Wasco State Prison Medical Inspection Report Cycle 5

Robert A. Barton Office of the Inspector General Inspector General Wasco State Prison Medical Inspection Results Cycle 5 August 2017 Medical Inspection Unit Page 1 Office of the Inspector General State of California Office of the Inspector General WASCO STATE PRISON Medical Inspection Results Cycle 5 Robert A. Barton Inspector General Roy W. Wesley Chief Deputy Inspector General Shaun R. Spillane Public Information Officer August 2017 T C ABLE OF ONTENTS Executive Summary ............................................................................................................................. i Overall Assessment: Adequate ................................................................................................ i Clinical Case Review and OIG Clinician Inspection Results ............................................... iii Compliance Testing Results.................................................................................................. iv Population-Based Metrics ..................................................................................................... vi Recommendations ................................................................................................................. vi Introduction ......................................................................................................................................... 1 About the Institution ........................................................................................................................ 1 Objectives, Scope, and Methodology.................................................................................................. 3 Case Reviews ................................................................................................................................... 4 Patient Selection for Retrospective Case Reviews ................................................................. 4 Benefits and Limitations of Targeted Subpopulation Review ............................................... 5 Case Reviews Sampled .......................................................................................................... 5 Compliance Testing ......................................................................................................................... 7 Sampling Methods for Conducting Compliance Testing ....................................................... 7 Scoring of Compliance Testing Results ................................................................................. 7 Overall Quality Indicator Rating for Case Reviews and Compliance Testing ................................ 8 Population-Based Metrics ................................................................................................................ 8 Medical Inspection Results ................................................................................................................. 9 1 — Access to Care ................................................................................................................. 11 Case Review Results ............................................................................................................ 11 Compliance Testing Results................................................................................................. 13 2 — Diagnostic Services ......................................................................................................... 15 Case Review Results ............................................................................................................ 15 Compliance Testing Results................................................................................................. 16 3 — Emergency Services ........................................................................................................ 18 Case Review Results ............................................................................................................ 18 4 — Health Information Management .................................................................................... 21 Case Review Results ............................................................................................................ 21 Compliance Testing Results................................................................................................. 22 5 — Health Care Environment ............................................................................................... 24 Compliance Testing Results................................................................................................. 24 6 — Inter- and Intra-System Transfers ................................................................................... 27 Case Review Results ............................................................................................................ 27 Compliance Testing Results................................................................................................. 28 7 — Pharmacy and Medication Management ........................................................................ 30 Case Review Results ............................................................................................................ 30 Compliance Testing Results................................................................................................. 31 8 — Prenatal and Post-Delivery Services .............................................................................. 36 9 — Preventive Services ......................................................................................................... 37 Compliance Testing Results................................................................................................. 37 Wasco State Prison, Cycle 5 Medical Inspection Table of Contents Office of the Inspector General State of California 10 — Quality of Nursing Performance ................................................................................... 39 Case Review Results ............................................................................................................ 39 11 — Quality of Provider Performance .................................................................................. 44 Case Review Results ............................................................................................................ 44 12 — Reception Center Arrivals ............................................................................................. 48 Case Review Results ............................................................................................................ 48 Compliance Testing Results................................................................................................. 49 13 — Specialized Medical Housing ........................................................................................ 51 Case Review Results ............................................................................................................ 51 Compliance Testing Results................................................................................................. 54 14 — Specialty Services .......................................................................................................... 55 Case Review Results ............................................................................................................ 55 Compliance Testing Results................................................................................................. 57 15 — Administrative Operations (Secondary) ........................................................................ 58 Compliance Testing Results................................................................................................. 58 Recommendations ............................................................................................................................. 61 Population-Based Metrics ................................................................................................................. 62 Appendix A — Compliance Test Results ......................................................................................... 65 Appendix B — Clinical Data ............................................................................................................ 79 Appendix C — Compliance Sampling Methodology ....................................................................... 83 California Correctional Health Care Services’ Response ................................................................. 90 Wasco State Prison, Cycle 5 Medical Inspection Table of Contents Office of the Inspector General State of California L T F IST OF ABLES AND IGURES WSP Executive Summary Table ........................................................................................................ ii WSP Health Care Staffing Resources as of January, 2017 .................................................................. 2 WSP Master Registry Data as of January 30, 2017 ............................................................................. 2 WSP Results Compared to State and National HEDIS Scores .......................................................... 64 Table B-1: WSP Sample Sets ............................................................................................................ 79 Table B-2: WSP Chronic Care Diagnoses ......................................................................................... 80 Table B-3: WSP Event — Program ................................................................................................... 81 Table B-4: WSP Review Sample Summary ...................................................................................... 82 Wasco State Prison, Cycle 5 Medical Inspection List of Tables and Figures Office of the Inspector General State of California E S XECUTIVE UMMARY Pursuant to California Penal Code Section 6126 et seq., which assigns the Office of the Inspector General (OIG) responsibility for oversight of the California Department of Corrections and Rehabilitation (CDCR), the OIG conducts a comprehensive inspection program to evaluate the delivery of medical care at each of CDCR’s 35 adult prisons. The OIG explicitly makes no determination regarding the constitutionality of care in the prison setting. That determination is left to the Receiver and the federal court. The assessment of care by the OIG is just one factor in the court’s determination whether care in the prisons meets constitutional standards. In Cycle 5, for the first time, the OIG will be inspecting institutions that have been delegated back to CDCR from the Receivership. There will be no difference in the standards used for assessment of a delegated institution versus an institution not yet delegated. The OIG’s inspections are mandated by the Penal Code and not aimed at specifically resolving the court’s questions on constitutional care. To the degree that they provide another factor for the court to consider, the OIG is pleased to provide added value to the taxpayers of California. This fifth cycle of inspections will continue evaluating the areas addressed in Cycle 4, which included clinical case review, compliance testing, and a population-based metric comparison of selected Healthcare Effectiveness Data Information Set (HEDIS) measures. In agreement with stakeholders, the OIG made changes to both the case review and compliance components. The OIG found that in every inspection in Cycle 4, larger samples were taken than were needed to assess the adequacy of medical care provided. As a result, the OIG reduced the number of case reviews and sample sizes for compliance testing. Also, in Cycle 4, compliance testing included two secondary (administrative) indicators (Internal Monitoring, Quality Improvement, and Administrative Operations; and Job Performance, Training, Licensing, and Certifications). For Cycle 5, these have been combined into one secondary indicator, Administrative Operations. Overall Assessment: Adequate The OIG performed its Cycle 5 medical inspection at Wasco State Prison (WSP) from February to April 2017. The inspection included in-depth reviews of 54 patient files conducted by clinicians, as well as reviews of documents from 456 patient files, covering 99 objectively scored tests of compliance with policies and procedures applicable to the delivery of medical care. The OIG assessed the case review and compliance results at WSP using 14 health care quality indicators applicable to the institution. To conduct clinical case reviews, the OIG employs a clinician team consisting of a physician and a registered nurse consultant, while compliance testing is done by a team of registered nurses trained in monitoring medical policy compliance. Of the indicators, eight were rated by both case review clinicians and compliance inspectors, three were rated by case review clinicians only, and three were rated by compliance inspectors only. The WSP Executive Summary Table on the following page identifies the applicable individual indicators and scores for this institution. Wasco State Prison, Cycle 5 Medical Inspection Page i Office of the Inspector General State of California WSP Executive Summary Table Cycle 5 Cycle 4 Case Review Compliance Inspection Indicators Overall Overall Rating Rating Rating Rating 1—Access to Care Adequate Adequate Adequate Proficient 2—Diagnostic Services Adequate Inadequate Adequate Adequate 3—Emergency Services Adequate Not Applicable Adequate Adequate 4—Health Information Adequate Inadequate Inadequate Inadequate Management 5—Health Care Environment Not Applicable Inadequate Inadequate Adequate 6—Inter- and Intra-System Adequate Proficient Proficient Adequate Transfers 7—Pharmacy and Medication Adequate Inadequate Inadequate Adequate Management 8—Prenatal and Post-Delivery Not Applicable Not Applicable Not Applicable Not Applicable Services 9—Preventive Services Not Applicable Inadequate Inadequate Adequate 10—Quality of Nursing Adequate Not Applicable Adequate Adequate Performance 11—Quality of Provider Adequate Not Applicable Adequate Inadequate Performance 12—Reception Center Arrivals Adequate Adequate Adequate Inadequate 13—Specialized Medical Housing Inadequate Adequate Inadequate Adequate 14—Specialty Services Adequate Proficient Adequate Inadequate 15—Administrative Operations Not Applicable Adequate Adequate Proficient* (Secondary) *In Cycle 4, there were two secondary (administrative) indicators. This score reflects the average of those two scores. Wasco State Prison, Cycle 5 Medical Inspection Page ii Office of the Inspector General State of California Clinical Case Review and OIG Clinician Inspection Results The clinicians’ case reviews sampled patients with high medical needs and included a review of 762 patient care events.1 Of the 13 indicators applicable to WSP, 11 were evaluated by clinician case review; 10 were adequate and one was inadequate. When determining the overall adequacy of care, the OIG paid particular attention to the clinical nursing and provider quality indicators, as adequate health care staff can sometimes overcome suboptimal processes and programs. However, the opposite is not true; inadequate health care staff cannot provide adequate care, even though the established processes and programs onsite may be adequate. The OIG clinicians identify inadequate medical care based on the risk of significant harm to the patient, not the actual outcome. Program Strengths — Clinical  WSP leadership had improved operations since the OIG’s Cycle 4 inspection. Managers stated that they targeted areas from the OIG’s Cycle 4 inspection report for quality improvement. These included the Reception Center Arrivals, Health Information Management, and Specialty Services indicators. Improvement was evident with case review ratings going from inadequate to adequate from Cycle 4 to Cycle 5.  WSP was able to effectively manage the demands of a high number of health care encounters in their Reception Center by effective health care team communication. This was facilitated by their well-attended and effective huddles, as well as other meetings.  The physicians had good morale, and felt supported by the leadership at WSP. There were no vacancies at the time of the inspection.  The nurse management team worked well together, and nursing staff in all clinical areas had good morale. Nurses working in positions such as telemedicine, public health, tuberculosis (TB) control, utilization management, and specialty services scheduling had additional cross-trained nursing staff to cover as needed. Program Weaknesses — Clinical  While the OIG found the Quality of Provider Performance adequate, there was still room for improvement. Two patients in the correctional treatment center (CTC) received inadequate care, with many significant deficiencies. These issues contributed to the Specialized Medical Housing indicator in this report to be rated inadequate.  In contrast to the good morale of the WSP physicians, the mid-level providers expressed dissatisfaction with their positions. This centered on a lack of salary adjustment for many 1 Each OIG clinician team includes a board-certified physician and registered nurse consultant with experience in correctional and community medical settings. Wasco State Prison, Cycle 5 Medical Inspection Page iii Office of the Inspector General State of California years. The mid-level providers stated that this would likely lead to some of them leaving state service to return to the community.  The Diagnostics Services indicator, while rated adequate, had multiple deficiencies related to failure to retrieve and scan radiology reports into the electronic health record. This failure to place the reports into the electronic medical records was in keeping with CCHCS policy, which was not to scan into the electronic health record, but instead to leave the reports only in the separate repository for radiology reports. Only the additional work and diligence of the WSP providers kept this indicator from an inadequate rating. The providers needed to spend time searching another report repository for this information to ensure appropriate patient care was given. However, some events were found when the information was not retrieved, and the providers were unaware of important radiology findings.  Although the Emergency Services indicator was rated adequate, the licensed vocational nurses and psychiatric technicians who serve as first medical responders would benefit by additional education and training on oxygen administration. All nursing staff involved in medical emergency responses would benefit by additional training for documentation of emergency medical events using sequential, timed entries rather than summarized entries. Compliance Testing Results Of the 14 health care indicators applicable to WSP, 11 were evaluated by compliance inspectors.2 Two were proficient, four were adequate, and five were inadequate. There were 99 individual compliance questions within those 11 indicators, generating 1,368 data points that tested WSP’s compliance with California Correctional Health Care Services (CCHCS) policies and procedures.3 Those 99 questions are detailed in Appendix A — Compliance Test Results. Program Strengths — Compliance The following are some of WSP’s strengths based on its compliance scores on individual questions in all the health care indicators:  Nursing staff reviewed sick call requests and completed face-to-face encounters within required time frames. In addition, all housing units inspected had health care request forms available for patients.  The institution provided timely laboratory services to patients, and providers reviewed and communicated laboratory results to patients within required time frames. 2 The OIG’s compliance inspectors are trained registered nurses with expertise in CDCR policies regarding medical staff and processes. 3 The OIG used its own clinicians to provide clinical expert guidance for testing compliance in certain areas where CCHCS policies and procedures did not specifically address an issue. Wasco State Prison, Cycle 5 Medical Inspection Page iv Office of the Inspector General State of California  Upon patient transfers to WSP from other CDCR institutions, nursing staff properly completed the Initial Health Screening form (CDCR Form 7277) on the same day the patient arrived, and completed the assessment and disposition sections of the form.  Patients that transferred to WSP from a county jail received a timely initial health screening, and nursing staff appropriately completed and signed the health screening form. In addition, reception center patients received all required laboratory tests, and providers reviewed and communicated the results to patients within required time frames.  Patients received their high-priority and routine specialty service appointments timely, and providers reviewed the specialty service reports within required time frames. Program Weaknesses — Compliance The following are some of the weaknesses identified by WSP’s compliance scores on individual questions in all the health care indicators:  The institution did not always provide pathology services timely, and providers did not always communicate pathology results to patients as required by CCHCS policy.  Scanning accuracy of patient documents into the electronic health record was poor.  Several clinic locations at WSP did not properly mitigate exposure to blood borne pathogens and contaminated waste because exam rooms lacked sharps containers, and not all clinic locations had essential supplies available to staff.  Several medication line locations at WSP did not follow proper security controls over narcotic medications, and several locations also did not properly store non-narcotic medications that did not require refrigeration.  The institution did not always monitor patients on TB medications as required. In addition, for those patients sampled for annual TB screening, inspectors found nursing staff did not always properly document their signs and symptoms or history of TB.  