The Colorado State Auditor found the health care provided to Colorado prisoners is lacking, as is the Colorado Department of Corrections' (CDOC) management of its Clinical Services Division.

In its 54-page report released on October 6, 2005, the Colorado State Auditor (Auditor) made ten recommendations regarding the health care provided to Colorado prisoners by the CDOC.  The CDOC's Division of Clinical Services is responsible for providing health care to state prisoners.  In Fiscal Year 2005 (FY2005) the Division, with a budget of nearly $61 million, provided services 153,500 times to 21,700 different prisoners.  The budget is split between internal and external services.  Internal services consist of basic medical care such as episodic complaints (e.g., cold and flu) and chronic illness (e.g., hypertension) and emergency care. Internal services consume almost $33 million.

The Rocky Mountain News reported that state lawmakers responded to the critical report by saying that "inmates are probably better served than many people who aren't behind bars."  Lawmakers should tell that to the family of Deric Barber, who died on January 6, 2006 of colon cancer.  As previously reported [See: Colorado DOC's Medical Oversight Found Remiss, PLN, 2006], Barber, 32, had complained for many months before receiving a colonoscopy, which found the fatal cancer.  He died after serving 12 years of a 43-year sentence for second-degree murder.

The Auditor recommended that the CDOC improve its quality of care by (1) meeting health screening standards for all prisoners on intake, (2) ensuring the consistent application of current standards of care, (3) improving medication management policies and practices, (4) ensuring prisoner medical records are complete and current.  In regard to management and oversight, the CDOC should (5) develop and implement a comprehensive and proactive quality management program, (6) improve use and management of critical decision-making information, and (7) ensure clinic staffing levels are appropriate. The CDOC should improve its cost containment by (8) ensuring copayment policies and practices comply with statutory intent, (9) ensuring the cost-effectiveness of prescription drug practices, and (10) improving drug inventory management practices. The CDOC agreed, or partially agreed with all ten recommendations and anticipates implementing the recommendations by July 2006.

The CDOC is statutorily required to assess each prisoner's health upon intake. The National Institute of Corrections acknowledges the initial screening may be the most important health standard.  Despite the well-known importance of intake screenings, the CDOC fails to meet its own standards.  The Auditor sampled the records of 99 male and female prisoners entering the CDOC between September 2004 and March 2005.  The CDOC failed to perform complete intake screenings for 51 percent of the sample prisoners.  Only 12 of the 99 prisoners were completely screened within the CDOC's own time frames.  Of those 66 persons needing additional screenings, 51 (77 percent) did not receive them.  Less than half of those requiring hepatitis screens received those tests even though prisoners are 10 times more likely to be infected with hepatitis C than the general public.  Hepatitis, furthermore, is a communicable disease.  None of those prisoners needing tests for sickle cell anemia received the tests.  The CDOC recommended that the CDOC develop strategic and contingency plans for completing intake screenings and examinations.  The CDOC blamed the large number of prisoners it receives, far greater than anticipated when its reception center was designed and built in 1989.  It has already increased staffing at the reception center to address the screening problem.

To assess the quality of care provided to prisoners, the Auditor reviewed 236 prisoner medical records.  The reviews were conducted by a Colorado-licensed physician and a pharmacist.  The review found that 86 (36 percent) of the records had 98 specific quality-of-care concerns.  These issues included missed opportunities (25), lack of documentation (20), lack of comprehensive examinations (14), and lack of proper medication and monitoring (10), among others.  The Auditor recommended that the CDOC review and expand its clinical standards, improve compliance with standards via checklists and flowsheets, and monitor for compliance through random record checks.  The CDOC agreed "that improvements can be made to the system," but believes its existing Quality Management Program (QMP) and policy and procedure committee will address these problems.

During the medical record review, the Auditor identified several concerns related to the dispensing of medication.  Clinical staff sometimes failed to adjust drug therapy according to disease states.  Prisoners with a history of gastrointestinal bleeding were prescribed nonsteroidal anti-inflammatory drugs, which should be avoided by such patients.  Clinical staff failed to consistently check for drug interactions although the information was readily available.  No standard process exists for adding or removing over-the-counter (OTC) medications from the canteen.

The Auditor recommended that the CDOC develop and ensure compliance with drug treatment protocols.  The CDOC should make drug-drug and drug-disease interaction information available to clinical staff.  Furthermore, the CDOC should establish a formal process for approving OTC drugs for sale through the canteen, and adopt a medication alert system to notify clinical staff of contra-indications.  The CDOC agreed with all four recommendations.

The CDOC fails to consistently keep complete medical records.  Fourteen percent of the reviewed records were missing chart notes; had incomplete, out-of-date or missing problem lists; were missing medication administration records; or were missing emergency room and hospital discharge summaries.  The Auditor recommended that the CDOC periodically review medical records to ensure compliance with established procedures and develop methods to ensure external provider information is recorded and timely follow-up care is provided.

