California State Prison Corcoran Medical Inspection OIG Report - April 2021
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Roy W. Wesley , Inspector General OIG Bryan B. Beyer, Chief Deputy Inspector General OFFICE of the INSPECTOR GENERAL Independent Prison Oversight April 2021 Cycle 6 Medical Inspection Report California State Prison Corcoran Electronic copies of reports published by the Office of the Inspector General are available free in portable document format (PDF) on our website. We also offer an online subscription service. For information on how to subscribe, visit www.oig.ca.gov. For questions concerning the contents of this report, please contact Shaun Spillane, Public Information Officer, at 916-255-1131. Return to Contents California State Prison, Corcoran iii Contents Introduction 1 Summary 3 Overall Rating: Inadequate Medical Inspection Results 3 7 Deficiencies Identified During Case Review 7 Case Review Results 7 Compliance Testing Results 8 Population-Based Metrics 9 HEDIS Results 9 Recommendations 11 Indicators 15 Access to Care 15 Diagnostic Services 21 Emergency Services 25 Health Information Management 29 Health Care Environment 34 Transfers 42 Medication Management 48 Preventive Services 56 Nursing Performance 57 Provider Performance 62 Specialized Medical Housing 67 Specialty Services 71 Administrative Operations 77 Appendix A: Methodology 79 Case Reviews 80 Compliance Testing 83 Indicator Ratings and the Overall Medical Quality Rating 84 Appendix B: Case Review Data 85 Appendix C: Compliance Sampling Methodology 88 California Correctional Health Care Services’ Response 95 Report Issued: April 2021 Office of the Inspector General, State of California Return to Contents iv Cycle 6 Medical Inspection Report Illustrations Tables 1. COR Summary Table 2. COR Policy Compliance Scores 3. COR Master Registry Data as of February 2020 4. COR Health Care Staffing Resources as of February 2020 5. COR Results Compared With State HEDIS Scores 6. Access to Care 7. Other Tests Related to Access to Care 8. Diagnostic Services 9. Health Information Management 10. Other Tests Related to Health Information Management 11. Health Care Environment 12. Transfers 13. Other Tests Related to Transfers 14. Medication Management 15. Other Tests Related to Medication Management 16. Preventive Services 17. Specialized Medical Housing 18. Specialty Services 19. Other Tests Related to Specialty Services 20. Administrative Operations 3 4 5 6 10 19 20 24 32 33 41 46 47 54 55 56 70 75 76 78 A–1. B–1. B–2. B–3. B–4. 80 85 86 87 87 Case Review Definitions Case Review Sample Sets Case Review Chronic Care Diagnoses Case Review Events by Program Case Review Sample Summary Figures A–1. Inspection Indicator Review Distribution for COR A–2. Case Review Testing A–3. Compliance Sampling Methodology 80 82 83 Photographs 1. Outdoor Waiting Area 2. Indoor Waiting Area 3. Individual Waiting Module 4. Residual Water Damage (view 1) 5. Residual Water Damage (view 2) 6. Expired Medical Supply 7. Expired Medical Supply 8. Expired Medical Supply 9. Staff Members’ Personal Items and Food Stored With Medical Supplies 10. Expired Lubricating Jelly 11. Expired Medical Supplies 12. Expired Medical Supplies 13. Blood on the Gurney Mattress 34 35 35 36 36 36 37 37 38 38 39 39 40 Cover: Rod of Asclepius courtesy of Thomas Shafee Office of the Inspector General, State of California Inspection Period: August 2019 – January 2020 Return to Contents California State Prison, Corcoran 1 Introduction Pursuant to California Penal Code section 6126 et seq., the Office of the Inspector General (OIG) is responsible for periodically reviewing and reporting on the delivery of the ongoing medical care provided to incarcerated persons1 in the California Department of Corrections and Rehabilitation (the department).2 In Cycle 6, the OIG continues to apply the same assessment methodologies used in Cycle 5, including clinical case review and compliance testing. These methods provide an accurate assessment of how the institution’s health care systems function regarding patients with the highest medical risk who tend to access services at the highest rate. This information helps to assess the performance of the institution in providing sustainable, adequate care.3 We continue to review institutional care using 15 indicators, as in prior cycles. Using each of these indicators, our compliance inspectors collect data in answer to compliance- and performance-related questions as established in the medical inspection tool (MIT).4 We determine a total compliance score for each applicable indicator and consider the MIT scores in the overall conclusion of the institution’s performance. In addition, our clinicians complete document reviews of individual cases and also perform on-site inspections, which include interviews with staff. In reviewing the cases, our clinicians examine whether providers used sound medical judgment in the course of caring for a patient. In the event we find errors, we determine whether such errors were clinically significant or led to a significantly increased risk of harm to the patient.5 At the same time, our clinicians examine whether the institution’s medical system mitigated the error. The OIG rates the indicators as proficient, adequate, or inadequate. 1. In this report, we use the terms patient and patients to refer to incarcerated persons. 2. The OIG’s medical inspections are not designed to resolve questions about the constitutionality of care, and the OIG explicitly makes no determination regarding the constitutionality of care the department provides to its population. 3. In addition to our own compliance testing and case reviews, the OIG continues to offer selected Healthcare Effectiveness Data and Information Set (HEDIS) measures for comparison purposes. 4. The department regularly updates its policies. The OIG updates our policy-compliance testing to reflect the department’s updates and changes. 