Nursing supervisors did not properly document their reviews of subordinate staff. Wasco State Prison, Cycle 5 Medical Inspection Page v Office of the Inspector General State of California Population-Based Metrics In general, WSP performed very well as measured by population-based metrics. In comprehensive diabetes care, WSP outperformed other State and national organizations in most measures. With regard to immunization measures, WSP’s comparative scores were mixed. However, WSP’s rates for colorectal cancer screening were higher than those of all other reporting entities. Overall, WSP’s performance demonstrated by the population-based metrics indicated that the chronic care program was well run and functioning properly. Recommendations The OIG recommends the institution develop a process to improve access to all radiology reports that have not been scanned into the eUHR since late 2015. The OIG recommends WSP leadership provide training for providers on spending adequate time reviewing the medical records of unfamiliar patients, even when caring for the patient for a brief time. This is especially important for the more complex patients in the CTC. Wasco State Prison, Cycle 5 Medical Inspection Page vi Office of the Inspector General State of California I NTRODUCTION Pursuant to California Penal Code Section 6126 et seq., which assigns the Office of the Inspector General (OIG) responsibility for oversight of the California Department of Corrections and Rehabilitation (CDCR), and at the request of the federal Receiver, the OIG developed a comprehensive medical inspection program to evaluate the delivery of medical care at each of CDCR’s 35 adult prisons. The OIG conducts a clinical case review and a compliance inspection, ensuring a thorough, end-to-end assessment of medical care within CDCR. Wasco State Prison (WSP) was the fourth medical inspection of Cycle 5. During the inspection process, the OIG assessed the delivery of medical care to patients using the primary clinical health care indicators applicable to the institution. The Administrative Operations indicator is purely administrative and is not reflective of the actual clinical care provided. ABOUT THE INSTITUTION Wasco State Prison (WSP) is one of two CDCR reception centers located in Kern County. As a reception center, the primary mission of WSP is to provide short-term housing necessary to process, classify, and evaluate incoming inmates from county jails to determine their security level, program requirements, and appropriate institutional placement. The institution runs multiple clinics where medical staff handles non-urgent requests for health care services. WSP also treats patients requiring urgent or emergency care in its triage and treatment area (TTA), and treats patients requiring inpatient health services in its correctional treatment center (CTC). California Correctional Health Care Services (CCHCS) has designated WSP a “basic” care institution. Basic institutions are located in rural areas away from tertiary care centers and specialty care providers whose services would likely be used frequently by higher-risk patients. Basic institutions have the capability to provide limited specialty medical services and consultation for a generally healthy patient population. WSP received accreditation from the Commission on Accreditation for Corrections on March 20, 2017. This nationally recognized accreditation program is a professional peer review process based on standards set by the American Correctional Association. Based on staffing data the OIG obtained from the institution, WSP’s vacancy rate among medical managers, primary care providers, supervisors, and rank-and-file nurses was 20 percent in January 2017, with the highest vacancy percentages among nursing staff at 23 percent. At the time of the OIG’s inspection, three nursing staff members were on long-term medical leave. Wasco State Prison, Cycle 5 Medical Inspection Page 1 Office of the Inspector General State of California WSP Health Care Staffing Resources as of January, 2017 Primary Care Nursing Management Nursing Staff Totals Providers Supervisors Description Number % Number % Number % Number % Number % Authorized 4 2% 12.5 6% 13.6 7% 162.8 84% 192.9 100% Positions Filled Positions 4 100% 12.5 100% 11.6 85% 126 77% 154.1 80% Vacancies 0 0% 0 0% 2 15% 36.8 23% 38.8 20% Recent Hires (within 12 1 25% 4.5 36% 4 34% 44 35% 53.5 35% months) Staff Utilized 0 0% 1 8% 0 0% 29 23% 30 19% from Registry Redirected Staff (to Non-Patient 0 0% 0 0% 1 9% 0 0% 1 1% Care Areas) Staff on Long-term 0 0% 0 0% 0 0% 3 2% 3 2% Medical Leave Note: WSP Health Care Staffing Resources data was not validated by the OIG. As of January 30, 2017, the Master Registry for WSP showed that the institution had a total population of 4,953. Within that total population, 1.2 percent were designated as high medical risk, Priority 1 (High 1), and 2.9 percent were designated as high medical risk, Priority 2 (High 2). Patients’ assigned risk levels are based on the complexity of their required medical care related to their specific diagnoses, frequency of higher levels of care, age, and abnormal labs and procedures. High 1 has at least two high-risk conditions; High 2 has only one. Patients at high medical risk are more susceptible to poor health outcomes than those at medium or low medical risk. Patients at high medical risk also typically require more health care services than do patients with lower assigned risk levels. The chart below illustrates the breakdown of the institution’s medical risk levels at the start of the OIG medical inspection. WSP Master Registry Data as of January 30, 2017 Medical Risk Level # of Patients Percentage High 1 61 1.2% High 2 146 2.9% Medium 1,755 35.4% Low 2,991 60.4% Total 4,953 100.0% Wasco State Prison, Cycle 5 Medical Inspection Page 2 Office of the Inspector General State of California O , S , M BJECTIVES COPE AND ETHODOLOGY In designing the medical inspection program, the OIG reviewed CCHCS policies and procedures, relevant court orders, and guidance developed by the American Correctional Association. The OIG also reviewed professional literature on correctional medical care; reviewed standardized performance measures used by the health care industry; consulted with clinical experts; and met with stakeholders from the court, the Receiver’s office, CDCR, the Office of the Attorney General, and the Prison Law Office to discuss the nature and scope of the OIG’s inspection program. With input from these stakeholders, the OIG developed a medical inspection program that evaluates medical care delivery by combining clinical case reviews of patient files, objective tests of compliance with policies and procedures, and an analysis of outcomes for certain population-based metrics. To maintain a metric-oriented inspection program that evaluates medical care delivery consistently at each State prison, the OIG identified 15 indicators (14 primary (clinical) indicators and one secondary (administrative) indicator) of health care to measure. The primary quality indicators cover clinical categories directly relating to the health care provided to patients, whereas the secondary quality indicator addresses the administrative functions that support a health care delivery system. These 15 indicators are identified in the WSP Executive Summary Table on page ii of this report. The OIG rates each of the quality indicators applicable to the institution under inspection based on case reviews conducted by OIG clinicians and compliance tests conducted by OIG registered nurses. The ratings may be derived from the case review results alone, the compliance test results alone, or a combination of both these information sources. For example, the ratings for the primary quality indicators Quality of Nursing Performance and Quality of Provider Performance are derived entirely from the case review done by clinicians, while the ratings for the primary quality indicators Health Care Environment and Preventive Services are derived entirely from compliance testing done by registered nurse inspectors. As another example, primary quality indicators such as Diagnostic Services and Specialty Services receive ratings derived from both sources. Consistent with the OIG’s agreement with the Receiver, this report only addresses the conditions found related to medical care criteria. The OIG does not review for efficiency and economy of operations. Moreover, if the OIG learns of a patient needing immediate care, the OIG notifies the chief executive officer of health care services and requests a status report. Additionally, if the OIG learns of significant departures from community standards, it may report such departures to the institution’s chief executive officer or to CCHCS. Because these matters involve confidential medical information protected by State and federal privacy laws, specific identifying details related to any such cases are not included in the OIG’s public report. In all areas, the OIG is alert for opportunities to make appropriate recommendations for improvement. Such opportunities may be present regardless of the score awarded to any particular Wasco State Prison, Cycle 5 Medical Inspection Page 3 Office of the Inspector General State of California quality indicator; therefore, recommendations for improvement should not necessarily be interpreted as indicative of deficient medical care delivery. CASE REVIEWS The OIG added case reviews to the Cycle 4 medical inspections at the recommendation of its stakeholders, which continues in Cycle 5 medical inspections. The OIG’s clinicians perform a retrospective chart review of selected patient files to evaluate the care given by an institution’s primary care providers and nurses. Retrospective chart review is a well-established review process used by health care organizations that perform peer reviews and patient death reviews. Currently, CCHCS uses retrospective chart review as part of its death review process and in its pattern-of-practice reviews. CCHCS also uses a more limited form of retrospective chart review when performing appraisals of individual primary care providers. Patient Selection for Retrospective Case Reviews Because retrospective chart review is time consuming and requires qualified health care professionals to perform it, OIG clinicians must carefully sample patient records. Accordingly, the group of patients the OIG targeted for chart review carried the highest clinical risk and utilized the majority of medical services. A majority of the patients selected for retrospective chart review were classified by CCHCS as high-risk patients. The reason the OIG targeted these patients for review is twofold: 1. The goal of retrospective chart review is to evaluate all aspects of the health care system. Statewide, high-risk and high-utilization patients consume medical services at a disproportionate rate; 11 percent of the total patient population are considered high-risk and account for more than half of the institution’s pharmaceutical, specialty, community hospital, and emergency costs. 2. Selecting this target group for chart review provides a significantly greater opportunity to evaluate all the various aspects of the health care delivery system at an institution. Underlying the choice of high-risk patients for detailed case review, the OIG clinical experts made the following three assumptions: 1. If the institution is able to provide adequate clinical care to the most challenging patients with multiple complex and interdependent medical problems, it will be providing adequate care to patients with less complicated health care issues. Because clinical expertise is required to determine whether the institution has provided adequate clinical care, the OIG utilizes experienced correctional physicians and registered nurses to perform this analysis. 2. The health of less complex patients is more likely to be affected by processes such as timely appointment scheduling, medication management, routine health screening, and Wasco State Prison, Cycle 5 Medical Inspection Page 4 Office of the Inspector General State of California immunizations. To review these processes, the OIG simultaneously performs a broad compliance review. 3. Patient charts generated during death reviews, sentinel events (unexpected occurrences involving death or serious injury, or risk thereof), and hospitalizations are mostly of high-risk patients. Benefits and Limitations of Targeted Subpopulation Review Because the selected patients utilize the broadest range of services offered by the health care system, the OIG’s retrospective chart review provides adequate data for a qualitative assessment of the most vital system processes (referred to as “primary quality indicators”). Retrospective chart review provides an accurate qualitative assessment of the relevant primary quality indicators as applied to the targeted subpopulation of high-risk and high-utilization patients. While this targeted subpopulation does not represent the prison population as a whole, the ability of the institution to provide adequate care to this subpopulation is a crucial and vital indicator of how the institution provides health care to its whole patient population. Simply put, if the institution’s medical system does not adequately care for those patients needing the most care, then it is not fulfilling its obligations, even if it takes good care of patients with less complex medical needs. Since the targeted subpopulation does not represent the institution’s general prison population, the OIG cautions against inappropriate extrapolation of conclusions from the retrospective chart reviews to the general population. For example, if the high-risk diabetic patients reviewed have poorly-controlled diabetes, one cannot conclude that the entire diabetic population is inadequately controlled. Similarly, if the high-risk diabetic patients under review have poor outcomes and require significant specialty interventions, one cannot conclude that the entire diabetic population is having similarly poor outcomes. Nonetheless, the health care system’s response to this subpopulation can be accurately evaluated and yields valuable systems information. In the above example, if the health care system is providing appropriate diabetic monitoring, medication therapy, and specialty referrals for the high-risk patients reviewed, then it can be reasonably inferred that the health care system is also providing appropriate diabetic services to the entire diabetic subpopulation. However, if these same high-risk patients needing monitoring, medications, and referrals are generally not getting those services, it is likely that the health care system is not providing appropriate diabetic services to the greater diabetic subpopulation. Case Reviews Sampled As indicated in Appendix B, Table B–1: WSP Sample Sets, the OIG clinicians evaluated medical charts for 54 unique patients. Appendix B, Table B–4: WSP Case Review Sample Summary, clarifies that both nurses and physicians reviewed charts for 7 of those patients, for 61 reviews in total. Physicians performed detailed reviews of 20 charts, and nurses performed detailed reviews of 7 Wasco State Prison, Cycle 5 Medical Inspection Page 5 Office of the Inspector General State of California charts, totaling 27 detailed reviews. For detailed case reviews, physicians or nurses looked at all encounters occurring in approximately six months of medical care. Nurses also performed a limited or focused review of medical records for an additional 34 patients. These generated 762 clinical events for review (Appendix B, Table B–3: WSP Event-Program). The inspection tool provides details on whether the encounter was adequate or had significant deficiencies, and identifies deficiencies by programs and processes to help the institution focus on improvement areas. While the sample method specifically pulled only 6 chronic care patient records, i.e., 3 diabetes patients and 3 anticoagulation patients (Appendix B, Table B–1: WSP Sample Sets), the 54 unique patients sampled included patients with 181 chronic care diagnoses, including 12 additional patients with diabetes (for a total of 15) and one additional anticoagulation patient (for a total of 4) (Appendix B, Table B–2: WSP Chronic Care Diagnoses). The OIG’s sample selection tool allowed evaluation of many chronic care programs because the complex and high-risk patients selected from the different categories often had multiple medical problems. While the OIG did not evaluate every chronic disease or health care staff member, the overall operation of the institution’s system and staff were assessed for adequacy. The OIG’s case review methodology and sample size matched other qualitative research. The empirical findings, supported by expert statistical consultants, showed adequate conclusions after 10 to 15 charts had undergone full clinician review. In qualitative statistics, this phenomenon is known as “saturation”. The OIG found the Cycle 4 medical inspection physician sample size of 30 detailed reviews far exceeded the saturation point necessary for an adequate qualitative review. At the end of Cycle 4 inspections, the case review results were re-analyzed using 50 percent of the cases, finding no significant differences in the ratings. To improve inspection efficiency, while preserving the quality of the inspection, the samples for Cycle 5 medical inspections were reduced in number of cases. For Cycle 5 inspections, basic institutions, with low high-risk populations, case review will use 67 percent of the case review samples used in Cycle 4 inspection, for both physician and nurse reviewed cases (20 detailed reviews). For intermediate institutions, or basic institutions housing many high-risk patients, the case review samples will use 83 percent (25 detailed reviews). Finally, the most medically complex institution, CHCF, has retained the full 100 percent samples of Cycle 4 inspections. With regard to reviewing charts from different providers, the case review is not intended to be a focused search for poorly performing providers; rather, it is focused on how the system cares for those patients who need care the most. Nonetheless, while not sampling cases by each provider at the institution, the OIG inspections adequately review most providers. Providers would only escape OIG case review if institutional management successfully mitigated patient risk by having the more poorly performing providers care for the less complicated, low-utilizing, and lower-risk patients. The OIG’s clinicians concluded that the case review sample size was more than adequate to assess the quality of services provided. Based on the collective results of clinicians’ case reviews, the OIG rated each quality indicator as either proficient (excellent), adequate (passing), inadequate (failing), or not applicable. A separate Wasco State Prison, Cycle 5 Medical Inspection Page 6 Office of the Inspector General State of California confidential WSP Supplemental Medical Inspection Results: Individual Case Review Summaries report details the case reviews OIG clinicians conducted and is available to specific stakeholders. For further details regarding the sampling methodologies and counts, see Appendix B — Clinical Data, Table B–1; Table B–2; Table B–3; and Table B–4. COMPLIANCE TESTING Sampling Methods for Conducting Compliance Testing From February to April 2017, registered nurse inspectors attained answers to 99 objective medical inspection test (MIT) questions designed to assess the institution’s compliance with critical policies and procedures applicable to the delivery of medical care. To conduct most tests, inspectors randomly selected samples of patients for whom the testing objectives were applicable and reviewed their electronic unit health records. In some cases, inspectors used the same samples to conduct more than one test. In total, inspectors reviewed health records for 456 individual patients and analyzed specific transactions within their records for evidence that critical events occurred. Inspectors also reviewed management reports and meeting minutes to assess certain administrative operations. In addition, during the week of February 13, 2017, field registered nurse inspectors conducted a detailed onsite inspection of WSP’s medical facilities and clinics; interviewed key institutional employees; and reviewed employee records, logs, medical appeals, death reports, and other documents. This generated 1,368 scored data points to assess care. In addition to the scored questions, the OIG obtained information from the institution that it did not score. This included, for example, information about WSP’s plant infrastructure, protocols for tracking medical appeals and local operating procedures, and staffing resources. For cycle 5 medical inspection testing, the OIG reduced the number of compliance samples tested for 18 indicator tests from a sample of 30 patients to a sample of 25 patients. The OIG also removed some inspection tests upon stakeholder agreement that either were duplicated in the case reviews or had limited value. Lastly, for cycle 4 medical inspections, the OIG tested two secondary (administrative) indicators; Internal Monitoring, Quality Improvement, and Administrative Operations; and Job Performance, Training, Licensing, and Certifications, and have combined these tests into one Administrative Operations indicator for cycle 5 inspections. For details of the compliance results, see Appendix A — Compliance Test Results. For details of the OIG’s compliance sampling methodology, see Appendix C — Compliance Sampling Methodology. Scoring of Compliance Testing Results After compiling the answers to the 99 questions for the 11 applicable indicators, the OIG derived a score for each quality indicator by calculating the percentage score of all Yes answers for each of the questions applicable to a particular indicator, then averaging those scores. Based on those Wasco State Prison, Cycle 5 Medical Inspection Page 7 Office of the Inspector General State of California results, the OIG assigned a rating to each quality indicator of proficient (greater than 85 percent), adequate (between 75 percent and 85 percent), or inadequate (less than 75 percent). OVERALL QUALITY INDICATOR RATING FOR CASE REVIEWS AND COMPLIANCE TESTING The OIG derived the final rating for each quality indicator by combining the ratings from the case reviews and from the compliance testing, as applicable. When combining these ratings, the case review evaluations and the compliance testing results usually agreed, but there were instances when the rating differed for a particular quality indicator. In those instances, the inspection team assessed the quality indicator based on the collective ratings from both components. Specifically, the OIG clinicians and registered nurse inspectors discussed the nature of individual exceptions found within that indicator category and considered the overall effect on the ability of patients to receive adequate medical care. To derive an overall assessment rating of the institution’s medical inspection, the OIG evaluated the various rating categories assigned to each of the quality indicators applicable to the institution, giving more weight to the rating results of the primary quality indicators, which directly relate to the health care provided to patients. Based on that analysis, OIG experts made a considered and measured overall opinion about the quality of health care observed. POPULATION-BASED METRICS The OIG identified a subset of Healthcare Effectiveness Data Information Set (HEDIS) measures applicable to the CDCR patient population. To identify outcomes for WSP, the OIG reviewed some of the compliance testing results, randomly sampled additional patients’ records, and obtained WSP data from the CCHCS Master Registry. The OIG compared those results to HEDIS metrics reported by other statewide and national health care organizations. Wasco State Prison, Cycle 5 Medical Inspection Page 8 Office of the Inspector General State of California M I R EDICAL NSPECTION ESULTS The quality indicators assess the clinical aspects of health care. As shown on the WSP Executive Summary Table on page ii of this report, 14 of the OIG’s indicators were applicable to WSP. Of those 14 indicators, 8 were rated by both the case review and compliance components of the inspection, 3 were rated by the case review component alone, and 3 were rated by the compliance component alone. The Administrative Operations indicator is a secondary indicator, and, therefore, was not relied upon for the overall score for the institution. Based on the analysis and results in the primary indicators, the OIG experts made a considered and measured opinion that the quality of health care at WSP was adequate. Summary of Case Review Results: The clinical case review component assessed 11 of the indicators applicable to WSP; OIG clinicians rated none proficient, ten adequate, and one inadequate. The OIG physicians rated the overall adequacy of care for each of the 20 detailed case reviews they conducted. Of these 20 cases, one was proficient, 13 were adequate, and 6 were inadequate. In the 764 events reviewed, there were 171 deficiencies, of which 64 were considered to be of such magnitude that, if left unaddressed, they would likely contribute to patient harm. Adverse Events Identified During Case Review: Adverse Events are medical errors which cause serious patient harm. Medical care is a complex dynamic process with many moving parts, subject to human error even within the best health care organizations. Adverse events are typically identified and tracked by all major health care organizations for the purpose of quality improvement. They are not generally representative of medical care delivered by the organization. The OIG identified adverse events for the dual purposes of quality improvement and the illustration of problematic patterns of practice found during the inspection. Because of the anecdotal description of these events, the OIG cautions against drawing inappropriate conclusions regarding the institution based solely on adverse events. There were three adverse events identified in the case reviews at WSP, as follows:  In case 1, there was a critically ill patient with dangerously low blood pressure. The transfer to the TTA, as well as transport to the hospital, was delayed by two hours. The patient eventually died, from an accidental overdose of blood pressure medication. While it was unlikely the death was preventable, WSP’s severely delayed emergency response worsened the patient’s chance of survival.  In case 8, the provider placed a patient at risk by having the patient undergo an elective surgery for back pain. The patient had a recent blood clot, and was placed at risk by temporarily stopping the blood thinning medication to allow the surgery. Fortunately, no harm came to the patient. Wasco State Prison, Cycle 5 Medical Inspection Page 9 Office of the Inspector General State of California  In case 9, the provider failed to change a seizure medication that was likely causing liver inflammation after the patient was hospitalized. The hospital physician who had cared for the patient had advised the change in the discharge report. Summary of Compliance Results: The compliance component assessed 11 of the 14 indicators applicable to WSP. Of these 11 indicators, OIG inspectors rated two proficient, four adequate, and five inadequate. The results of those assessments are summarized within this section of the report. The test questions used to assess compliance for each indicator are detailed in Appendix A. Wasco State Prison, Cycle 5 Medical Inspection Page 10 Office of the Inspector General State of California 1 — ACCESS TO CARE This indicator evaluates the institution’s ability to provide patients Case Review Rating: with timely clinical appointments. Areas specific to patients’ access Adequate to care are reviewed, such as initial assessments of newly arriving Compliance Score: patients, acute and chronic care follow-ups, face-to-face nurse Adequate appointments when an patient requests to be seen, provider referrals (84.6%) from nursing lines, and follow-ups after hospitalization or specialty Overall Rating: care. Compliance testing for this indicator also evaluates whether Adequate patients have Health Care Services Request forms (CDCR Form 7362) available in their housing units. Case Review Results The OIG clinicians reviewed 278 provider and nurse encounters relating to access to care, and identified 16 deficiencies 7 of which were significant. WSP, with regard to the Access to Care indicator, was rated adequate. Provider-to-Provider Follow-up Appointments Three deficiencies consisted of provider-to-provider appointments that were delayed or missed. Two of these were significant:  In case 9, the provider-requested three-day follow-up for a patient with acute hepatitis did not occur. However, the patient did see an infectious disease specialist one month later.  