The CDOC responded by touting its incomplete in-house electronic medical record system. It has also presented providers with lectures by the Colorado Attorney General's Office regarding the medico-legal aspects of documentation.  A peer review process has been initiated.  It is unclear what is being reviewed.

The CDOC's QMP was found to be scattershot, with eight committees and groups reviewing deaths, infectious disease, and resource utilization.  Some members serve on five or six committees.  The QMP is retrospective rather than prospective in nature.  Meeting minutes, when kept, fail to delineate corrective steps to be taken or to assign responsibility for corrective action.

The Auditor recommended that the CDOC revamp its QMP to create multidisciplinary committees meeting and reporting consistently in which responsibility and accountability are clearly assigned.  The CDOC responded by stating that it meets ACA standards.  It has an oversight Quality Management Committee as well as subcommittees and ad-hoc committees, precisely the organization the Auditor derided as "fragmented" and "lacking a central systemwide focus."  The CDOC has also implemented a Continuous Quality Improvement program, complete with all the latest management buzzwords like "proactive."  Sadly, the CQI is admittedly "retrospective in nature."

It was found that the CDOC does not routinely compile and analyze data from available sources such, as prisoner medical records and grievances.  As a result, the CDOC does not know the most common medical service provided, the most frequent reasons for clinic visits, the most common chronic condition, the number of prisoners with chronic conditions, costs and workload per clinic, per staffer, or per inmate, among others.  The Auditor recommended that the CDOC improve its use and management of information.  The CDOC recognized the need and stated that its Clinical Services Users Board meets monthly to prioritize data collection projects.  The CDOC believes it "'is being resourceful given the current allocation of funding and personnel."

The Auditor was dissatisfied with the CDOC's documentation of its staffing methodology. The Auditor recommended that the CDOC identify all critical factors needed to establish optimal staffing levels, conduct staffing analysis annually, and apply the analysis.  The CDOC only partially agreed and argued that, because of its tight budget, it is impossible to establish optimal staffing levels, but it constantly analyzes staffing levels.  However, it could not document its staffing analyses and standards.  The Auditor maintains that this is "key to controlling staffing costs while maintaining sufficient levels of service."

The CDOC has not been charging prisoners copayments for all medical services as has been statutorily mandated since 1998.  The CDOC has not been charging for follow-up appointments, intake examinations, or referrals to specialists.  These exemptions are contrary to statute.  In FY2005, the CDOC collected nearly $210,000 in copayments rather than the $766,400 the Auditor estimated should have been collected.  The Auditor recommended the CDOC assess copayments for every clinic encounter or propose legislation to change the statute.  The CDOC agreed to change its policy to charge copayments for every clinic encounter. The CDOC discussed reducing the copayment, which is not statutorily mandated, from $5 to $3 and proposing new legislation regarding

The CDOC spent $8.4 million on medications during FY2005.  It maintains a formulary, an approved list of medications, of 320 medications.  The formulary, however, has not been updated since 2002.  The committee responsible for updating the formulary had not met for nearly a year, during which time the FDA had approved some 80 new medications.  The Auditor recommended the CDOC update its formulary, set a specific date by which its outside pharmacy shall update the formulary, establish a schedule to review drug use and prescription patterns, and control non-formulary requests.  The CDOC agreed and noted that it will be contracting with Secure Pharmacies to provide pharmacy services.  The new pharmacy contract is expected to incorporate the recommendations.

Of critical concern was the lack of adequate control over drug inventory.  This issue was also reported by the Auditor in 1999.  Clinics do not consistently record accurate information in the computerized Medication Administration Record system (MAR).  If a dose of medication is two tablets, one clinic may enter a quantity of one, while another may enter a quantity of two.  Some clinics, furthermore, destroy refused medications rather than returning them to the pharmacy for disposal, contrary to CDOC protocol.  The Auditor recommended that the CDOC ensure staff consistently enter data into the MAR.  It should also adopt a standard drug destruction policy.  The CDOC agrees and anticipates developing a new inventory management system in conjunction with Secure Pharmacy to correct these problems.

The CDOC's defensive responses to the Auditor recommendations bear out Milton Friedman's observation that "Hell hath no fury like a bureaucrat scorned."  Unless the CDOC's private-sector partners, Physician Health Partners and Secure Pharmacies, step up, it does not appear that the CDOC will make real, meaningful change in response to any of the Auditor's recommendations.  Real change first requires sincere acknowledgment that a problem exists.

The full report is available at www.state.co.us/auditor. Additional sources: The Rocky Mountain News, The Pueblo Chieftain. 

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