Wasco State Prison Cycle 6 Medical Inspection

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 Wasco 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 Wasco 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 11 HEDIS Results 11 Recommendations 12 Indicators 14 Access to Care 14 Diagnostic Services 19 Emergency Services 23 Health Information Management 27 Health Care Environment 32 Transfers 37 Medication Management 42 Preventive Services 50 Nursing Performance 51 Provider Performance 56 Reception Center 61 Specialized Medical Housing 65 Specialty Services 68 Administrative Operations 73 Appendix A: Methodology 75 Case Reviews 76 Compliance Testing 79 Indicator Ratings and the Overall Medical Quality Rating 80 Appendix B: Case Review Data 81 Appendix C: Compliance Sampling Methodology 84 California Correctional Health Care Services’ Response 91 Report Issued: August 2020 Office of the Inspector General, State of California Return to Contents iv Cycle 6 Medical Inspection Report Illustrations Tables 1. WSP Summary Table 3 2. WSP Policy Compliance Scores 4 3. WSP Master Registry Data as of June 2019 5 4. WSP Health Care Staffing Resources as of June 2019 6 5. WSP Results Compared With State HEDIS Scores 10 6. Access to Care 17 7. Other Tests Related to Access to Care 18 8. Diagnostic Services 22 9. Health Information Management 30 10. Other Tests Related to Health Information Management 31 11. Health Care Environment 36 12. Transfers 40 13. Other Tests Related to Transfers 41 14. Medication Management 48 15. Other Tests Related to Medication Management 49 16. Preventive Services 50 17. Reception Center 63 18. Other Tests Related to Reception Center 64 19. Specialized Medical Housing 67 20. Specialty Services 71 21. Other Tests Related to Specialty Services 72 22. Administrative Operations 74 A–1. Case Review Definitions 76 B–1. Case Review Sample Sets 81 B–2. Case Review Chronic Care Diagnoses 82 B–3. Case Review Events by Program 83 B–4. Case Review Sample Summary 83 Figures A–1. Inspection Indicator Review Distribution 75 A–2. Case Review Testing 78 A–3. Compliance Sampling Methodology 79 Photographs 1. Indoor waiting area 32 2. Examination table with insufficient space for a patient to lie down 33 3. Expired medical supplies dated August 2018 34 4. Expired medical supplies dated August 2017 34 Cover: Rod of Asclepius courtesy of Thomas Shafee Office of the Inspector General, State of California Inspection Period: December 2018 – May 2019 Return to Contents Wasco 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 inmates 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 Wasco State Prison (WSP), the receiver had not delegated this institution back to the department. We completed our sixth inspection of WWSSPP, and this report presents our assessment of the health care provided at that institution during the inspection period between December 2018 and May 2019.5 Notably, our report of WSP was not impacted by the novel coronavirus disease pandemic (COVID-19). The data we obtained for WSP 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. WSP is located in Wasco, Kern County, houses medium-custody general population, reception center, and minimum-custody inmates. It is designated as a basic care institution, providing general outpatient health care services through its 11 clinics, which handle nonurgent requests for medical services. Patients needing urgent or emergent care are treated in its triage and treatment area (TTA), and inpatient health services in its correctional treatment center (CTC). 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 May 2019, and registered nurse (RN) sick calls that occurred between January 2019 and July 2019. Office of the Inspector General, State of California Inspection Period: December 2018 – May 2019 Return to Contents Wasco State Prison 3 Summary We completed the Cycle 6 inspection of WSP in August 2019. OIG inspectors monitored the Overall institution’s delivery of medical care that occurred between December 2018 and May 2019. Rating The OIG rated the overall quality of health care at Adequate WSP as adequate. We list the individual indicators and ratings applicable for this institution in Table 1 below. Table 1. WSP 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 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 417 patient records and 1,326 data points and observed WSP’s processes during an on-site inspection in July 2019. They used the data to answer 103 policy questions. Table 2 below lists WSP’s average scores from Cycles 4, 5, and 6. OIG case review clinicians (a team of physicians and nurse consultants) reviewed 69 cases, which contained 787 patient-related events. After examining the medical records, our clinicians conducted a follow-up on-site inspection in August 2019 to verify their initial findings. The OIG physicians rated the quality of care for 23 comprehensive case reviews. Table 2. WSP 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 88% 85% 94% 2 Diagnostic Services 60% 73% 55% 4 Health Information Management 74% 70% 87% 5 Health Care Environment 82% 65% 79% 6 Transfers 75% 86% 62% 7 Medication Management 88% 63% 63% 8 Prenatal and Postpartum Care N/A N/A N/A 9 Preventive Services 77% 71% 72% 12 Reception Center 62% 84% 61% 13 Specialized Medical Housing 76% 85% 85% 14 Specialty Services 74% 87% 82% 15 Administrative Operations 93% 79% 78% * 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: December 2018 – May 2019 Return to Contents Wasco State Prison 5 Of these 23 cases, our clinicians rated 19 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 14 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 that 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 WSP Summary Table. In June 2019, the Health Care Services Master Registry showed that WSP had a total population of 5,132. A breakdown of the medical risk level of the WSP population as determined by the department is set forth in Table 3 below. Table 3. WSP Master Registry Data as of June 2019 Medical Risk Level Number of Patients Percentage High 1 35 0.7% High 2 85 1.7% Medium 1838 35.8% Low 3,174 61.8% Total 5,132 100.0% Source: Cycle 6 medical inspection preinspection questionnaire staffing matrix received on June 6, 2019, from Wasco State Prison. 6. The indicator for Prenatal Care does not apply to WSP. 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, WSP had no vacant nurse supervisor positions, but seven vacant nurse positions. At the time of the OIG’s inspection, WSP had no staff on extended leave. Table 4. WSP Health Care Staffing Resources as of June 2019 Executive Primary Care Nursing Nursing Positions Leadership * Providers Supervisors Staff † Total Authorized Positions 5 11 14 162.1 192.1 Filled by Civil Service 5 11 14 155.4 185.4 Vacant 0 0 0 6.7 6.7 Percentage Filled by Civil Service 100% 100% 100% 96% 97% Filled by Telemedicine 0 0.4 0 0 0.4 Percentage Filled by Telemedicine 0 3.6% 0 0 0.2% Filled by Registry 0 0.8 0 0 0.8 Percentage Filled by Registry 0 7.3% 0 0 0.4% Total Filled Positions 5 12.2 14 155.4 186.6 Total Percentage Filled 100% 111% 100% 95.9% 97.1% Appointments in Last 12 Months 0 2 0 6 8 Redirected Staff 0 0 0 0 0 Staff on Extended Leave ‡ 0 0 0 0 0 Adjusted Total: Filled Positions 5 12.2 14 155.4 185.4 Adjusted Total: Percentage Filled 100% 110.9% 100% 95.9% 97.1% * 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 May 6, 2019, from Wasco State Prison. Office of the Inspector General, State of California Inspection Period: December 2018 – May 2019 Return to Contents Wasco 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 WSP during the Cycle 6 inspection. Case Review Results OIG case reviewers (a team of physicians and nurse consultants) assessed 11 of the 14 indicators applicable to WSP. Of these 11 indicators, OIG clinicians rated three proficient, six adequate, and two inadequate. The OIG physicians also rated the overall adequacy of care for each of the 23 detailed case reviews they conducted. Of these 23 cases, 19 were adequate and four were inadequate. In the 787 events reviewed, there were 228 deficiencies, 34 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 WSP: • Similarly to Cycle 5, WSP continued to effectively manage the demands of a high number of health care encounters in the reception center. • The physicians reported good morale and felt supported by leadership at WSP. There were no vacancies at the time of the inspection. This also did not change from Cycle 5. • WSP medical staff diligently worked to continue to improve patients’ access to medical care. The institution has continued to improve from an inadequate rating in Cycle 4 to a proficient rating in Cycle 6 in the Access to Care indicator. • WSP improved its Specialized Medical Housing indicator rating from inadequate in Cycle 5 to proficient in Cycle 6. The institution assigned one provider to the CTC who provided continuity and delivered sound medical judgments. 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 • WSP’s Health Information Management rating improved in Cycle 6 due to institution of the EHRS. The automated integration of diagnostics and progress notes reduced the number of deficiencies due to human error. Our clinicians found WSP could improve in the following areas: • While we rated the Provider Performance indicator adequate, we found a pattern of deficient performance. One provider was responsible for the majority of the quality deficiencies. The provider did not consistently take appropriate histories based on the complaints and did not always consider diagnostic or therapeutic options effectively. He did not know that he needed to reconcile medications and orders when the patient returned from the hospital. He did not carefully coordinate care with other providers. The other providers’ efforts kept this indicator from receiving an inadequate rating. • While WSP improved in the handling of radiology reports in Cycle 6, the Diagnostics Services indicator was rated inadequate due to poor stat laboratory and pathology report retrieval. Providers also did not consistently review laboratory results in a timely manner. • WSP continued to have problems with Medication Management. Its staff performed poorly in medication administration for patients en route from one institution to another and who had a temporary layover at WSP. Medical staff also did not consistently ensure that patients received their hospital discharge medications. These were the same issues found during Cycle 5. In addition, specialized medical housing and transfer-in patients often did not receive their medications timely. Compliance Testing Results Our compliance inspectors assessed 11 of the 14 indicators applicable to WSP. Of these 11 indicators, our compliance inspectors rated two proficient, three adequate, and six 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. WSP demonstrated a high rate of policy compliance in the following areas: • Nursing staff at WSP processed health care services request forms (sick call) and performed face-to-face encounters timely. Furthermore, inspected WSP housing units had adequate supplies of health care services request forms. Office of the Inspector General, State of California Inspection Period: December 2018 – May 2019 Return to Contents Wasco State Prison 9 • WSP excelled in providing follow-up appointments for patients who returned from hospital admission, specialty services, and chronic care appointments within the required time frames. • Health information management staff at WSP timely scanned health care documents into the patient’s electronic health care records. • The institution timely provided initial appointments for high- priority, medium-priority, and routine specialty services. In addition, follow-up specialty services appointments were completed within the required time frames. WSP demonstrated a low rate of policy compliance in the following areas: • Providers at WSP often did not review radiology and stat laboratory results timely. There were delays in communication for the majority of the diagnostic tests. In addition, some patient letters communicating these results were missing the date of the diagnostic test, the date of the radiology results, and whether the results were within normal limits. • Patients often did not receive their chronic care medications and hospital discharge medications as prescribed by the provider. In addition, there was a poor continuity of medications for patients who were newly arrived, had transferred, or had a temporary layover at WSP. • The institution did not adequately perform annual tuberculosis (TB) screening and evaluation. Additionally, nursing staff did not adequately monitor patients on TB medications as required by CCHCS policy. Report Issued: August 2020 Office of the Inspector General, State of California Return to Contents 10 Cycle 6 Medical Inspection Report Table 5. WSP Results Compared With State HEDIS Scores California California WSP 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%) ‡,§ 14% 35% 24% 19% HbA1c Control (< 8.0%) ‡ 75% 54% 63% 71% Blood Pressure Control (< 140/90) ‡ 87% 66% 76% 85% Eye Examinations 48% 61% 75% 84% Influenza – Adults (18 – 64) 47% – – – Influenza – Adults (65 +) 83% – – – Pneumococcal – Adults (65 +) 100% – – – Colorectal Cancer Screening 83% – – – Notes and Sources * Unless otherwise stated, data were collected in June 2019 by reviewing medical records from a sample of WSP’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 WSP population was tested. § For this measure only, a lower score is better. Office of the Inspector General, State of California Inspection Period: December 2018 – May 2019 Return to Contents Wasco State Prison 11 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 WSP’s performance with population-based metrics to assess the macroscopic view of the institution’s health care delivery. WSP’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) ), WSP performed lower in eye examinations. Immunizations Statewide comparative data were not available for immunization measures; however, we include these data for informational purposes. WSP had a 47 percent immunization rate for adults 18 to 64 years old, and an 83 percent immunization rate for adults 65 years of age and older.8 The pneumococcal vaccination rate was 100 percent. 8. The low immunization rate for adults 18 to 64 years old was due resulted from patient refusals. Report Issued: August 2020 Office of the Inspector General, State of California Return to Contents 12 Cycle 6 Medical Inspection Report Recommendations As a result of our assessment of WSP’s performance, we offer the following recommendations to the department: • Because most of the provider deficiencies were due to one provider, we recommend that medical leadership closely monitor a select number of the provider’s notes and provide specific recommendations to improve history-taking, physical examinations, assessments, and plans in a correctional setting. We believe this provider can improve the care rendered with the proper guidance. • Medical leadership should review stat laboratory processes to improve the collection and reporting of these important laboratory tests. • Health information management supervisors should perform daily laboratory audits and coordinate with the chief physician and surgeon (CP&S) to notify providers to endorse their laboratory results. • The Emergency Medical Response Review Committee (EMRRC) should more thoroughly review emergency response events to improve identification of deficiencies. • We recommend consistent and accurate documentation of time lines for emergency events. This could be achieved by standard utilization of computer times or the use of an atomic clock. • Medical leadership should remind providers to send patient notification letters for pathology and laboratory results. • Nursing leadership should remind TTA nurses to notify providers of stat laboratory results. • Nursing leadership and medical record supervisors should ensure all specialty reports are retrieved and scanned timely. • Medical staff should be reminded to follow protocols for managing and storing bulk medical supplies. • Medical staff should be reminded to clean, sanitize, and disinfect clinical health care areas appropriately. • Medical staff should be 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: December 2018 – May 2019 Return to Contents Wasco State Prison 13 • Medical leadership should clarify medication reconciliation responsibilities for patients returning from the hospital or the emergency department. • Nursing leadership should remind nursing staff to provide complete patient assessments in the areas of reception and receiving (R&R), TTA, intrasystem transfers, and clinics. • Nursing leadership should refresh training for nursing staff on recognizing abnormal vital signs and patients with urgent or emergent symptoms. • Fatigue should be added into the electronic health record system (EHRS) as a sign and a symptom for TB screening.9 • Nursing leadership should remind nurses to document the delivery of patient education related to access to care and the complete care model for newly arrived patients to WSP. • In the CTC, we observed the nurses provided patient care at the bedside and then went to a stationary computer to complete their chart assessments. We recommend WSP consider purchasing portable workstations to improve timely and accurate documentation in the CTC. • Nursing and pharmacy leadership should review processes to improve timely medication administration. • The Emergency Medical Response Review Committee (EMRRC) should review emergency medical response incidents timely at the regular monthly meeting following the date of the incidents. • Nursing leadership should ensure timely annual clinical competency testing for nurses. 