In case 19, the provider-requested one-week follow-up for a patient with valley fever was delayed for two months. RN Sick Call Access The institution performed well for RN appointments related to sick call. The OIG identified only one minor appointment and scheduling deficiency in this area. RN-to-Provider Referrals Nurses performing sick call assessments are required to refer the patient to a provider if a situation requires a higher level of care. WSP did well for most of these referrals. The OIG identified only two minor deficiencies in cases 7 and 9. RN Follow-up Appointments The institution performed well with scheduling and completing RN appointments that were generated by WSP clinicians. The OIG found no deficiencies. Wasco State Prison, Cycle 5 Medical Inspection Page 11 Office of the Inspector General State of California Intra-System Transfers and Reception Center WSP did well with appointments and scheduling for patients transferring from other prisons or into the reception center. This was remarkable for an institution with nearly 5,000 patients. According to WSP leadership, the institution conducts approximately 15,000 health care appointments per month for medical, dental, mental health, or diagnostic services. Follow-up After Hospitalization or Urgent/Emergent Care WSP did well with appointments and scheduling for patients transferring from offsite hospitals. The OIG reviewed 26 events and found no deficiencies. The OIG reviewed six cases in which the patient was managed in the TTA at WSP and returned to housing. All follow-up appointments occurred without deficiency. Specialized Medical Housing WSP did well with provider follow-up visits in the CTC. The OIG reviewed 46 events and found five deficiencies, two of which were significant, and both in the same case:  In case 16, there were two gaps in care where the patient was not seen by a provider for 7 and 11 days. Specialty Access and Follow-up WSP did well with appointments for specialty services and procedures. The OIG reviewed 50 events and found two deficiencies, both of which were significant:  In case 9, the provider requested an infectious disease follow-up visit in two weeks, but the appointment occurred in five weeks.  In case 16, the patient was not seen by the plastic surgery specialist for follow-up within the four-week time interval recommended. The patient paroled 12 weeks later without having received the follow-up visit. Provider Follow-up After Specialty and Diagnostic Services The OIG reviewed 50 events related to specialty services. All provider follow-ups occurred without deficiency. Clinician Onsite Inspection The leadership at WSP discussed the challenges of being a reception center and the high number of encounters required for the large patient population. They monitored appointments for backlogs, which occurred infrequently. Their success in managing this was helped by robust daily huddles in each health care area, which included all medical, nursing, custody, and support staff. During these huddles, the patients with appointment dates nearing out-of-compliance dates were given new, Wasco State Prison, Cycle 5 Medical Inspection Page 12 Office of the Inspector General State of California earlier appointment times. Clinic staff all stated they had no appointment backlogs. Nurses and providers worked closely to manage sick call patients, often with joint visits. This led to more efficient care and fewer provider follow-up appointments. Leaders also stated that they used the OIG Cycle 4 inspection report for quality improvement in specialty services. The used a tracking system to manage appointments. This is further discussed in the Specialty Services indicator. Case Review Conclusion The WSP health care staff managed the challenges of a reception center with a large patient population and encounter rate well. The case review rating for this indicator was adequate. Compliance Testing Results WSP scored in the adequate range in the Access to Care indicator with a compliance score of 84.6 percent. The following four tests earned proficient scores:  Inspectors sampled 35 Health Care Services Request forms (CDCR Form 7362) submitted by patients across all facility clinics. Nursing staff reviewed all service request forms on the same day they were received (MIT 1.003).  Of the four patients sampled who were referred to and seen by a provider and for whom the provider subsequently ordered a follow-up appointment, all four received their follow-up appointments timely (MIT 1.006).  Patients had access to health care services request forms at all six housing units the OIG inspected (MIT 1.101).  Nursing staff completed a timely face-to-face triage encounter for all 35 sampled patients; however, for one patient, nursing staff did not document the required SOAPE assessment (97 percent) (MIT 1.004). The institution scored in the adequate range on two tests, as follows:  Among 25 patients sampled who transferred into WSP from other institutions and were referred to a provider based on nursing staff’s initial health care screening, 20 (80 percent) were seen timely. One patient received his provider appointment 6 days late; the remaining four patients received their appointments 22, 38, 48, and 96 days late (MIT 1.002).  Twenty of 25 sampled patients who were discharged from a community hospital (80 percent) received a timely PCP follow-up appointment upon their return to WSP. Five patients received their follow-up appointments one to four days late (MIT 1.007). Wasco State Prison, Cycle 5 Medical Inspection Page 13 Office of the Inspector General State of California With inadequate scores, WSP showed room for improvement in the following three areas:  Only 20 of 27 sampled patients who received a high-priority or routine specialty service (74 percent) also received a timely follow-up appointment with a provider. Among those seven patients who did not receive timely follow-up appointments, the following exceptions occurred (MIT 1.008): o One patient’s high-priority specialty service follow-up appointment was one day late. o One patient’s high-priority specialty follow-up did not occur. o Two patients’ routine specialty follow-ups were 22 and 42 days late. o Two patients’ routine specialty follow-ups did not occur. o For the final patient with a routine specialty service follow-up appointment, the provider did see the patient, but there was no discussion of the specialty service results, thus no true follow-up ever occurred.  Inspectors sampled 25 patients who suffered from one or more chronic care conditions; only 17 patients timely received their provider-ordered follow-up appointments (68 percent). Eight other patients received their appointments late or not at all, including three patients whose follow up appointments occurred between one and two days late; but for five other patients, there was no medical record evidence found to indicate they were ever seen (MIT 1.001).  Among eight service request forms sampled on which nursing staff referred the patient for a provider appointment, only five patients (62 percent) received a timely appointment. Two patients received their appointments 3 and 4 days late and one patient did not receive a provider visit at all (MIT 1.005). Wasco State Prison, Cycle 5 Medical Inspection Page 14 Office of the Inspector General State of California 2 — DIAGNOSTIC SERVICES This indicator addresses several types of diagnostic services. Case Review Rating: Specifically, it addresses whether radiology and laboratory services Adequate were timely provided to patients, whether the primary care provider Compliance Score: timely reviewed the results, and whether the results were Inadequate communicated to the patient within the required time frames. In (73.5%) addition, for pathology services, the OIG determines whether the Overall Rating: institution received a final pathology report and whether the Adequate provider timely reviewed and communicated the pathology results to the patient. The case reviews also factor in the appropriateness, accuracy, and quality of the diagnostic test(s) ordered and the clinical response to the results. For this indicator, the OIG’s case review and compliance review process yielded different results, with the case review giving an adequate rating and the compliance review resulting in an inadequate score. The OIG’s internal review process considered those factors that led to both scores and ultimately rated this indicator adequate. Although the compliance testing showed deficiencies in retrieval and scanning of radiology and pathology reports, the case review process found that these delays did not affect patient care, as the providers spent additional time to independently retrieve the results. Case Review Results The OIG clinicians reviewed 146 diagnostic events and found 17 deficiencies, 8 of which were significant. WSP performed well with regard to diagnostic services, and the indicator rating was adequate. Appointment and Scheduling Staff performed most laboratory tests, X-rays, and EKGs as ordered. However, there was one significant deficiency:  In case 9, the provider ordered laboratory tests to recheck abnormal liver function be done on the same day; however, they were not done. Health Information Management Thirteen of the deficiencies in this indicator were due to an X-ray report not being retrieved or scanned into the electronic medical record. The OIG identified this problem in many Cycle 4 inspections, which are noted to continue into Cycle 5 inspections. Failure to retrieve radiology reports increases the risk of patient harm due to the chance of a lapse in care from a provider being unaware of the report. Even if the ordering provider was initially notified of the report and reviewed it, the report would still not be readily available to any subsequent medical staff. Any nurse or provider who cared for the patient in the coming months or years would face a tremendous barrier Wasco State Prison, Cycle 5 Medical Inspection Page 15 Office of the Inspector General State of California in attempting to review radiology reports that had not been scanned into the electronic medical record. The OIG clinicians identified deficiencies in the retrieval and scanning of radiology reports in cases 7, 13, 15, 16, and 17, twice in case 18, and three times in cases 8 and 19. WSP clinicians did a good job ensuring that the reports were reviewed despite the extra barrier to reviewing those results. However, in some cases, the report was not reviewed at all. The OIG found significant deficiencies in cases 16, 17, 18 (twice), and the following:  In case 8, the chest X-ray radiology report showing possible lung cancer was not timely reviewed by the provider. Also in case 8, the CT scan eventually performed was also not timely reviewed. Fortunately, the results suggested chronic scarring, not cancer.  In case 15, the patient had an abnormal chest X-ray shortly after transferring to WSP. This finding also could have represented a new lung cancer or infection. As this report was not in the electronic medical record, but only in the secondary depository, providers seeing the patient at multiple follow-up visits were unaware of a potentially serious finding. The patient had follow-up of this only by chance when he was admitted to a community hospital for pneumonia. At the onsite inspection, WSP leadership explained that they had stopped scanning radiology reports from a secondary report repository into the primary electronic medical record (eUHR) based on a memo from CCHCS headquarters. Health care staff at WSP (and other CDCR institutions) now face a seemingly unnecessary barrier to the retrieval and review of those critically important reports, which creates an ongoing risk of lapses in care. Case Review Conclusion The OIG found that WSP performed well with regard to diagnostic services and, therefore, rated this indicator adequate. Compliance Testing Results The institution received a compliance score of 73.5 percent in the Diagnostic Services indicator, which encompasses radiology, laboratory, and pathology services. For clarity, each type of diagnostic service is discussed separately below: Radiology Services  Radiology services were timely performed for nine of ten patients sampled (90 percent); one patient received testing one day late (MIT 2.001). Radiology reports were only found in a non-electronic-medical-record databank (RIS-PACS). CCHCS policy requires providers to initial and date radiology reports to evidence having reviewed them; for none of the ten sampled reports did the provider provide this evidence by initialing and dating, for a score of Wasco State Prison, Cycle 5 Medical Inspection Page 16 Office of the Inspector General State of California zero (MIT 2.002). However, providers did timely communicate the test results to nine of the ten patients (90 percent). In one case, there was no evidence that the provider communicated the test results to the patient (MIT 2.003). Laboratory Services  For nine of the ten sampled laboratory services (90 percent), the patients’ ordered diagnostic services were timely performed; one patient’s laboratory services were performed six days late (MIT 2.004). For nine of the ten sampled services (90 percent), the provider timely reviewed the laboratory report and timely communicated the result to the patient. In one case, although the provider initialed the report, no date was found (MIT 2.005). For nine of the ten sampled services (90 percent), the provider timely communicated the results of the laboratory study to the patient within specified time frames. In one case, although the notification of diagnostic test results was initialed, there was no signature or date (MIT 2.006). Pathology Services  WSP received four of the nine applicable final pathology reports timely (44 percent). Two diagnostic reports were received between 5 and 17 days late; in addition, three pathology reports were not found in the electronic medical record (MIT 2.007). Providers properly evidenced review of all applicable sampled final pathology reports by initialing and dating them (MIT 2.008). However, providers communicated pathology results timely to only four of the six applicable patients who received the service (67 percent). For two patients, the provider communicated the results between one and two days late (MIT 2.009). Wasco State Prison, Cycle 5 Medical Inspection Page 17 Office of the Inspector General State of California 3 — EMERGENCY SERVICES An emergency medical response system is essential to providing Case Review Rating: effective and timely emergency medical response, assessment, Adequate treatment, and transportation 24 hours per day. Provision of Compliance Score: urgent/emergent care is based on a patient’s emergency situation, Not Applicable clinical condition, and need for a higher level of care. The OIG reviews emergency response services including first aid, basic life Overall Rating: support (BLS), and advanced cardiac life support (ACLS) Adequate consistent with the American Heart Association guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiovascular care, and the provision of services by knowledgeable staff appropriate to each individual’s training, certification, and authorized scope of practice. The OIG evaluates this quality indicator entirely through clinicians’ reviews of case files and conducts no separate compliance testing element. Case Review Results The OIG clinicians reviewed 31 urgent/emergent events and found 21 deficiencies, 6 of which were significant, in various aspects of emergency care. Provider Performance The OIG identified seven deficiencies in provider performance, one significant. The six minor deficiencies were all due to the provider on call not documenting the telephone call and management of the patient. In addition, for one of the minor deficiencies, the TTA nurse needed to contact an alternative physician as the provider on call was not reached in a timely fashion. The one significant deficiency for provider performance in Emergency Services was as follows:  In case 1, the patient presented to the TTA with an elevated blood pressure of 160/100 and symptoms of headache, dizziness, and four days of left facial numbness. These symptoms, in a “worst case scenario,” could be a possible stroke. A thorough history and neurological exam by a provider should have been performed, and if indicated, a CT scan of the head should have been conducted to rule out stroke. These symptoms were not adequately evaluated. Fortunately, the patient did not have a stroke. Nursing Performance In general, nurses at WSP provided good care during emergency medical response incidents. Although the majority of the nursing deficiencies were not significant and did not affect the patient’s outcome, several case review examples demonstrated two areas for improvement. Wasco State Prison, Cycle 5 Medical Inspection Page 18 Office of the Inspector General State of California One area of significant deficiencies was the implementation of timely nursing intervention and the accurate documentation of nursing assessments and interventions, as illustrated by the following cases:  In case 1, an unexplained 45-minute delay occurred in transferring a patient found lying on the ground with fatigue and drowsiness to the TTA for evaluation. TTA nursing documentation showed an unexplained gap in care of 15 minutes after the patient arrived in the TTA until nurses first started nursing assessments. Nurses documented widely discrepant TTA arrival times with differences as much as 22 minutes, and incorrectly dated various nursing documents about this emergency response event.  In case 6, the licensed vocational nurse (LVN) and psychiatric technician (PT) medical responders initiated low oxygen doses and connected the unresponsive patient with shallow breathing to the automated external defibrillator (AED). The LVNs did not consult an RN regarding increasing the oxygen dose per CCHCS nursing protocol for patients with loss of consciousness, and did not assess the patient’s vital signs or activate the AED to check heart rhythm. Upon arrival in the TTA, nursing staff initiated CPR when they were unable to obtain the patient’s vital signs and the AED advised chest compressions. Documentation by the LVN first responder and the TTA nurse had discrepant entries about the time and the patient’s status on arrival in the TTA. The second key area of significant deficiencies was the patient care environment specifically related to availability of pertinent onsite communications support and necessary equipment for medical staff at the time of emergency medical responses.  In case 1, the custody staff in the watch commander’s office did not answer the phone when TTA staff called for a Code 3 (emergent) ambulance for transfer to a community hospital for a higher-level evaluation. The request to County Emergency Medical Services for a Code 3 ambulance transport to by the watch commander’s office was delayed 13 to 15 minutes.  In case 3, the medical responder arrived on scene, and the pulse oximeter (machine to check circulating oxygen level) was not available in the emergency response bag. The nurse could not insert an intravenous fluid line and administer medications because necessary equipment was not available in the yard clinic.  In case 4, the RN emergency responder was unable to assess the unresponsive patient’s circulating oxygen level because the pulse oximeter was malfunctioning. Wasco State Prison, Cycle 5 Medical Inspection Page 19 Office of the Inspector General State of California Health Information Management Documentation in the TTA was good. The OIG reviewed 32 TTA encounters at WSP and identified only three minor deficiencies. These included documents misdated by one day and one record with a time stamp partially obscuring other parts of the record. Emergency Medical Response Review Committee The Emergency Medical Response Review Committee (EMRRC) reviewed Code 2 and Code 3 unscheduled medical transports to community hospitals for a higher level of care. However, the EMRRC did not address the malfunctioning and unavailable equipment (pulse oximeter) in its reviews of emergency responses in cases 3 and 4. Clinician Onsite Inspection During the onsite visit, the OIG clinicians found the patient care TTA environment was neat and well organized for providing emergent medical care. The TTA had an adequate number of experienced nurses, access to online patient records, and supplies and equipment for the usual medical response activities. Nursing administrators at WSP acknowledged issues with time discrepancies in emergency medical response documentation, and described various strategies underway for improvement. Strategies included identification of a designated “recorder” during the morning huddle for emergency medical responses in each yard during clinic hours, and documenting emergency response entries in timeline format rather than a generalized summary of assessments, interventions, and results. The plan of action also included providing training sessions for LVN and PT emergency medical responders regarding oxygen doses, and working with administrators to establish an emergency medical vehicle stocked with necessary equipment and supplies for providing emergency care outside of the TTA. Case Review Conclusion Overall, the case reviews showed that patients requiring urgent or emergent services received adequate and timely care in the majority of cases reviewed. Nursing administrators were aware of the issues identified in the case review, and had initiated interventions to make improvements. The OIG rated this indicator adequate. Wasco State Prison, Cycle 5 Medical Inspection Page 20 Office of the Inspector General State of California 4 — HEALTHINFORMATION MANAGEMENT Health information management is a crucial link in the delivery of Case Review Rating: medical care. Medical personnel require accurate information in Adequate order to make sound judgments and decisions. This indicator Compliance Score: examines whether the institution adequately manages its health care Inadequate information. This includes determining whether the information is (70.0%) correctly labeled and organized and available in the electronic health Overall Rating: record; whether the various medical records (internal and external, Inadequate e.g., hospital and specialty reports and progress notes) are obtained and scanned timely into the patient’s electronic health record; whether records routed to clinicians include legible signatures or stamps; and whether hospital discharge reports include key elements and are timely reviewed by providers. In this indicator, the OIG’s case review and compliance review processes yielded different results, with the case review giving an adequate rating and the compliance testing resulting in an inadequate score. After considering both case review and compliance testing results, the OIG inspection team determined the final overall rating of inadequate was appropriate. This decision was primarily due to an excessive number of health care documents that WSP staff either mislabeled or misfiled in the electronic medical record. This could result in important health care records not being identified, which could contribute to patient harm. During the OIG’s testing period, WSP had not converted to the new Electronic Health Record System (EHRS) (expected transition October 2017); therefore, all testing for WSP in Cycle 5 occurred in the electronic Unit Health Record (eUHR) system. Case Review Results The OIG clinicians reviewed 764 events and found 29 deficiencies related to health information management, 10 of which were significant. Six of the deficiencies (once in cases 16 and 17, and twice in cases 8 and 18) were when X-ray reports were not scanned into the electronic medical record, which was explained by the institution’s understanding of a CCHCS directive to not scan X-ray reports. This is discussed in detail in the Diagnostics Services indicator. The OIG clinicians rated this indicator adequate. Interdepartmental Transmission The OIG did not identify any problems in communication between the departments within the institution. Hospital Records The OIG reviewed 22 outside emergency department and community hospital events. There were four deficiencies, one of which was significant (case 1). The institution generally performed well in Wasco State Prison, Cycle 5 Medical Inspection Page 21 Office of the Inspector General State of California retrieving emergency department physician reports and hospital discharge summaries as well as forwarding the reports to the provider for review, with only one not signed properly. The one significant deficiency occurred in the case of a patient who died in the hospital:  In case 1, the hospital discharge summary was scanned into the electronic medical record ten days after it was received from the hospital. Specialty Services, Diagnostic Reports, and Urgent/Emergent Records WSP did well with retrieval and scanning of most records for specialty services. These events are discussed in the Specialty Services indicator (case 16 had two significant deficiencies). The OIG reviewed 32 TTA encounters at WSP, and identified three minor deficiencies. These are discussed further in the Emergency Services indicator. Scanning Performance The WSP scanning deficiencies were mostly minor. They consisted of scanning with incorrect labels (cases 1, 5, 14, 16, 17, 23, and 26), scans missing altogether (cases, 13, 14, 24, and 52, and two in case 9), or failing to have a provider sign the report (cases 9, 12, 13, and 18). One significant deficiency occurred when one page of a county correctional document was not scanned into the eUHR (case 52). Clinician Onsite Inspection While onsite, the OIG discussed some of the health information management deficiencies identified during the case review. The medical records supervisor was able to review the issues found, and had already put into place appropriate training and corrective plans. The supervisor indicated corrective actions in place to improve accuracy and timeliness of scanning. This efficient corrective action likely explained the improvement found in health information management at WSP from the OIG’s Cycle 4 medical inspection, with a reduction in both minor and significant deficiencies in this indicator. Case Review Conclusion The OIG clinicians rated WSP adequate in this indicator. Compliance Testing Results The institution received an inadequate compliance score of 70.0 percent in the Health Information Management indicator, showing room for improvement in the following areas:  The institution scored zero in its labeling and filing of documents scanned into patients’ electronic unit health records. Most errors included mislabeled and misfiled documents. However, there was also a missing Non-CDCR Hospital Admission Report and one instance of a medication reconciliation order scanned into the incorrect patient’s file. For this test, Wasco State Prison, Cycle 5 Medical Inspection Page 22 Office of the Inspector General State of California once the OIG identifies 24 mislabeled or misfiled documents, the maximum points are lost and the resulting score is zero. For the WSP medical inspection, inspectors identified a total of 30 documents with scanning errors, 6 more than the maximum allowable errors (MIT 4.006).  