5. If we learn of a patient needing immediate care, we notify the institution’s chief executive officer. Report Issued: April 2021 Office of the Inspector General, State of California Return to Contents 2 Cycle 6 Medical Inspection Report The OIG has adjusted Cycle 6 reporting in two ways. First, commencing with this reporting period, we interpret compliance and case review results together, providing a more holistic assessment of the care; and, second, we consider whether institutional medical processes lead to identifying and correcting provider or system errors. The review assesses the institution’s medical care on both system and provider levels. As we did during Cycle 5, our office is continuing to inspect both those institutions remaining under federal receivership and those delegated back to the department. There is no difference in the standards used for assessing a delegated institution versus an institution not yet delegated. At the time of the Cycle 6 inspection of California State Prison, Corcoran (COR), the receiver had delegated this institution back to the department. We completed our sixth inspection of COR and herein present our assessment of the health care provided at COR during the inspection period between August 2019 and January 2020.6 Notably, our report of COR was not impacted by the novel coronavirus disease pandemic (COVID-19). The data we obtained for COR predate COVID-19, so neither case review nor compliance testing were affected. Similarly, the on-site regional nurse review was not impacted by COVID-19. However, during our on-site case review inspection, COR had patients who had tested positive for the virus. The inspection was otherwise completed with no further adjustments. California State Prison, Corcoran, is located in the city of Corcoran in Kings County. As of January 2020, the institution housed more than 2,900 incarcerated persons. COR operates multiple clinics, including a specialty clinic, where staff members handle nonurgent requests for medical services; a receiving and release clinic (R&R), where staff conduct screenings; a triage and treatment area (TTA) for patients requiring urgent or emergency care; a correctional treatment center (CTC) to house patients requiring inpatient health services; and an outpatient housing unit (OHU) to treat patients who require assistance with activities of daily living, but who do not require a higher level of inpatient care. California Correctional Health Care Services (CCHCS) has designated COR as 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 higherrisk patients. Basic institutions have the capability to provide limited specialty medical services and consultation for a patient population that is generally healthy. 6. Samples are obtained per case review methodology shared with stakeholders in prior cycles. The case reviews include death reviews that occurred between April 2019 and February 2020, death reviews between February 2019 and January 2020, hospitalization reviews that occurred between July 2019 and February 2020, registered nurse sick call reviews that occurred between August 2019 and February 2020, and CTC reviews that occurred between January 2019 and December 2019. Office of the Inspector General, State of California Inspection Period: August 2019 – January 2020 Return to Contents California State Prison, Corcoran 3 Summary We completed the Cycle 6 inspection of California State Prison, Corcoran (COR), in July 2020. OIG inspectors monitored the institution’s delivery of medical care that occurred between August 2019 and January 2020. Overall Rating Inadequate The OIG rated the overall quality of health care at COR as inadequate. We list the individual indicators and ratings applicable for this institution in Table 1 below. Table 1. COR Summary Table Ratings Proficient Adequate Inadequate Overall Change Since Cycle 5 * N/A N/A N/A N/A Cycle 6 Ratings Health Care Indicators Case Review Compliance Access to Care Diagnostic Services Emergency Services N/A Health Information Management Health Care Environment N/A Transfers Medication Management Prenatal and Postpartum Care N/A Preventive Services N/A N/A Nursing Performance N/A Provider Performance N/A Reception Center N/A N/A Specialized Medical Housing Specialty Services Administrative Operations † N/A * The symbols in this column correspond to changes that occurred in indicator ratings between the medical inspections conducted during Cycle 5 and Cycle 6. The equals sign means there was no change in the rating. The single arrow means the rating rose or fell one level, and the double arrow means the rating rose or fell two levels (green, from inadequate to proficient; pink, from proficient to inadequate). † Administrative Operations is a secondary indicator and is not considered when rating the institution’s overall medical quality. Source: The Office of the Inspector General medical inspection results. Report Issued: April 2021 Office of the Inspector General, State of California Return to Contents 4 Cycle 6 Medical Inspection Report To test the institution’s policy compliance, our compliance inspectors (a team of registered nurses) monitored the institution’s compliance with its medical policies by answering a standardized set of questions that measure specific elements of health care delivery. Our compliance inspectors examined 402 patient records and 1,266 data points and used the data to answer 92 policy questions. In addition, we observed COR’s processes during an on-site inspection in March 2020. Table 2 below lists COR’s average scores from Cycles 4, 5, and 6. OIG case review clinicians (a team of physicians and nurse consultants) reviewed 57 cases, which contained 957 patient-related events. After examining the medical records, our clinicians conducted a follow-up on-site inspection in July 2020 to verify their initial findings. The OIG physicians rated the quality of care for 20 comprehensive case reviews. Table 2. COR Policy Compliance Scores Scoring Ranges 100% – 85.0% Medical Inspection Tool (MIT) 84.9% – 75.0% 74.9% – 0 Average Score Policy Compliance Category Cycle 4 Cycle 5 Cycle 6 1 Access to Care 68.9% 81.1% 80.0% 2 Diagnostic Services 69.1% 74.8% 49.6% 4 Health Information Management 65.8% 67.2% 89.9% 5 Health Care Environment 70.2% 70.7% 45.8% 6 Transfers 53.1% 43.0% 51.2% 7 Medication Management 59.1% 56.1% 51.4% 8 Prenatal and Postpartum Care N/A N/A N/A 9 Preventive Services 68.6% 87.0% 59.8% N/A N/A N/A 12 Reception Center 13 Specialized Medical Housing 70.0% 76.7% 85.0% 14 Specialty Services 64.2% 77.3% 71.6% 15 Administrative Operations 65.2% 65.2% 71.9% * In Cycle 4, there were two secondary (administrative) indicators, and this score reflects the average of those two scores. In Cycle 5 and moving forward, the two indicators were merged into one, with only one score as the result. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: August 2019 – January 2020 Return to Contents California State Prison, Corcoran 5 Of these 20 cases, our physicians rated 14 adequate and six inadequate. Our physicians did not find any adverse events during this inspection. The OIG then considered the results from both case review and compliance testing and drew overall conclusions, which we report in the 13 health care indicators.7 Multiple OIG physicians and nurses performed quality control reviews; their subsequent collective deliberations ensured consistency, accuracy, and thoroughness. Our clinicians acknowledged institutional structures that catch and resolve mistakes which may occur throughout the delivery of care. As noted above, we listed the individual indicators and ratings applicable for this institution in Table 1, the COR Summary Table. In February 2020, the Health Care Services Master Registry showed that COR had a total population of 2,976. A breakdown of the medical risk level of the COR population as determined by the department is set forth in Table 3 below.8 Table 3. COR Master Registry Data as of February 2020 Medical Risk Level Number of Patients Percentage High 1 17 2.5% High 2 196 6.6% Medium 1,413 47.5% Low 1,293 43.4% Total 2,976 100% Source: Data for the population medical risk level were obtained from the CCHCS Master Registry dated 2-28-20. 