9. In April 2020, after our review but before this report was published, CCHCS reported having added the symptom of fatigue into the EHRS for TB symptom monitoring. Report Issued: August 2020 Office of the Inspector General, State of California Return to Contents 14 Cycle 6 Medical Inspection Report 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 (94%) WSP excelled in providing access to the providers, nurses, CTC, specialty, specialty follow-ups, and hospitalization follow-ups. The institution voiced concerns because it was the busiest reception center and elimination of the copays for sick calls doubled the institution’s triage needs. Despite these challenges, WSP performed very well. The OIG rated the indicator proficient. Case Review Results We reviewed 224 provider, nursing, specialty, and hospital events that required the institution to generate follow-up appointments. We identified 10 deficiencies in 59 cases related to Access to Care, two of which were significant.10 Access to Clinic Providers WSP performed exceptionally with referrals to providers and requests for provider follow-up in our case review and compliance testing. Failure to ensure provider appointment availability can cause lapses in care. Our compliance testing found chronic care follow-ups occurred timely (MIT 1.001, 92%). When nurses requested a provider follow-up for patient sick-call symptoms, the patients were seen promptly (MIT 1.005, 100%). We reviewed 141 outpatient encounters that requested follow-up and identified only two deficiencies in cases 22 and in 18. The one significant deficiency follows: • In case 18, the clinic nurse requested a PCP follow-up in three days to evaluate the patient’s claim of a skin infection. The institution scheduled the follow-up 10 days later, which was a seven-day delay. Access to Specialized Medical Housing Providers WSP performed well with access in the CTC. When staff admitted patients to the CTC, the providers examined them promptly. Our compliance team found that all history and physical evaluations (H&Ps) 10. We identified deficiencies in cases 3, 11, 18, 20, 22, 27, 39, 65, and 69; and significant deficiencies in cases 18 and 22. Office of the Inspector General, State of California Inspection Period: December 2018 – May 2019 Return to Contents Wasco State Prison 15 were done timely (MIT 13.002, 100%). The CTC provider had a one-to- two-day delay with the required interval follow-ups in three of the nine samples reviewed (MIT 13.003, 67%). Our case review team did not find any problems with access to the CTC provider; the provider saw the patient every three days in the three cases we reviewed. Access to Clinic Nurses Access to clinic nurses was adequate at WSP. Compliance testing showed that registered nurses reviewed the patient’s request for service on the same day the sick-call request was received in 97 percent of the cases tested (MIT 1.003). Our clinicians found that clinic nurses often evaluated their patients for routine sick calls within one business day. This finding correlated with the compliance test result of 94 percent (MIT 1.004). Despite these high compliance scores, case reviewers found delays in access to care when nurses did not recognize urgent medical symptoms in patients’ sick-call requests. We identified these deficiencies in nine cases,11 which is discussed further in the Nursing Performance indicator. WSP had no problems ensuring timely access to other clinic nurses, including RN follow-up and RN care coordination appointments. Access to Specialty Services WSP performed well with access to specialty services. Our compliance testing showed impeccable access for high-priority (MIT 14.001, 100%), medium-priority (MIT 14.004, 100%), and routine-priority (MIT 14.007, 100%) referrals. When the specialist requested a follow-up appointment, the institution scheduled the requested follow-up timely within the appropriate time frames of high-priority (MIT 14.003, 80%, medium- priority (MIT 14.006, N/A), and routine-priority (MIT 14.009, 100%) appointments. Our case review team reviewed 128 specialty events and identified three minor deficiencies with access to the specialists in cases 20, 65, and 69. • In case 20, the provider ordered an endocrinology follow-up within 80 days; however, the patient was scheduled for 90 days instead (a delay of 12 days). • In case 65, the physical therapist recommended four sessions of hand therapy over a two-week period. However, the patient did not receive the last two sessions until a month after the first two sessions were completed. • In case 69, the provider requested a nephrectomy (surgical removal of a kidney) for renal cell carcinoma (kidney cancer) with a routine priority, but wrote “as soon as possible” in the comments section. The patient had the surgery 50 days later. 11. Cases 3, 9, 10, 18, 23, 24, 48, 54, and 63. Report Issued: August 2020 Office of the Inspector General, State of California Return to Contents 16 Cycle 6 Medical Inspection Report Follow-Up After Specialty Service WSP performed well in ensuring that primary care providers had an appointment with the patient after a specialty appointment. Compliance testing revealed that the follow-ups occurred timely (MIT 1.008, 87%). The case review clinicians did not find any problems with access to the PCP after a specialty service appointment. Follow-Up After Hospitalization WSP generally ensured that patients saw their providers promptly after they returned from an off-site hospital. Our compliance testing showed two of the 25 samples were delayed by one business day (MIT 1.007, 92%). Our case review testing did not find any deficiencies in this area out of 18 hospitalizations or emergency department visits. Please refer to the Transfers indicator for additional information. Follow-Up After Urgent or Emergent Care (TTA) WSP providers saw their patients promptly after urgent or emergent care in the TTA. Case reviewers did not find any access problems with follow- up after TTA visits. Follow-Up After Transferring Into the Institution Our clinicians did not identify any delays in provider follow-up for patients who transferred to WSP from another departmental institution or other agencies. Our compliance testing reflected timely R&R RN-to- PCP referrals of newly arrived patients (MIT 12.003, 100%) and initial H&Ps by the providers (MIT 12.004, 100%) for patients received from a county jail. Patients transferred from another departmental institution were also seen within required time frames (MIT 1.002, 88%). Case reviewers did not find any deficiencies in this area. Clinician On-Site Inspection At the on-site inspection, we interviewed leadership, providers, nurses, ancillary support supervisors, and staff. WSP did not have any backlogs for its clinic appointments. The institution reported it had been dealing with an almost doubling of sick-call visits due to the elimination of patient copays. To handle the increased volume, WSP opened nursing clinics on the weekends, stacked (consolidated) appointments, and provided extra nursing staff to the clinics. The CP&S reported he monitored daily access through a master registry. He adjusted staffing to match appointment needs. Although he conducted the provider meetings and was busy with administrative duties, the CP&S was available for any providers’ requests for assistance. On the second day of our on-site inspection, we witnessed a provider request help seeing patients. The CP&S asked two other providers to assist when they were done with their patients. The CP&S also volunteered to see patients as well. Office of the Inspector General, State of California Inspection Period: December 2018 – May 2019 Return to Contents Wasco State Prison 17 Recommendations Because most of the provider deficiencies were due to one provider, we recommend that medical leadership closely monitor a select number of the provider’s notes and provide specific recommendations to improve history-taking, physical examinations, assessments, and plans in a correctional setting. We believe this provider can improve the care rendered with the proper guidance. 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? 21 3 0 88% (1.002) * Clinical appointments: Did a registered nurse review the patient’s request for service the same day it was received? (1.003) * 34 1 0 97% Clinical appointments: Did the registered nurse complete a face-to- face visit within one business day after the CDCR Form 7362 was 33 2 0 94% 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 8 0 27 100% 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 0 0 35 N/A 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 23 2 0 92% frame? (1.007) * Specialty service follow-up appointments: Did the clinician follow-up visits occur within required time frames? (1.008) * ,† 27 4 2 87% 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): 94% * 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. Report Issued: August 2020 Office of the Inspector General, State of California Return to Contents 18 Cycle 6 Medical Inspection Report 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 20 0 0 100% 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 20 0 0 100% 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 10 0 0 100% 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, 6 3 1 67% 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? 4 1 10 80% (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 3 0 0 100% 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 0 0 3 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? 7 0 8 100% (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. Office of the Inspector General, State of California Inspection Period: December 2018 – May 2019 Return to Contents Wasco State Prison 19 Diagnostic Services Overall In this indicator, OIG inspectors evaluated the institution’s ability Rating to timely complete radiology, laboratory, and pathology tests. Our Inadequate inspectors determined whether the institution properly retrieved the resultant reports and whether providers reviewed the results correctly. Case Review In addition, in Cycle 6, we examined the institution’s ability to timely Rating complete and review stat (immediate) laboratory tests. Inadequate Results Overview Compliance Score Inadequate Although WSP performed well in test completion and health information management of routine labs and radiographic studies in case reviews, (55%) it performed poorly with stat laboratory management, pathology report retrieval, and review on compliance testing. Case review saw delays in two of the three stat labs, which did not meet policy guidelines. Case review also found that providers did not consistently review laboratory results timely. Consequently, we rated the Diagnostic Services indicator inadequate. Case Review Results We reviewed 100 diagnostic events and found 12 deficiencies, of which one was significant.12 Of those 12 deficiencies, we found five related to health information management and two for the completion of diagnostic tests. For health information management, we considered test reports that were never retrieved or reviewed as severe a problem as tests that were not performed. Our compliance testing found issues with stat laboratory services. Test Completion Our compliance testing found high performance with completing laboratory (MIT 2.004, 90%) and radiology (MIT 2.001, 90%) services within the required time frames. The institution performed in these two areas similarly in Cycle 5 with the same scores. Our case review testing also showed high performance, as our clinicians identified only one test completion delay and one test that was not done. • In case 22, the provider ordered a urine collection test that was not completed. The test was eventually canceled more than a month later. • In case 27, the provider ordered a blood test be performed on a specific date. However, the diagnostics team drew the blood four days late. WSP performed poorly handling stat laboratory tests (MIT 2.007, 40%); only four of the 10 samples were collected and results compiled within the required time frames. Detailed review of the compliance cases showed four-to-six-hour delays from the stat laboratory collection and 12. Deficiencies in cases 12, 18, 19, 22, and 27; significant in case 22. Report Issued: August 2020 Office of the Inspector General, State of California Return to Contents 20 Cycle 6 Medical Inspection Report result receipt. Two samples were collected late and five results were received late (analysis of these cases indicated the providers did review the stat test results). Our clinicians reviewed three cases that had stat laboratory tests and found delays in documenting results in two of them. Although patients generally received the care they needed, the delays in these stat tests did not meet CCHCS policy. Please see further discussion in the Health Information Management indicator. Health Information Management WSP staff obtained laboratory and diagnostic reports promptly and routed the reports to the providers for review. Our compliance testing showed providers signed the laboratory reports (MIT 2.005, 90%) on time. The providers fared worse in signing the radiology reports (MIT 2.002, 60%). When we analyzed this situation, we found the providers were ordering X-rays on emergent cases and reviewed the X-rays themselves immediately. The providers signed the X-ray reports when the final reading was available. On the case review side, our clinicians found six occurrences in four of the 21 detailed cases in which the provider did not endorse the reports timely; this occurred in cases 3, 12, 18, and 19. The following are two examples: • In case 12, the provider endorsed the laboratory results four days after the results were available. • In case 18, the provider endorsed an abdominal ultrasound 12 days after the result was available. • Our compliance testing showed nurses either delayed or neglected to document notifying the ordering provider within the required one-hour time frame when stat test results were available for review (MIT 2.008 10%). Our compliance testing found the institution retrieved pathology reports 70 percent of the time (MIT 2.010) and the providers signed those reports 75 percent of the time (MIT 2.011). Our case reviews did not identify any deficiencies related to the handling of pathology reports. Clinician On-Site Inspection At the on-site inspection, we interviewed the diagnostic services supervisor, providers, and ancillary staff. Providers reported no concerns with on-site or off-site radiology services. We learned WSP had recent challenges with laboratory testing. Staff reported diagnostics building renovations shifted sample collection from a centralized location to the five different yards. Instead of bringing patients to the diagnostics building, the two phlebotomists had to navigate the five different yards to obtain the samples; this may have caused delays and increased patient refusals for the blood work. Office of the Inspector General, State of California Inspection Period: December 2018 – May 2019 Return to Contents Wasco State Prison 21 The office technician and laboratory staff explained the stat process. When stat labs were obtained during business hours, the nurse contacted a specific courier to pick up the samples, and they were sent to a contracted off-site diagnostic processing service. After hours, the stat labs were processed at a local hospital instead. These facilities were more than 30 minutes from the institution. This may have increased the turnaround time from collection to results over the four-hour deadline for stat laboratory test results. Medical leadership should review stat laboratory processes to improve collection and reporting of these important laboratory tests. Recommendations Medical leadership should review stat laboratory processes to improve the collection and reporting of these important laboratory tests. Health information management supervisors should perform daily laboratory audits and coordinate with the CP&S to notify providers to endorse their laboratory results. Report Issued: August 2020 Office of the Inspector General, State of California Return to Contents 22 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) * 9 1 0 90% 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 4 6 0 40% frames? (2.003) Laboratory: Was the laboratory service provided within the time frame specified in the health care provider’s order? (2.004) * 9 1 0 90% Laboratory: Did the health care provider review and endorse the laboratory report within specified time frames? (2.005) * 9 1 0 90% 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) * 4 6 0 40% Laboratory: Did the nursing staff notify the health care provider within one (1) hour from receiving the STAT laboratory results? (2.008) * 1 9 0 10% 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) * 7 3 0 70% Pathology: Did the health care provider review and endorse the pathology report within specified time frames? (2.011) * 6 2 2 75% Pathology: Did the health care provider communicate the results of the pathology study to the patient within specified time frames? 