For 14 of 20 specialty service consultant reports sampled (70 percent), WSP staff scanned the reports into the patient’s health record file within five calendar days. However, three documents were scanned between two and five days late; also for three other documents, no evidence was found that they were actually scanned (MIT 4.003). The following two tests earned adequate scores:  WSP’s medical records staff timely scanned miscellaneous non-dictated documents such as provider progress notes, nursing initial health screening forms, and patient requests for health care services. Specifically, 16 of the 20 documents sampled (80 percent) were timely scanned into the patient’s electronic medical record within three calendar days of the patient’s encounter. For four patients, a provider’s progress note was scanned between one and 25 days late (MIT 4.001).  The OIG reviewed community hospital discharge reports and treatment records for 25 sampled patients sent to an outside hospital. For 20 of the 25 patients (80 percent), the discharge summary reports were complete and timely reviewed by WSP providers. For one patient, WSP providers reviewed the hospital discharge summary reports one day late. For four patients, the discharge report was missing key information and there was no evidence that WSP followed up with the hospital to obtain it (MIT 4.007). The institution scored in the proficient range on two tests in this indicator:  WSP medical records staff timely scanned medication administration records (MARs) into the patients’ electronic medical records in 18 of 19 samples tested (95 percent). One MAR was scanned one day late (MIT 4.005).  The OIG also tested 20 of the patients’ discharge records to determine if staff timely scanned the records into the patient’s electronic medical record. Nineteen of the 20 samples (95 percent) were compliant. One record was scanned one day late (MIT 4.004). Wasco State Prison, Cycle 5 Medical Inspection Page 23 Office of the Inspector General State of California 5 — HEALTH CARE ENVIRONMENT This indicator addresses the general operational aspects of the Case Review Rating: institution’s clinics, including certain elements of infection control Not Applicable and sanitation, medical supplies and equipment management, the Compliance Score: Inadequate availability of both auditory and visual privacy for patient visits, and (65.0%) the sufficiency of facility infrastructure to conduct comprehensive medical examinations. Rating of this component is based entirely on Overall Rating: the compliance testing results from the visual observations Inadequate inspectors make at the institution during their onsite visit. This indicator is evaluated entirely by compliance inspectors, so there is no case review component. Compliance Testing Results The institution received an inadequate compliance score of 65.0 percent in the Health Care Environment indicator, showing need for improvement the following areas:  The non-clinic bulk medical supply storage areas did not meet the supply management process or support the needs of the medical care program, earning a score of zero on this test. Specifically, WSP health care management expressed concerns about having poor cooperation between warehouse staff and medical supply staff, and inspectors found medical supplies that were stored beyond manufacturers’ guidelines (MIT 5.106).  Only two of nine clinic locations (18 percent) met compliance requirements for essential core medical equipment and supplies. The remaining seven clinics displayed one or more of the following deficiencies (MIT 5.108): o Four clinic exam rooms did not have a biohazard receptacle or bags. o Four clinic exam rooms did not have operational oto-ophthalmoscopes. o Two clinic exam rooms did not have hemoccult cards or developer. o Two clinic exam rooms did not have an established distance line for the Snellen eye chart. o One clinic had a weight scale with a missing calibration sticker. o One clinic exam room had a broken overhead light and was missing disposable paper on the exam table and lubricating jelly.  Only 6 of 11 clinics demonstrated proper protocols to mitigate exposure to blood-borne pathogens and contaminated waste. WSP received a score of only 55 percent on this test Wasco State Prison, Cycle 5 Medical Inspection Page 24 Office of the Inspector General State of California because five clinics had one or more exam rooms that lacked a sharps container (MIT 5.105).  Clinicians followed good hand hygiene practices in only six of the ten clinics the OIG observed (60 percent). At four clinic locations, clinicians failed to wash their hands before or after patient contact or before applying gloves (MIT 5.104).  Only 7 of 11 clinic exam rooms observed (64 percent) had appropriate space, configuration, supplies, and equipment to allow clinicians to perform proper clinical examinations. Four clinic exam rooms had confidential records that were accessible to inmate porters because they had not been destroyed properly, and two clinic exam rooms had exam tables with torn vinyl (Figure 1). One clinic exam room did not offer the patient visual privacy, and another clinic exam room did not have properly labeled cabinets (MIT 5.110). Figure 1: Torn vinyl on exam table.  Inspectors examined emergency response bags to determine if they were inspected daily and inventoried monthly and whether they contained all essential items. Emergency response bags were compliant in only 7 of the 11 clinical locations where they were stored (64 percent). At two clinic locations, the oxygen tank was not at the required pressure. One clinic location had a bag that was missing a medium size airway, and one other clinic locations was missing a large size blood pressure cuff (MIT 5.111). The following tests earned WSP adequate scores:  Of the 11 clinic locations inspected, 9 (82 percent) had operable sinks and sufficient quantities of hand hygiene supplies in the exam areas. However, two clinics’ patient restrooms were without antiseptic soap, and one of those also lacked disposable towels (MIT 5.103).  Inspectors found that 9 of the 11 applicable clinics (82 percent) followed adequate medical supply storage and management protocols. At one clinic, a provider did not have access to scissors to remove a patient’s bandages, and at another clinic, medical supplies were stored in the same location as cleaning supplies (MIT 5.107). Wasco State Prison, Cycle 5 Medical Inspection Page 25 Office of the Inspector General State of California The institution scored in the proficient range in three tests, as follows:  All 11 clinics were appropriately disinfected, cleaned, and sanitary. More specifically, in all clinics, inspectors observed areas that were clean and not visibly dusty or dirty. In addition, cleaning logs were present and completed, indicating cleaning crews regularly cleaned the clinic (MIT 5.101).  Clinical health care staff at all 11 applicable clinics ensured that reusable invasive and non-invasive medical equipment was properly sterilized or disinfected (MIT 5.102).  Clinic common areas at 10 of the 11 clinics (91 percent) had environments conducive to providing medical services. One clinic common area did not provide patient auditory privacy at the triage and vital sign check stations because the area was also used as a waiting area for clinical appointments (MIT 5.109). Non-Scored Results  The OIG gathered information to determine if the institution’s physical infrastructure was maintained in a manner that supported health care management’s ability to provide timely or adequate health care. The OIG did not score this question. When OIG inspectors interviewed health care managers, they did not identify any significant concerns. At the time of the OIG’s medical inspection, WSP had several significant infrastructure projects underway, which included construction and renovation improvements on Yards A, B, C, and D, and the R&R, as well as the construction of new medication distribution rooms in the institution. These projects began in January 2016, and all projects were scheduled to be completed by September 2018 (MIT 5.999). Wasco State Prison, Cycle 5 Medical Inspection Page 26 Office of the Inspector General State of California 6 — INTER- AND INTRA-SYSTEM TRANSFERS This indicator focuses on the management of patients’ medical Case Review Rating: needs and continuity of patient care during the inter- and Adequate intra-facility transfer process. The patients reviewed for Inter- and Compliance Score: Intra-System Transfers include patients received from other CDCR Proficient facilities and patients transferring out of WSP to another CDCR (86.3%) facility. The OIG review includes evaluation of the institution’s Overall Rating: ability to provide and document health screening assessments, Proficient initiation of relevant referrals based on patient needs, and the continuity of medication delivery to patients arriving from another institution. For those patients, the OIG clinicians also review the timely completion of pending health appointments, tests, and requests for specialty services. For patients who transfer out of the facility, the OIG evaluates the ability of the institution to document transfer information that includes pre-existing health conditions, pending appointments, tests and requests for specialty services, medication transfer packages, and medication administration prior to transfer. The OIG clinicians also evaluate the care provided to patients returning to the institution from an outside hospital and check to ensure appropriate implementation of the hospital assessment and treatment plans. In this indicator, the OIG’s case review and compliance testing processes yielded different results, with the case review giving an adequate rating and the compliance review resulting in a proficient score. The OIG’s internal review process considered the factors that led to both scores. The clinicians found a relatively low number of deficiencies in this indicator, so the compliance result of proficient was the appropriate overall rating for this indicator. Case Review Results The OIG clinicians reviewed 35 encounters relating to Inter- and Intra-System Transfers, including information from both the sending and receiving institutions. These included 26 hospitalization events, each of which resulted in a transfer back to the institution. In general, the inter- and intra-system transfer processes at WSP were adequate. Of the 35 encounters reviewed, seven deficiencies were identified, of which two were significant (cases 1 and 9, discussed below). Transfers In and Out and Hospitalizations One minor nursing documentation omission deficiency occurred in all the transfer cases reviewed. Patients returning from hospitalizations are some of the highest-risk encounters due to two factors. First, these patients are generally hospitalized for a severe illness or injury. Second, they are at risk due to potential lapses in care that can occur during any transfer. The two significant deficiencies in this indicator were in this area: Wasco State Prison, Cycle 5 Medical Inspection Page 27 Office of the Inspector General State of California  In case 1, the patient had been admitted to the community hospital for altered consciousness and respiratory failure. He developed seizures in the emergency department and was admitted to the intensive care unit, where his condition worsened and he eventually died. There was a significant delay in the retrieval and review of the hospital discharge summary. The summary was dictated at the hospital 20 days after the patient’s death, and the institution signed and scanned the report 12 days after that.  In case 9, the patient returned from a hospitalization with elevated liver function tests and on high doses of a seizure medication that can be toxic to the liver. The hospital physician had discontinued the medication and recommended an alternative seizure medication. The WSP provider was aware of the hospital discharge medication change recommendations, but failed to make the change to a different medication. Clinician Onsite Inspection Patients returning from hospital discharge were assessed by the TTA nurse. The case reviews supported evidence that nursing staff completed patient assessment, reviewed hospital discharge recommendations with the provider, and made appropriate follow-up referrals. Case Review Conclusion The Inter- and Intra-System Transfers indicator at WSP was adequate. The staff and processes involved with inmate transfers were well organized and coordinated, and they contributed to continuity of health care services for transferring inmates. Compliance Testing Results The institution obtained a proficient score of 86.3 percent in the Inter- and Intra-System Transfers indicator, with three tests scoring in the proficient range, as follows:  The OIG inspected the transfer packages of ten patients who were transferring out of the facility to determine whether the packages included required medications and support documentation. All ten transfer packages were compliant (MIT 6.101).  Nursing staff timely completed the assessment and disposition sections of the screening form on the same day staff completed the health screening for 23 of 24 applicable patients (96 percent). For one patient, nursing staff completed the assessment and disposition one day after the health screening (MIT 6.002).  For 22 out of the 25 sampled patients who transferred into WSP from other CDCR facilities (88 percent), nursing staff completed an Initial Health Screening form (CDCR Form 7277) on the same day the patient arrived. For one patient, there was no evidence in the electronic medical record that staff completed the form. For another patient, staff failed to complete the Wasco State Prison, Cycle 5 Medical Inspection Page 28 Office of the Inspector General State of California form; for one other patient, staff dated the form one day prior to the patient’s actual arrival (MIT 6.001). The institution earned an adequate score in one test in this indicator:  Inspectors sampled 20 patients who transferred out of WSP to other CDCR institutions to determine whether WSP identified scheduled specialty service appointments on the patients’ health care transfer forms. Nursing staff correctly listed the pending specialty service appointments for 15 of 20 patients (75 percent). Staff failed to list pending specialty services for five patients (MIT 6.004). The institution scored within the inadequate range on the following test:  Of 25 sampled patients who transferred into WSP, 11 had an existing medication order upon arrival; only 8 of the 11 applicable patients (73 percent) received their medications without interruption. Three patients incurred medication interruptions of one or more dosing periods upon arrival (MIT 6.003). Wasco State Prison, Cycle 5 Medical Inspection Page 29 Office of the Inspector General State of California 7 — PHARMACY AND MEDICATION MANAGEMENT This indicator is an evaluation of the institution’s ability to provide Case Review Rating: appropriate pharmaceutical administration and security management, Adequate encompassing the process from the written prescription to the Compliance Score: administration of the medication. By combining both a quantitative Inadequate (62.6%) compliance test with case review analysis, this assessment identifies issues in various stages of the medication management process, Overall Rating: including ordering and prescribing, transcribing and verifying, Inadequate dispensing and delivering, administering, and documenting and reporting. Because effective medication management is affected by numerous entities across various departments, this assessment considers internal review and approval processes, pharmacy, nursing, health information systems, custody processes, and actions taken by the prescriber, staff, and patient. In this indicator, the OIG’s case review and compliance review processes yielded different results, with the case review giving an adequate rating, and the compliance review resulting in an inadequate score. The OIG’s internal review process considered those factors that led to both scores and ultimately rated this indicator inadequate. While case review focused on medication administration, the compliance testing was a more robust assessment of medication administration and pharmacy protocols combined with onsite observations of medication and pharmacy operations. As a result, the compliance score of inadequate was deemed appropriate for the overall indicator rating. Case Review Results The OIG clinicians evaluate pharmacy and medication management as secondary processes as they relate to the quality of clinical care provided. Compliance testing is a more targeted approach and is heavily relied on for the overall rating of this indicator. The OIG clinicians evaluated 31 events related to medications and found four minor deficiencies. Medication Continuity Patients received their medications as prescribed and timely as scheduled with one exception:  In case 3, the patient arrived at WSP from a county correctional facility, and did not receive his prescribed antidepressant and antipsychotic medications on the day of arrival. The patient received the prescribed medications the following day. Medication Administration (Nursing) Nursing staff performed adequately regarding accurate and timely administration of prescribed keep-on-person (KOP) and nurse-administered medications. Although there were no significant Wasco State Prison, Cycle 5 Medical Inspection Page 30 Office of the Inspector General State of California deficiencies identified in the cases reviewed, there were some deficiencies that warranted quality improvement interventions.  In case 8, the provider ordered a cholesterol medication for 10 days, but it was not given to the patient on two of the next ten consecutive days. There was no documentation on the patient’s MAR to indicate whether the patient refused the medication or was offsite on those two days.  In case 53, the patient with elevated blood glucose refused his insulin dose and signed a refusal of treatment form. The nurse did not notify the provider about the patient’s elevated blood glucose level or his refusal of insulin. Pharmacy Errors  In case 15, the pharmacy failed to catch the provider’s medication order error for concurrent prescriptions. The provider had ordered both albuterol and levalbuterol inhalers for a patient with chronic obstructive pulmonary disease. These medications are essentially the same, and only one should be prescribed at a time. Clinician Onsite Inspection The OIG clinicians found the LVNs and PTs responsible for medications to be knowledgeable about their patients, medication preparation and administration safety, and operational processes on their assigned yards, and they were located in close proximity to the clinic primary care nurses and providers. These LVNs and PTs described an appropriate process at WSP for verifying new medication orders and reconciling continuing medication orders. These clinical staff members were an integral part of the larger primary care team on each yard by also serving as first medical responders for medical emergencies during hours of clinic operations. Case Review Conclusion Since the identified medication errors did not pose dangers to the patients, the OIG clinicians rated pharmacy and medication administration at WSP adequate. Compliance Testing Results The institution received an inadequate compliance score of 62.6 percent in the Pharmacy and Medication Management indicator. For discussion purposes below, this indicator is divided into three sub-indicators: medication administration, observed medication practices and storage controls, and pharmacy protocols. Wasco State Prison, Cycle 5 Medical Inspection Page 31 Office of the Inspector General State of California Medication Administration In this sub-indicator, the institution received an adequate score of 79.7 percent, scoring in the proficient range in two tests, as follows:  Inspectors reviewed files of nine applicable patients who recently arrived at WSP from a county jail for whom a WSP provider had ordered medications upon their arrival. Inspectors found that all nine applicable patients received their medications timely. As a result, WSP received a score of 100 percent for this test (MIT 7.004).  Inspectors found that 24 of 25 patients sampled (96 percent) received their newly ordered medication in a timely manner. For one patient, staff failed to date the MAR, so there was no evidence that the patient received medication within the required time frame (MIT 7.002). The institution scored in the adequate range on two tests in this sub-indicator:  Among 19 sampled patients, 16 (84 percent) timely received their chronic care medications. Three patients either did not receive all ordered medications or did not receive required counseling for missed doses (MIT 7.001).  Of the 25 sampled patients at WSP who had transferred from one housing unit to another, 21 (84 percent) received their prescribed nurse-administered medications without interruption. Four patients did not receive one or more doses of their medications at the next dosing interval after the transfer occurred (MIT 7.005). The final two tests in this sub-indicator showed areas for improvement at WSP:  Nursing staff administered medications without interruption to seven of ten patients who were en route from one institution to another and had a temporary layover at WSP (70 percent). For two patients, there was no evidence found that medications, including those for HIV and high blood pressure, were administered as ordered. For one patient, there was no evidence that one of his medications was given (MIT 7.006).  WSP timely provided hospital discharge medications to 11 of 25 patients sampled (44 percent). Providers did not prescribe discharge medications within the required time frame for six patients. For two patients, medications were not dispensed as ordered; six other patients did not timely receive ordered medications (MIT 7.003). Wasco State Prison, Cycle 5 Medical Inspection Page 32 Office of the Inspector General State of California Observed Medication Practices and Storage Controls In this sub-indicator, the institution received an inadequate score of 51.6 percent. Four tests scored in the inadequate range, as follows:  WSP properly stored non-narcotic medications not requiring refrigeration in only two of the ten applicable clinic and medication line storage locations (20 percent). In eight locations, one or more of the following deficiencies were observed: four locations had internal and external medications stored together; three locations did not have an identifiable system for return-to-pharmacy medications; one medication location had a single-dose medication used as a multi-dose diluent; another medication line location had pre-filled syringes without a label to identify the medication; and one other location had a medication not marked with the date it was opened (MIT 7.102).  Non-narcotic refrigerated medications were properly stored at only two of ten clinics and medication line storage locations (20 percent). At eight locations, there was no clearly identified process in place to separate return-to-pharmacy medications, and one of the medication lines also had a medication not marked with the date it was opened (MIT 7.103).  The institution employed adequate security controls over narcotic medications in three of the eight applicable clinic and medication line locations where narcotics were stored (38 percent). At five medication line locations, the narcotics log books did not have nursing co-signatures for shift counts on multiple dates (MIT 7.101).  