) Did the institution conduct medical emergency response drills during each watch of the most recent quarter, and did health care and 3 0 0 100% custody staff participate in those drills? (15.101) Did the responses to medical grievances address all of the inmates’ 10 0 0 100% grieved issues? (15.102) Did the medical staff review and submit initial inmate death reports 2 0 0 100% to the CCHCS Death Review Unit on time? (15.103) Did nurse managers ensure the clinical competency of nurses who 10 0 0 100% administer medications? (15.104) Did physician managers complete provider clinical performance 5 2 2 71% appraisals timely? (15.105) Did the providers maintain valid state medical licenses? (15.106) 12 0 0 100% Did the staff maintain valid Cardiopulmonary Resuscitation (CPR), Basic Life Support (BLS), and Advanced Cardiac Life Support (ACLS) 2 0 1 100% certifications? (15.107) Did the nurses and the pharmacist-in-charge (PIC) maintain valid professional licenses and certifications, and did the pharmacy 6 0 1 100% maintain a valid correctional pharmacy license? (15.108) Did the pharmacy and the providers maintain valid Drug Enforcement 1 0 0 100% Agency (DEA) registration certificates? (15.109) Did nurse managers ensure their newly hired nurses received the 0 1 0 0 required onboarding and clinical competency training? (15.110) This is a nonscored test. Please Did the CCHCS Death Review Committee process death review refer to the discussion in this reports timely? (15.998) indicator. This is a nonscored test. Please What was the institution’s health care staffing at the time of the OIG refer to Table 4 for CCHCS- medical inspection? (15.999) provided staffing information. Overall percentage (MIT 15): 83% Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: September 2018 – April 2019 Return to Contents Valley State Prison 65 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 Access to Care Emergency Health Care W Services Diagnostic Services Environment C O E I Health Information Management M V P E Nursing Preventive Transfers L R Performance Services I A E Medication Management N S C A C Provider Specialized Medical Housing Administrative E Performance Operations Specialty Services Source: The Office of the Inspector General medical inspection results. Report Issued: August 2020 Office of the Inspector General, State of California Return to Contents 66 Cycle 6 Medical Inspection Report Case Reviews The OIG added case reviews to the Cycle 4 medical inspections at the recommendation of its stakeholders, which continues in the Cycle 6 medical inspections. Below, Table A–1 provides important definitions that describe this process. Table A–1. Case Review Definitions The medical care provided to one patient over a Case, Sample, specific period, which can comprise detailed or focused or Patient case reviews. A review that includes all aspects of one patient’s medical Comprehensive care assessed over a six-month period. This review allows Case Review the OIG clinicians to examine many areas of health care delivery, such as access to care, diagnostic services, health information management, and specialty services. A review that focuses on one specific aspect of medical Focused care. This review tends to concentrate on a singular Case Review facet of patient care, such as the sick call process or the institution’s emergency medical response. A direct or indirect interaction between the patient and the health care system. Examples of direct interactions Event include provider encounters and nurse encounters. An example of an indirect interaction includes a provider reviewing a diagnostic test and placing additional orders. Case Review A medical error in procedure or in clinical judgment. Both procedural and clinical judgment errors can result in policy Deficiency noncompliance, elevated risk of patient harm, or both. Adverse Event An event that caused harm to the patient. Office of the Inspector General, State of California Inspection Period: September 2018 – April 2019 Return to Contents Valley State Prison 67 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, nonclinician 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 standardized protocol and select samples for clinicians to review. Samples are obtained per the case review methodology shared with stakeholders in prior cycles. 