7. The indicators for Reception Center and Prenatal Care do not apply to COR. 8. For a definition of medical risk, see CCHCS HCDOM 1.2.14, Appendix 1.9. Report Issued: April 2021 Office of the Inspector General, State of California Return to Contents 6 Cycle 6 Medical Inspection Report Based on staffing data the OIG obtained from California Correctional Health Care Services (CCHCS), as identified in Table 4 below, COR had 1.4 vacant primary care provider positions and 12.4 vacant nursing staff positions. Table 4. COR Health Care Staffing Resources as of February 2020 Positions Executive Leadership * Primary Care Providers Nursing Supervisors Nursing Staff † Total Authorized Positions 6 9.4 21.2 197.5 234.1 Filled by Civil Service 6 8 21 213.5 248.5 Vacant 0 1.4 0.2 12.4 28 100% 85.1% 99.1% 108.1% 106.2% 0 0 2 0 0 0.9% Percentage Filled by Civil Service Filled by Telemedicine 0 Percentage Filled by Telemedicine 0 Filled by Registry 0 0 0 35 35 Percentage Filled by Registry 0 0 0 17.7% 15% Total Filled Positions 6 10 Total Percentage Filled 100% 2 21.3% 106.4% 21 248.5 285.5 99.1% 125.8% 102.8% Appointments in Last 12 Months 2 2 5 55 64 Redirected Staff 0 0 0 1 1 Staff on Extended Leave ‡ 0 1 0 8 9 Adjusted Total: Filled Positions 6 9 21 239.5 275.5 99.1% 121.3% 117.7% Adjusted Total: Percentage Filled 100% 95.8% * Executive Leadership includes the Chief Physician and Surgeon. † Nursing Staff includes Senior Psychiatric Technician and Psychiatric Technician. ‡ In Authorized Positions. Notes: The OIG does not independently validate staffing data received from the department. Positions are based on fractional time-base equivalents. Source: Cycle 6 medical inspection preinspection questionnaire staffing matrix received February 2020, from California State Prison, Corcoran. Office of the Inspector General, State of California Inspection Period: August 2019 – January 2020 Return to Contents California State Prison, Corcoran 7 Medical Inspection Results Deficiencies Identified During Case Review Deficiencies are medical errors that increase the risk of patient harm. Deficiencies can be minor or significant, depending on the severity of the deficiency. An adverse event occurs when the deficiency caused harm to the patient. All major health care organizations identify and track adverse events. We identify deficiencies and adverse events to highlight concerns regarding the provision of care and for the benefit of the institution’s quality improvement program to provide an impetus for improvement.9 Our inspectors did not find any adverse events at COR during the Cycle 6 inspection. Case Review Results OIG case reviewers (a team of physicians and nurse consultants) assessed 10 of the 13 indicators applicable to COR. Of these 10 indicators, OIG clinicians rated seven adequate and three inadequate. The OIG physicians also rated the overall adequacy of care for each of the 20 detailed case reviews they conducted. Of these 20 cases, 14 were adequate and six were inadequate. Our clinicians reviewed 957 events and identified 270 deficiencies, 61 of which they considered to be of such magnitude that, if left unaddressed, would likely contribute to patient harm. Our clinicians found the following strengths at COR: • Access to care was good, and provider, nurse, and specialty appointments in the CTC were timely. • The institution performed well in obtaining hospital discharge reports, scanning, and labeling medical records. • Providers and nurses delivered good care with emergency services and in specialized medical housing units. Our clinicians found room for improvement in the following areas: • COR should improve transfer processes to ensure continuity of specialty referrals and medication. • Providers should document their emergency care completely and accurately. • Nursing staff should improve assessments and documentation in the outpatient and emergency settings. • COR should improve medication administration processes. • COR should improve care for hypoglycemic diabetic patients. 9. For a further discussion of an adverse event, see Table A–1. Report Issued: April 2021 Office of the Inspector General, State of California Return to Contents 8 Cycle 6 Medical Inspection Report Compliance Testing Results Our compliance inspectors assessed 10 of the 13 indicators applicable to COR. Of these 10 indicators, our compliance inspectors rated two proficient, one adequate, and seven inadequate. We tested only policy compliance in the Health Care Environment, Preventive Services, and Administrative Operations indicators as these indicators do not have a case review component. COR demonstrated a high rate of policy compliance in the following areas: • Staff maintained adequate supplies of sick-call forms and designated lock boxes in housing units. • Nursing staff completed initial assessments of patients admitted to specialized medical housing within the required time frame. • Providers performed history and physical examinations timely for patients admitted to specialized medical housing. COR demonstrated a low rate of policy compliance in the following areas: • Providers often did not create patient letters when communicating diagnostic test results. • Patients did not receive their chronic care medications, newly ordered medications, and hospital discharge medications timely. There was also poor medication continuity for patients transferring in from other facilities, transferring within the facility, and layover patients. • Health care staff poorly monitored patients taking tuberculosis (TB) medications. • Clinics and the medical warehouse stored medical supplies beyond manufacturers’ guidelines. • Health care staff did not regularly follow universal hand hygiene precautions during patient encounters. Population-Based Metrics In addition to our own compliance testing and case reviews, as noted above, the OIG presents selected measures from the Healthcare Effectiveness Data and Information Set (HEDIS) for comparison purposes. The HEDIS is a set of standardized quantitative performance measures designed by the National Committee for Quality Assurance to ensure that the public has the data it needs to compare the performance of health care plans. Because the Veterans Administration no longer publishes its individual HEDIS scores, we removed them from our comparison for Cycle 6. Likewise, Kaiser (commercial plan) no longer publishes HEDIS scores, but the OIG obtained Kaiser Medi‑Cal HEDIS scores through the California Department of Health Care Services’ Office of the Inspector General, State of California Inspection Period: August 2019 – January 2020 Return to Contents California State Prison, Corcoran 9 Medi‑Cal Managed Care