Inspectors observed the medication preparation and administration processes at seven applicable medication line locations. Nursing staff were compliant regarding proper hand hygiene and contamination control protocols at four locations (57 percent). At three locations, not all nursing staff washed or sanitized their hands when required, such as prior to putting on gloves and administering medications and before each subsequent re-gloving (MIT 7.104). Wasco State Prison, Cycle 5 Medical Inspection Page 33 Office of the Inspector General State of California The institution received an adequate score on the following test in this sub-indicator:  Nursing staff followed appropriate administrative controls and protocols when distributing medications to patients at six of eight applicable medication preparation and administrative locations (75 percent). At two medication line locations, there was insufficient overhang or shade protection during extreme heat or inclement weather Figure 2: Insufficient overhang to protect (Figure 2) (MIT 7.106). patients waiting at pill lines from inclement weather or extreme heat One test earned WSP a proficient score of 100 percent:  Nursing staff at all eight of the inspected medication line locations employed appropriate administrative controls and followed appropriate protocols during medication preparation (MIT 7.105). Pharmacy Protocols In this sub-indicator, the institution received an average score of 55.2 percent, comprised of scores received at the institution’s main pharmacy. The following two tests earned scores of zero:  In its main pharmacy, WSP did not properly store non-refrigerated medication. Inspectors found food items stored in the same location as medications (MIT 7.108).  Inspectors found that WSP pharmacy staff did not properly account for narcotic medications. Pharmacy staff did not complete a narcotics count for an entire month during the inspection period (MIT 7.110). One test in this indicator scored in the adequate range:  The institution’s pharmacist in charge followed required protocols for 19 of the 25 medication error reports and monthly statistical reports reviewed (76 percent). There was no evidence that five sampled medication error reports were shared with the local Pharmacy and Therapeutic Committee and applicable quality improvement committees. One sampled report was completed one day late (MIT 7.111). Two tests earned proficient scores of 100 percent:  The institution’s main pharmacy properly stored all refrigerated and frozen medications (MIT 7.109). Wasco State Prison, Cycle 5 Medical Inspection Page 34 Office of the Inspector General State of California  In its main pharmacy, the institution followed general security, organization, and cleanliness management protocols (MIT 7.107). Non-Scored Tests  In addition to testing reported medication errors, OIG inspectors follow up on any significant medication errors found during the case reviews or compliance testing to determine whether the errors were properly identified and reported. The OIG provides those results for information purposes only; however, at WSP, the OIG found no applicable medication errors with which to conduct this test (MIT 7.998).  Inspectors interviewed patients housed in isolation units to determine if they had immediate access to their prescribed KOP rescue inhalers and nitroglycerin medications. Nine of ten applicable patients interviewed indicated they had access to their rescue medications. One patient indicated that he had disposed of his inhaler. Upon notification, WSP took timely action to replace the patient’s inhaler (MIT 7.999). Wasco State Prison, Cycle 5 Medical Inspection Page 35 Office of the Inspector General State of California 8 — PRENATAL AND POST-DELIVERY SERVICES This indicator evaluates the institution’s capacity to provide timely Case Review Rating: and appropriate prenatal, delivery, and postnatal services to Not Applicable pregnant patients. This includes the ordering and monitoring of Compliance Score: indicated screening tests, follow-up visits, referrals to higher levels Not Applicable of care, e.g., high-risk obstetrics clinic, when necessary, and Overall Rating: postnatal follow-up. Not Applicable Because WSP housed only male patients, this indicator did not apply. Wasco State Prison, Cycle 5 Medical Inspection Page 36 Office of the Inspector General State of California 9 — PREVENTIVE SERVICES This indicator assesses whether various preventive medical services Case Review Rating: are offered or provided to patients. These include cancer screenings, Not Applicable tuberculosis (TB) screenings, and influenza and chronic care Compliance Score: Inadequate immunizations. This indicator also assesses whether certain (71.4%) institutions take preventive actions to relocate patients identified as being at higher risk for contracting coccidioidomycosis Overall Rating: (valley fever). Inadequate The OIG rates this indicator entirely through the compliance testing component; the case review process does not include a separate qualitative analysis for this indicator. Compliance Testing Results The institution performed in the inadequate range in the Preventive Services indicator, with a compliance score of 71.4 percent. Areas showing room for improvement were as follows:  OIG inspectors sampled 30 patients to determine whether they received a TB screening within the last year. Among the 30 sampled patients, 15 were classified as a Code 22 (requiring a TB skin test in addition to a signs and symptoms check), and 15 sampled patients were classified as Code 34 (subject only to an annual signs and symptoms check). Of all 30 sampled patients, nursing staff timely and appropriately conducted those screenings for only 14 (47 percent). More specifically, nurses properly screened 12 of the Code 22 patients and 2 of the Code 34 patients. Inspectors identified the following deficiencies (MIT 9.003): o For one Code 22 patient, nursing staff’s documentation of the signs and symptoms review was incomplete, and for two patients, the history section was incomplete. o For 13 Code 34 patients, nursing staff did not complete the required history section review of the Tuberculin Testing/Evaluation Report (CDCR Form 7331).  The OIG tested whether WSP offered required influenza, pneumococcal, and hepatitis vaccinations to patients who suffered from a chronic care condition; only 10 of the 18 patients sampled (56 percent) were offered them. For eight patients, inspectors did not find evidence that the patients were offered the recommended pneumococcal or hepatitis vaccinations (MIT 9.008).  The institution scored poorly for monitoring of patients on TB medications. For 10 of 24 patients sampled, the institution either failed to complete monitoring at all required intervals, Wasco State Prison, Cycle 5 Medical Inspection Page 37 Office of the Inspector General State of California failed to document weight monitoring, or failed to scan the monitoring form into the patient’s medical record in a timely manner (58 percent) (MIT 9.002). Two tests earned adequate scores:  WSP scored 80 percent for administering timely TB medications to patients with TB. Twenty of 25 patients received their medication timely, while three patients missed one to five required medication doses and did not receive the required provider counseling for the missed dosage. For two patients, no evidence was found in the electronic medical record that they received medications for an entire month (MIT 9.001).  The OIG sampled 20 patients at high risk for contracting valley fever who were identified as medically restricted and ineligible to reside at WSP to determine if the patients were transferred out of the institution within 60 days from the time they were determined ineligible. WSP was compliant for 15 of the 20 patients sampled, scoring 75 percent. The five remaining patients were transferred out of WSP 2, 7, 9, 10, and 96 days late (MIT 9.009). The institution scored in the proficient range in two tests in this sub-indicator, as follows:  WSP offered annual influenza vaccinations to 24 of 25 sampled patients subject to the annual screening requirement (96 percent). For one patient, there was no medical record evidence found that health care staff offered an influenza vaccination within the most recent flu season (MIT 9.004).  WSP offered colorectal cancer screenings to 22 of 25 sampled patients subject to the annual screening requirement (88 percent). For one patient, there was no medical record evidence either that health care staff offered a colorectal cancer screening within the previous 12 months or that the patient had a normal colonoscopy within the last ten years. Also, for two patients whose colonoscopies were abnormal, there was no medical record evidence that health care staff offered a colorectal cancer screening within the previous 12 months (MIT 9.005). Wasco State Prison, Cycle 5 Medical Inspection Page 38 Office of the Inspector General State of California 10 — QUALITY OF NURSING PERFORMANCE The Quality of Nursing Performance indicator is a qualitative Case Review Rating: evaluation of the institution’s nursing services. The evaluation is Adequate completed entirely by OIG nursing clinicians within the case Compliance Score: review process, and does not have a score under the OIG Not Applicable compliance testing component. Case reviews include face-to-face encounters and indirect activities performed by nursing staff on Overall Rating: behalf of the patient. Review of nursing performance includes all Adequate nursing services performed on site, such outpatient, inpatient, urgent/emergent, inmate transfers, care coordination, and medication management. The key focus areas for evaluation of nursing care include appropriateness and timeliness of patient triage and assessment, identification and prioritization of health care needs, use of the nursing process to implement interventions, and accurate, thorough, and legible documentation. Although nursing services provided in the OHU, CTC, or other inpatient units are reported in the Specialized Medical Housing indicator and nursing services provided in the TTA or related to emergency medical responses are reported in the Emergency Services indicator, all areas of nursing services are summarized in this Quality of Nursing Performance indicator. Case Review Results The OIG clinicians reviewed 256 nursing encounters, of which 125 were outpatient nursing encounters. Most outpatient nursing encounters were for sick call requests, walk-in visits, and RN care manager follow-up visits. In all, there were 40 deficiencies related to nursing care services, of which 11 were significant. The Quality of Nursing Performance indicator at WSP was rated adequate. Nursing Assessment A major part of providing adequate nursing care is the quality of nursing assessments, including both the subjective (patient interview) and the objective (evaluation and observation) portions. The majority of nurses at WSP consistently included both subjective and objective nursing assessments of their patients. During the case review process, one area of nursing services that particularly stood out as a positive was the provision of comprehensive patient-specific nursing assessments by staff in the reception center. Nursing Intervention A major determining factor in appropriate nursing interventions is the performance of an accurate assessment. Since nurses at WSP usually performed appropriate assessments, nursing interventions were also usually timely and appropriate. However, there were several minor deficiencies that demonstrated areas to target for system evaluation, staff education, and other quality improvement strategies, as follows: Wasco State Prison, Cycle 5 Medical Inspection Page 39 Office of the Inspector General State of California  In case 16, the newly-discharged patient from the CTC had refused his dressing changes for several days, and the LVNs did not notify the RN care manager or the provider. Additionally, one LVN decided to discontinue the ordered ointment application to the wound without contacting the provider or receiving an order for discontinuation.  In case 20, the provider ordered finger-stick blood glucose to be checked in the morning and before meals for three weeks for the diabetic patient. These blood glucose checks were not done. Nursing Documentation Nursing documentation in all areas of nursing services was generally good at WSP. However, there was a noticeable pattern of documentation deficiencies. There were frequent inconsistencies in the documentation of the timeline, or sequence of events, from different nurses involved in the emergency medical response (also discussed in the Emergency Services indicator). Although not significant, the following deficiencies displayed areas to target for further nursing evaluation and quality improvement:  In case 8, the patient in the CTC developed a fever and was sent offsite to a community hospital. The nurse did not document an assessment of the patient’s condition or nursing interventions that led up to sending the patient out for a higher level of care. Additionally, the patient’s vital signs were documented as taken at a time after he had been transported out of the institution to the hospital.  In case 16, a third-watch CTC nurse consistently documented a dressing change regimen that was different from the most recent wound care orders. Sick Call The sick call process at WSP was timely and met the majority of patients’ needs regarding access to health care services. However, aspects of the sick call process clearly indicated a need for targeted quality improvement strategies. Although sick call nurses generally performed appropriate nursing assessment and intervention, there were cases in which patients were not assessed timely or appropriately based on the symptoms they described on the sick call request (CDCR Form 7362). The following examples of minor deficiencies illustrate this pattern:  In case 10, the patient submitted a sick call request for chest pain and shortness of breath. The sick call nurse did not assess the patient until three hours after reviewing the request form, at which time the patient was transferred to the TTA and eventually out to a community hospital for a higher level of care.  In case 17, the patient had been sent out to the emergency room for kidney stones. After returning to WSP, he repeatedly submitted sick call requests for painful urination, blood in his urine, vomiting, diarrhea, continuing to pass kidney stones, and renewal of his prescribed Wasco State Prison, Cycle 5 Medical Inspection Page 40 Office of the Inspector General State of California pain medication. On numerous occasions, the sick call nurse did not provide a face-to-face assessment of the patient, and did not refer him to a provider even after receiving the third request for the same complaint. On one occasion when the sick call nurse did see the patient at a face-to-face visit for vomiting and diarrhea (for four days), blood in the urine, and kidney stone pain, the nurse did not assess the patient’s vital signs or order a urinalysis.  In case 35, the patient, who was being followed in the oncology (cancer) clinic, submitted a sick call request for renewal of his pain medication for continuing chronic pain. The patient’s last administered dose of pain medication had been two days prior to the sick call visit according to his medication administration record. The sick call nurse did not assess the patient’s pain level, document the location of his pain, or notify the provider about the pain medication. The patient did not receive his pain medication until two weeks later when the provider renewed the pain medication at a follow-up visit. Care Management The role of the RN primary care manager includes assessing patients, initiating appropriate interventions to support goals in the patient’s treatment plan, and monitoring patients with chronic health needs and those at increased risk for developing serious health complications. Although not significant, the following case reviews demonstrated the need for evaluation of the communication processes in place at WSP for notifying the RN primary care managers about the needs of patients upon discharge from the CTC, thereby supporting their ability to appropriately assess, coordinate, and advocate for needed health care services.  In case 16, the patient with a recurrent slow-healing leg wound infection had been treated with antibiotics in the CTC and was discharged with orders for daily wound care and physical therapy. The RN care manager assessed the patient four days after his discharge from the CTC and addressed his long-term chronic health conditions. However, the RN care manager did not address the patient’s daily refusals of wound care and physical therapy during the three days since his discharge from the CTC.  In case 17, the RN care manager assessed the patient five days after his discharge from the CTC, where he had been treated for pancreatitis (pancreas inflammation) and pneumonia. The RN care manager did not address the patient’s status after CTC discharge or his use of a rescue inhaler (for sudden wheezing) and pain management since the CTC discharge. Urgent/Emergent Care Although issues with malfunctioning medical equipment were identified in the case reviews, the medical responders and TTA nurses provided appropriate care to patients during emergency medical responses. The clinic LVNs and PTs serve as first medical responders in the yards at WSP. The OIG clinicians identified issues that fell into two patterns of deficiencies in the cases reviewed. One pattern was that the LVNs and PTs always administered the lowest dose (2 liters per minute) of Wasco State Prison, Cycle 5 Medical Inspection Page 41 Office of the Inspector General State of California oxygen when higher doses (up to 6 liters per minute) would have been more appropriate. The second pattern of deficiencies was the timeline documentation inconsistencies of emergency response events. This is further discussed in the Emergency Services indicator. After Hospital Returns Patients returning to WSP after hospital discharge were assessed by a TTA nurse and received appropriate nursing assessments and follow-up referrals. The TTA nurses reconciled discharge recommendations from the hospital with the provider, and most patients received medications and treatments as recommended. This is further discussed in the Inter- and Intra-System Transfers indicator. Specialized Medical Housing CTC nurses provided adequate nursing care services. This is further discussed in the Specialized Medical Housing indicator. Transfers and Reception Center Nurses in the reception center provided adequate nursing care services and documentation. This is further discussed in the Inter- and Intra-System Transfers and Reception Center indicators. Offsite Medical Return and Specialty Care The telemedicine nurse did not review the most current patient information prior to scheduled telemedicine appointments. However, during the onsite visit, nursing administrators indicated the telemedicine nurse and backup nurse had been provided education about conducting a comprehensive review for current patient information prior to telemedicine appointments to ensure the most current information is made available for telemedicine appointments. This is further discussed in the Specialty Services indicator. Medication Administration System processes in place at WSP supported nursing and pharmacy staff in providing timely medication administration to patients. This is further discussed in the Pharmacy and Medication Management indicator. Clinician Onsite Inspection The OIG nurse clinicians attended the weekly WSP Supervising Nurses meeting during the onsite visit. The CNE facilitated the lively, well-attended meeting in which nursing supervisors discussed topics such as plans for implementation of the EHRS, status updates on various nursing projects, potential educational strategies, and suggestions for staff morale-boosting activities to implement for the upcoming National Nurses Week event at WSP. Wasco State Prison, Cycle 5 Medical Inspection Page 42 Office of the Inspector General State of California Case Review Conclusion The OIG nurse clinician team facilitated a meeting with the CNE and nurse supervisory team to discuss the case review and onsite visit findings. The WSP nurse managers had done their research on the cases presented and were well prepared to address the issues and interventions underway for improvement. The OIG commended the WSP nurses for their successful implementation of the excellent care team huddle process established in the clinics and CTC, the cohesiveness and involvement of the nurse management and supervisory team, and the good morale observed among all levels of nursing staff in each nursing service area. The OIG rated the Quality of Nursing Performance indicator at WSP adequate. Wasco State Prison, Cycle 5 Medical Inspection Page 43 Office of the Inspector General State of California 11 — QUALITY OF PROVIDER PERFORMANCE In this indicator, the OIG physicians provide a qualitative Case Review Rating: evaluation of the adequacy of provider care at the institution. Adequate Appropriate evaluation, diagnosis, and management plans are Compliance Score: reviewed for programs including, but not limited to, nursing sick Not Applicable call, chronic care programs, TTA, specialized medical housing, and specialty services. The assessment of provider care is Overall Rating: performed entirely by OIG physicians. There is no compliance Adequate testing component associated with this quality indicator. Case Review Results The OIG clinicians reviewed 149 medical provider encounters and identified 62 deficiencies related to provider performance, 26 were significant. Ten of the significant deficiencies occurred in the CTC and contributed to the inadequate rating of the Specialized Medical Housing indicator. As such, they are weighted less in this Quality of Provider Performance indicator. The OIG reviewed 20 detailed case reviews, and found one proficient, 13 adequate, and 6 inadequate. The OIG clinicians rated this indicator adequate, but identified areas still needing improvement. Assessment and Decision-Making Some provider decisions were excellent and exceeded expectations:  In case 10, a patient returned from an outside hospital after a heart attack. The patient refused important testing in the hospital to determine if another heart attack was likely to occur in the future. The patient left against medical advice and returned to WSP. The WSP primary care provider spent considerable time and discussion to convince the patient to have the additional testing. The patient ultimately agreed to have the testing, which was emergently needed in a few days when he had another massive heart attack. This required complex, lifesaving surgery. Some provider decisions were problematic. The following cases are also discussed in the Specialized Medical Housing indicator:  In case 8, the provider demonstrated poor clinical judgment when this patient was scheduled for non-urgent surgery. The patient had had a blood clot in his legs two weeks earlier. The surgery should have been delayed until a time when blood-thinning medications could more safely have been temporarily stopped. Fortunately, no harm came to the patient when the blood-thinning medication was stopped.  Again in case 8, the regular provider misinterpreted laboratory studies. A very elevated ferritin (iron) level was incorrectly interpreted as indicating that the patient was iron deficient. The provider inappropriately prescribed iron supplements. Wasco State Prison, Cycle 5 Medical Inspection Page 44 Office of the Inspector General State of California  In case 14, there was no adjustment to increase warfarin (blood thinner) after a third laboratory test showed a low therapeutic level.  In case 15, the TTA provider failed to administer an antidote for a possible narcotics overdose to an unconscious patient with signs upon physical examination that strongly suggested he had overdosed. Fortunately, the patient had not overdosed, but instead had had a severe infection.  In case 16, the provider failed to recognize that only ten days of antibiotics was insufficient for a wound caused by a bone infection. The provider also failed to order diagnostic tests to ensure treatment was complete. Finally, the provider failed to appropriately examine the wound. The wounds never healed over the months of medical care reviewed. Review of Records Some errors were likely a result of providers being unfamiliar with a patient in the CTC because of spending insufficient time to review the medical records. These deficiencies are described in detail in the Specialized Medical Housing indicator. Other examples in outpatient care where significant deficiencies resulted from incomplete record review are as follows:  In case 1, the provider evaluated the patient two days after a recent TTA visit. The provider failed to review the TTA visit and did not address the new symptom of facial numbness. A complete examination, and likely a CT scan of the head, should have been performed to eliminate stroke as the cause.  