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 scenarios 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. Report Issued: August 2020 Office of the Inspector General, State of California Return to Contents 68 Cycle 6 Medical Inspection Report Figure A–2. Case Review Testing The OIG clinicians examine the chosen samples, performing either a comprehensive case review or a focused case review, to determine the events that occurred. Sample = Patient = Case No Deficiency or Minor Deficiency Sample Events Significant Deficiency * A sample leading to events Deficiencies Not all events lead to deficiencies (medical errors); however, if errors did occur, then the OIG clinicians determine whether any were adverse. Significant Sample Events Deficiency * A sample leading to events that could cause harm Did the event cause harm to the patient? * If an event (in this case, a significant deficiency) caused harm, the OIG clinician labels it adverse. Yes No AAddvveerrssee Significant EEvveenntt Deficiency Source: The Office of the Inspector General medical inspection analysis. Office of the Inspector General, State of California Inspection Period: September 2018 – April 2019 Return to Contents Valley State Prison 69 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 Total Patient Population Filters Subpopulation Randomize Sample Flagging Source: The Office of the Inspector General medical inspection analysis. 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. Report Issued: August 2020 Office of the Inspector General, State of California Return to Contents 70 Cycle 6 Medical Inspection Report 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 also obtain information regarding plant infrastructure and local operating procedures. 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 (greater than 85 percent), adequate (between 75 percent and 85 percent), or inadequate (less than 75 percent). Indicator Ratings and the Overall Medical Quality Rating To reach an overall quality rating, our inspectors collaborate and examine all the inspection findings. We consider the case review and the compliance testing results for each indicator. After considering all the findings, our inspectors reach consensus on an overall rating for the institution. Office of the Inspector General, State of California Inspection Period: September 2018 – April 2019 Return to Contents Valley State Prison 71 Appendix B: Case Review Data Table B–1. Case Review Sample Sets Anticoagulation 4 CTC / OHU 3 Death Review / Sentinel Events 3 Diabetes 3 Emergency Services – CPR 2 Emergency Services – Non-CPR 3 High Risk 5 Hospitalization 4 Intrasystem Transfers In 3 Intrasystem Transfers Out 3 RN Sick Call 20 Specialty Services 4 57 Report Issued: August 2020 Office of the Inspector General, State of California Return to Contents 72 Cycle 6 Medical Inspection Report Table B–2. Case Review Chronic Care Diagnoses Diagnosis Total Anemia 6 Anticoagulation 4 Arthritis / Degenerative Joint Disease 3 Asthma 10 COPD 4 Cancer 6 Cardiovascular Disease 8 Chronic Kidney Disease 2 Chronic Pain 10 Cirrhosis / End-Stage Liver Disease 5 Coccidioidomycosis 2 Deep Venous Thrombosis / Pulmonary Embolism 3 Diabetes 17 Gastroesophageal Reflux Disease 10 Hepatitis C 17 Hyperlipidemia 27 Hypertension 26 Mental Health 22 Migraine Headaches 1 Seizure Disorder 5 Sleep Apnea 3 Thyroid Disease 3 194 Office of the Inspector General, State of California Inspection Period: September 2018 – April 2019 Return to Contents Valley State Prison 73 Table B–3. Case Review Events by Program Diagnosis Total Diagnostic Services 181 Emergency Care 81 Hospitalization 37 Intrasystem Transfers In 10 Intrasystem Transfers Out 5 Not Specified 1 Outpatient Care 512 Specialized Medical Housing 103 Specialty Services 153 1,083 Table B–4. Case Review Sample Summary MD Reviews Detailed 25 MD Reviews Focused 1 RN Reviews Detailed 17 RN Reviews Focused 28 Total Reviews 71 Total Unique Cases 57 Overlapping Reviews (MD & RN) 14 Report Issued: August 2020 Office of the Inspector General, State of California Return to Contents 74 Cycle 6 Medical Inspection Report Appendix C: Compliance Sampling Methodology Valley State Prison Quality No. of Indicator Sample Category Samples Data Source Filters Access to Care MIT 1.001 Chronic Care 25 Master Registry • Chronic care conditions (at least Patients one condition per patient — any risk level) • Randomize