0 8 2 0 (2.012) Overall percentage (MIT 2): 55% * 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: December 2018 – May 2019 Return to Contents Wasco State Prison 23 Emergency Services Overall In this indicator, OIG clinicians evaluated the quality of emergency Rating medical care. Our clinicians reviewed emergency medical services by Adequate 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 WSP staff provided good emergency care. Emergency medical responses were generally timely. As WSP does not have emergency response vehicles, TTA staff responded to emergencies on foot; nonetheless, patients received care without delay. Providers generally evaluated patients appropriately and made sound assessments and plans. Provider meetings at the beginning and end of the workday helped all providers stay abreast of urgent patient medical issues. Nursing assessments were good, but documentation continued to be an area that offered opportunities for improvement. Factoring in all aspects of emergency care, we rated this indicator adequate. Case Review Results We reviewed 24 urgent/emergent events and found 29 emergency care deficiencies. Of these 29 deficiencies, four were significant.13 The main pattern was documentation deficiencies, specifically, inconsistent or incorrect time lines. Emergency Medical Response WSP staff provided satisfactory care for emergent medical events. WSP was generally able to provide care within policy time frames. The following two case review examples of delays were isolated deficiencies: • In case 3, the patient’s transfer to the TTA was delayed due to custody count. This resulted in a delay of care. During the on-site visit, the institution agreed with this deficiency. The institution provided training to nursing and custody staff. 13. Deficiencies occurred in cases 1, 2, 3, 4, 5, 6, 7, 9, 10, 22, 23, 24, 28, and 37, and were significant in cases 2, 3, and 28. Report Issued: August 2020 Office of the Inspector General, State of California Return to Contents 24 Cycle 6 Medical Inspection Report • In case 9, the patient was found unconscious and unresponsive in the yard. The institution staff did not activate the 9-1-1 emergency system until after the patient arrived in the TTA. Although the patient was transferred for further care in the TTA, the 9-1-1 emergency system should have been activated in the yard for this symptomatic patient. This resulted in a delay of care. Provider Performance WSP providers performed well with urgent and emergent patient encounters during regular and after-hours care. Generally, the providers acted quickly with accurate diagnoses, complete documentation, and appropriate triage. WSP provided excellent intraday and after-hours coverage for emergency care. Our case reviewers found five deficiencies, two of which were significant. The three minor deficiencies14 were due to lack of documentation of a progress note, which did not increase the risk of harm significantly. The two significant deficiencies follow below: • In case 2, the patient presented to the TTA with chest pain. The provider inappropriately sent the patient with tachycardia (rapid heart rate) back to his housing unit without examining the patient. The patient warranted an examination because of his recent heart attack and cardiac stent placement. • In case 3, the patient had headaches and confusion. The TTA provider was not aware of these symptoms and did not thoroughly review the chart to consider neurological causes. Instead of sending the patient to the hospital for more urgent care, the patient was observed in the TTA and returned to housing. The patient eventually had head imaging that showed a brain bleed. Nursing Performance The overall nursing performance by the TTA staff was good. The majority of the 14 cases15 with nursing deficiencies were related to poor documentation and communication. The following two cases show other nursing areas for improvement. • In case 28, the patient transferred into WSP after a hospital discharge for diabetic ketoacidosis (a potentially life-threatening elevation of blood sugar) with a blood sugar level of 535 and was emergently transferred to the TTA. Although, the TTA RN gave insulin and rechecked the blood sugar level one hour later, he did not perform a complete assessment. He did not note symptoms of hyperglycemia, vital signs, disposition, and patient education. Although the patient had no adverse issues, this was below nursing standards. 14. Minor deficiencies in cases 2 and 28. 15. Cases 1, 2, 3, 4, 5, 6, 7, 9, 10, 22, 23, 24, 28, and 37. Office of the Inspector General, State of California Inspection Period: December 2018 – May 2019 Return to Contents Wasco State Prison 25 • In case 2, despite the presence of chest pain and an increased heart rate, TTA staff allowed the patient to ambulate to the TTA. Nursing Documentation Nursing documentation problems accounted for the majority of identified deficiencies within emergency services. Most of the documentation problems were of inaccurate or conflicting times. The nurses also did not always document administration of medications associated with protocols, that is, Narcan or aspirin. Although these documentation issues did not significantly affect patient care, they did not meet CCHCS policy. Emergency Medical Response Review Committee WSP reviewed approximately 40 to 70 emergency responses each month. The TTA SRN II reviewed all emergency cases to confirm time lines were made and policies were followed. For all deficiencies identified, the nursing supervisors and instructors provided training for the staff. Of the 14 cases we reviewed, 13 were emergency send-outs that required review by the EMRRC. We found that the SRN II reviewed the events timely, and all were presented at the monthly meeting following the date of the event. In seven out of 13 cases, the EMRRC reviews did not note several of the deficiencies that were identified by the OIG clinicians. • In case 5, the committee did not identify that the first medical responder used a nonrebreather mask on a patient who was not breathing. The institution addended the progress note after the OIG notified its staff of the deficiency. Clinician On-Site Inspection We found WSP had an efficient and organized process to provide emergent medical care through mutual cooperation between custody, first responders, and TTA staff. Yard staff and pill-line LVNs served as first responders and provided care until TTA staff arrived and assumed care. TTA staff responded to all medical alarms on foot. The TTA area had two beds and was in the process of expansion to accommodate the high volume of patients. Although the current occupied space was compact, the area was clean and organized without clutter. WSP held two daily provider meetings during which staff discussed urgent and emergent cases, including on-call cases. All providers attended and were involved in detailed discussions, including important medications, pertinent laboratory tests and results, and pending actions. The meetings ensured smooth transitions of care and continuity. This hand-off process would be useful at other institutions. Report Issued: August 2020 Office of the Inspector General, State of California Return to Contents 26 Cycle 6 Medical Inspection Report At the time of the case review on-site inspection, the TTA was staffed with two RNs around the clock. There was a provider on-site during normal operating hours and a provider on call after hours. There is often a greater number of emergencies and man-downs16 that occur simultaneously on the third watch, and extra staff had already been requested to meet the increased work load. Staff from other areas were redirected to assist with emergency responses on an as-needed basis. Prior to the case review on-site inspection, WSP made improvements to the TTA by increasing staffing levels, providing better equipment, and improving communication between shifts per the supervisor. Local emergency medical systems staff attended EMRRC meetings and assisted with emergency response training. WSP had implemented improvement projects to enhance emergency care since Cycle 5. This included implementation of disaster carts for multicasualty incidents, updated supplemental emergency medical response bags, and initiation of a hands-on emergency response skills laboratory. Recommendations The EMRRC should more thoroughly review emergency response events to improve identification of deficiencies. We recommend consistent and accurate documentation of time lines for emergency events. This could be achieved by standard utilization of computer times or the use of an atomic clock. 16. This refers to when a patient is found on the ground. Office of the Inspector General, State of California Inspection Period: December 2018 – May 2019 Return to Contents Wasco State Prison 27 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 Compliance checked whether staff labeled and organized documents in the medical Score record correctly. Proficient (87%) Results Overview We compared WSP’s health information management with respect to the new electronic health record system (EHRS). In Cycle 5, WSP was still using the older electronic unit health record system (eUHR). The transition to the EHRS reduced the number of heath information management deficiencies in this cycle. WSP performed well with hospital discharge, urgent or emergent reports, and routine diagnostic reports. The institution had some difficulty with retrieving specialty reports and ensuring providers reviewed them timely. Its staff should work to improve stat laboratory information management. Factoring compliance testing and case reviews, we rated this indicator adequate. Case Review Results The OIG clinicians reviewed 787 events and found 26 deficiencies related to health information management. Of those 26 deficiencies, only one was significant.17 Hospital Discharge Reports WSP performed very well in retrieving and scanning hospital discharge records within the required time frames (MIT 4.003, 100%). Compliance testing showed that the provider reviewed records and the institution obtained complete discharge records 80 percent of the time (MIT 4.005). Case review clinicians reviewed 18 off-site emergency department and hospital events. Our case reviewers did not identify any deficiencies in this area. We discussed hospital discharge reports in the Transfers indicator. Specialty Reports WSP had mixed results with compliance testing for handling of specialty reports. The institution performed well in obtaining provider signatures for urgent high-priority specialty reports (MIT 14.002, 93%) and routine specialty reports (MIT 14.008, 77%). However, medium-priority specialty 17. Deficiencies in cases 1, 2, 12, 17, 18, 19, 20, 22, 23, 24, 25, 27, 65, 69, and 70; significant in case 24. Report Issued: August 2020 Office of the Inspector General, State of California Return to Contents 28 Cycle 6 Medical Inspection Report reports did not score well (MIT 14.005, 0%). A review of these three medium-priority compliance samples showed all were obtained from one to two days late, and one was signed by the provider five days late. Specialty reports were signed late or had no signatures in clinical review of cases 18, 19, 25, 65, 70, and the following two examples: • In case 69, the institution did not obtain the provider’s endorsement of the oncology specialty report. • In case 27, the institution did not obtain the provider’s endorsement of the orthopedic specialty report. Specialty report scanning rates were good in compliance testing (MIT 4.002, 77%). Our case reviewers identified problems with specialty report processing. Retrieval and scanning of the specialty reports were not completed timely in cases 1, 23, 65, and the following: • In case 24, the interventional radiologist performed a vein pressure measurement. However, the institution did not retrieve the specialty report with the measurement. Also in this case, the patient saw the gastrointestinal specialist, but the report was obtained five days later. We also discuss these findings in the Specialty Services indicator. Diagnostic Reports WSP performed well with the handling of diagnostic reports in case review analysis. Out of 100 diagnostic events, only five minor deficiencies were identified;18 they involved one provider not endorsing reports timely. Compliance testing revealed that stat laboratory reports and patient communication of pathology results did not occur within specified time frames. Nurses often did not document notification to the ordering provider within the required one-hour time frame when the stat test results were available for review (MIT 2.008 10%). Analysis of these compliance cases revealed the providers took appropriate action when clinically indicated. The providers reviewed and signed the pathology reports (MIT 2.011, 75%). However, the providers failed to communicate the results to the patients with letters (MIT 2.012, zero %). In review of these compliance cases, the providers usually followed up with the patient and reviewed the results in person, or the specialist who performed the procedure reviewed results with the patient. Our case review testing showed similar results; providers discussed test results with the patients at follow-up clinic appointments instead of sending patient letters. Although 18. Deficiencies in cases 12, 18, and 19. Office of the Inspector General, State of California Inspection Period: December 2018 – May 2019 Return to Contents Wasco State Prison 29 technically a failure to follow CCHCS policy, there were no negative outcomes to the patients. Please refer to the Diagnostic Services indicator for further detailed discussion about diagnostics. Urgent and Emergent Records WSP performed very well with urgent and emergent records. We reviewed 24 TTA and emergency encounters at WSP, which had no health information management deficiencies. Refer to the Emergency Services indicator for additional information regarding emergency care documentation. Scanning Performance Our compliance testing sample revealed minor errors in proper scanning of medication records (MIT 4.004, 79%). Likewise, our case review clinicians identified duplication errors and misfiling of documents as follows: • We identified misfiled documents in cases 1, 2, 17, 20, 24, and 25. • We found scanned duplicates of surgery consultation documents in case 22. Clinician On-Site Inspection At the on-site inspection, we discussed the health information management processes and deficiencies identified during the case review with WSP office technicians, diagnostic staff, nurses, and providers. The medical records supervisor described the processes of retrieving documents from on-site and off-site reports, along with routing them to the providers for review. The providers reported medical records staff obtained outside records quickly and records were routed appropriately for review. Health information for stat laboratory tests was possibly affected by a few factors. WSP used two off-site contractors, a private processing laboratory and a local hospital, which were more than 30 minutes from the institution. This may have resulted in a delayed turnaround from collection to results. Please see the discussion in the Diagnostic Services indicator for further information. Recommendations Medical leadership should remind providers to send patient notification letters for pathology and laboratory results. Nursing leadership should remind TTA nurses to notify providers of stat laboratory results. Nursing leadership and medical record supervisors should ensure all specialty reports are retrieved and scanned timely. Report Issued: August 2020 Office of the Inspector General, State of California Return to Contents 30 Cycle 6 Medical Inspection Report 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 20 0 15 100% date? (4.001) Are specialty documents scanned into the patient’s electronic health 17 5 11 77% 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 20 0 5 100% hospital discharge? (4.003) * During the inspection, were medical records properly scanned, 19 5 0 79% 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): 87% * 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: December 2018 – May 2019 Return to Contents Wasco State Prison 31 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 1 9 0 10% one (1) hour from receiving the STAT laboratory results? (2.008) * Pathology: Did the health care provider review and endorse the 6 2 2 75% pathology report within specified time frames? (2.011) * Pathology: Did the health care provider communicate the results of the 0 8 2 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 0 3 0 0 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 10 3 2 77% 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. Report Issued: August 2020 Office of the Inspector General, State of