In case 9, there were three significant deficiencies. The provider reviewed the hospital discharge summary and did not address the hospitalist’s recommendation for discontinuing valproic acid (seizure medication). By reordering the valproic acid, a medication known for causing liver injury in some patients, the provider placed the patient with elevated liver enzymes at risk for further liver damage. On another encounter, the provider reviewed laboratory tests showing an elevated valproic acid level. Again, the provider failed to address the elevated valproic acid level in a patient with elevated liver enzymes. Finally, on another encounter, the provider evaluated the patient after another hospitalization, but did not address the hospitalist’s discharge diagnosis of hyponatremia (low salt level) and elevated liver enzymes, likely due to medication.  In case 12, the provider failed to review the laboratory tests, even though test result review was one of the reasons for the medical appointment. This resulted in the patient’s new diagnosis of hepatitis C being overlooked and unaddressed.  In case 17, the provider failed to review the CT scan showing the presence of a kidney stone. Wasco State Prison, Cycle 5 Medical Inspection Page 45 Office of the Inspector General State of California Chronic Care The providers sometimes provided poor care for patients with chronic medical conditions, as illustrated in the following examples:  In case 17, the provider refilled a narcotic pain medication without an appropriate evaluation or follow-up visit.  In case 17, on another encounter, the provider failed to appropriately adjust insulin for a patient with high bedtime glucose levels. The provider inappropriately increased the long-acting insulin, which placed the patient at risk for low morning glucose levels. The provider also ordered an inappropriately long follow-up interval of 90 days before the next appointment. In addition, the patient’s chronic hepatitis C infection was not addressed.  Also in case 17, on another encounter, the provider failed to manage recent findings of a kidney stone on a CT scan and a TTA visit with blood in the urine. The provider failed to consider many other causes of the patient’s abdominal discomfort other than kidney stones.  In case 19, the provider did not address the asthma patient’s shortness of breath and poor control of asthma.  In case 20, on three encounters, the providers failed to appropriately treat a patient with high blood glucose average (HemA1c rising to 9.9).  In case 21, the provider did not adequately manage a very high glucose average (HemA1c of 9.9) by only increasing metformin, one type of diabetes medication. Without adding a second diabetes medication, this one change would not be expected to have the patient’s glucose level at target. Urgent/Emergent Care The providers performed well in emergency services, with one significant deficiency. Most minor deficiencies were the on-call provider’s failures to record a telephone call progress note. There was one event in which the provider failed to fully evaluate a patient in the TTA with elevated blood pressure and new neurological symptoms that suggested an acute stroke (case 1). This is also discussed in the Emergency Services indicator. Specialty Services Provider performance related to specialty services was good. The case review process did not find any deficiencies in provider performance. This is also discussed in the Specialty Services indicator. Wasco State Prison, Cycle 5 Medical Inspection Page 46 Office of the Inspector General State of California Specialized Medical Housing There were ten significant deficiencies identified for WSP in this area. Most occurred during the care given to two patients (cases 8 and 16). While the continuity of care was generally good when provided by the main CTC provider, serious errors arose when this one provider had an extended absence and other providers covered the patients. The providers indicated to the OIG during the onsite inspection that they had not fully reviewed the medical records due to time constraints and knowing that their CTC coverage was limited to one or two days until the regular provider returned. It is likely this contributed to the errors. These deficiencies are described further in the Specialized Medical Housing indicator. Clinician Onsite Inspection The medical leadership stated they had worked to make improvements to WSP since the OIG’s Cycle 4 inspection report. This was apparent in the improvements noted in specialty services and chronic care of patients with heart disease. However, for the other patients in the specialized medical housing and for some patients with diabetes, the care would still improve with additional provider training. At the time of the onsite inspection, there were no provider vacancies. The chief medical executive (CME) was concerned that this may not be the case in the future because of two issues. At the time of the onsite inspection, in order to improve recruitment and retention of physicians at certain institutions (not including WSP), CCHCS had planned a future salary increase. The CME opined that his physicians would possibly apply to other institutions, specifically two nearby, where the salary increase was planned. The other issue concerned mid-level providers. Both nurse practitioners and physician assistants had voiced dissatisfaction with salaries, which had not changed for many years. Two mid-level providers indicated plans to leave state service and return to community positions. Otherwise, provider morale was good. They felt strongly supported by the chief physician and surgeon (CP&S), with an excellent communication process in place with three daily meetings. All physicians, mid-level providers, and the CP&S started each day with a morning report to review the on-call events of the prior day and evening. This was followed by huddles in each of the health care areas by all primary care team members, custody, mental health, and dental. The third daily meeting was at the end of the day, during which the physicians shared important events and briefed the provider on call that evening. Case Review Conclusion For the most part, provider care at WSP was good. There were many significant provider deficiencies identified in the Specialized Medical Housing indicator for two patients. Those deficiencies strongly contributed to the inadequate rating for that indicator. The OIG clinicians, therefore, gave those deficiencies less weight in this Quality of Provider Performance indicator. Although the OIG clinicians rated this indicator adequate, there was opportunity for improved care. Wasco State Prison, Cycle 5 Medical Inspection Page 47 Office of the Inspector General State of California 12 — RECEPTION CENTER ARRIVALS This indicator focuses on the management of medical needs and Case Review Rating: continuity of care for patients arriving from outside the CDCR Adequate system. The OIG review includes evaluation of the ability of the Compliance Score: institution to provide and document initial health screenings, initial Adequate (83.8%) health assessments, continuity of medications, and completion of required screening tests; address and provide significant Overall Rating: accommodations for disabilities and health care appliance needs; Adequate and identify health care conditions needing treatment and monitoring. The patients reviewed for reception center cases are those received from non-CDCR facilities, such as county jails. Case Review Results The OIG clinicians reviewed 14 reception center arrival patients and 43 events. There were five deficiencies, two of which were significant (cases 52 and 54). The case review rating for the Reception Center Arrivals indicator at WSP was adequate. Access to Care Patients who arrived at WSP from county correctional facilities received timely and appropriate health care services. The reception center nursing staff adequately screened patients, completed physical assessments, noted durable medical equipment needs, and made appropriate follow-up referrals. All reception center arrivals were evaluated by a provider within one week at WSP, and all had timely dental and mental health screenings. Missing documentation in patients’ medical records causes the inability to appropriately determine current health care status and medical needs. One such significant deficiency occurred:  In case 52, page 2 of the three-page medical transfer summary records from the county correctional facility was not scanned into the patient’s electronic health record. Medication Continuity Reception center nurses consistently reviewed patients’ current medications from county facilities and reconciled medication orders with a provider. Although new arrivals generally received medications continuously without interruption, the following significant deficiency was identified:  In case 54, the diabetic patient arrived at WSP in the morning. The provider ordered a morning and an evening dose of insulin, but the patient did not receive any insulin doses until the following day. Wasco State Prison, Cycle 5 Medical Inspection Page 48 Office of the Inspector General State of California Clinician Onsite Inspection Annually, thousands of patients enter CDCR institutions through the WSP reception center. During the onsite visit, clinicians toured a well-organized reception area where nurses screened newly arrived patients. Each patient was scheduled with a medical provider at the diagnostics clinic for the initial history and physical examination during his first week after arrival, with primary care teams’ follow-up in the yard clinics. The leadership at WSP stated that a priority was to carefully monitor the appointments and successfully avoid backlogs. These processes likely contributed to the dramatic improvements in operations for this reception center since the OIG’s Cycle 4 inspection. Case Review Conclusion The OIG clinicians rated the Reception Center Arrivals indicator at WSP adequate. Compliance Testing Results The institution earned an adequate compliance score of 83.8 percent in the Reception Center Arrivals indicator, with proficient scores in the following tests:  Inspectors sampled 20 reception center patients to ensure that they received timely health screenings upon arrival at the institution. All sampled patients had timely screenings (MIT 12.001).  Reception center nursing staff timely completed, signed, and dated the assessment and disposition section of the initial health screening form for all 20 patients sampled (MIT 12.002).  Inspectors sampled 20 reception center patients for required intake tests; all patients timely received all applicable intake tests (MIT 12.005).  Providers timely reviewed and communicated intake test results for 19 of the 20 reception center patients who arrived at WSP during the sample period (95 percent). There was no evidence found that the provider communicated the results to one patient (MIT 12.006). The following test scored in the adequate range:  The institution timely offered or administered a valley fever skin test to 15 of the 20 sampled reception center patients (75 percent). Five patients consented to a valley fever test, but inspectors found no evidence WSP ever administered the test to them (MIT 12.008). The following tests showed areas for improvement:  Among 20 sampled patients who received an intake screening and whom the intake nurse referred to a provider, only 14 patients (70 percent) were seen timely by a provider. Six patients were seen between 3 and 25 days late (MIT 12.003). Furthermore, providers timely Wasco State Prison, Cycle 5 Medical Inspection Page 49 Office of the Inspector General State of California completed reception center history and physical examinations within seven calendar days of arrival for only 14 of the same 20 sampled patients (70 percent). For six patients, the history and physical was completed 3 to 25 days late (MIT 12.004).  The OIG sampled 20 reception center arrivals to ensure that each patient had a timely completed and properly documented TB skin test. While all 20 patients had their skin tests initiated within 72 hours of arrival, only 12 were properly conducted (60 percent). The following errors occurred among the other eight sampled patients (MIT 12.007): o Staff read six patients’ TB test results prior to the minimum 48 hours. o One patient had a prior positive TB test but did not have a chest X-ray completed. o Another patient was administered a TB test, but staff did not document the time of administration; therefore, OIG inspectors were unable to confirm that the test result was read within the specific time range of 48 to 72 hours. Wasco State Prison, Cycle 5 Medical Inspection Page 50 Office of the Inspector General State of California 13 — SPECIALIZED MEDICAL HOUSING This indicator addresses whether the institution follows appropriate Case Review Rating: policies and procedures when admitting patients to onsite inpatient Inadequate facilities, including completion of timely nursing and provider Compliance Score: assessments. The chart review assesses all aspects of medical care Adequate related to these housing units, including quality of provider and (85.0%) nursing care. WSP’s only specialized medical housing unit was a Overall Rating: CTC. Inadequate For this indicator, the OIG’s case review and compliance review processes yielded different results, with the case review giving an inadequate rating and the compliance testing resulting in an adequate score. The OIG’s internal review process considered those factors that led to both scores and ultimately rated this indicator inadequate. The key factors were that the case review had a larger sample size, and the case review focused on the quality of care provided. As a result, the case review testing results were deemed a more accurate reflection of the appropriate overall indicator rating. Case Review Results The 16-bed CTC at WSP had 11 beds designated for patients with medical care needs and five for mental health patients. There was one negative pressure room, a space designed to minimize the spread of airborne infections. The OIG clinicians reviewed 101 events among eight CTC patients. This included 46 provider and 36 nursing encounters, some of which included several consecutive days of nursing care. The OIG clinicians identified 30 deficiencies, of which 13 were significant. While the nursing care was well done, multiple significant deficiencies in provider performance contributed to the inadequate rating. Provider Performance The provider performance was poor in the CTC. There were 20 deficiencies in the 46 provider encounters. Ten of the deficiencies were significant. Three of the significant deficiencies were in case 8. This patient had a new blood clot in his leg, and a lack of appropriate and careful medical record review contributed to this patient not receiving adequate care.  In case 8, the provider demonstrated poor clinical judgment when this patient was scheduled for non-urgent surgery. The patient had had a recent blood clot in his legs two weeks earlier. The surgery should have been delayed until a time when the blood-thinning medications could more safely have been temporarily stopped. Fortunately, no harm came to the patient when the blood-thinning medication was held. Wasco State Prison, Cycle 5 Medical Inspection Page 51 Office of the Inspector General State of California  Also in case 8, significant deficiencies occurred when a provider not familiar with the patient failed to adequately review the medical records and incorrectly concluded that the patient was receiving anticoagulation, when in fact it was being held because of surgery.  In addition for case 8, the regular provider misinterpreted laboratory studies. A very elevated ferritin (iron) level was incorrectly interpreted as meaning the patient was iron deficient. The provider inappropriately prescribed iron supplements. Notably, the ordinarily good continuity of provider care at WSP was absent in the CTC because the main CTC provider was away from the institution for much of the OIG’s inspection period. Six of the significant provider deficiencies in this indicator occurred in case 16. This was a complex patient who had non-healing wounds for years. Nonetheless, the providers failed on multiple occasions to provide the care needed to reverse what was a significant underlying bone infection in his leg. All of the following deficiencies occurred in case 16:  The CTC provider referred the patient to a vascular surgeon, but should have referred the patient to a surgeon or infection specialist for evaluation of possible osteomyelitis (bone infection).  The same provider failed to recognize that a 10-day antibiotic course was likely insufficient, and failed to order diagnostic tests to determine if the osteomyelitis had resolved.  Again, the same provider failed to review the orthopedic consult that was available in the electronic medical record. The provider failed to order the wound culture or the laboratory tests that the specialist recommended.  The CTC provider failed to follow-up on the possibility of osteomyelitis. The provider again failed to carefully review the orthopedic surgery consult, which recommended further laboratory tests and a wound culture. The patient was lost to orthopedic follow-up after the provider’s failure to follow the recommendations.  The covering CTC provider wrote that the patient had osteomyelitis, but did not assess whether any confirmatory diagnostic testing had been performed (it had not), or if the patient had been adequately treated for osteomyelitis (he had not). The provider performed insufficient chart review and did not address all of the patient’s ongoing medical conditions. Finally, the provider did not examine the wounds.  The original CTC provider did not complete an adequate discharge summary. The provider’s notes were scant and failed to discuss of the possibility of osteomyelitis, the unusual and hard to treat infection, or the limited antibiotics given while in the CTC. The provider did not discuss the abnormal X-rays or the plans for them. The scant and inadequate discharge summary reflected poor chart review and markedly increased the risk of a lapse in care. Wasco State Prison, Cycle 5 Medical Inspection Page 52 Office of the Inspector General State of California Nursing Performance Overall, the nursing staff at WSP provided adequate nursing care to patients in the CTC. Nurses conducted appropriate daily patient assessments that included physical examination, general status regarding activities of daily living, and re-assessment after providing an intervention such as pain medication. Nursing documentation was fairly thorough and generally included subjective information from the patient, changes in patient status, and provider contacts. The nursing wound care was well done and likely reflects quality improvement measures implemented following the OIG’s Cycle 4 inspection report. There was one significant deficiency identified in the CTC patient cases reviewed.  In case 4, the patient had a peripheral intravenous central catheter (PICC) line for a course of antibiotic therapy. After the antibiotic treatment course ended, CTC nurses did not perform regular daily maintenance by flushing with normal saline to ensure the patient’s PICC line was not obstructed, per nursing protocol. The patient’s PICC line was not given a maintenance flush until 16 days after the previous maintenance flush. Clinician Onsite Inspection During the onsite visit, the OIG clinicians found the CTC to be well staffed with experienced nurses and sufficient custody staff to support timely access for the provision of needed care to patients. Morning huddle occurred promptly at the designated time and location. Participants included the medical provider, mental health provider, nursing staff and supervisors, office support staff, and custody officers. Each patient was discussed with reports from numerous participants on the patient’s current status, issues, treatment, and plan of care. The CTC huddle clearly demonstrated an appropriate practice model for the care team’s morning reporting process. For the providers, the continuity of care was usually excellent in the CTC with one provider responsible for the day to day coverage. However, many of the significant deficiencies found during the OIG case review were during the main provider’s absence from the institution. During the onsite interviews, the providers who temporarily covered the CTC indicated they did not fully review the medical records as they were only seeing the patient for one or two days. It is likely this cursory record review contributed to some of deficiencies found for otherwise providers capable of good care. Case Review Conclusion Due to significant deficiencies identified in provider performance regarding failure to provide the care needed, the OIG clinicians rated the Specialized Medical Housing indicator inadequate. Wasco State Prison, Cycle 5 Medical Inspection Page 53 Office of the Inspector General State of California Compliance Testing Results The institution scored an adequate 85.0 percent in the Specialized Medical Housing indicator, with proficient scores in the following three tests:  For all ten patients sampled, nursing staff timely completed an initial health assessment on the day the patient was admitted to the CTC (MIT 13.001).  Inspectors observed the working order of sampled call buttons in CTC patient rooms and found all working properly. In addition, according to staff members interviewed, custody officers and clinicians were able to expeditiously access patients’ locked rooms when emergent events occurred (MIT 13.101).  Providers evaluated nine of ten sampled patients within 24 hours of admission and completed the required history and physical exam (90 percent). For one patient, the provider failed to document the time on the exam form; therefore, inspectors were unable to verify that the history and physical was completed within 24 hours of the patient’s admission (MIT 13.002). The final test in this indicator received an inadequate score:  The OIG tested whether providers completed their Subjective, Objective, Assessment, Plan, and Education (SOAPE) notes at required three-day intervals. Providers timely completed SOAPE notes for only five of the ten sampled patients (50 percent). Five patients’ provider notes were either one to two days late or not found at all (MIT 13.003). Wasco State Prison, Cycle 5 Medical Inspection Page 54 Office of the Inspector General State of California 14 — SPECIALTY SERVICES This indicator focuses on specialist care from the time a request for Case Review Rating: services or physician’s order for specialist care is completed to the Adequate time of receipt of related recommendations from specialists. This Compliance Score: indicator also evaluates the providers’ timely review of specialist Proficient records and documentation reflecting the patients’ care plans, (86.8%) including course of care when specialist recommendations were not Overall Rating: ordered, and whether the results of specialists’ reports are Adequate communicated to the patients. For specialty services denied by the institution, the OIG determines whether the denials are timely and appropriate, and whether the patient is updated on the plan of care. For this indicator, the OIG’s case review and compliance review process yielded different results, with the case review giving an adequate rating and the compliance review resulting in a proficient score. The OIG’s internal review process considered those factors that led to both scores and ultimately rated this indicator adequate. While compliance testing just reached the proficient score, case review identified a number of significant deficiencies which kept the overall rating in the adequate range. Case Review Results The OIG clinicians reviewed 60 events related to specialty services, which included 45 specialty consultations and procedures and 15 nursing encounters. Ten deficiencies were found in this category, five of which were significant. The case review clinicians rated this indicator adequate. Access to Specialty Services While specialty services were generally provided within reasonable time frames for both routine and urgent services, significant delays in specialty follow-ups occurred in two cases. These placed the patients at risk for serious harm.  In case 9, the provider requested an infectious disease follow-up visit in two weeks, but the appointment occurred in five weeks.  In case 16, the provider requested a follow-up with the plastic surgery specialist in four weeks to determine if surgery was warranted. The patient did not have follow-up with the specialist at all. Nursing Performance Nursing care was adequate in offsite medical returns assessments, interventions, and documentation. The deficiencies in this category were related to poor communication. One telemedicine nurse deficiency was significant: Wasco State Prison, Cycle 5 Medical Inspection Page 55 Office of the Inspector General State of California  In case 14, the telemedicine nurse failed to review the medical record, which showed the patient was sent to the hospital two days earlier for a possible heart attack. The patient left the hospital before important testing could be completed to see if his symptoms were from the heart or some other condition. This failure of the telemedicine nurse to review the record resulted in the cardiology consultant being unaware of a possible change in the patient’s condition. Fortunately, no harm came to the patient. Provider Performance Provider performances related to specialty services were good. The case review process did not find any deficiencies in provider performance. Patients were referred appropriately and were seen in a timely fashion. Providers reviewed specialty recommendations thoroughly. Health Information Management Health information management deficiencies related to specialty services included reports that were scanned into the electronic medical record without a signature and reports that were not scanned into the electronic medical record. There were 63 events with seven deficiencies identified. The two significant deficiencies are listed below.  