MIT 1.002 Nursing Referrals 25 OIG Q: 6.001 • See Transfers MITs 1.003 – 006 Nursing Sick Call 30 MedSATS • Clinic (each clinic tested) (6 per clinic) • Appointment date (2 – 9 months) • Randomize MIT 1.007 Returns From 25 OIG Q: 4.005 • See Health Information Community Management (Medical Records) Hospital (returns from community hospital) MIT 1.008 Specialty Services 30 OIG Q: 14.001, • See Specialty Services Follow-Up 14.004 & 14.007 MIT 1.101 Availability of 6 OIG on-site review • Randomly select one housing unit Health Care from each yard Services Request Forms Diagnostic Services MITs 2.001 – 003 Radiology 10 Radiology Logs • Appointment date (90 days – 9 months) • Randomize • Abnormal MITs 2.004 – 006 Laboratory 10 Quest • Appt. date (90 days – 9 months) • Order name (CBC or CMPs only) • Randomize • Abnormal MITs 2.007 – 009 Laboratory STAT 10 Quest • Appt. date (90 days – 9 months) • Order name (CBC or CMPs only) • Randomize • Abnormal MITs 2.010 – 012 Pathology 10 InterQual • Appt. date (90 days – 9 months) • Service (pathology related) • Randomize Office of the Inspector General, State of California Inspection Period: September 2018 – April 2019 Return to Contents Valley State Prison 75 Quality No. of Indicator Sample Category Samples Data Source Filters Health Information Management (Medical Records) MIT 4.001 Health Care Services 20 OIG Qs: 1.004 • Nondictated documents Request Forms • First 20 IPs for MIT 1.004 MIT 4.002 Specialty Documents 20 OIG Qs: 14.002, • Specialty documents 14.005 & 14.008 • First 10 IPs for each question MIT 4.003 Hospital Discharge 20 OIG Q: 4.005 • Community hospital discharge Documents documents • First 20 IPs selected MIT 4.004 Scanning Accuracy 24 Documents for any • Any misfiled or mislabeled tested inmate document identified during OIG compliance review (24 or more = No) MIT 4.005 Returns From 25 CADDIS off-site • Date (2 – 8 months) Community Hospital Admissions • Most recent 6 months provided (within date range) • Rx count • Discharge date • Randomize Health Care Environment MITs 5.101 – 105 Clinical Areas 9 OIG inspector • Identify and inspect all on-site MITs 5.107 – 111 on-site review clinical areas. Transfers MITs 6.001 – 003 Intrasystem Transfers 25 SOMS • Arrival date (3 – 9 months) • Arrived from (another departmental facility) • Rx count • Randomize MIT 6.101 Transfers Out 9 OIG inspector • R&R IP transfers with medication on-site review Report Issued: August 2020 Office of the Inspector General, State of California Return to Contents 76 Cycle 6 Medical Inspection Report Quality No. of Indicator Sample Category Samples Data Source Filters Pharmacy and Medication Management MIT 7.001 Chronic Care 25 OIG Q: 1.001 See Access to Care Medication • At least one condition per patient — any risk level • Randomize MIT 7.002 New Medication 25 Master Registry • Rx count Orders • Randomize • Ensure no duplication of IPs tested in MIT 7.001 MIT 7.003 Returns From 25 OIG Q: 4.005 • See Health Information Community Hospital Management (Medical Records) (returns from community hospital) MIT 7.004 RC Arrivals — N/A at this OIG Q: 12.001 • See Reception Center Medication Orders institution MIT 7.005 Intrafacility Moves 25 MAPIP transfer • Date of transfer (2 – 8 months) data • To location/from location (yard to yard and to/from ASU) • Remove any to/from MHCB • NA/DOT meds (and risk level) • Randomize MIT 7.006 En Route 0 SOMS • Date of transfer (2– 8 months) • Sending institution (another departmental facility) • Randomize • NA/DOT meds MITs 7.101 – 103 Medication Storage Varies OIG inspector • Identify and inspect clinical Areas by test on-site review & med line areas that store medications MITs 7.104 – 107 Medication Varies OIG inspector • Identify and inspect on-site Preparation and by test on-site review clinical areas that prepare and Administration Areas administer medications MITs 7.108 – 111 Pharmacy 1 OIG inspector • Identify & inspect all on-site on-site review pharmacies MIT 7.112 Medication Error 14 Medication error • All medication error reports with Reporting reports Level 4 or higher • Select total of 25 medication error reports (recent 12 months) MIT 7.999 Isolation Unit KOP 1 On-site active • KOP rescue inhalers & Medications medication listing nitroglycerin medications for IPs housed in isolation units Office of the Inspector General, State of California Inspection