Technical Report to use in conducting our analysis, and we present them here for comparison. HEDIS Results We considered COR’s performance with population-based metrics to assess the macroscopic view of the institution’s health care delivery. COR’s results compared favorably with those found in State health plans for diabetic care measures. We list the five HEDIS measures in Table 5. Comprehensive Diabetes Care When compared with statewide Medi-Cal programs (California Medi-Cal, Kaiser Northern California (Medi-Cal), and Kaiser Southern California (Medi-Cal) ), COR performed better in three of the five diabetic measures. The institution scored lower than Kaiser Southern California (Medi-Cal) for blood pressure control and scored lower than all Medi-Cal programs for eye examinations. Immunizations Statewide comparative data were not available for immunization measures; however, we include these data for informational purposes. COR had a 40 percent influenza immunization rate for adults 18 to 64 years old, and a 57 percent influenza immunization rate for adults 65 years of age and older.10 The pneumococcal vaccines are only administered once for patients who are older than 65 years of age; therefore, the vaccine may not have occurred during the inspection period. The pneumococcal vaccination rate was 80 percent. Colorectal Cancer Screening Statewide comparative data were not available for colorectal cancer screening; however, we include these data for informational purposes. COR had a 67 percent colorectal cancer screening rate. 10. The pneumococcal vaccines administered are the 13 valent pneumococcal vaccine (PCV13) or 23 valent pneumococcal vaccine (PPSV23), depending on the patient’s medical conditions. For the adult population, the influenza or pneumococcal vaccine may have been administered at a different institution other than the one in which the patient was currently housed during the inspection period. Report Issued: April 2021 Office of the Inspector General, State of California Return to Contents 10 Cycle 6 Medical Inspection Report Table 5. COR Results Compared With State HEDIS Scores COR HEDIS Measure HbA1c Screening Cycle 6 Results * California Medi-Cal 2018 † California Kaiser NorCal Medi-Cal 2018 † California Kaiser SoCal Medi-Cal 2018 † 100% 88% 94% 95% Poor HbA1c Control (> 9.0%) ‡,§ 12% 34% 24% 20% HbA1c Control (< 8.0%) ‡ 79% 55% 62% 70% Blood Pressure Control (< 140/90) ‡ 84% 67% 75% 85% Eye Examinations 36% 63% 77% 83% Influenza – Adults (18 – 64) 40% – – – Influenza – Adults (65 +) 57% – – – Pneumococcal – Adults (65 +) 80% – – – Colorectal Cancer Screening 67% – – – Notes and Sources * Unless otherwise stated, data were collected in March 2020 by reviewing medical records from a sample of COR’s population of applicable patients. These random statistical sample sizes were based on a 95 percent confidence level with a 15 percent maximum margin of error. † HEDIS Medi-Cal data were obtained from the California Department of Health Care Services publication titled, Medi-Cal Managed Care External Quality Review Technical Report, dated July 1, 2017 – June 30, 2018 (published April 2019). ‡ For this indicator, the entire applicable COR population was tested. § For this measure only, a lower score is better. Source: Institution information provided by the California Department of Corrections and Rehabilitation. Health Care plan data obtained from the CCHCS Master Registry. Office of the Inspector General, State of California Inspection Period: August 2019 – January 2020 Return to Contents California State Prison, Corcoran 11 Recommendations As a result of our assessment of COR’s performance, we offer the following recommendations to the department. Where we recommend an internal review of the root cause of identified problems, we further recommend that the institution consider all remedial measures to address challenges, including both systemic adjustments and individual accountability: Access to Care • Medical leadership should determine the root cause of challenges in the timely provision of chronic care appointments with providers, nurse-to-provider referrals, and follow-up specialty appointments and implement remedial measures as appropriate. Diagnostic Services • Medical leadership should determine the root cause of challenges with scanning, retrieving, and reviewing of laboratory, radiology, and pathology results and implement remedial measures as appropriate to ensure they are performed within required time frames. • Medical leadership should ascertain causative factors with timely provision of pathology and laboratory results letters to patients and implement remedial measures as appropriate. • The department should consider developing and implementing a patient results letter template which autopopulates with all elements required per CCHCS policy. Emergency Services • Medical leadership should determine the root cause of challenges with providers’ completion of progress notes for emergent events and implement remedial measures as appropriate to ensure they are completed. • The Emergency Medical Response Review Committee (EMRRC) should identify and address delays in the transfer of patients to a higher level of care, including delays due to availability of custody staff. • Nursing leadership should identify root causes that prevent nurses from completely and accurately documenting assessments and medication administration in emergent events and implement remedial measures as appropriate. Health Information Management • Medical leadership should determine the root cause of challenges in timely scanning, retrieving, and reviewing specialty Report Issued: April 2021 Office of the Inspector General, State of California Return to Contents 12 Cycle 6 Medical Inspection Report service reports and implement remedial measures as appropriate to ensure they are performed within required time frames. Health Care Environment • Nursing leadership should consider performing random spot checks to ensure staff follow equipment and medical supply management protocols. • Medical leadership should remind staff to follow universal hand hygiene precautions. Implementing random spot checks could improve compliance. • Nursing leadership should have each clinic nurse supervisor review the monthly EMRB logs to ensure the EMRBs are regularly inventoried and sealed. Transfers • Nursing leadership should determine the cause of challenges in providing medications to newly arriving patients without interruption and implement remedial measures as appropriate. • The department should consider developing and implementing an electronic alert to ensure nurses in receiving and release (R&R) properly complete initial health screening questions and follow up as needed. Medication Management • Medical leadership should determine the cause of challenges related to medication continuity for chronic care, transferin, hospital discharge, and en route patients and implement remedial