California Return to Contents 32 Cycle 6 Medical Inspection Report Health Care Environment Overall Rating In this indicator, OIG compliance inspectors tested clinics’ waiting areas, Adequate infection control, sanitation procedures, medical supplies, equipment management, and examination rooms. Inspectors also tested clinics’ Case Review ability to maintain auditory and visual privacy for clinical encounters. Rating Compliance inspectors asked the institution’s health care administrators (N/A) to comment on their facility’s infrastructure and its ability to support health care operations. The OIG rated this indicator solely on the Compliance compliance score, using the same scoring thresholds as in the Cycle 4 Score and Cycle 5 medical inspections. Our case review clinicians typically do Adequate not rate this indicator. (79%) Compliance Testing Results For this indicator, WSP’s performance improved compared with its performance in Cycle 5. Waiting areas were adequate and core medical equipment was available. However, improvement was needed in other aspects of WSP’s health care environment. Some examination rooms lacked space for examination. In a few clinics, our compliance inspectors found unidentified medical supplies and expired medical supplies. Lastly, WSP staff did not regularly wash their hands when examining their patients or when applying gloves. On the whole, however, WSP’s performance in this indicator was adequate. Outdoor Waiting Areas With the new health care facility improvement program construction of WSP clinics, there were no waiting areas that required patients to be outdoors. Indoor Waiting Areas We inspected indoor patient waiting areas. Health care custody staff reported the existing waiting areas had sufficient seating capacity. The staff also explained that they call and escort a few patients at a time to prevent overcrowding. At the time of our inspection, we did not observe overcrowding of patients in any of the clinics’ indoor waiting areas (Photo 1, left). Photo 1. Indoor waiting area (photographed 7/8/19). Office of the Inspector General, State of California Inspection Period: December 2018 – May 2019 Return to Contents Wasco State Prison 33 Clinic Environment Nine of the 11 clinic environments were sufficiently conducive for medical care; they provided reasonable auditory privacy, appropriate waiting areas, wheelchair accessibility, and nonexamination room workspace. In one clinic, the blood draw station did not provide reasonable auditory privacy. In another clinic, the vital sign check stations’ configuration did not provide reasonable auditory privacy (MIT 5.109, 82%). Of the 11 clinics we observed, eight contained appropriate space, configuration, supplies, and equipment to allow their clinicians to perform proper clinical examinations. The remaining three clinics had one or more of the following deficiencies: a torn examination table cover, examination rooms lacking visual privacy, examination table placement preventing patients from fully lying down, or unsecured confidential medical records (MIT 5.110, 73%) (Photo 2, below). Photo 2. Examination table with insufficient space for a patient to lie down (photographed on 7/11/19). Clinic Supplies Six of the 11 clinics followed adequate medical supply storage and management protocols. The remaining five clinics had one or more of the following deficiencies: cleaning supplies stored in the same area with medical supplies, unidentified medical supplies, medical supplies stored directly on the floor, and expired medical supplies (MIT 5.107, 55%) (Photos 3 and 4, next page). Report Issued: August 2020 Office of the Inspector General, State of California Return to Contents 34 Cycle 6 Medical Inspection Report Nine of the 11 clinics met requirements for essential core medical equipment and supplies (MIT 5.108, 82%). One clinic did not have an oto-ophthalmoscope. At another clinic, we found the Snellen reading chart was placed at an improper distance. We examined emergency medical response bags (EMRBs) to determine if they contained all essential items. We checked if staff inspected the bags daily and inventoried them monthly. Seven of the nine EMRBs passed our test. In nine clinics, staff ensured the EMRBs’ compartments were sealed and intact (MIT 5.111, 78%). Photo 3. Expired medical supplies dated August 2018 (photographed on 7/10/19). Medical Supply Management The institution scored 100 percent in this test. Staff in the medical supply storage areas outside the clinics (e.g., warehouse, Conex containers, etc.) did well in storing clinic medical supplies (MIT 5.106). According to the chief executive officer (CEO), the institution’s nurse supervisors performed the medical supply inventory with an office technician and submitted orders on a weekly basis, and deliveries of medical supplies were scheduled the following week after receiving the orders. Furthermore, health care managers expressed no concerns about either the medical supply chain or their communication process with the existing system in place. Photo 4. Expired medical supplies dated August 2017 (photographed on 7/10/19). Office of the Inspector General, State of California Inspection Period: December 2018 – May 2019 Return to Contents Wasco State Prison 35 Infection Control and Sanitation Staff appropriately cleaned, sanitized, and disinfected eight of 11 clinics (MIT 5.101, 73%). In two clinics, the staff did not appropriately maintain the cleaning logs. In one clinic, cleaning staff did not empty the biohazardous waste bin from the previous day. Staff in 10 of 11 clinics properly sterilized or disinfected medical equipment (MIT 5.102, 91%). In one clinic, when describing their daily protocol, staff did not discuss disinfecting the examination table prior to the start of their shift. We found operating sinks and hand hygiene supplies in the examination rooms in all 11 clinics (MIT 5.103, 100%). We observed patient encounters in 10 clinics. Clinicians followed good hand hygiene practices in four clinics. In six clinics, clinicians failed to wash their hands before examining their patients, or before donning gloves (MIT 5.104, 40%). Health care staff in all 11 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, WSP was renovating and adding clinic spaces to four medical clinics. These projects began in 2016, and health care managers estimated completion of projects by summer of 2020. According to the institution’s CEO, the renovation and expansion of one clinic was expected to be delayed by approximately 60 days due to the change of a temporary clinic location. However, the CEO did not believe this delay would negatively impact the provision of patient care (MIT 5.999). Recommendations Medical staff should be reminded to follow protocols for managing and storing bulk medical supplies. Medical staff should be reminded to clean, sanitize, and disinfect clinical health care areas appropriately. Medical staff should also be reminded to follow universal hand hygiene precautions. Implementing random spot checks may help with compliance. Report Issued: August 2020 Office of the Inspector General, State of California Return to Contents 36 Cycle 6 Medical Inspection Report Table 11. Health Care Environment Scored Answer Compliance Questions Yes No N/A Yes % Infection control: Are clinical health care areas appropriately 8 3 0 73% 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 10 1 0 91% disinfected as warranted? (5.102) Infection control: Do clinical health care areas contain operable sinks 11 0 0 100% and sufficient quantities of hygiene supplies? (5.103) Infection control: Does clinical health care staff adhere to universal 4 6 1 40% hand hygiene precautions? (5.104) Infection control: Do clinical health care areas control exposure to 11 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 1 0 0 100% of the medical health care program? (5.106) Clinical areas: Does each clinic follow adequate protocols for 6 5 0 55% managing and storing bulk medical supplies? (5.107) Clinical areas: Do clinic common areas and exam rooms have 9 2 0 82% essential core medical equipment and supplies? (5.108) Clinical areas: Are the environments in the common clinic areas 9 2 0 82% conducive to providing medical services? (5.109) Clinical areas: Are the environments in the clinic exam rooms 8 3 0 73% 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, 7 2 2 78% 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): 79% * 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: December 2018 – May 2019 Return to Contents Wasco State Prison 37 Transfers Overall Rating In this indicator, OIG inspectors examined the transfer process for Adequate those patients who transferred into the institution, as well as for those who transferred to other institutions. For newly arrived patients, our inspectors assessed the quality of health screenings and the continuity Case Review of provider appointments, specialist referrals, diagnostic tests, and Rating Adequate 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 (62%) 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 WSP performed well in the following areas: R&R nurses completed initial health screens with minor deficiencies, ensured timely provider follow- up for new arrivals and hospital discharges, and medication continuity for patients transferring from one housing unit to another within the facility. WSP did well in preparing transfer packets for patients transferring out of WSP and in the timely scanning of hospital discharge documents. Furthermore, WSP providers generally reviewed discharge documents timely. Areas that demonstrated opportunities for improvement were in ensuring medication continuity for patients who transferred into the institution, with hospital discharge medications, and in timely providing medications to layover patients. Considering compliance and case reviews, on balance, we rated this indicator adequate. Case Review Results We reviewed 21 cases in which patients transferred into or out of the institution or returned from an off-site hospital or emergency room. We identified 18 deficiencies, two of which were significant. Transfers In Compliance testing showed WSP nurses did not complete the initial health screening in 22 of the 24 patients tested (MIT 6.001, 8%). The symptom of fatigue was not included in the nursing form, so it was not addressed in the tuberculosis (TB) screening, resulting in low scores. Case review clinicians reviewed five cases and identified seven minor Report Issued: August 2020 Office of the Inspector General, State of California Return to Contents 38 Cycle 6 Medical Inspection Report deficiencies.19 We found minor deficiencies with health screenings in cases 17, 28, and 29. The nurses did not obtain the patient’s vital signs and did not assess the patient’s dialysis access in one case. These deficiencies did not harm the patient. Provider follow-up appointments for patients who transferred into WSP occurred timely (MIT 1.002, 88%). WSP scheduled specialty appointments for patients who arrived into the institution with approved specialty appointment orders 75 percent of the time (MIT 14.010). The case review clinicians found one scheduling deficiency in case 11 due to an order-entry error for wound care. Case review clinicians did not find any deficiencies with provider follow-ups or approved specialty appointment orders. Medication continuity was an area that showed room for improvement. Compliance testing results were poor (MIT 6.003, 38%) for transfer-in patients at WSP. Close review of the samples showed most medication delays were hours to one day late, which were not clinically significant. Case review clinicians found one of the four patients reviewed did not receive medications in a timely manner. • In case 29, the R&R nurse did not ensure that the patient received his blood pressure medication as the provider ordered. In case review, when patients transferred from one housing unit to another, they received their medications without interruption. The institution performed well; most patients tested received their medications without disruption (MIT 7.005, 84%). WSP performed poorly when it came to medicating layover patients timely. Only one out of six layover patients received his ordered medications without interruption (MIT 7.006 17%). This area showed room for improvement.20 Transfers Out WSP performed well when our compliance inspectors tested patients transfer packages for required transfer medications and documents (MIT 6.101, 100%). Our case review clinicians reviewed three cases of patients who transferred out of WSP and identified three deficiencies. Nurses did not obtain vital signs before the patient transferred out in cases 11 and 32; nurses did not ensure the patient had all his transfer medications in case 23. These were isolated and minor deficiencies that did not affect the patient’s care. Hospitalizations Patients returning from an off-site hospitalization or emergency room are at high-risk for lapses in care. They can require more care and place 19. Transfer-in cases reviewed: 3, 11, 17, 28, and 29; deficiencies in cases 11, 17, 28, and 29. 20. After the compliance review period at WSP, CCHCS changed its forms regarding keep- on-person (KOP) documentation for layovers. Office of the Inspector General, State of California Inspection Period: December 2018 – May 2019 Return to Contents Wasco State Prison 39 strain on the institution’s resources. Successful health information transfer is necessary for good quality care. A lapse in care can result in serious consequences for these patients. Compliance testing showed WSP did not perform well in continuity of medication after hospital discharge (MIT 7.003, 32%). In the samples that failed this measure, patients received their medications hours to one day late in most cases. Case review clinicians reviewed 21 cases of patients who returned from the hospital and identified eight deficiencies in the hospital return process. Problems with hospital discharge medication occurred in case 1, and in the following two cases: • In case 3, the nurse did not ensure that the patient received all the medications that the hospitalist recommended.21 • In case 12, the institution delayed administering the patient’s chronic care medications after returning from the hospital. The rest of the deficiencies were due to late provider signatures in cases 2 and 69; misdated record in case 2; and nurses performing incomplete assessments in cases 6 and 22. WSP performed well in providing timely provider follow-up for patients returning from the hospital (MIT 1.007, 92%). Discharge documents were scanned into the patient’s electronic health record within the required time frame for all the samples tested (MIT 4.003, 100%). For the quality and timely provider review of the hospital discharge documents, WSP received a score of 80 percent (MIT 4.005). Clinician On-Site Inspection During our on-site inspection at WSP, we learned that due to the large number of patients transferring out of WSP, the institution had assigned a nurse (transfer nurse) specifically to prepare packets for patients transferring out of the institution. The nurse ensured the packet included all required transfer medications, documents, and durable medical equipment. Please see the Reception Center indicator for additional information. Recommendations Medical leadership should clarify medication reconciliation responsibilities for patients returning from the hospital or the emergency department. Nursing leadership should remind nursing staff to provide complete patient assessments in the areas of reception and receiving (R&R) and intrasystem transfers. 