Period: September 2018 – April 2019 Return to Contents Valley State Prison 77 Quality No. of Indicator Sample Category Samples Data Source Filters Prenatal and Postpartum Care MITs 8.001 – 007 Recent Deliveries N/A at this OB Roster • Delivery date (2 – 12 months) institution • Most recent deliveries (within date range) Pregnant Arrivals N/A at this OB Roster • Arrival date (2 – 12 months) institution • Earliest arrivals (within date range) Preventive Services MITs 9.001 – 002 TB Medications 8 Maxor • Dispense date (past 9 months) • Time period on TB meds (3 months or 12 weeks) • Randomize MIT 9.003 TB Evaluation, 25 SOMS • Arrival date (at least 1 year prior Annual Screening to inspection) • Birth month • Randomize MIT 9.004 Influenza 25 SOMS • Arrival date (at least 1 year prior Vaccinations to inspection) • Randomize • Filter out IPs tested in MIT 9.008 MIT 9.005 Colorectal Cancer 25 SOMS • Arrival date (at least 1 year prior Screening to inspection) • Date of birth (51 or older) • Randomize MIT 9.006 Mammogram N/A at this SOMS • Arrival date (at least 2 yrs. prior institution to inspection) • Date of birth (age 52 – 74) • Randomize MIT 9.007 Pap Smear N/A at this SOMS • Arrival date (at least three yrs. institution prior to inspection) • Date of birth (age 24 – 53) • Randomize MIT 9.008 Chronic Care 25 OIG Q: 1.001 • Chronic care conditions (at least Vaccinations 1 condition per IP — any risk level) • Randomize • Condition must require vaccination(s) MIT 9.009 Valley Fever N/A at this Cocci transfer • Reports from past 2 – 8 months (number will vary) institution status report • Institution • Ineligibility date (60 days prior to inspection date) • All Report Issued: August 2020 Office of the Inspector General, State of California Return to Contents 78 Cycle 6 Medical Inspection Report Quality No. of Indicator Sample Category Samples Data Source Filters Reception Center MITs 12.001 – 008 RC N/A at this SOMS • Arrival date (2 – 8 months) institution • Arrived from (county jail, return from parole, etc.) • Randomize Specialized Medical Housing MITs 13.001 – 004 Specialized Health 10 CADDIS • Admit date (2 – 8 months) Care Housing Unit • Type of stay (no MH beds) • Length of stay (minimum of 5 days) • Rx count • Randomize MIT 13.101 Call Buttons All OIG inspector • Specialized Health Care Housing on-site review • Review by location Specialty Services MITs 14.001 – 003 High-Priority 15 MedSATS • Approval date (3 – 9 months) Initial and Follow-Up • Remove consult to gynecology, RFS consult to public health/Specialty RN, dialysis, ECG 12-Lead (EKG), mammogram, occupational therapy, ophthalmology, optometry, oral surgery, physical therapy, or podiatry • Randomize MITs 14.004 – 006 Medium-Priority N/A MedSATS • Approval date (3 – 9 months) Initial and Follow-Up • Remove consult to gynecology, RFS consult to public health/Specialty RN, dialysis, ECG 12-Lead (EKG), mammogram, occupational therapy, ophthalmology, optometry, oral surgery, physical therapy, or podiatry • Randomize MITs 14.007 – 009 Routine-Priority 15 MedSATS • Approval date (3 – 9 months) Initial and Follow-Up • Remove consult to gynecology, RFS consult to public health/Specialty RN, dialysis, ECG 12-Lead (EKG), mammogram, occupational therapy, ophthalmology, optometry, oral surgery, physical therapy, or podiatry • Randomize MIT 14.010 Specialty Services 20 MedSATS • Arrived from (other departmental Arrivals institution) • Date of transfer (3 – 9 months) • Randomize MITs 14.011 – 012 Denials 20 InterQual • Review date (3 – 9 months) • Randomize 0 IUMC/MAR • Meeting date (9 months) Meeting Minutes • Denial upheld • Randomize Office of the Inspector General, State of California Inspection Period: September 2018 – April 2019 Return to Contents Valley State Prison 79 Quality No. of Indicator Sample Category Samples Data Source Filters Administrative Operations MIT 15.001 N/A – Adverse/sentinel • Adverse/Sentinel events events report (2 – 8 months) MIT 15.002 QMC Meetings 6 Quality • Meeting minutes (12 months) Management Committee meeting minutes MIT 15.003 EMRRC 12 EMRRC meeting • Monthly meeting minutes minutes (6 months) MIT 15.004 LGB N/A LGB meeting • Quarterly meeting minutes minutes (12 months) MIT 15.101 Medical Emergency 3 On-site summary • Most recent full quarter Response Drills reports & • Each watch documentation for ER drills MIT 15.102 Institutional