measures as appropriate. Preventative Services • Medical leadership should remind nursing staff to perform weekly monitoring and address the symptoms of patients taking TB medications. Nursing Performance • Nursing leadership should consider implementing a performance review or audit to ensure nurses properly intervene when patients present with acute medical symptoms and notify providers of abnormal values timely. • Nursing leadership should review the cause of lapses in chronic care coordination for diabetic patients and implement remedial measures as appropriate. • Nursing leadership should determine the root cause of challenges that prevent outpatient and special housing nurses from performing complete assessments and documentation Office of the Inspector General, State of California Inspection Period: August 2019 – January 2020 Return to Contents California State Prison, Corcoran 13 of care accurately and implement remedial measures as appropriate. Provider Performance • Medical leadership should ascertain causative factors in the timely provider review of hospital and specialty reports and with provider follow through of recommendations. Medical leadership should implement remedial measures as appropriate. Specialized Medical Housing • Nursing leadership should determine the root cause of challenges in ensuring patients who are admitted into the CTC and OHU receive their medications timely upon admission and implement remedial measures as appropriate. Specialty Services • Nursing leadership should determine the root cause of challenges in nurses’ review of specialty reports and challenges of informing providers of specialists’ recommendations and implement remedial measures as appropriate. • Medical leadership should identify the root cause in timely provision of ordered specialty services and implement remedial measures as appropriate. Administrative Operations • The medical and nursing leadership should ensure clinical competency evaluations and performance appraisals are completed timely. Report Issued: April 2021 Office of the Inspector General, State of California Return to Contents 14 Cycle 6 Medical Inspection Report (This page left blank for reproduction purposes.) Office of the Inspector General, State of California Inspection Period: August 2019 – January 2020 Return to Contents California State Prison, Corcoran Access to Care In this indicator, OIG inspectors evaluated the institution’s ability to provide patients with timely clinical appointments. Our inspectors reviewed the scheduling and appointment timeliness for newly arrived patients, sick calls, and nurse follow-up appointments. We examined referrals to primary care providers, provider follow-ups, and specialists. Furthermore, we evaluated the follow-up appointments for patients who received specialty care or returned from an off-site hospitalization. Results Overview COR provided good access to care. Most provider, nurse, and specialty appointments in the correctional treatment center (CTC) were completed timely. Our clinicians found COR had room for improvement in timely appointments for specialty follow up, provider chronic care, and nurse referrals to providers. Overall, the OIG rated this indicator adequate. 15 Overall Rating Adequate Case Review Rating Adequate Compliance Score Adequate (80.0%) Case Review Results We reviewed 264 provider, nursing, specialty, and hospital events that required the institution to generate appointments. We identified 19 deficiencies relating to Access to Care, 13 of which were significant.11 Access to Clinic Providers COR had a mixed performance with access to providers. Compliance testing showed chronic care follow-up visits occurred within the ordered time frames at a rate of 64.0 percent (MIT 1.001). Four of the nine compliance samples that did not meet time frames were less than 10 days late. When sick call nurses referred their patients to a provider, the provider appointments occurred about half the time (MIT 1.005, 58.3%). In four of these samples, the patients were seen within seven days. Only seven of the 13 patients were seen within the required time frames. When providers ordered follow-up appointments for sick-call conditions, patients were always seen within the ordered time frames (MIT 1.006, 100%). Our case review found four deficiencies related to provider access,12 three of which are illustrated in the cases below: • In case 10, the provider ordered a provider chronic care appointment. However, the appointment was scheduled for two months later. • In case 18, the patient was seen in the triage and treatment area (TTA). The provider ordered a provider follow-up appointment for the next day, but it was not scheduled for the next day. 11. Deficiencies occurred in cases 10, 15, 16, 18, 19, 21, 22, 36, 45, 48, 49, 51, 52, 53, and 55. Significant deficiencies occurred in cases 10, 15, 16, 18, 19, 22, 45, 48, 49, 51, 53, and 55. 12. Deficiencies occurred in cases 10, 18, 36, and 52. Report Issued: April 2021 Office of the Inspector General, State of California Return to Contents 16 Cycle 6 Medical Inspection Report • In case 52, the provider discharged the patient from the outpatient housing unit (OHU) without ordering a five-day provider follow-up appointment, as per policy. A provider saw the patient a month later. Access to Specialized Medical Housing Providers COR performed well with provider access in the CTC. When staff admitted patients to the CTC, providers performed history and physicals on patients timely. Compliance testing showed similar results; COR scored 100 percent (MIT 13.002). The OIG clinicians assessed 62 CTC provider encounters and did not identify any missed or late provider appointments. Access to Clinic Nurses As in Cycle 5, COR nurses performed well with same-day triage of sick call requests. The compliance testing result corroborated our case review finding (MIT 1.003, 87.5%). For RN sick call appointments, compliance testing showed these appointments generally occurred within one business day (MIT 1.004, 87.5%). In our case reviews, we identified occasional delays and lapses in the following cases: • In cases 15 and 48, the RN sick-call appointment occurred one and two days late, respectively. • In cases 45, 48, and 49, the RN sick-call appointments did not occur. RN care management and care coordination visits occurred within specified time frames. Provider-to-nurse referrals also occurred within the requested time frames with the exception of two cases: • In case 18, the RN follow-up appointment occurred four days late. • In case 36, the RN follow-up appointment occurred three days late. Overall, patients’ access to clinic nurses was satisfactory. Access to Specialty Services Compliance testing showed very good specialty access for high-priority (MIT 14.001, 93.3%), medium-priority (MIT 14.004, 80.0%), and routinepriority appointments (MIT 14.007, 100%). Case reviewers found patients not receiving appointments or receiving