21. This is discussed further in the Specialized Medical Housing indicator. Report Issued: August 2020 Office of the Inspector General, State of California Return to Contents 40 Cycle 6 Medical Inspection Report 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 22 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 23 0 1 100% 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, 5 8 11 38% 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 10 0 0 100% transfer packet required documents? (6.101) * Overall percentage (MIT 6): 62% * 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: December 2018 – May 2019 Return to Contents Wasco State Prison 41 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 21 3 0 88% 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 23 2 0 92% 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 20 0 5 100% 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 8 17 0 32% patient within required time frames? (7.003) * Upon the patient’s transfer from one housing unit to another: Were 21 4 0 84% 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 1 5 0 17% 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 3 1 0 75% 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. Report Issued: August 2020 Office of the Inspector General, State of California Return to Contents 42 Cycle 6 Medical Inspection Report Medication Management Overall Rating In this indicator, OIG inspectors evaluated the institution’s ability to Inadequate administer prescription medications on time and without interruption. The inspectors examined this process from the time a provider Case Review prescribed medication until the nurse administered the medication to Rating the patient. When rating this indicator, the OIG strongly considered Adequate the compliance test results, which tested medication processes to a much greater degree than case review testing. In addition to examining Compliance medication administration, our compliance inspectors also tested many Score other processes, including medication handling, storage, error reporting, Inadequate and other pharmacy processes. (63%) Results Overview WSP performed similarly to its performance in Cycle 5. Compliance performance was poor in chronic medication continuity, hospital discharge medications, specialized medical housing medications, and medication continuity upon transferring into the institution. Its staff performed well in new medication prescriptions and ensuring patients had medications when they transferred out of the institution. Case review clinicians found some deficiencies in each subcategory that did not significantly increase the risk of harm to patients. On-site, case review clinicians found that WSP had an efficient medication management process without any medication backlogs. Providers reported good pharmacy support and medication administration. In this indicator, the OIG’s compliance testing and case review processes yielded different results with the compliance review giving an inadequate score and the case review giving an adequate rating. While case review focused on medication administration and its clinical impact, compliance testing gave a more comprehensive assessment of medication administration and pharmacy protocols together with on-site observation of medication and pharmacy operations. As a result, compliance testing was given more weight; we rated this indicator inadequate. Case Review Results Case review clinicians examined 26 cases related to medications and found 16 medication deficiencies, two of which were significant.22 New Medication Prescriptions WSP performed well with availability, administration, and the delivery of new medications at required time frames. Our compliance testing showed that the patients frequently received their new medications on time (MIT 7.002, 83%). Similarly, our case reviews revealed prompt handling of new medications. Our case review clinicians found new 22. Deficiencies in cases 1, 2, 3, 9, 10, 12, 18, 20, 23, 29, 39, 63, 65, and 71; significant in cases 3 and 12. Office of the Inspector General, State of California Inspection Period: December 2018 – May 2019 Return to Contents Wasco State Prison 43 medication prescriptions that were administered late in three cases and not given in one case (case 9). • In case 10, an antibiotic was prescribed by the dentist to start the same day. The patient received the antibiotic a day late. • In case 39, the provider ordered a new pain medication for back pain. The patient received it one day late. • In case 63, the patient had flu symptoms with cough and sore throat. The provider ordered medication to alleviate the throat pain, but the patient received it one day late. Chronic Medication Continuity Compliance testing showed low results for medication continuity of patients with chronic medical conditions (MIT 7.001, 32%). Poor documentation in the medication administration record made it unclear if medications were available within policy. Our case review testing showed that patients usually received their chronic care medications without interruption. We identified only two cases with medication continuity problems. • In case 2, the high blood pressure medication was not renewed, and the patient did not receive it for the rest of the review period. • In case 3, the patient with diabetes received his chronic diabetic medication two days late. Hospital Discharge Medications Our compliance testing showed a below-average score with patients receiving their discharge medications upon return to WSP from an off-site hospitalization or emergency room visit in 25 sample cases (MIT 7.003, 32%). Our review of these compliance cases showed most medications were administered from one dose late to two days late, which did not significantly affect the patients. Our case reviewer examined 18 hospitalization discharges during the course of the review period and found two deficiencies related to the medications. The following are examples: • In case 1, the patient was hospitalized for pneumonia with recommendations to take antibiotics for three days. The antibiotic was not available, and the patient missed two doses. • In case 12, the patient was hospitalized for chest pain. The provider ordered aspirin, and blood pressure and heart medications, which were given between one and two days late. Specialized Medical Housing Medications Compliance testing performance was low in the area of specialized medical housing (MIT 13.004, 60%). However, in case reviews, patients in specialized medical housing mostly received their medications on time Report Issued: August 2020 Office of the Inspector General, State of California Return to Contents 44 Cycle 6 Medical Inspection Report without any significant deficiencies. We identified one minor deficiency in which the patient did not receive one dose of his acid-reducing medication because it was not available. Transfer Medications WSP’s performance in this area was poor. Compliance testing of medication continuity in newly transferred patients (to WSP from a county jail) revealed a low score (MIT 7.004, 71%). Our clinicians reviewed 10 reception center transfers and found one deficiency: • In case 9, the provider prescribed an asthma inhaler for a patient who had just arrived from the county jail. The patient did not receive the medication. Our compliance testing showed patients received their prescribed medications timely upon arrival from another institution in only five of 12 samples we tested (MIT 6.003, 38%). Our clinicians found an example: • In case 29, the patient transferred in from another institution and did not receive the transfer medications timely. The blood pressure medications and vitamin D were administered a day late. For patients en-route (lay over at the institution), only one of six patients had existing medications that were administered or delivered without interruption (MIT 7.006, 17%). In contrast, WSP ensured medication continuity for patients transferring out of the institution. Our compliance testing showed all patients received their medications and transfer documents (MIT 6.101, 100%). Our case reviewers found one deficiency: • In case 23, the staff did not give the patient all of his medications when he transferred out of WSP. When the patients transferred from one housing unit to another, WSP maintained medication continuity (MIT 7.005, 84%). Our case reviewers found no deficiencies. For additional details, please refer to the Transfers indicator. Medication Administration Our compliance testing showed nurses correctly administered TB medications as prescribed 92 percent of the time (MIT 9.001), but monitored patients on TB medications less than half the time per policy (MIT 9.002, 40%). WSP nurses did not fully document TB symptoms for monitoring. Case reviews of medication administration showed good performance with the following two exceptions. • In case 65, the patient did not receive one dose of his Zantac (acid-reducing medication) because it was not available. Office of the Inspector General, State of California Inspection Period: December 2018 – May 2019 Return to Contents Wasco State Prison 45 • In case 18, the nurse did not timely document Bactrim (antibiotic to treat soft tissue infection) administration in the medication administration record per policy. It was documented that Bactrim was given two days later in a progress note. Lack of documentation in this medication administration record was a violation of policy. Clinician On-site Inspection WSP had a high-volume reception center with a continual daily influx of patients. We interviewed medication administration staff who described workflows and discussed our case review findings with pharmacy and nursing leadership. At morning team huddles, the primary care team discussed medication renewals, new prescriptions, transfer medications, and patient refusals. Our case review clinicians inspected the pill lines and found no backlogs. All keep-on-person (KOP) medications were given to patients when they were delivered from the pharmacy. In sampling three pill medication drawers, no outstanding or late medications were identified. Provider meetings occurred twice daily, once at 7:00 a.m. and later at 2:30 p.m., which included discussions of important medication changes for the patients. Compliance Testing Results Medication Practices and Storage Controls The institution adequately stored and secured narcotic medications in two of eight applicable clinic and medication line locations. In six locations, we found one or more of the following deficiencies: two licensed nurses did not countersign the narcotics logbook during a change-of-shift inventory count; medication nurses did not document the administration time; and medication nurses did not document the quantity of medications remaining in stock after completing medication administration (MIT 7.101, 25%). WSP appropriately stored and secured nonnarcotic medications in all 11 clinic and medication line locations (MIT 7.102, 100%). Staff kept medications protected from physical, chemical, and temperature contamination in six of the 11 clinic and medication line locations. In five locations, staff did not properly separate storage of oral and topical medications (MIT 7.103, 55%). Staff successfully stored valid, unexpired medications in seven of the 11 clinic and medication line locations. In four locations, medication nurses failed to initial or label the multi-use vial medication as required by CCHCS policy (MIT 7.104, 64%). Nurses exercised proper hand hygiene and contamination control protocols in five of seven applicable medication line locations. In two Report Issued: August 2020 Office of the Inspector General, State of California Return to Contents 46 Cycle 6 Medical Inspection Report locations, nurses neglected to wash or resanitize their hands before each subsequent regloving (MIT 7.105, 71%). Staff in six of seven medication preparation and administration areas demonstrated appropriate administrative controls and protocols. In one location, nurses did not maintain unissued medications in their original labeled packaging (MIT 7.106, 86%). Staff in five of seven medication preparation and administration areas demonstrated appropriate administrative controls and protocols. In two locations, medication nurses did not always ensure that patients swallowed direct observation therapy (DOT) medications (MIT 7.107, 71%). Pharmacy Protocols WSP followed general security, organization, and cleanliness management protocols in its pharmacy. In addition, the pharmacy properly stored nonrefrigerated and refrigerated medications (MITs 7.108, 7.109, and 7.110, 100%). The pharmacist-in-charge (PIC) did not correctly review monthly inventories of controlled substances in the institution’s clinic and medication storage locations. Specifically, the nurses present at the completion of the medication area inspection checklist (CDCR Form 7477) form did not print his or her name, sign, or date the form. These errors resulted in a score of zero percent in this test (MIT 7.111). We examined 25 medication error reports. The PIC timely or correctly processed only 12 of these 25 reports. For 10 medication error reports, the PIC did not provide documentation that a pharmacy follow-up review was performed. For the remaining three medication error reports, the PIC or pharmacist designee did not notify the patient or the prescribing physician of the medication error (MIT 7.112, 48%). Nonscored Tests In addition to testing the institution’s self-reported medication errors, our inspectors also followed up on any significant medication errors found during compliance testing. We did not score this test; we provide these results for informational purposes only. At WSP, the OIG did not find any applicable medication errors (MIT 7.998). The OIG interviewed two patients in isolation units to determine whether they had immediate access to their prescribed asthma rescue inhalers medications. One patient indicated he had access to his rescue inhaler medications. For the remaining patient, he refused the need for a rescue inhaler. We promptly notified the CEO of the patient’s refusal of a rescue inhaler, and health care management immediately documented a new patient refusal (MIT 7.999). Office of the Inspector General, State of California Inspection Period: December 2018 – May 2019 Return to Contents Wasco State Prison 47 Recommendations Medical leadership should clarify medication reconciliation responsibilities for patient returning from a hospital or the emergency department. Nursing and pharmacy leadership should review processes to improve timely medication administration. Report Issued: August 2020 Office of the Inspector General, State of California Return to Contents 48 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 6 13 6 32% no-shows? (7.001) * Did health care staff administer, make available, or deliver new order 20 4 0 83% 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 8 17 0 32% 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 5 2 13 71% delivered to the patient within the required time frames? (7.004) * Upon the patient’s transfer from one housing unit to another: Were 21 4 0 84% 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 1 5 0 17% 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 2 6 3 25% 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 11 0 0 100% 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 6 5 0 55% 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 7 4 0 64% the assigned storage areas? (7.104) Medication preparation and administration areas: Do nursing staff employ and follow hand hygiene contamination control protocols during medication 5 2 4 71% preparation and medication administration processes? (7.105) Medication preparation and administration areas: Does the institution employ appropriate administrative controls and protocols when preparing medications 6 1 4 86% for patients? (7.106) Medication preparation and administration areas: Does the institution employ appropriate administrative controls and protocols when administering 5 2 4 71% 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 1 0 0 100% medications? (7.110) Pharmacy: Does the institution’s pharmacy properly account for narcotic 0 1 0 0% medications? (7.111) Pharmacy: Does the institution follow key medication error reporting 12 13 0 48% 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): 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: December 2018 – May 2019 Return to Contents Wasco State Prison 49 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, 5 8 11 38% 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 10 0 0 100% transfer-packet required documents? (6.101) * Patients prescribed TB medication: Did the institution administer the 23 2 0 92% 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 10 15 0 40% the medication? (9.002) * Upon the patient’s admission to specialized medical housing: Were all medications ordered, made available, and administered to the patient 6 4 0 60% 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 50 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 out patients 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. OIG case review Score clinicians do not rate this indicator. Inadequate (72%) Recommendations Fatigue should be added into the EHRS as a sign and a symptom for TB screening (see footnote 9, page 13). 