In case 16, there was a failure to retrieve, scan, and review the dictated cardiology specialty report.  Also in case 16, there was a failure to retrieve, scan, and review the specialty report from plastic surgery. There were orders from the specialist scanned under the “Other” tab in the electronic medical record, but there was no report regarding the full plan. Clinician Onsite Inspection While onsite, the leadership stated they had used the OIG’s Cycle 4 inspection report to improve specialty services operations, especially in tracking appointments and scheduling. The OIG found a large improvement in the number of deficiencies for this indicator. However, the decrease in significant deficiencies for this indicator was only slightly improved. Case Review Conclusion The OIG clinicians found the overall processes in specialty services to be functioning well, and rated this indicator adequate. Wasco State Prison, Cycle 5 Medical Inspection Page 56 Office of the Inspector General State of California Compliance Testing Results The institution received a proficient compliance score of 86.8 percent in the Specialty Services indicator, with five tests earning high scores, as follows:  For all 15 patients sampled, high-priority specialty service appointments occurred within 14 calendar days of the provider’s order (MIT 14.001).  For all 15 patients sampled, routine specialty service appointments occurred within 90 calendar days of the provider’s order (MIT 14.003).  WSP received a score of 100 percent when the OIG tested the timeliness of the denials of providers’ specialty services requests for 20 patients (MIT 14.006).  Providers timely received and reviewed the specialists’ reports for 13 of 15 sampled patients (87 percent). For two patients, there was no evidence of a specialist’s report in the electronic medical record. Although progress notes indicated that results were reviewed, both appointments occurred after the required time frame (19 and 29 days late) (MIT 14.002).  Specialists’ reports were timely reviewed by a provider following routine specialty service appointments for 12 of the 14 patients sampled (86 percent). For two patients, the specialty report was not reviewed by the provider at all (MIT 14.004). One test in this indicator received an adequate score:  When an institution approves or schedules a patient for specialty services appointments and then transfers the patient to another institution, policy requires that the receiving institution ensure a patient’s appointment occurs timely. At WSP, 16 of the 20 sampled patients transferring in received their specialty services appointment within the required time frame (80 percent). Two patients received their appointments between 5 and 25 days late, and for the other two patients, there was no evidence in the medical record that an appointment was ever held (MIT 14.005). The institution showed room for improvement in one test area:  Among 18 patients sampled for whom WSP’s health care management denied a specialty service, only ten patients (56 percent) received a timely notification of the denied service, including the provider meeting with the patient within 30 days to discuss alternative treatment strategies. For three patients, the provider’s follow-up visit occurred from 20 to 68 days late. For five patients, there was no provider follow-up to discuss the denial at all (MIT 14.007). Wasco State Prison, Cycle 5 Medical Inspection Page 57 Office of the Inspector General State of California 15 — ADMINISTRATIVE OPERATIONS (SECONDARY) This indicator focuses on the institution’s administrative health Case Review Rating: care oversight functions. The OIG evaluates whether the institution Not Applicable promptly processes patient medical appeals and addresses all Compliance Score: appealed issues. Inspectors also verify that the institution follows Inadequate reporting requirements for adverse/sentinel events and patient (78.6%) deaths. The OIG verifies that the Emergency Medical Response Overall Rating: Review Committee (EMRRC) performs required reviews and that Adequate staff perform required emergency response drills. Inspectors also assess whether the Quality Management Committee (QMC) meets regularly and adequately addresses program performance. For those institutions with licensed facilities, inspectors also verify that required committee meetings are held. In addition, OIG examines whether the institution adequately manages its health care staffing resources by evaluating whether job performance reviews are completed as required; specified staff possess current, valid credentials and professional licenses or certifications; nursing staff receive new employee orientation training and annual competency testing; and clinical and custody staff have current medical emergency response certifications. The Administrative Operations indicator is a secondary indicator, and, therefore, was not relied on for the overall score for the institution. Compliance Testing Results The institution received an adequate compliance score of 78.6 percent in the Administrative Operations indicator, with 12 tests scoring in the proficient range::  The institution promptly processed all inmate medical appeals in each of the most recent 12 months (MIT 15.001).  The QMC met monthly, evaluated program performance, and took action when management identified areas for improvement opportunities (MIT 15.003).  The OIG inspected incident package documentation for 12 emergency medical responses reviewed by the institution’s EMRRC during the prior six-month period; all 12 sampled packages complied with policy (MIT 15.005).  Inspectors reviewed the last 12 months of WSP’s local governing body (LGB) meeting minutes and determined that the LGB met at least quarterly and exercised responsibility for the quality management of patient heath care each quarter, as documented in the meeting minutes. As a result, WSP scored 100 percent for this test (MIT 15.006).  Inspectors reviewed drill packages for three medical emergency response drills conducted in the prior quarter, and they contained all required summary reports and related Wasco State Prison, Cycle 5 Medical Inspection Page 58 Office of the Inspector General State of California documentation. In addition, the drills included participation by both health care and custody staff (MIT 15.101).  Based on a sample of ten second-level medical appeals, the institution’s responses addressed all of the patients’ appealed issues (MIT 15.102).  All ten nurses sampled were current with their clinical competency validations (MIT 15.105).  All providers at the institution were current with their professional licenses. Similarly, all nursing staff and the pharmacist in charge were current with their professional licenses and certification requirements (MIT 15.107, 15.109).  All active duty providers, nurses, and custody staff were current with their emergency response certifications (MIT 15.108).  All nursing staff hired within the last year timely received new employee orientation training (MIT 15.111).  The OIG reviewed performance evaluation packets for WSP’s 11 providers; WSP met all performance review requirements for ten of them. For one provider, the annual performance appraisal was not properly completed by the supervisor (MIT 15.106). The institution showed room for improvement in the following areas:  The institution had not taken adequate steps to ensure the accuracy of its Dashboard data. Although the institution provided substantial evidence of discussion of the methodologies used to conduct periodic data validation and the results of that data validation testing, the QMC meetings did not include discussion of methodologies used to train staff who collected Dashboard data and, therefore, WSP received a score of zero (MIT 15.004).  The OIG inspected records for five nurses to determine if their nursing supervisors properly completed monthly performance reviews. Inspectors identified the following deficiencies for the five nurses’ monthly nursing reviews (MIT 15.104): o The supervisor’s review did not summarize aspects that were well done for any of the five nurses. o With two of the nurses, the supervisor did not discuss the findings of the review on a monthly basis.  The pharmacist in charge did not have a system in place to ensure that the providers’ Drug Enforcement Agency registrations did not expire, resulting in a score of zero on this test (15.110). Wasco State Prison, Cycle 5 Medical Inspection Page 59 Office of the Inspector General State of California  WSP had three inmate deaths occur during the OIG’s sample test period. The institution did not timely notify the CCHCS’s Death Review Unit for one of the three deaths. As a result, the institution scored 67 percent on this test (MIT 15.103). Non-Scored Results  The OIG gathered non-scored data regarding the completion of death review reports by CCHCS’s Death Review Committee (DRC). Two deaths occurred during the OIG’s review period, both of which were unexpected (Level 1) deaths. The DRC was required to complete its death review summary report within 60 calendar days from the date of death and submit the report to the institution’s CEO within seven calendar days thereafter. However, the DRC completed its report of the first death 4 days late (64 days after the death) and submitted it to WSP’s CEO 13 days late. The second death review summary report was completed 192 days late (252 days after the death), but the report was submitted to WSP’s CEO within the 7-day required time frame after the completion of the report (MIT 15.998).  The OIG discusses the institution’s health care staffing resources in the About the Institution section of this report (MIT 15.999). Wasco State Prison, Cycle 5 Medical Inspection Page 60 Office of the Inspector General State of California R ECOMMENDATIONS The OIG recommends the institution develop a process to improve access to all radiology reports that have not been scanned into the eUHR since late 2015. The OIG recommends WSP leadership provide training for providers on spending adequate time reviewing the medical records of unfamiliar patients, even when caring for the patient for a brief time. This is especially important for the more complex patients in the CTC. Wasco State Prison, Cycle 5 Medical Inspection Page 61 Office of the Inspector General State of California P -B M OPULATION ASED ETRICS The compliance testing and the case reviews give an accurate assessment of how the institution’s health care systems are functioning with regard to the patients with the highest risk and utilization. This information is vital to assess the capacity of the institution to provide sustainable, adequate care. However, one significant limitation of the case review methodology is that it does not give a clear assessment of how the institution performs for the entire population. For better insight into this performance, the OIG has turned to population-based metrics. For comparative purposes, the OIG has selected several Healthcare Effectiveness Data and Information Set (HEDIS) measures for disease management to gauge the institution’s effectiveness in outpatient health care, especially chronic disease management. The Healthcare Effectiveness Data and Information Set is a set of standardized performance measures developed by the National Committee for Quality Assurance with input from over 300 organizations representing every sector of the nation’s health care industry. It is used by over 90 percent of the nation’s health plans as well as many leading employers and regulators. It was designed to ensure that the public (including employers, the Centers for Medicare and Medicaid Services, and researchers) has the information it needs to accurately compare the performance of health care plans. Healthcare Effectiveness Data and Information Set data is often used to produce health plan report cards, analyze quality improvement activities, and create performance benchmarks. Methodology For population-based metrics, the OIG used a subset of HEDIS measures applicable to the CDCR patient population. Selection of the measures was based on the availability, reliability, and feasibility of the data required for performing the measurement. The OIG collected data using various information sources, including the eUHR, the Master Registry (maintained by CCHCS), as well as a random sample of patient records analyzed and abstracted by trained personnel. Data obtained from the CCHCS Master Registry and Diabetic Registry was not independently validated by the OIG and is presumed to be accurate. For some measures, the OIG used the entire population rather than statistically random samples. While the OIG is not a certified HEDIS compliance auditor, the OIG uses similar methods to ensure that measures are comparable to those published by other organizations. Comparison of Population-Based Metrics For Wasco State Prison, nine HEDIS measures were selected and are listed in the following WSP Results Compared to State and National HEDIS Scores table. Multiple health plans publish their HEDIS performance measures at the state and national levels. The OIG has provided selected results for several health plans in both categories for comparative purposes. Wasco State Prison, Cycle 5 Medical Inspection Page 62 Office of the Inspector General State of California Results of Population-Based Metric Comparison Comprehensive Diabetes Care For chronic care management, the OIG chose measures related to the management of diabetes. Diabetes is the most complex common chronic disease requiring a high level of intervention on the part of the health care system in order to produce optimal results. WSP performed well with its management of diabetes compared to most state and national plans. When compared statewide, WSP outperformed Medi-Cal in all five measures, but only outperformed or performed similarly to Kaiser Permanente in three of five diabetic measures selected. Kaiser, North region, scored 1 percentage point higher than WSP for patients under good control. Kaiser, both North and South regions, scored 2 percentage points better than WSP for diabetic blood pressure control. WSP scored 7 percentage points lower than Kaiser, South, for diabetic eye exams. When compared nationally, WSP outperformed Medicaid, Medicare, and commercial health plans in all five diabetic measures. WSP outscored the United States Department of Veterans Affairs (VA) in two of the applicable measures (patients under poor control and diabetic blood pressure control) but scored lower than the VA in diabetic eye exams and diabetic monitoring. Immunizations Comparative data for immunizations was only fully available for the VA and partially available for Kaiser, commercial plans, Medicaid, and Medicare. With respect to administering influenza vaccinations to younger adults, WSP performed poorly, outscoring only Medicaid. However, the 53 percent patient refusal rate negatively affected the institution’s score. Nevertheless, WSP outperformed both Medicare and the VA regarding influenza shots for older adults. For administering pneumococcal vaccines to older adults, WSP scored much lower than Medicare and the VA. Cancer Screening With respect to colorectal cancer screening, WSP outperformed all other health care entities, statewide and national. Summary WSP’s population-based metrics performance reflected a well-functioning chronic care program in comparison to other state and national health care entities. The institution may improve its scores for immunizations by reducing patient refusals through patient education. Wasco State Prison, Cycle 5 Medical Inspection Page 63 Office of the Inspector General State of California WSP Results Compared to State and National HEDIS Scores California National HEDIS WSP Kaiser HEDIS HEDIS Clinical Measures HEDIS (No. Kaiser HEDIS Com- HEDIS VA Cycle 5 Medi-Cal CA) (So.CA) Medicaid mercial Medicare Average Results1 20152 20163 20163 20164 20164 20164 20155 Comprehensive Diabetes Care HbA1c Testing (Monitoring) 97% 86% 94% 94% 86% 90% 93% 98% Poor HbA1c Control (>9.0%)6, 7 14% 39% 20% 23% 45% 34% 27% 19% HbA1c Control (<8.0%)6 69% 49% 70% 63% 46% 55% 63% - Blood Pressure Control (<140/90)6 81% 63% 83% 83% 59% 60% 62% 74% Eye Exams 74% 53% 68% 81% 53% 54% 69% 89% Immunizations Influenza Shots - Adults (18–64) 42% - 56% 57% 39% 48% - 55% Influenza Shots - Adults (65+) 83% - - - - - 72% 76% Immunizations: Pneumococcal 50% - - - - - 71% 93% Cancer Screening Colorectal Cancer Screening 85% - 79% 82% - 63% 67% 82% 1. Unless otherwise stated, data was collected in March 2017 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. 2. HEDIS Medi-Cal data was obtained from the California Department of Health Care Services 2015 HEDIS Aggregate Report for Medi-Cal Managed Care. 3. Data was obtained from Kaiser Permanente November 2016 reports for the Northern and Southern California regions. 4. National HEDIS data for Medicaid, commercial plans, and Medicare was obtained from the 2016 State of Health Care Quality Report, available on the NCQA website: www.ncqa.org. The results for commercial plans were based on data received from various health maintenance organizations. 5. The Department of Veterans Affairs (VA) data was obtained from the VA’s website, www.va.gov. For the Immunizations: Pneumococcal measure only, the data was obtained from the VHA Facility Quality and Safety Report - Fiscal Year 2012 Data. 6. For this indicator, the entire applicable WSP population was tested. 7. For this measure only, a lower score is better. For Kaiser, the OIG derived the Poor HbA1c Control indicator using the reported data for the <9.0% HbA1c control indicator. Wasco State Prison, Cycle 5 Medical Inspection Page 64 Office of the Inspector General State of California A A — C T R PPENDIX OMPLIANCE EST ESULTS Wasco State Prison Range of Summary Scores: 62.58% - 86.85% Indicator Compliance Score (Yes %) 1–Access to Care 84.64% 2–Diagnostic Services 73.46% 3–Emergency Services Not Applicable 4–Health Information Management (Medical Records) 69.96% 5–Health Care Environment 64.96% 6–Inter- and Intra-System Transfers 86.31% 7–Pharmacy and Medication Management 62.58% 8–Prenatal and Post-Delivery Services Not Applicable 9–Preventive Services 71.37% 10–Quality of Nursing Performance Not Applicable 11–Quality of Provider Performance Not Applicable 12–Reception Center Arrivals 83.75% 13–Specialized Medical Housing (OHU, CTC, SNF, Hospice) 85.00% 14–Specialty Services 86.85% 15–Administrative Operations 78.60% Wasco State Prison, Cycle 5 Medical Inspection Page 65 Office of the Inspector General State of California Scored Answers Yes Reference + 1–Access to Care Number Yes No No Yes % N/A Chronic care follow-up appointments: Was the patient’s most recent chronic care visit within the health care guideline’s 1.001 17 8 25 68.00% 0 maximum allowable interval or within the ordered time frame, whichever is shorter? For endorsed patients received from another CDCR institution: If 1.002 the nurse referred the patient to a provider during the initial health 20 5 25 80.00% 0 screening, was the patient seen within the required time frame? Clinical appointments: Did a registered nurse review the patient’s 1.003 35 0 35 100% 0 request for service the same day it was received? Clinical appointments: Did the registered nurse complete a 1.004 face-to-face visit within one business day after the CDCR Form 34 1 35 97.14% 0 7362 was reviewed? Clinical appointments: If the registered nurse determined a referral to a primary care provider was necessary, was the patient 1.005 5 3 8 62.50% 27 seen within the maximum allowable time or the ordered time frame, whichever is the shorter? Sick call follow-up appointments: If the primary care provider 1.006 ordered a follow-up sick call appointment, did it take place within 4 0 4 100% 31 the time frame specified? Upon the patient’s discharge from the community hospital: Did 1.007 the patient receive a follow-up appointment within the required 20 5 25 80.00% 0 time frame? Specialty service follow-up appointments: Do specialty service 1.008 primary care physician follow-up visits occur within required time 20 7 27 74.07% 3 frames? Clinical appointments: Do patients have a standardized process to 1.101 6 0 6 100% 0 obtain and submit health care services request forms? Overall percentage: 84.64% Wasco State Prison, Cycle 5 Medical Inspection Page 66 Office of the Inspector General State of California Scored Answers Yes Reference + 2–Diagnostic Services Number Yes No No Yes % N/A Radiology: Was the radiology service provided within the time 2.001 9 1 10 90.00% 0 frame specified in the provider’s order? Radiology: Did the primary care provider review and initial the 2.002 0 10 10 0.00% 0 diagnostic report within specified time frames? Radiology: Did the primary care provider communicate the results 2.003 9 1 10 90.00% 0 of the diagnostic study to the patient within specified time frames? Laboratory: Was the laboratory service provided within the time 2.004 9 1 10 90.00% 0 frame specified in the provider’s order? Laboratory: Did the primary care provider review and initial the 2.005 9 1 10 90.00% 0 diagnostic report within specified time frames? Laboratory: Did the primary care provider communicate the 2.006 results of the diagnostic study to the patient within specified time 9 1 10 90.00% 0 frames? Pathology: Did the institution receive the final diagnostic report 2.007 4 5 9 44.44% 1 within the required time frames? Pathology: Did the primary care provider review and initial the 2.008 6 0 6 100% 4 diagnostic report within specified time frames? Pathology: Did the primary care provider communicate the results 2.009 4 2 6 66.67% 4 of the diagnostic study to the patient within specified time frames? Overall percentage: 73.46% 3–Emergency Services This indicator is evaluated only by case review clinicians. There is no compliance testing component. Wasco State Prison, Cycle 5 Medical Inspection Page 67 Office of the Inspector General State of California Scored Answers Yes Reference + 4–Health Information Management Number Yes No No Yes % N/A Are non-dictated health care documents (provider progress notes) 4.001 16 4 20 80.00% 0 scanned within 3 calendar days of the patient encounter date? Are dictated/transcribed documents scanned into the patient’s 4.002 electronic health record within five calendar days of the encounter Not Applicable date? Are High-Priority specialty notes (either a Form 7243 or other 4.003 scanned consulting report) scanned within the required time 14 6 20 70.00% 0 frame? Are community hospital discharge documents scanned into the 4.004 patient’s electronic health record within three calendar days of 19 1 20 95.00% 0 hospital discharge? Are medication administration records (MARs) scanned into the 4.005 18 1 19 94.74% 0 patient’s electronic health record within the required time frames? During the inspection, were medical records properly scanned, 4.006 0 24 24 0.00% 0 labeled, and included in the correct patients’ files? For patients discharged from a community hospital: Did the preliminary hospital discharge report include key elements and 4.007 20 5 25 80.00% 0 did a primary care provider review the report within three calendar days of discharge? Overall percentage: 69.96% Wasco State Prison, Cycle 5 Medical Inspection Page 68 Office of the Inspector General State of California Scored Answers Yes Reference + 5–Health Care Environment Number Yes No No Yes % N/A Are clinical health care areas appropriately disinfected, cleaned 5.101 11 0 11 100% 0 and sanitary? Do clinical health care areas ensure that reusable invasive and 5.102 non-invasive medical equipment is properly sterilized or 11 0 11 100% 0 disinfected as warranted? Do clinical health care areas contain operable sinks and sufficient 5.103 9 2 11 81.82% 0 quantities of hygiene supplies? Does clinical health care staff adhere to universal hand hygiene 5.104 6 4 10 60.00% 1 precautions? Do clinical health care areas control exposure to blood-borne 5.105 6 5 11 54.55% 0 pathogens and contaminated waste? Warehouse, Conex and other non-clinic storage areas: Does the 5.106 medical supply management process adequately support the needs 0 1 1 0.00% 1 of the medical health care program? Does each clinic follow adequate protocols for managing and 5.107 9 2 11 81.82% 0 storing bulk medical supplies? Do clinic common areas and exam rooms have essential core 5.108 2 9 11 18.18% 0 medical equipment and supplies? Do clinic common areas have an adequate environment conducive 5.109 10 1 11 90.91% 0 to providing medical services? Do clinic exam rooms have an adequate environment conducive 5.110 7 4 11 63.64% 0 to providing medical services? Emergency response bags: Are TTA and clinic emergency 5.111 medical response bags inspected daily and inventoried monthly, 7 4 11 63.64% 0 and do they contain essential items? Overall percentage: 64.96% Wasco State Prison, Cycle 5 Medical Inspection Page 69 Office of the Inspector General State of California