delayed specialty appointments in case 16 and the following case: • In case 53, the provider ordered an urgent orthopedic appointment to perform a aspiration procedure on the patient’s hip; however, the patient did not receive the appointment within the urgent time frame. Office of the Inspector General, State of California Inspection Period: August 2019 – January 2020 Return to Contents California State Prison, Corcoran 17 When specialists requested follow-up appointments, staff generally scheduled the requested appointments timely (MIT 14.003, 80.0%; MIT 14.006, 75.0%; and MIT 14.009, 70.0%). Our case reviewers found patients did not receive or received delayed specialty follow-up appointments in cases 19, 51, and the following case: • In case 15, the provider ordered a follow-up cardiology appointment to review the patient’s heart test results; however, the patient did not receive the appointment. Follow-up After Specialty Service Staff generally arranged for provider follow-up appointments following specialty consultations. Compliance testing results reflected this good performance (MIT 1.008, 81.0%). In case review, our clinicians found only one deficiency: • In case 21, the patient returned from hand surgery. The nurse planned to order a provider follow-up appointment in three days, but instead ordered a 14-day follow-up appointment. Follow-up After Hospitalization After returning from an off-site hospitalization, patients were often scheduled follow-up appointments with a provider. Compliance testing results showed these follow-up appointments occurred within the required time frames 78.3 percent of the time (MIT 1.007). The OIG clinicians reviewed 21 hospital returns and did not identify any missed or delayed appointments. Follow-up After Urgent or Emergent Care (TTA) COR providers saw patients promptly after they received urgent or emergent care in the TTA. Our clinicians reviewed 55 TTA events and did not find any missed or delayed provider or nurse follow up appointments. The Emergency Services indicator discusses urgent and emergent patient care in more detail. Follow-up After Transferring Into the Institution COR generally performed well with ensuring provider access for patients who recently transferred into the institution. Our compliance inspectors found most patients saw a provider timely after arrival (MIT 1.002, 80.0%). Our clinicians reviewed three transfer-in cases and did not find any deficiencies. Clinician On-Site Inspection We interviewed the leadership, supervisors, utilization management (UM), office technicians, and nurses regarding access to care. We were informed that during the review months, providers underwent training Report Issued: April 2021 Office of the Inspector General, State of California Return to Contents 18 Cycle 6 Medical Inspection Report for the electronic medical records, hepatitis C management, and licensing for substance abuse treatment. In addition, providers were out ill and on vacation. Training and absences resulted in backlogs. COR currently has two telemedicine providers to deliver primary care access. The UM and supervisors reported that the institution reduced access to the limited available providers for a few specialty services, such as cardiology. For the previous three months, COR implemented an online consultation referral process. Providers consult with a specialist and receive a response sooner than they would with an in-person appointment. Medical leadership and providers agree this has helped the institution with specialty access. Our on-site inspection occurred during the COVID-19 pandemic. We observed all staff wearing masks and practicing social distancing when possible. Providers were still seeing patients with urgent conditions, but nonurgent appointments were moved to a later date. Some off-site specialists had closed their clinics, which affected in-person specialty appointments. Recommendations • Medical leadership should determine the root cause of challenges in timely provision of chronic care appointments with providers, nurse-to-provider referrals, and follow-up specialty appointments and implement remedial measures as appropriate. Office of the Inspector General, State of California Inspection Period: August 2019 – January 2020 Return to Contents California State Prison, Corcoran 19 Compliance Testing Results Table 6. Access to Care Scored Answer Compliance Questions Yes No Chronic care follow-up appointments: Was the patient’s most recent chronic care visit within the health care guideline’s maximum allowable interval or within the ordered time frame, whichever is shorter? (1.001) * 16 9 0 64.0% For endorsed patients received from another CDCR institution: Based on the patient’s clinical risk level during the initial health screening, was the patient seen by the clinician within the required time frame? (1.002) * 20 5 0 80.0% Clinical appointments: Did a registered nurse review the patient’s request for service the same day it was received? (1.003) * 35 5 0 87.5% Clinical appointments: Did the registered nurse complete a face-toface visit within one business day after the CDCR Form 7362 was reviewed? (1.004) * 35 5 0 87.5% Clinical appointments: If the registered nurse determined a referral to a primary care provider was necessary, was the patient seen within the maximum allowable time or the ordered time frame, whichever is the shorter? (1.005) * 7 5 28 58.3% Sick call follow-up appointments: If the primary care provider ordered a follow-up sick call appointment, did it take place within the time frame specified? (1.006) * 2 0 38 Upon the patient’s discharge from the community hospital: Did the patient receive a follow-up appointment within the required time frame? (1.007) * 18 5 2 78.3% Specialty service follow-up appointments: Did the clinician follow-up visits occur within required time frames? (1.008) *,† 34 8 3 81.0% 5 1 0 83.3% Clinical appointments: Do patients have a standardized process to obtain and submit health care services request forms? (1.101) N/A Yes % 100% Overall percentage (MIT 1): 80.0% * The OIG clinicians considered these compliance tests along with their case review findings when determining the quality rating for this indicator. † CCHCS changed its specialty policies in April 2019, removing the requirement for primary care physician follow-up visits following specialty services. As a result, we tested MIT 1.008 only for high-priority specialty services or when staff ordered follow-ups. The OIG continued to test the clinical appropriateness of specialty follow-ups through its case review testing. Source: The Office of the Inspector General medical inspection results. Report Issued: April 2021 Office of the Inspector General, State of California Return to Contents 20 Cycle 6 Medical Inspection Report Table 7. Other Tests Related to Access to Care Scored Answer Compliance Questions Yes No N/A Yes % For patients received from a county jail: If, during the