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 23 2 0 92% 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 10 15 0 40% the medication? (9.002) Annual TB screening: Was the patient screened for TB within the last 5 20 0 20% year? (9.003) Were all patients offered an influenza vaccination for the most recent 24 1 0 96% 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 7 8 59% (9.008) Are patients at the highest risk of coccidioidomycosis (valley fever) 22 0 0 100% infection transferred out of the facility in a timely manner? (9.009) Overall percentage (MIT 9): 72% * 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: December 2018 – May 2019 Return to Contents Wasco State Prison 51 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 The overall nursing care was appropriate and timely. Most deficiencies were minor. The significant deficiencies identified were limited and isolated. The OIG’s rating for this indicator was adequate. Case Review Results We reviewed 231 nursing encounters in 64 cases. Of the nursing encounters we reviewed, 117 were in the outpatient setting. We identified 88 nursing performance deficiencies, nine of which were significant.23 Nursing Assessment and Interventions WSP nurses provided appropriate and timely care the majority of the time. We found proficient nursing care in the reception center and the CTC. However, we identified incomplete nursing assessments in the TTA, intrasystem transfers, and clinics. Incomplete assessments were responsible for most of the significant deficiencies. Some of the deficiencies identified included not recognizing abnormal vital signs, poor recognition of patients with urgent/emergent symptoms, and missing major components of a focused assessment based on specific complaints. • In case 2, the patient complained of leg pain and a stomach acid problem. The nurse did not address the patient’s elevated heart rate (121 beats per minute) and stomach acid problem, nor did the nurse check the affected leg. Although these errors did not harm the patient, they fell below established standards of nursing care. 23. Significant deficiencies in cases 2, 3, 10, 14, 18, 28, 38, and 54. Report Issued: August 2020 Office of the Inspector General, State of California Return to Contents 52 Cycle 6 Medical Inspection Report We identified that the majority of intervention deficiencies were related to TTA events during which staff utilized nursing protocols when addressing urgent/emergent situations. We were able to determine these deficiencies were isolated occurrences. • In case 2, the patient complained of chest pain and the nurse failed to obtain an EKG (electrical tracing of the heart’s rhythm) and did not insert an IV. This is below the established standards of nursing care. Nursing Documentation Overall, the nurses at WSP provided care and documented their findings very well. We identified minimal documentation deficiencies with the exception of the following two events: • In case 22, the nurses did not document a complete assessment of the patient who returned from the hospital after abdominal surgery. • In case 28, the patient with an elevated blood sugar level was seen in the TTA, but the nurse did not document an assessment, an intervention, and a plan of care. Nursing Sick Call We reviewed 98 sick-call events and identified 13 deficiencies24 directly related to inappropriate triage by nursing. The triage deficiencies were responsible for improper scheduling for face-to-face evaluations. Some of the most significant cases are discussed below. • In case 3, the patient complained of continuing headache, and the nurse did not triage the sick-call request appropriately. The patient was not seen within one business day. • In case 18, the nurse did not assess the patient the same day the sick-call request was received with complaint of an infection to his legs. The patient had a prior diagnosis of bacterial infection and presented with the same complaints. • In case 54, the patient submitted a sick-call request with complaint of being sick, his asthma was acting up, and he requested an inhaler and breathing treatment. The nurse failed to evaluate the patient the same day the sick call was triaged. • In case 63, the patient submitted a sick-call request on Friday with a complaint of having a “bad case of the flu, swollen throat, runny nose, chills.” The patient was not evaluated until the next business day, which was three days later. This placed the institution at a risk of outbreak of a potentially infectious disease. 24. Deficiencies in cases 3, 9, 10, 14, 18, 22, 23, 24, 48, 54, 63, and 64. Office of the Inspector General, State of California Inspection Period: December 2018 – May 2019 Return to Contents Wasco State Prison 53 Care Coordinators The care coordinator positions at WSP were held by registered nurses. They review huddle reports of new arrivals and schedule high-risk patients for additional care and teaching. The care coordinators schedule dietary consultations and provide education to patients about disease processes including diabetes and hypertension. Wound Care We reviewed seven cases in which wound care was provided for the patients. We only identified one minor deficiency. While on site, we were advised that wound care is normally the responsibility of the LVNs, but an RN is required to perform an assessment on a weekly basis. The nurse instructors informed the on-site clinicians that wound care was included in the annual skills-day review. Emergency Services Nursing staff provided satisfactory care for all emergency services. Documentation deficiencies continued to be problematic with regard to inconsistent time lines, but this did not alter or affect patient care. A detailed discussion of these deficiencies is found in the Emergency Services indicator. Hospital Returns We reviewed 12 cases that were out to medical hospital returns after admission for a multitude of complaints. All patients returned to the institution through the TTA. The nurses completed assessments, reviewed hospital documents, notified the provider of recommendations, and obtained orders for continuity of care. We identified two cases with minor deficiencies, both related to documentation. Transfers The review of the transfer process at WSP consists of the quality of nursing care provided for intrasystem transfers-in, intrasystem transfers- out, and patients who arrived through the reception center. We reviewed six cases that involved the transfer-out process, noting only two minor deficiencies. We reviewed four cases involving the transfer- in process with four minor deficiencies identified. The identified deficiencies were all related to incomplete assessments that included not obtaining weights or vitals and incomplete documentation of wounds or dialysis access sites. We evaluated 10 cases that arrived at WSP through the reception center. The nurses did not document patient education in four cases.25 During 25. Identified in cases 1, 11, 23, and 34. Report Issued: August 2020 Office of the Inspector General, State of California Return to Contents 54 Cycle 6 Medical Inspection Report our on-site clinician visit, we were provided with the written information given to all new arrivals that fully discussed the sick-call process and the access-to-care model. Specialized Medical Housing Seven cases with a total of 27 events were reviewed. Each event bundled up to two weeks of patient care provided in the CTC. We only identified three minor deficiencies. Nursing staff provided very good care. For more specific details, please refer to the Specialized Medical Housing indicator. Specialty Services We reviewed 10 cases in which patients were out to medical off-site returns after specialty procedures and consultations. There were 11 minor deficiencies. The main deficiencies were abnormal vital signs with lack of intervention and poor communication. Prior to our clinical on-site visit, the facility had already identified and addressed the issue of poor identification of abnormal vital signs. Parameters and policy regarding appropriate intervention had been reviewed with staff. Upon our arrival, different categories of nursing staff, from CNAs to RNs, were able to verbalize correct parameters and proper interventions including manually rechecking abnormal vitals and communication with the providers. Laminated notices of Abnormal Vital Signs as identified by CCHCS were placed on or near the automatic vital signs machines (printed on letter-size sheets of paper). • In case 25, the patient returned to the institution on two separate dates after a stress test and an echocardiogram for the first event and a cardiology consultation on the second event. Upon return from both visits, the patient’s blood pressure was elevated. The nurse did not recheck the vital signs nor communicate abnormal results to the provider. Medication Management The OIG clinicians examined 120 events involving medication management and administration. We found 17 deficiencies with two significant deficiencies. Neither were related to quality of nursing care. For an additional discussion of categories and deficiencies, please refer to the Medication Management indicator. Clinician On-Site Inspection We attended several huddles, which were organized, timely, and well- attended with all pertinent information discussed. Office of the Inspector General, State of California Inspection Period: December 2018 – May 2019 Return to Contents Wasco State Prison 55 Staff from multiple yards and the CTC were very positive about their working conditions and supervision. Staff verbalized they felt supported and could speak to management with ease. Nursing management spoke highly of staff, noting a low turnover rate, improved quality of care, and appropriate interventions. Implemented projects since Cycle 5 included an emergency response skills laboratory and the procurement of nursing equipment to improve care. Recommendations Nursing leadership should remind nursing staff to provide complete patient assessments in the areas of reception and receiving, the TTA, intrasystem transfers, and clinics. Nursing leadership should refresh training for nursing staff on recognizing abnormal vital signs and patients with urgent or emergent symptoms. Report Issued: August 2020 Office of the Inspector General, State of California Return to Contents 56 Cycle 6 Medical Inspection Report Provider Performance Overall Rating In this indicator, OIG case review clinicians evaluated the quality of Adequate care the institution’s providers (physicians, physician assistants, and nurse practitioners) delivered. Our clinicians assessed the institution’s Case Review providers’ ability to evaluate, diagnose, and manage their patients Rating properly. We examined provider performance across several clinical Adequate settings and programs, including sick call, emergency services, outpatient care, chronic care, specialty services, intake, transfers, Compliance hospitalizations, and specialized medical housing. The OIG assessed Score provider care through case review only and performed no compliance (N/A) testing for this indicator. Results Overview We carefully reviewed the clinical cases, incorporated our on-site observations, and considered staff responses to our questions to determine the final rating. During our chart reviews, we identified one provider who was responsible for most of the deficiencies due to insufficient record reviews, superficial history-taking, and poor decision- making. He overlooked hypertension and an abnormal heart rate on multiple occasions. He did not reconcile pending specialty appointments which were canceled due to patient hospitalizations. We had the opportunity to observe this provider during a morning huddle. The huddle was run well, and the provider demonstrated good hepatitis C care coordination with the CCHCS headquarters hepatitis team. During the interview, the provider stated that he deferred hypertension management to the nephrologist if patients were on dialysis or the cardiologist if the cardiologist was consulted. He also deferred action when the transplant work-up revealed diagnostic abnormalities. He was not aware of his specific responsibilities to ensure reconciliation of medications and appointments upon patients’ return from hospitalizations. When we considered his deficiencies, his management during his huddle, length of state service, and interview responses, we concluded that his care would likely improve with close monitoring and feedback. As this sole provider’s care was not representative of the care that other providers offered, we rated this indicator adequate. Case Review Results Case review clinicians found a total of 79 provider deficiencies. Of those 79 deficiencies, 20 were significant. One provider was responsible for the majority of all the provider deficiencies and most of the significant deficiencies (17 out of 20). Our case review clinicians examined the care quality in 23 comprehensive case reviews. Office of the Inspector General, State of California Inspection Period: December 2018 – May 2019 Return to Contents Wasco State Prison 57 Assessment and Decision-Making The majority of the providers made good assessments and decisions. Out of the 49 deficiencies26 that were due to assessment and decision- making, one provider was responsible for the vast majority of them. The provider demonstrated minimal history-taking, a very limited differential diagnoses, and overall poor decision-making. On-site, the provider explained that most of the cases involved specialists, and he deferred management to the specialists. Examples from this provider are as follows: • In case 2, the patient had a recent implantation of a cardiac stent (medical scaffolding that holds arteries open to improve blood flow) and heart failure. The provider repeatedly ignored elevated blood pressures, missed ordering appropriate postprocedural cardiac care, and neglected to consider cardiac causes when the patient had anginal chest pain (pain relieved with nitroglycerin). This increased the patient’s risk of cardiovascular complications. • In case 2, when the patient had uncontrolled hypertension, the provider reduced the dosing frequency of clonidine, resulting in higher blood pressures. • In case 3, the provider did not recognize that headache in combination with confusion and methamphetamine abuse required emergent evaluation. The provider did not send the patient to the hospital for emergent evaluation or urgent head imaging and instead ordered a routine head scan. The patient had an imaging for the hand, and by happenstance, the head imaging was done at the same time, which identified a brain bleed that necessitated emergent neurosurgery. Had WSP scheduled this scan a few days later, the patient likely would have died. Review of Records WSP providers did not always review records carefully. We found 11 deficiencies in nine cases.27 The previously mentioned provider also did not review records carefully to ensure that patients received the care that the patient needed. • In case 3, the provider did not completely reconcile the patient’s medication when he admitted the patient to the CTC after hospital discharge. The patient was missing two chronic condition medications and was started on a new medication without documentation. Although these medication issues were addressed five days later, this demonstrated that the provider did not properly review and ensure the patient had the appropriate medications during transitions in care. 26. Poor assessments and decision-making occurred in cases 1, 2, 3, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 23, 24, 25, 26, 27, 69, and 70. 27. Review deficiencies in cases 1, 2, 3, 13, 14, 15, 17, 25, and 29. Report Issued: August 2020 Office of the Inspector General, State of California Return to Contents 58 Cycle 6 Medical Inspection Report • In case 13, the patient had a diagnosis of a blood clot in the lungs. When the provider reviewed the patient’s outside medical records that showed this was an erroneous diagnosis, he did not correct the medical chart. This increased the risk of harm as the patient did not need the blood thinner. • In case 17, the provider did not review the chart to identify that the patient had refused a Holter monitor six days earlier.28 As a result, this work-up describing this refusal was not completed. Emergency Care WSP providers appropriately managed patients presenting to the TTA with urgent or emergent conditions. The providers aptly examined, diagnosed, and triaged those patients. We found two significant29 and three minor deficiencies30 in this area. We discuss emergency provider performance further in the Emergency Services indicator. • In case 2, on two separate occasions, the provider sent the patient back to housing without an appropriate examination despite chest pain and a history of coronary artery disease. This increased the risk of untreated heart attack and death. Later, the patient was sent to the hospital, diagnosed with a heart attack, and had a cardiac stent implantation. • In case 3, the patient was sent to the TTA for headache and confusion. The provider did not obtain much history from the patient and instead relied on information from custody. The provider attributed the symptoms to drug abuse and sent the patient back to housing after some observation. Later, the patient had an emergent condition with a subdural hematoma (brain bleed) that caused his headache and confusion. Chronic Care In most instances, the WSP providers appropriately managed their patient’s chronic health conditions. However, we identified a pattern in which the providers ignored elevated blood pressures in cases 11, 18, 23, and the following cases: • In case 24, the provider documented an elevated blood pressure of 162/89 (normal is lower than 140/90), but did not provide any assessment nor treatment plans. • In case 25, the provider noted the elevated blood pressure of 154/89, despite recent blood pressure medication changes. The provider did not schedule a follow-up appointment to check on the patient’s blood pressure. 28. A Holter monitor refers to a heart test in which the patient wears a heart monitor for about 24 hours to measure the heart’s activity such as the rate and the rhythm. 29. Significant provider deficiencies in emergency care occurred in cases 2 and 3. 