Scored Answers Yes Reference + 6–Inter- and Intra-System Transfers Number Yes No No Yes % N/A For endorsed patients received from another CDCR institution or COCF: Did nursing staff complete the initial health screening and 6.001 22 3 25 88.00% 0 answer all screening questions on the same day the patient arrived at the institution? For endorsed patients received from another CDCR institution or COCF: When required, did the RN complete the assessment and disposition section of the health screening form; refer the patient 6.002 23 1 24 95.83% 1 to the TTA, if TB signs and symptoms were present; and sign and date the form on the same day staff completed the health screening? For endorsed patients received from another CDCR institution or COCF: If the patient had an existing medication order upon 6.003 8 3 11 72.73% 14 arrival, were medications administered or delivered without interruption? For patients transferred out of the facility: Were scheduled 6.004 specialty service appointments identified on the patient’s health 15 5 20 75.00% 0 care transfer information form? For patients transferred out of the facility: Do medication transfer 6.101 packages include required medications along with the 10 0 10 100% 0 corresponding transfer packet required documents? Overall percentage: 86.31% Wasco State Prison, Cycle 5 Medical Inspection Page 70 Office of the Inspector General State of California Scored Answers 7–Pharmacy and Medication Yes Reference + Management Number Yes No No Yes % N/A Did the patient receive all chronic care medications within the 7.001 required time frames or did the institution follow departmental 16 3 19 84.21% 6 policy for refusals or no-shows? Did health care staff administer, make available, or deliver new 7.002 order prescription medications to the patient within the required 24 1 25 96.00% 0 time frames? Upon the patient’s discharge from a community hospital: Were all 7.003 ordered medications administered, made available, or delivered to 11 14 25 44.00% 0 the patient within required time frames? For patients received from a county jail: Were all medications ordered by the institution’s reception center provider 7.004 9 0 9 100% 11 administered, made available, or delivered to the patient within the required time frames? Upon the patient’s transfer from one housing unit to another: 7.005 21 4 25 84.00% 0 Were medications continued without interruption? For patients en route who lay over at the institution: If the 7.006 temporarily housed patient had an existing medication order, were 7 3 10 70.00% 0 medications administered or delivered without interruption? All clinical and medication line storage areas for narcotic 7.101 medications: Does the Institution employ strong medication 3 5 8 37.50% 3 security over narcotic medications assigned to its clinical areas? All clinical and medication line storage areas for non-narcotic medications: Does the Institution properly store non-narcotic 7.102 2 8 10 20.00% 1 medications that do not require refrigeration in assigned clinical areas? All clinical and medication line storage areas for non-narcotic 7.103 medications: Does the institution properly store non-narcotic 2 8 10 20.00% 1 medications that require refrigeration in assigned clinical areas? Medication preparation and administration areas: Do nursing staff employ and follow hand hygiene contamination control protocols 7.104 4 3 7 57.14% 4 during medication preparation and medication administration processes? Medication preparation and administration areas: Does the 7.105 institution employ appropriate administrative controls and 8 0 8 100% 3 protocols when preparing medications for patients? Medication preparation and administration areas: Does the 7.106 Institution employ appropriate administrative controls and 6 2 8 75.00% 3 protocols when distributing medications to patients? Pharmacy: Does the institution employ and follow general 7.107 security, organization, and cleanliness management protocols in 1 0 1 100% 0 its main and satellite pharmacies? Wasco State Prison, Cycle 5 Medical Inspection Page 71 Office of the Inspector General State of California Scored Answers 7–Pharmacy and Medication Yes Reference + Management Number Yes No No Yes % N/A Pharmacy: Does the institution’s pharmacy properly store 7.108 0 1 1 0.00% 0 non-refrigerated medications? Pharmacy: Does the institution’s pharmacy properly store 7.109 1 0 1 100% 0 refrigerated or frozen medications? Pharmacy: Does the institution’s pharmacy properly account for 7.110 0 1 1 0.00% 0 narcotic medications? Does the institution follow key medication error reporting 7.111 19 6 25 76.00% 0 protocols? Overall percentage: 62.58% 8–Prenatal and Post-Delivery Services The institution has no female patients, so this indicator is not applicable. Wasco State Prison, Cycle 5 Medical Inspection Page 72 Office of the Inspector General State of California Scored Answers Yes Reference + 9–Preventive Services Number Yes No No Yes % N/A Patients prescribed TB medication: Did the institution administer 9.001 20 5 25 80.00% 0 the medication to the patient as prescribed? Patients prescribed TB medication: Did the institution monitor the 9.002 patient monthly for the most recent three months he or she was on 14 10 24 58.33% 1 the medication? Annual TB Screening: Was the patient screened for TB within the 9.003 14 16 30 46.67% 0 last year? Were all patients offered an influenza vaccination for the most 9.004 24 1 25 96.00% 0 recent influenza season? All patients from the age of 50 - 75: Was the patient offered 9.005 22 3 25 88.00% 0 colorectal cancer screening? Female patients from the age of 50 through the age of 74: Was the 9.006 Not Applicable patient offered a mammogram in compliance with policy? Female patients from the age of 21 through the age of 65: Was 9.007 Not Applicable patient offered a pap smear in compliance with policy? Are required immunizations being offered for chronic care 9.008 10 8 18 55.56% 7 patients? Are patients at the highest risk of coccidioidomycosis (valley 9.009 15 5 20 75.00% 0 fever) infection transferred out of the facility in a timely manner? Overall percentage: 71.37% 10–Quality of Nursing Performance This indicator is evaluated only by case review clinicians. There is no compliance testing component. 11–Quality of Provider Performance This indicator is evaluated only by case review clinicians. There is no compliance testing component. Wasco State Prison, Cycle 5 Medical Inspection Page 73 Office of the Inspector General State of California Scored Answers Yes Reference + 12–Reception Center Arrivals Number Yes No No Yes % N/A 12.001 For inmate-patients received from a county jail: Did nursing staff complete the initial health screening and answer all screening 20 0 20 100% 0 questions on the same day the inmate-patient arrived at the institution? 12.002 For inmate-patients received from a county jail: When required, did the RN complete the assessment and disposition section of the 20 0 20 100% 0 health screening form, and sign and date the form on the same day staff completed the health screening? 12.003 For inmate-patients received from a county jail: If, during the assessment, the nurse referred the inmate-patient to a provider, 14 6 20 70.00% 0 was the inmate-patient seen within the required time frame? 12.004 For inmate-patients received from a county jail: Did the inmate-patient receive a history and physical by a primary care 14 6 20 70.00% 0 provider within seven calendar days? 12.005 For inmate-patients received from a county jail: Were all required 20 0 20 100% 0 intake tests completed within specified timelines? 12.006 For inmate-patients received from a county jail: Did the primary care provider review and communicate the intake test results to 19 1 20 95.00% 0 the inmate-patient within specified timelines? 12.007 For inmate-patients received from a county jail: Was a tuberculin 12 8 20 60.00% 0 test both administered and read timely? 12.008 For inmate-patients received from a county jail: Was a Coccidioidomycosis (Valley Fever) skin test offered, administered 15 5 20 75.00% 0 and read timely? Overall percentage: 83.75% Wasco State Prison, Cycle 5 Medical Inspection Page 74 Office of the Inspector General State of California Scored Answers Yes Reference + 13–Specialized Medical Housing Number Yes No No Yes % N/A For OHU, CTC, and SNF: Did the registered nurse complete an 13.001 initial assessment of the patient on the day of admission, or within 10 0 10 100%% 0 eight hours of admission to CMF’s Hospice? For CTC and SNF only: Was a written history and physical 13.002 9 1 10 90.00% 0 examination completed within the required time frame? For OHU, CTC, SNF, and Hospice: Did the primary care provider complete the Subjective, Objective, Assessment, Plan, and 13.003 5 5 10 50.00% 0 Education (SOAPE) notes on the patient at the minimum intervals required for the type of facility where the patient was treated? For OHU and CTC Only: Do inpatient areas either have properly working call systems in its OHU & CTC or are 30-minute patient 13.101 1 0 1 100% 0 welfare checks performed; and do medical staff have reasonably unimpeded access to enter patient’s cells? Overall percentage: 85.00% Wasco State Prison, Cycle 5 Medical Inspection Page 75 Office of the Inspector General State of California Scored Answers Yes Reference + 14–Specialty Services Number Yes No No Yes % N/A Did the patient receive the high priority specialty service within 14.001 14 calendar days of the primary care provider order or the 15 0 15 100% 0 Physician Request for Service? Did the primary care provider review the high priority specialty 14.002 13 2 15 86.67% 0 service consultant report within the required time frame? Did the patient receive the routine specialty service within 90 14.003 calendar days of the primary care provider order or Physician 15 0 15 100% 0 Request for Service? Did the primary care provider review the routine specialty service 14.004 12 2 14 85.71% 1 consultant report within the required time frame? For endorsed patients received from another CDCR institution: If the patient was approved for a specialty services appointment at 14.005 16 4 20 80.00% 0 the sending institution, was the appointment scheduled at the receiving institution within the required time frames? Did the institution deny the primary care provider request for 14.006 20 0 20 100% 0 specialty services within required time frames? Following the denial of a request for specialty services, was the 14.007 10 8 18 55.56% 2 patient informed of the denial within the required time frame? Overall percentage: 86.85% Wasco State Prison, Cycle 5 Medical Inspection Page 76 Office of the Inspector General State of California Scored Answers Yes Reference 15–Administrative Operations + Number Yes No No Yes % N/A Did the institution promptly process inmate medical appeals 15.001 13 0 13 100% 0 during the most recent 12 months? Does the institution follow adverse / sentinel event reporting 15.002 Not Applicable requirements? Did the institution Quality Management Committee (QMC) meet at least monthly to evaluate program performance, and did the 15.003 6 0 6 100% 0 QMC take action when improvement opportunities were identified? Did the institution’s Quality Management Committee (QMC) or 15.004 other forum take steps to ensure the accuracy of its Dashboard 0 1 1 0.00% 0 data reporting? Does the Emergency Medical Response Review Committee 15.005 perform timely incident package reviews that include the use of 12 0 12 100% 0 required review documents? For institutions with licensed care facilities: Does the Local Governing Body (LGB), or its equivalent, meet quarterly and 15.006 4 0 4 100% 0 exercise its overall responsibilities for the quality management of patient health care? Did the institution complete a medical emergency response drill 15.101 for each watch and include participation of health care and 3 0 3 100% 0 custody staff during the most recent full quarter? Did the institution’s second level medical appeal response address 15.102 10 0 10 100% 0 all of the patient’s appealed issues? Did the institution’s medical staff review and submit the initial 15.103 2 1 3 66.67% 0 inmate death report to the Death Review Unit in a timely manner? Does the institution’s Supervising Registered Nurse conduct 15.104 0 5 5 0.00% 0 periodic reviews of nursing staff? Are nursing staff who administer medications current on their 15.105 10 0 10 100% 0 clinical competency validation? 15.106 Are structured clinical performance appraisals completed timely? 10 1 11 90.91% 0 15.107 Do all providers maintain a current medical license? 13 0 13 100% 0 Are staff current with required medical emergency response 15.108 2 0 2 100% 1 certifications? Are nursing staff and the Pharmacist-in-Charge current with their professional licenses and certifications, and is the pharmacy licensed as a correctional pharmacy by the California State Board 15.109 6 0 6 100% 1 of Pharmacy? Wasco State Prison, Cycle 5 Medical Inspection Page 77 Office of the Inspector General State of California Scored Answers Yes Reference 15–Administrative Operations + Number Yes No No Yes % N/A Do the institution’s pharmacy and authorized providers who 15.110 prescribe controlled substances maintain current Drug 0 1 1 0.00% 0 Enforcement Agency (DEA) registrations? 15.111 Are nursing staff current with required new employee orientation? 1 0 1 100% 0 Overall percentage: 78.60% Wasco State Prison, Cycle 5 Medical Inspection Page 78 Office of the Inspector General State of California A B — C D PPENDIX LINICAL ATA Table B-1: WSP Sample Sets Sample Set Total Anticoagulation 3 Death Review/Sentinel Events 2 Diabetes 3 Emergency Services — CPR 4 Emergency Services — Non-CPR 2 High Risk 4 Hospitalization 4 Intra-System Transfers In 3 Intra-System Transfers Out 3 RN Sick Call 21 Reception Center Transfers 3 Specialty Services 2 54 Wasco State Prison, Cycle 5 Medical Inspection Page 79 Office of the Inspector General State of California Table B-2: WSP Chronic Care Diagnoses Diagnosis Total Anemia 3 Anticoagulation 4 Arthritis/Degenerative Joint Disease 6 Asthma 7 COPD 7 Cancer 2 Cardiovascular Disease 16 Chronic Kidney Disease 7 Chronic Pain 15 Cirrhosis/End Stage Liver Disease 1 Coccidioidomycosis 2 Deep Venous Thrombosis/Pulmonary Embolism 6 Diabetes 15 Gastroesophageal Reflux Disease 8 Hepatitis C 21 Hyperlipidemia 16 Hypertension 27 Mental Health 13 Seizure Disorder 3 Sleep Apnea 1 Thyroid Disease 1 Total 181 Wasco State Prison, Cycle 5 Medical Inspection Page 80 Office of the Inspector General State of California Table B-3: WSP Event — Program Program Total Diagnostic Services 141 Emergency Care 40 Hospitalization 49 Intra-system Transfers-In 3 Intra-system Transfers-Out 3 Not Specified 2 Outpatient Care 319 Reception Center Care 43 Specialized Medical Housing 99 Specialty Services 63 762 Wasco State Prison, Cycle 5 Medical Inspection Page 81 Office of the Inspector General State of California Table B-4: WSP Review Sample Summary Total MD Reviews Detailed 20 MD Reviews Focused 0 RN Reviews Detailed 7 RN Reviews Focused 34 Total Reviews 61 Total Unique Cases 54 Overlapping Reviews (MD & RN) 7 Wasco State Prison, Cycle 5 Medical Inspection Page 82 Office of the Inspector General State of California A C — C S M PPENDIX OMPLIANCE AMPLING ETHODOLOGY Wasco State Prison Sample Category Quality (number of Indicator samples) Data Source Filters Access to Care MIT 1.001 Chronic Care Patients Master Registry  Chronic care conditions (at least one condition per patient—any risk level) (25)  Randomize MIT 1.002 Nursing Referrals OIG Q: 6.001  See Intra-system Transfers (25) MITs 1.003-006 Nursing Sick Call MedSATS  Clinic (each clinic tested) (5 per clinic)  Appointment date (2–9 months) (35)  Randomize MIT 1.007 Returns from OIG Q: 4.007  See Health Information Management (Medical Community Hospital Records) (returns from community hospital) (25) MIT 1.008 Specialty Services OIG Q: 14.001 &  See Specialty Services Follow-up 14.003 (30) MIT 1.101 Availability of Health OIG onsite  Randomly select one housing unit from each yard Care Services review Request Forms (6) Diagnostic Services MITs 2.001–003 Radiology Radiology Logs  Appointment date (90 days–9 months)  Randomize (10)  Abnormal MITs 2.004–006 Laboratory Quest  Appt. date (90 days–9 months)  Order name (CBC or CMPs only)  Randomize (10)  Abnormal MITs 2.007–009 Pathology InterQual  Appt. date (90 days–9 months)  Service (pathology related) (10)  Randomize Wasco State Prison, Cycle 5 Medical Inspection Page 83 Office of the Inspector General State of California Sample Category Quality (number of Indicator samples) Data Source Filters Health Information Management (Medical Records) MIT 4.001 Timely Scanning OIG Qs: 1.001,  Non-dictated documents (20) 1.002, & 1.004  1st 10 IPs MIT 1.001, 1st 5 IPs MITs 1.002, 1.004 MIT 4.002 OIG Q: 1.001  Dictated documents (0)  First 20 IPs selected MIT 4.003 OIG Qs: 14.002  Specialty documents (20) & 14.004  First 10 IPs for each question MIT 4.004 OIG Q: 4.007  Community hospital discharge documents (20)  First 20 IPs selected MIT 4.005 OIG Q: 7.001  MARs (19)  First 20 IPs selected MIT 4.006 Documents for  Any misfiled or mislabeled document identified (24) any tested inmate during OIG compliance review (24 or more = No) MIT 4.007 Returns From Inpatient claims  Date (2–8 months) Community Hospital data  Most recent 6 months provided (within date range)  Rx count  Discharge date  Randomize (each month individually)  First 5 patients from each of the 6 months (if not 5 in a month, supplement from another, as needed) (25) Health Care Environment MIT 5.101-105 Clinical Areas OIG inspector  Identify and inspect all onsite clinical areas. MIT 5.107–111 (11) onsite review Inter- and Intra-System Transfers MIT 6.001-003 Intra-System SOMS  Arrival date (3–7 months) Transfers  Arrived from (another CDCR facility)  Rx count  Randomize (25) MIT 6.004 Specialty Services MedSATS  Date of transfer (3–9 months) Send-Outs  Randomize (20) MIT 6.101 Transfers Out OIG inspector  R&R IP transfers with medication (10) onsite review Wasco State Prison, Cycle 5 Medical Inspection Page 84 Office of the Inspector General State of California Sample Category Quality (number of Indicator samples) Data Source Filters Pharmacy and Medication Management MIT 7.001 Chronic Care OIG Q: 1.001 See Access to Care Medication  At least one condition per patient—any risk level  Randomize (25) MIT 7.002 New Medication Master Registry  Rx count Orders  Randomize (25)  Ensure no duplication of IPs tested in MIT 7.001 MIT 7.003 Returns from OIG Q: 4.007  See Health Information Management (Medical Community Hospital Records) (returns from community hospital) (25) MIT 7.004 RC Arrivals – OIG Q: 12.001  See Reception Center Arrivals Medication Orders (20) MIT 7.005 Intra-Facility Moves MAPIP transfer  Date of transfer (2–8 months) data  To location/from location (yard to yard and to/from ASU)  Remove any to/from MHCB  NA/DOT meds (and risk level) (30)  Randomize MIT 7.006 En Route SOMS  Date of transfer (2–8 months)  Sending institution (another CDCR facility)  Randomize (10)  NA/DOT meds MITs 7.101-103 Medication Storage OIG inspector  Identify and inspect clinical & med line areas that Areas onsite review store medications (varies by test) MITs 7.104–106 Medication OIG inspector  Identify and inspect onsite clinical areas that Preparation and onsite review prepare and administer medications Administration Areas (varies by test) MITs 7.107-110 Pharmacy OIG inspector  Identify & inspect all onsite pharmacies (1) onsite review MIT 7.111 Medication Error Monthly  All monthly statistic reports with Level 4 or higher Reporting medication error  Select a total of 5 months (25) reports MIT 7.999 Isolation Unit KOP Onsite active  KOP rescue inhalers & nitroglycerin medications Medications medication for IPs housed in isolation units (8) listing Prenatal and Post-Delivery Services MIT 8.001-007 Recent Deliveries OB Roster  Delivery date (2–12 months) N/A at this institution  Most recent deliveries (within date range) Pregnant Arrivals OB Roster  Arrival date (2–12 months) N/A at this institution  Earliest arrivals (within date range) Wasco State Prison, Cycle 5 Medical Inspection Page 85 Office of the Inspector General State of California Sample Category Quality (number of Indicator samples) Data Source Filters Preventive Services MITs 9.001–002 TB Medications Maxor  Dispense date (past 9 months)  Time period on TB meds (3 months or 12 weeks) (25)  Randomize MIT 9.003 TB Code 22, Annual SOMS  Arrival date (at least 1 year prior to inspection) TST  TB Code (22) (15)  Randomize TB Code 34, Annual SOMS  Arrival date (at least 1 year prior to inspection) Screening  TB Code (34) (15)  Randomize MIT 9.004 Influenza SOMS  Arrival date (at least 1 year prior to inspection) Vaccinations  Randomize (25)  Filter out IPs tested in MIT 9.008 MIT 9.005 Colorectal Cancer SOMS  Arrival date (at least 1 year prior to inspection) Screening  Date of birth (51 or older) (25)  Randomize MIT 9.006 Mammogram SOMS  Arrival date (at least 2 yrs prior to inspection)  Date of birth (age 52–74) N/A at this institution  Randomize MIT 9.007 Pap Smear SOMS  Arrival date (at least three yrs prior to inspection)  Date of birth (age 24–53) N/A at this institution  Randomize MIT 9.008 Chronic Care OIG Q: 1.001  Chronic care conditions (at least 1 condition per Vaccinations IP—any risk level)  Randomize (25)  Condition must require vaccination(s) MIT 9.009 Valley Fever Cocci transfer  Reports from past 2–8 months status report  Institution (20)  Ineligibility date (60 days prior to inspection date)  All Wasco State Prison, Cycle 5 Medical Inspection Page 86 Office of the Inspector General State of California Sample Category Quality (number of Indicator samples) Data Source Filters Reception Center Arrivals MITs 12.001–008 RC SOMS  Arrival date (2–8 months)  Arrived from (county jail, return from parole, etc.) (20)  Randomize Specialized Medical Housing MITs 13.001–004 CTC CADDIS  Admit date (1–6 months)  Type of stay (no MH beds)  Length of stay (minimum of 5 days) (10)  Randomize MIT 13.101 Call Buttons OIG inspector  Review by location CTC (all) onsite review Specialty Services Access MITs 14.001–002 High-Priority MedSATS  Approval date (3–9 months) (15)  Randomize MITs 14.003–004 Routine MedSATS  Approval date (3–9 months)  Remove optometry, physical therapy or podiatry (15)  Randomize MIT 14.005 Specialty Services MedSATS  Arrived from (other CDCR institution) Arrivals  Date of transfer (3–9 months) (20)  Randomize MIT 14.006-007 Denials InterQual  Review date (3–9 months) (19)  Randomize IUMC/MAR  Meeting date (9 months) Meeting Minutes  Denial upheld (1)  Randomize Wasco State Prison, Cycle 5 Medical Inspection Page 87 Office of the Inspector General State of California Sample Category Quality (number of Indicator samples) Data Source Filters Administrative Operations MIT 15.001 Medical Appeals Monthly medical  Medical appeals (12 months) (all) appeals reports MIT 15.002 Adverse/Sentinel Adverse/sentinel  Adverse/sentinel events (2–8 months) Events events report (0) MITs 15.003–004 QMC Meetings Quality  Meeting minutes (12 months) Management Committee (6) meeting minutes MIT 15.005 EMRRC EMRRC meeting  Monthly meeting minutes (6 months) (12) minutes MIT 15.006 LGB LGB meeting  Quarterly meeting minutes (12 months) (4) minutes MIT 15.101 Medical Emergency Onsite summary  Most recent full quarter Response Drills reports &  Each watch documentation (3) for ER drills MIT 15.102 2nd Level Medical Onsite list of  Medical appeals denied (6 months) Appeals appeals/closed (10) appeals files MIT 15.103 Death Reports Institution-list of  Most recent 10 deaths deaths in prior 12  Initial death reports (3) months MIT 15.104 RN Review Onsite supervisor  RNs who worked in clinic or emergency setting Evaluations periodic RN six or more days in sampled month reviews  Randomize (5) MIT 15.105 Nursing Staff Onsite nursing  On duty one or more years Validations education files  Nurse administers medications (10)  Randomize MIT 15.106 Provider Annual OIG Q:16.001  All required performance evaluation documents Evaluation Packets (11) MIT 15.107 Provider licenses Current provider  Review all listing (at start of (13) inspection) MIT 15.108 Medical Emergency Onsite  All staff Response certification o Providers (ACLS) Certifications tracking logs o Nursing (BLS/CPR) (all)  Custody (CPR/BLS) MIT 15.109 Nursing staff and Onsite tracking  All required licenses and certifications Pharmacist in system, logs, or Charge Professional employee files Licenses and Certifications (all) Wasco State Prison, Cycle 5 Medical Inspection Page 88 Office of the Inspector General State of California Sample Category Quality (number of Indicator samples) Data Source Filters Administrative Operations MIT 15.110 Pharmacy and Onsite listing of  All DEA registrations Providers’ Drug provider DEA Enforcement Agency registration #s & (DEA) Registrations pharmacy registration (all) document MIT 15.111 Nursing Staff New Nursing staff  New employees (hired within last 12 months) Employee training logs  Orientations (all) MIT 15.998 Death Review OIG summary  Between 35 business days & 12 months prior Committee log - deaths  CCHCS death reviews (2) Wasco State Prison, Cycle 5 Medical Inspection Page 89 Office of the Inspector General State of California C C ALIFORNIA ORRECTIONAL H C S ’ EALTH ARE ERVICES R ESPONSE Wasco State Prison, Cycle 5 Medical Inspection Page 90 Office of the Inspector General State of California