assessment, the nurse referred the patient to a provider, was the patient seen within the required time frame? (12.003) * N/A N/A N/A N/A For patients received from a county jail: Did the patient receive a history and physical by a primary care provider within seven calendar days? (12.004) * N/A N/A N/A N/A For CTC and SNF only (effective 4/2019, include OHU): Was a written history and physical examination completed within the required time frame? (13.002) * 10 0 0 100% N/A N/A N/A N/A 14 1 0 93.3% Did the patient receive the subsequent follow-up to the high-priority specialty service appointment as ordered by the primary care provider? (14.003) * 8 2 5 80.0% Did the patient receive the medium-priority specialty service within 15-45 calendar days of the primary care provider order or the Physician Request for Service? (14.004) * 12 3 0 80.0% 6 2 7 75.0% 15 0 0 7 3 5 For OHU, CTC, SNF, and Hospice (applicable only for samples prior to 4/2019): Did the primary care provider complete the Subjective, Objective, Assessment, and Plan notes on the patient at the minimum intervals required for the type of facility where the patient was treated? (13.003) *,† Did the patient receive the high-priority specialty service within 14 calendar days of the primary care provider order or the Physician Request for Service? (14.001) * Did the patient receive the subsequent follow-up to the mediumpriority specialty service appointment as ordered by the primary care provider? (14.006) * Did the patient receive the routine-priority specialty service within 90 calendar days of the primary care provider order or Physician Request for Service? (14.007) * Did the patient receive the subsequent follow-up to the routine-priority specialty service appointment as ordered by the primary care provider? (14.009) * 100% 70.0% * The OIG clinicians considered these compliance tests along with their case review findings when determining the quality rating for this indicator. † CCHCS changed its policies and removed mandatory minimum rounding intervals for patients located in specialized medical housing. After April 2, 2019, MIT 13.003 only applied to CTCs that still had statemandated rounding intervals. OIG case reviewers continued to test the clinical appropriateness of provider follow-ups within specialized medical housing units through case reviews. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: August 2019 – January 2020 Return to Contents California State Prison, Corcoran Diagnostic Services In this indicator, OIG inspectors evaluated the institution’s ability to timely complete radiology, laboratory, and pathology tests. Our inspectors determined whether the institution properly retrieved the resultant reports and whether providers reviewed the results correctly. In addition, in Cycle 6, we examined the institution’s ability to timely complete and review stat (immediate) laboratory tests. Results Overview COR had variable performance in this indicator. COR performed well in radiology test completion and provider review of laboratory and pathology results. However, the institution faltered in completing laboratory tests and retrieving pathology results timely. Additionally, providers often did not send patient letters for laboratory and pathology results. COR’s poor compliance performance weighed heavily in our rating for this indicator, which we rated inadequate. 21 Overall Rating Inadequate Case Review Rating Adequate Compliance Score Inadequate (49.6%) Case Review Results The OIG clinicians reviewed 117 diagnostic events and found 30 deficiencies, six of which were significant. Of the 30 deficiencies, 24 were related to health information management and 4 pertained to completing diagnostic tests.13 For health information management, we considered test reports that were never retrieved or reviewed as severe of a problem as tests that were not performed. Test Completion Compliance testing showed COR often completed radiology tests within the required time frames (MIT 2.001, 80.0%). Our clinicians also found similar results in case reviews, with the exception of case 55 and the following case: • In case 2, the provider ordered the patient have a neck X-ray in 14 days; however, the appointment was not scheduled, and the patient did not receive the X-ray. In contrast to the radiology completion rate, laboratory tests were completed within the specified time frames at a lower rate (MIT 2.004, 50.0%). This rate was lower than the institution’s rate of 100 percent during Cycle 5 for the same test. Detailed review of the compliance cases showed the laboratory tests were completed between one and six days late. The following cases also show delays in laboratory test completion: • In case 9, the provider ordered laboratory tests to be performed on a specific date; however, the tests were done eight days late. 13. Deficiencies occurred in cases 1, 2, 8, 9, 11, 12, 15, 18, 19, 22, 23, 50, 51, 54, 55, and 57. Significant deficiencies occurred in cases 2, 12, 18, 19, 55, and 57. Report Issued: April 2021 Office of the Inspector General, State of California Return to Contents 22 Cycle 6 Medical Inspection Report • In case 18, the provider ordered a blood count laboratory test to be performed on a specific date, instead the test was scheduled to be performed six days late. Compliance testing did not have applicable samples for the evaluation of STAT laboratory test completion (MIT 2.007, N/A). Our case review clinicians did not find any deficiencies in STAT laboratory test completion; however, in one case a STAT radiology test was performed late: • In case 55, the provider evaluated the patient and ordered a STAT abdominal X-ray; however, it was performed four days later. Health Information Management COR had mixed results in diagnostic health information management. Our compliance testing showed providers reviewed laboratory reports on time (MIT 2.005, 100%). However, our case review clinicians found seven instances of delayed review of laboratory test results.14 Some examples include the following cases: • In case 12, the provider endorsed the laboratory reports ten days after the results were available. • In case 51, the provider endorsed the laboratory reports fifteen days after the results were available. The providers communicated laboratory test results to patients within specified time frames at a low rate (MIT 2.006, 10.0%). Our case review clinicians found that a provider did not send a laboratory result letter in case 54. The providers endorsed radiology reports within specified time frames at a low rate (MIT 2.002, 66.7%). In two of the compliance samples, we found no evidence the provider endorsed the radiology report. Our case review clinicians found examples of providers not reviewing or endorsing radiology reports late in the following cases: • In case 1, the provider ordered an abdominal X-ray; however, the results were not endorsed by a provider. • In case 51, the provider endorsed the chest X-ray results nine days after they were available. COR had variable scores with handling of pathology results in compliance testing. COR retrieved pathology reports 40.0 percent of the time (MIT 2.010). In the compliance samples, three pathology results were obtained one to 70 days late, while in three other samples, the final pathology results were not retrieved. Our case review clinicians also identified a delay in the following case: • In case 18, the patient had an esophageal biopsy performed, but the biopsy results were retrieved over five months later. 