30. We observed minor provider deficiencies in emergency care in cases 2 and 28. Office of the Inspector General, State of California Inspection Period: December 2018 – May 2019 Return to Contents Wasco State Prison 59 Specialty Services The providers appropriately referred patients for specialty consultation when needed. When specialists made recommendations, the providers followed those recommendations appropriately. We discuss providers’ specialty performance further in the Specialty Services indicator. Documentation Quality In general, WSP providers provided accurate documentation. However, the CTC provider cloned parts of his history of present illness and physical exams in five cases.31 These were minor deficiencies and will be discussed in more detail in the Specialized Medical Housing indicator. Provider Continuity Generally, the institution offered good provider continuity. We identified only one case that was affected by lack of care continuity. • In case 15, five different providers saw the diabetic patient and during the review period, his diabetes sugar levels worsened. Clinician On-site Inspection The institution held provider meetings twice a day; one meeting before the clinic huddle in the morning and another one at the end of the workday. The CP&S and all providers were present. The provider- on-call discussed any overnight TTA events, send-outs, and hospital returns during the morning meeting. In the afternoon meeting, the providers discussed the CTC sign-outs, pending studies, and medically active patients with the oncoming provider-on-call. The CP&S was very involved in both meetings and gave updates about the hospitalized patients. We spoke with the CP&S about provider staffing. WSP has seven physicians, four advanced practitioners, two part-time registry providers, and two retired annuitants. One of the positions was staffed by telemedicine. WSP has no vacancies and good provider retention, despite not having a 15 percent recruitment and retention bonus. The CP&S reported that WSP averages about 1,500 appointments per month and about 60 to 100 patient transfers daily. About 15,000 to 18,000 patients per year are processed through the institution. The institution has six dialysis chairs with a current patient dialysis population of 14. The CP&S reported WSP has the same number of provider positions as a neighboring reception center, despite processing one thousand more patients. The CP&S attaches to each provider’s inbox to check that documents and laboratory results were addressed timely. He monitored access every day on the dashboard. He did not have any problems with the providers. 31. Elements of cloned notes were seen in cases 1, 3, 22, 23, and 65. Report Issued: August 2020 Office of the Inspector General, State of California Return to Contents 60 Cycle 6 Medical Inspection Report The providers unanimously supported their medical leadership. The CP&S established camaraderie among the staff by involving them with scheduling and allowing flexibility to swap calls. The providers themselves scheduled patients around their vacations to avoid burdening other providers. The CP&S assisted the providers as needed. He developed multiple back-up systems for coverage in case of unanticipated absences or needs. The providers felt the CME and the CP&S were both approachable and fair. They voiced high morale; their only complaint was that they did not receive the recruitment and retention bonus that some other institutions have received. Recommendations Because most of the provider deficiencies were due to one provider, we recommend that medical leadership closely monitor a select number of the provider’s notes and provide specific recommendations to improve history-taking, physical examinations, assessments, and plans in a correctional setting. We believe this provider can improve the care rendered with the proper guidance. Office of the Inspector General, State of California Inspection Period: December 2018 – May 2019 Return to Contents Wasco State Prison 61 Reception Center Overall Rating This indicator focuses on the management of medical needs and Proficient continuity of care for patients arriving from outside the department’s system. The OIG review includes evaluating the ability of the institution to provide and document initial health screenings, initial health Case Review assessments, continuity of medications, and completion of required Rating screening tests; to address and provide significant accommodations for Proficient disabilities and health care appliance needs; and to identify health care conditions needing treatment and monitoring. The patients reviewed Compliance for reception center cases are those received from nondepartmental Score Inadequate facilities, such as county jails. (61%) Results Overview Despite the large number of patients that are processed in and out of WSP, the institution had only isolated minor deficiencies which did not clinically affect its patients. The low compliance scores were due to the following: The initial health screening did not include fatigue as a symptom of TB. In addition, providers did not communicate results of intake laboratory results to the patient via letters, however, abnormal laboratory results were addressed. Factoring the compliance and case review results, we rated this indicator proficient. Case Review Results Leadership reported that WSP maintains the largest reception center within the State prison system; its staff process a large number of patients who transfer in from the county jail daily. We reviewed 14 cases and identified nine deficiencies,32 none of which were significant. Provider Access WSP utilized its advanced practitioners mainly in the reception center. They provided excellent access in the reception center. Compliance testing found excellent provider access. New patients from county jails were seen within the required time frame (MIT 12.003, 100%). The providers evaluated the patients and performed H&Ps within seven days (MIT 12.004, 100%). They almost always offered all intake tests (MIT 12.005, 95%). Our case review clinicians also did not find any problems with provider access. The providers documented detailed and comprehensive H&Ps without any delays. We did find three minor deficiencies; deficiencies ordering prolonged follow-ups in cases 9 and 13 along with the following: • In case 12, the patient arrived at the reception center with known high blood pressure. The provider ordered most of his 32. Reception center cases: 1, 9, 10, 11, 12, 13, 15, 22, 23, 27, 33, 34, 35, and 36; deficiencies in cases 1, 9, 11, 12, 13, 23, and 34. Report Issued: August 2020 Office of the Inspector General, State of California Return to Contents 62 Cycle 6 Medical Inspection Report medications to start that same day, except for the lisinopril (blood pressure medication). The medication was ordered to start two days later. Nursing Performance We reviewed 10 cases that arrived via the reception center and found no deficiencies with timeliness of evaluation and no unaddressed problems or complaints. This agreed with the compliance results (MIT 12.002, 100%). However, WSP scored zero percent when addressing all signs and symptoms of TB (MIT 12.001). The low score was due to not addressing the symptom of fatigue. There were no noted lapses in offering and ordering of intake testing. Compliance testing noted only one discrepancy for a laboratory test that was canceled for unknown reason by the provider. Appropriate specialty service follow-up appointments were completed in almost every case. The majority of nursing deficiencies that were present in four of the cases we reviewed resulted from a lack of documentation. The identified deficiencies were all related to incomplete assessments that included not obtaining weights or vital signs and incomplete documentation of wounds or dialysis access sites. This is further discussed in the Nursing Performance indicator. Clinician On-Site Inspection The reception center at WSP was busy processing patients through the multitude of steps involved in the intake procedure. The nursing triage was well organized and fully staffed to handle the large number of patients. The R&R nurse informed us that they have between 100 to 130 layovers alone, during the middle of the week. A new staging area was under construction designed to accommodate single rooms for five RNs to interview patients simultaneously. The staff reported that management increased the staffing for the reception center with the implementation of the EHRS, which helped with the high workload. The institution had four to five RNs and two LVNs assigned during the day shift. A copy of WSP’s Reception Center 2019 Inmate Orientation Manual, which is provided for every new arrival, was presented to the OIG case review team during our on-site visit. While awaiting the various medical evaluations, patients watched an orientation video. The nursing staff instructed the patients where to get more information and how to access medical care. Office of the Inspector General, State of California Inspection Period: December 2018 – May 2019 Return to Contents Wasco State Prison 63 Recommendations Fatigue should be added into the EHRS as a sign and a symptom for TB screening (see footnote 9, page 13). Nursing leadership should remind nurses to document the delivery of patient education related to access to care and the complete care model for newly arrived patients to WSP. Compliance Testing Results Table 17. Reception Center Scored Answer Compliance Questions Yes No N/A Yes % For patients received from a county jail: Prior to 4/2019: Did nursing staff complete the initial health screening and answer all screening questions on the same day the patient arrived at the institution? 0 20 0 0 Effective 4/2019: Did nursing staff complete the initial health screening and answer all screening questions upon arrival of the patient at the reception center? (12.001) * For patients received from a county jail: Prior to 4/2019: When required, did the RN complete the assessment and disposition section of the health screening form, and sign and date the form on the same day staff completed the health screening? Effective 4/2019: 19 0 1 100% Did the RN complete the assessment and disposition section, and sign and date the completed health screening form upon patient’s arrival at the reception center? (12.002) * For patients received from a county jail: If, during the assessment, the nurse referred the patient to a provider, was the patient seen 20 0 0 100% within the 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 20 0 0 100% days? (12.004) * For patients received from a county jail: Were all required intake tests 19 1 0 95% completed within specified timelines? (12.005) * For patients received from a county jail: Did the primary care provider review and communicate the intake test results to the 0 20 0 0 patient within specified timelines? (12.006) For patients received from a county jail: Was a tuberculin test both 0 20 0 0 administered and read timely? (12.007) For patients received from a county jail: Was a coccidioidomycosis (valley fever) skin test offered, administered, read, or refused timely? 19 1 0 95% (12.008) Overall percentage (MIT 14): 61% * 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 64 Cycle 6 Medical Inspection Report Table 18. Other Tests Related to Reception Center Scored Answer Compliance Questions Yes No N/A Yes % For patients received from a county jail: Were all medications ordered by the institution’s reception center provider administered, made 5 2 13 71% available, or delivered to the patient within the required time frames? (7.004) * * The OIG clinicians considered these compliance tests along with their own 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: December 2018 – May 2019 Return to Contents Wasco State Prison 65 Specialized Medical Housing Overall In this indicator, OIG inspectors evaluated the quality of care in the Rating specialized medical housing units. WSP’s only specialized medical Proficient 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 Proficient 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 one another while Score providing continuity of care. Our clinicians also interpreted relevant Adequate compliance results and incorporated them into this indicator. (85%) Results Overview The CTC at WSP was well organized and we were able to identify few deficiencies. There was good communication amongst the staff. In this indicator, the case review clinicians and the compliance team yielded different ratings. The compliance team rated this indicator adequate due to medication management and provider rounding. However, the case review clinicians rated this indicator proficient due to minor deficiencies that did not clinically affect the patients’ overall care in the CTC. Therefore, we rated this indicator proficient. Case Review Results We reviewed seven CTC cases, which included 31 provider events and 27 nursing events. Because of the care volume that occurs in specialized medical housing units, each provider event represents up to one month of provider care and each nursing event represents from one week to one month of nursing care based on patient needs, orders and diagnoses. We identified 18 deficiencies, only one of which was significant.33 Provider Performance WSP has one provider assigned to the CTC. The provider generally demonstrated good decision-making for the most medically complex patients at the institution. Compliance testing identified that the provider performed H&Ps timely (MIT 13.002, 100%), but that the provider did not complete progress notes within proper intervals (MIT 13.003, 67%). Delays were from one to two days. Case review clinicians concluded CTC H&Ps were comprehensive, and the provider completed progress notes in clinically appropriate intervals, without delays. The quality of documentation was generally good with the exception of cloned elements from previous progress notes. We identified eight provider deficiencies in four of the seven CTC cases that we reviewed. Most of the deficiencies were due to cloned notes that occurred in cases 1, 3, 22, and 65. The sole significant deficiency follows: 33. Deficiencies in cases 1, 3, 22, and 65; significant in case 3. Report Issued: August 2020 Office of the Inspector General, State of California Return to Contents 66 Cycle 6 Medical Inspection Report • In case 3, the CTC provider did not review and reconcile the patient’s medications to identify that the patient was missing his lisinopril (blood pressure medication), Lantus (long-acting insulin), and was erroneously started on glipizide (diabetes medication). Nursing Performance The quality of nursing care provided in the CTC was very good. Of the 18 identified deficiencies in the seven cases we reviewed, only eight deficiencies were tied to nursing, and all but one was deemed minor. Case 3 as discussed in the provider performance above is a shared deficiency with nursing. Medication reconciliation upon admission is an identified area for improved performance. Compliance testing of medication continuity and administration upon admission showed a result of 60 percent (MIT 13.004). In reviewing these compliance cases, two patients received medications one day late and in two patients, one dose was missed. The nurses evaluated the patients upon admission, completed rounds daily, and assessed the patients every shift. Compliance and case review agreed that 100 percent of the time, within eight hours, the patient was assessed head to toe with an emphasis on areas that led to their admission (MIT 13.001). Vital signs were obtained, percentages of meals consumed were noted, medication was ordered and given, and activity was monitored. There were very few intermittent missing data points. In addition, the medical staff made sure to document pain level, “as needed” medication given and the effectiveness of the majority of as needed medication given. We verified that WSP’s CTC has an operating call system that coincided with the 100% score (MIT 13.101). Clinician On-Site Inspection The case review clinicians were able to attend a CTC daily huddle. Participants from all required disciplines were present in addition to the attendance of the UM nurse, the dietitian, ancillary staff, and custody staff. All patients were discussed, and all pertinent information reported. We met with the CTC SRN II who reported that evaluation of nursing care and documentation are completed through two audits monthly. One audit focused on compliance issues, and a second audit evaluated appropriate and timely rounding. We were advised that the deficiencies identified in the monthly audits are relayed to staff often during the daily huddles. The CTC dietitian provided insight on patient referrals and discussed continuous monitoring of all patients through evaluation of weekly Office of the Inspector General, State of California Inspection Period: December 2018 – May 2019 Return to Contents Wasco State Prison 67 weights and daily percentages of meals consumed to distinguish triggers for further evaluations. We noted that all staff worked well together as a team. Recommendations In the CTC, we observed the nurses provided patient care at the bedside and then went to a stationary computer to complete their chart assessments. We recommend WSP consider purchasing portable workstations to improve timely and accurate documentation in the CTC. Compliance Testing Results Table 19. 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? 