Level 10 On-site list of • Medical grievances closed Medical Grievances grievances/closed (6 months) grievance files MIT 15.103 Death Reports 2 Institution-list of • Most recent 10 deaths deaths in prior • Initial death reports 12 months MIT 15.104 Nursing Staff 10 On-site nursing • On duty one or more years Validations education files • Nurse administers medications • Randomize MIT 15.105 Provider Annual 9 On-site • All required performance Evaluation Packets provider evaluation documents evaluation files MIT 15.106 Provider Licenses 12 Current provider • Review all listing (at start of inspection) MIT 15.107 Medical Emergency All On-site • All staff Response certification ◦ Providers (ACLS) Certifications tracking logs ◦ Nursing (BLS/CPR) • Custody (CPR/BLS) MIT 15.108 Nursing Staff and All On-site tracking • All required licenses and Pharmacist in Charge system, logs, or certifications Professional Licenses employee files and Certifications Report Issued: August 2020 Office of the Inspector General, State of California Return to Contents 80 Cycle 6 Medical Inspection Report Quality No. of Indicator Sample Category Samples Data Source Filters Administrative Operations MIT 15.109 Pharmacy and On-site listing • All DEA registrations Providers’ Drug of provider DEA Enforcement Agency registration #s (DEA) Registrations & pharmacy registration Nursing Staff All document New Employee Orientations Death Review Committee MIT 15.110 Nursing staff • New employees (hired within last All training logs 12 months) MIT 15.998 OIG summary log: • Between 35 business days & deaths 12 months prior 2 • Health Care Services death reviews Office of the Inspector General, State of California Inspection Period: September 2018 – April 2019 Return to Contents Valley State Prison 81 California Correctional Health Care Services’ Response March 30, 2020 Roy Wesley, Inspector General Office of the Inspector General 10111 Old Placerville Road, Suite 110 Sacramento, CA 95827 Dear Mr. Wesley: The Office of the Receiver has reviewed the draft report of the Office of the Inspector General (OIG) Medical Inspection Results for Valley State Prison (VSP) conducted from September 2018 to April 2019. California Correctional Health Care Services (CCHCS) acknowledges the OIG findings. Thank you for preparing the report. Your efforts have advanced our mutual objective of ensuring transparency and accountability in CCHCS operations. If you have any questions or concerns, please contact me at (916) 691-3747. Sincerely, DeAnna Gouldy Associate Director Risk Management Branch California Correctional Health Care Services cc: Clark Kelso, Receiver Diana Toche, D.D.S., Undersecretary, Health Care Services, CDCR Richard Kirkland, Chief Deputy Receiver, CCHCS Katherine Tebrock, Chief Assistant Inspector General, OIG Doreen Pagaran, R.N., Nurse Consultant Program Review, OIG Jennifer Barretto, Director, Health Care Policy and Administration, CCHCS R.Steven Tharratt, M.D., M.P.V.M., FACP, Director, Health Care Operations, CCHCS Roscoe Barrow, Chief Counsel, CCHCS Office of Legal Affairs Lara Saich, Deputy Director, Policy and Risk Management Services, CCHCS Renee Kanan, M.D., Deputy Director, Medical Services, CCHCS Barbra Barney-Knox, R.N., Deputy Director (A), Nursing Services, CCHCS Annette Lambert, Deputy Director, Quality Management, CCHCS Donald B. McElroy, Regional Health Care Executive, Region II, CCHCS Meet Boparai, M.D., Regional Deputy Medical Executive (A), Region II, CCHCS Laura Schaper, Regional Nursing Executive, Region II, CCHCS Raul Recarey, Chief Executive Officer, VSP Amanda Oltean, Staff Services Manager II, Program Compliance Section, CCHCS Leticia Martinez, Staff Services Manager I, Program Compliance Section, CCHCS Misty Palasik, Staff Services Manager I, OIG CALIFORNIA CORRECTIONAL P .0. Box 588500 HEALTH CARE SERVICES Elk Grove, CA 95758 Report Issued: August 2020 Office of the Inspector General, State of California Return to Contents 82 Cycle 6 Medical Inspection Report (This page left blank for reproduction purposes.) Office of the Inspector General, State of California Inspection Period: September 2018 – April 2019 Return to Contents Cycle 6 Medical Inspection Report for Valley State Prison OFFICE of the INSPECTOR GENERAL Roy W. Wesley Inspector General Bryan B. Beyer Chief Deputy Inspector General STATE of CALIFORNIA August 2020 OIG