10 0 0 100% 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 10 0 0 100% 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 6 3 1 67% 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 6 4 0 60% 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): 85% * 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 68 Cycle 6 Medical Inspection Report Specialty Services Overall In this indicator, OIG inspectors evaluated the quality of specialty Rating Adequate services. The OIG clinicians focused on the institution’s ability to provide needed specialty care. Our clinicians also examined specialty appointment scheduling, providers’ specialty referrals, Case Review and medical staff’s retrieval, review, and implementation of any Rating specialty recommendations. Adequate Compliance Results Overview Score Adequate WSP displayed excellent specialty access for patients. Providers (82%) performed well with appropriate referral patterns and follow-ups. Nurses also performed well with minor deficiencies, such as missing vital signs upon the patient’s return from off-site appointments. There was room for improvement in both the timeliness and the accuracy of scanning reports, and in ensuring providers reviewed them within appropriate time frames. Overall, the OIG’s rating for this indicator was adequate. Case Review Results We reviewed 103 events related to Specialty Services; 77 were specialty consultations and procedures. We found 35 deficiencies in this category, five of which were significant.34 Access to Specialty Services Our compliance testing showed excellent access to specialty care at WSP for routine-priority requests (MIT 14.007, 100%), medium-priority requests (MIT 14.004, 100%), and high-priority requests (MIT 14.001, 100%). WSP performed acceptably with patients who transferred into the institution with preapproved specialty services (MIT 14.010, 75%). Our case review analysis corresponded with the compliance testing results; WSP ensured specialty access in almost all cases. We found only two minor specialty access deficiencies: • In case 20, the provider ordered a routine endocrinology follow- up appointment for the patient’s hyperparathyroidism. The appointment was scheduled 12 days late. • In case 65, the physical therapist recommended four sessions of hand therapy. After the first two sessions, the institution canceled the last two sessions. Eventually, the provider reordered the remaining two sessions about one month later. The consequence was a delayed recovery of hand function. 34. Deficiencies in cases 1, 2, 17, 20, 22, 24, 25, 27, 65, 69, and 70; significant in cases 2, 17, and 24. Office of the Inspector General, State of California Inspection Period: December 2018 – May 2019 Return to Contents Wasco State Prison 69 Provider Performance WSP providers performed well with specialty services. Providers ordered appropriate specialty consultations within the proper time frames, provided timely follow-up appointments, and generally followed specialists’ recommendations. Our compliance testing found the providers saw their patients promptly (MIT 1.008, 87%). Our clinicians found one provider did not always follow the recommendations for specialty follow-ups. He was responsible for all five provider deficiencies in specialty services. This was discussed further in the Provider Performance indicator. The deficiencies occurred in cases 69, 70, and the following: • In case 2, the patient was discharged after a heart attack and cardiac stent placement with recommendations for a one-to- two-week follow-up with cardiology. The provider made two errors. He initially ordered a routine cardiology follow-up instead of a two-week follow-up. Before the appointment, the patient was sent out to the emergency department for chest pain. Consequently, his initial cardiology follow-up appointment was canceled. The provider then made a second error by requesting a 28-day follow-up, further delaying cardiology specialty care. • In case 17, the patient’s cardiologist recommended work-up for noncardiac causes of chest pain, with the potential of performing a cardiac stress test in the future. The provider did not follow these recommendations, did not document why, and did not complete the work-up. Nursing Performance WSP nursing performance with specialty services was good. The nurses evaluated patients returning from off-site appointments. They generally performed good assessments, reviewed the specialty reports, communicated findings to the provider, and carried out orders. Our clinicians analyzed 60 specialty events and identified 11 minor nursing deficiencies.35 Most of these nursing deficiencies were for incomplete assessments such as rechecking a patient’s vital signs when abnormal. Assessment deficiencies were found in cases 22, 24, 25, and 65. Health Information Management WSP performed well in the handling of specialty service reports. It also scored well in retrieving and ensuring providers reviewed high-priority specialty service consultant reports within the required time frame (MIT 14.002, 93%, MIT 14.008, 77%) and in scanning specialty notes in specified time frames (MIT 4.002, 77%). 35. Deficiencies in cases 2, 17, 22, 24, 25, and 65. Report Issued: August 2020 Office of the Inspector General, State of California Return to Contents 70 Cycle 6 Medical Inspection Report Our case reviewers found 17 deficiencies related the handling of specialty health information. The institution did not timely retrieve and scan the specialty report in cases 25, 65, and multiple times in case 24. One example follows: • In case 24, the interventional radiologist evaluated the patient and measured portal blood vessel pressures. The institution did not retrieve this report. This is also discussed in the Health Information Management indicator. WSP misfiled and mislabeled specialty reports in cases 1, 17, 22, 24, and 25. • In case 1, the patient was scheduled to see the cardiologist. The scanned form had no patient identifier, and the form was misfiled as a nephrology specialty note. In addition, the institution did not retrieve the final report. • In case 17, the patient’s dialysis record was misfiled as “Outside Records – Jail.” • In case 25, the institution misfiled the echocardiogram and myocardial perfusion tests as cardiology consults instead of the respective tests. • The institution did not obtain provider signatures for medium- priority specialty service consultant report (MIT 14.005, zero %). Our case reviewers identified delays in provider review in cases 25, 65, 70, and multiple instances in 69. • In case 69, the institution delayed obtaining, scanning, and ensuring provider review of a urology report in a patient with kidney cancer. Although the patient received cancer care, this deficiency demonstrates a mishandling of this patient’s specialty reports. We also discussed WSP’s performance in this area in the Health Information Management indicator. Clinician On-Site Inspection We discussed with the WSP managers, providers, and utilization nursing staff the management of specialty referrals. WSP reported that it maintained tracking with lists to monitor referrals, follow-up appointments, and reports. Providers reported they were able to easily refer patients, whether for routine, medium, or urgent appointments. Office technicians reported they had direct access to the electronic medical records of a locally contracted hospital, enabling quick access of some specialty reports. Recommendations Nursing leadership and medical record supervisors should ensure all specialty reports are retrieved and scanned timely. Office of the Inspector General, State of California Inspection Period: December 2018 – May 2019 Return to Contents Wasco State Prison 71 Compliance Testing Table 20. 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 4 1 10 80% 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 3 0 0 100% 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 0 3 0 0 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 0 0 3 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 10 3 2 77% 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 7 0 8 100% provider? (14.009) * For endorsed patients received from another CDCR institution: If the patient was approved for a specialty services appointment at the 3 1 0 75% 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 3 1 0 75% 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? 2 0 2 100% (14.012) Overall percentage (MIT 14): 82% * 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 72 Cycle 6 Medical Inspection Report Table 21. 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 27 4 2 87% visits occur within required time frames? (1.008) *, † Are specialty documents scanned into the patient’s electronic health 17 5 11 77% 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: December 2018 – May 2019 Return to Contents Wasco State Prison 73 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 (78%) 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. Nonscored Results We obtained CCHCS Death Review Committee (DRC) reporting records. Six unexpected (Level 1) deaths occurred during our review period. The DRC must complete its death review summary report within 60 calendar days of the death. When the DRC completes the death review summary report, it must submit the report to the institution’s CEO within seven calendar days after completion. The DRC completed four death review summary reports. Two completed reports were reviewed timely; however, the death review summary results were reported 12 and 34 days late to the institution’s CEO. For the other two completed reports, the DRC completed the death review summary 13 and 227 days late, and reported death review summary results to the institution’s CEO nine and 22 days late, respectively. The remaining two incomplete reports were overdue at the time of our inspection (MIT 15.998). CCHCS provides health care staffing data to the OIG. We did not independently validate CCHCS data. We present the WSP’s health care staffing data in the administrative operations table (MIT 15.999). Recommendations The EMRRC should review emergency medical response incidents timely at the regular monthly meeting following the date of the incidents. Nursing leadership should ensure timely annual clinical competency testing for nurses. Report Issued: August 2020 Office of the Inspector General, State of California Return to Contents 74 Cycle 6 Medical Inspection Report Compliance Testing Results Table 22. Administrative Operations Scored Answer Compliance Questions Yes No N/A Yes % For health care incidents requiring root cause analysis (RCA): Did the 0 1 0 0 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 2 10 0 17% 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 3 1 0 75% 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 6 0 0 100% to the CCHCS Death Review Unit on time? (15.103) Did nurse managers ensure the clinical competency of nurses who 2 8 0 20% administer medications? (15.104) Did physician managers complete provider clinical performance 9 2 0 82% appraisals timely? (15.105) Did the providers maintain valid state medical licenses? (15.106) 13 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 1 0 0 100% 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): 78% Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: December 2018 – May 2019 Return to Contents Wasco State Prison 75 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 WSP Access to Care Emergency Diagnostic Services Health Care W Services Environment C E Health Information Management O I M V Transfers P E Nursing Preventive L R Performance Services Medication Management I A E N S Reception Center C A C Provider Administrative E Performance Specialized Medical Housing 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 76 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: December 2018 – May 2019 Return to Contents Wasco State Prison 77 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 78 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: December 2018 – May 2019 Return to Contents Wasco State Prison 79 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 80 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: December 2018 – May 2019 Return to Contents Wasco State Prison 81 Appendix B: Case Review Data Table B–1. Case Review Sample Sets Anticoagulation 2 CTC / OHU 4 Death Review / Sentinel Events 3 Diabetes 3 Emergency Services – CPR 5 Emergency Services – Non-CPR 3 High Risk 4 Hospitalization 4 Intrasystem Transfers In 2 Intrasystem Transfers Out 3 RN Sick Call 28 Reception Center Transfers 4 Specialty Services 4 69 Report Issued: August 2020 Office of the Inspector General, State of California Return to Contents 82 Cycle 6 Medical Inspection Report Table B–2. Case Review Chronic Care Diagnoses Diagnosis Total Anemia 6 Anticoagulation 1 Arthritis / Degenerative Joint Disease 3 Asthma 14 COPD 2 Cancer 4 Cardiovascular Disease 7 Chronic Kidney Disease 5 Chronic Pain 10 Cirrhosis / End-Stage Liver Disease 4 Coccidioidomycosis 1 Deep Venous Thrombosis / Pulmonary Embolism 2 Diabetes 16 Gastroesophageal Reflux Disease 6 Hepatitis C 18 Hyperlipidemia 18 Hypertension 30 Mental Health 22 Rheumatological Disease 1 Seizure Disorder 5 HIV 1 176 Office of the Inspector General, State of California Inspection Period: December 2018 – May 2019 Return to Contents Wasco State Prison 83 Table B–3. Case Review Events by Program Diagnosis Total Diagnostic Services 107 Emergency Care 38 Hospitalization 34 Intrasystem Transfers In 6 Intrasystem Transfers Out 7 Not Specified 6 Outpatient Care 343 Specialized Medical Housing 83 Specialty Services 139 Reception Center 24 787 Table B–4. Case Review Sample Summary MD Reviews Detailed 23 MD Reviews Focused 1 RN Reviews Detailed 16 RN Reviews Focused 44 Total Reviews 84 Total Unique Cases 69 Overlapping Reviews (MD & RN) 15 Report Issued: August 2020 Office of the Inspector General, State of California Return to Contents 84 Cycle 6 Medical Inspection Report Appendix C: Compliance Sampling Methodology Wasco 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 24 OIG Q: 6.001 • See Transfers MITs 1.003 – 006 Nursing Sick Call 35 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 33 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: December 2018 – May 2019 Return to Contents Wasco State Prison 85 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 22 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 11 OIG inspector • Identify and inspect all on-site MITs 5.107 – 111 on-site review clinical areas. Transfers MITs 6.001 – 003 Intrasystem Transfers 24 SOMS • Arrival date (3 – 9 months) • Arrived from (another departmental facility) • Rx count • Randomize MIT 6.101 Transfers Out 10 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 86 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 24 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 — 20 OIG Q: 12.001 • See Reception Center Medication Orders 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 6 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 25 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: December 2018 – May 2019 Return to Contents Wasco State Prison 87 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 25 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 22 Cocci transfer • Reports from past 2 – 8 months (number will vary) 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 88 Cycle 6 Medical Inspection Report Quality No. of Indicator Sample Category Samples Data Source Filters Reception Center MITs 12.001 – 008 RC 20 SOMS • Arrival date (2 – 8 months) • 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 3 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 4 MedSATS • Arrived from (other departmental Arrivals institution) • Date of transfer (3 – 9 months) • Randomize MITs 14.011 – 012 Denials 4 InterQual • Review date (3 – 9 months) • Randomize N/A IUMC/MAR • Meeting date (9 months) Meeting Minutes • Denial upheld • Randomize Office of the Inspector General, State of California Inspection Period: December 2018 – May 2019 Return to Contents Wasco State Prison 89 Quality No. of Indicator Sample Category Samples Data Source Filters Administrative Operations MIT 15.001 N/A 1 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 4 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 6 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 11 On-site • All required performance Evaluation Packets provider evaluation documents evaluation files MIT 15.106 Provider Licenses 13 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 90 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 All Nursing staff • New employees (hired within last training logs 12 months) MIT 15.998 6 OIG summary log: • Between 35 business days & deaths 12 months prior • Health Care Services death reviews Office of the Inspector General, State of California Inspection Period: December 2018 – May 2019 Return to Contents Wasco State Prison 91 California Correctional Health Care Services’ Response Report Issued: August 2020 Office of the Inspector General, State of California Return to Contents 92 Cycle 6 Medical Inspection Report (This page left blank for reproduction purposes.) Office of the Inspector General, State of California Inspection Period: December 2018 – May 2019 Return to Contents Cycle 6 Medical Inspection Report for Wasco 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