14. This deficiencies occurred in cases 1, 12, 18, 51, 54, and 57. Office of the Inspector General, State of California Inspection Period: August 2019 – January 2020 Return to Contents California State Prison, Corcoran 23 Compliance testing showed providers performed well endorsing pathology results (MIT 2.011, 100%). However, the providers did not send result letters to the patients within the required time frames (MIT 2.012, zero). On further review of these compliance samples, we confirmed that although providers did not send result letters to their patients, they did discuss the pathology results with their patients at subsequent appointments. This correlated with our case review clinicians’ findings. Compliance testing did not have applicable samples for the evaluation of STAT laboratory test results management by the nurse and provider (MIT 2.008, 2.009, N/A). Case review clinicians did not find any deficiencies in handling of STAT laboratory test results. Clinician On-Site Inspection During our on-site inspection, we interviewed COR leadership, providers, supervisors, and staff regarding their diagnostic processes. Providers reported good laboratory services; however, radiology staff reported the X-ray machine was broken from September 2019 to May 2020. X-rays had to be performed at a nearby institution or at the local hospital, accounting for some delays in the ordered X-rays during the review period. Since this time, the X-ray machine has been repaired and COR now has no X-ray backlogs. Furthermore, ancillary service leadership reported implementing tracking logs to monitor timely test completion. The chief medical executive (CME) and chief physician and surgeon (CP&S) also audit providers monthly to ensure laboratory and radiology tests are reviewed within the required time frames. Recommendations • Medical leadership should determine the root cause of challenges with scanning, retrieving, and reviewing of laboratory, radiology, and pathology results and implement remedial measures as appropriate to ensure they are performed within required time frames. • Medical leadership should ascertain causative factors with timely provision of pathology and laboratory results letters to patients and implement remedial measures as appropriate. • The department should consider developing and implementing a patient results letter template which autopopulates with all elements required per CCHCS policy. Report Issued: April 2021 Office of the Inspector General, State of California Return to Contents 24 Cycle 6 Medical Inspection Report Compliance Testing Results Table 8. Diagnostic Services Scored Answer Compliance Questions Yes No Radiology: Was the radiology service provided within the time frame specified in the health care provider’s order? (2.001) * 8 2 0 80.0% Radiology: Did the ordering health care provider review and endorse the radiology report within specified time frames? (2.002) * 6 3 1 66.7% Radiology: Did the ordering health care provider communicate the results of the radiology study to the patient within specified time frames? (2.003) 0 9 1 Laboratory: Was the laboratory service provided within the time frame specified in the health care provider’s order? (2.004) * 5 5 0 10 0 0 1 9 0 Laboratory: Did the institution collect the STAT laboratory test and receive the results within the required time frames? (2.007) * N/A N/A N/A N/A Laboratory: Did the nursing staff notify the health care provider within one (1) hour from receiving the STAT laboratory results? (2.008) * N/A N/A N/A N/A Laboratory: Did the health care provider endorse the STAT laboratory results within the required time frames? (2.009) N/A N/A N/A N/A Pathology: Did the institution receive the final pathology report within the required time frames? (2.010) * 4 6 0 Pathology: Did the health care provider review and endorse the pathology report within specified time frames? (2.011) * 7 0 3 100% Pathology: Did the health care provider communicate the results of the pathology study to the patient within specified time frames? (2.012) 0 7 3 0 Laboratory: Did the health care provider review and endorse the laboratory report within specified time frames? (2.005) * Laboratory: Did the health care provider communicate the results of the laboratory test to the patient within specified time frames? (2.006) N/A Yes % 0 50.0% 100% 10.0% 40.0% Overall percentage (MIT 2): 49.6% * The OIG clinicians considered these compliance tests along with their case review findings when determining the quality rating for this indicator. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: August 2019 – January 2020 Return to Contents California State Prison, Corcoran Emergency Services In this indicator, OIG clinicians evaluated the quality of emergency medical care. Our clinicians reviewed emergency medical services by examining the timeliness and appropriateness of clinical decisions made during medical emergencies. Our evaluation included examining the emergency medical response, cardiopulmonary resuscitation (CPR) quality, triage and treatment area (TTA) care, provider performance, and nursing performance. Our clinicians also evaluated the Emergency Medical Response Review Committee’s (EMRRC) ability to identify problems with its emergency services. The OIG assessed the institution’s emergency services through case review only; we did not perform compliance testing for this indicator. 25 Overall Rating Adequate Case Review Rating Adequate Compliance Score (N/A) Results Overview COR’s overall performance in this indicator was similar to Cycle 5. COR generally delivered prompt life support care during medical emergencies. Providers performed adequate evaluations for patients and delivered appropriate interventions. Areas for improvement included delays in transferring patients to the TTA and community hospital and first medical responder and nursing assessment and documentation. We rated this indicator adequate. Case Review Results Our clinicians reviewed 19 cases with 55 urgent or emergent events and found 43 emergency care deficiencies, seven of which were significant.15 Emergency Medical Response Staff responded promptly to emergencies throughout the institution, they initiated CPR, activated emergency medical services (EMS), and notified TTA staff in a timely manner. First medical responders generally performed initial assessments at the scene and provided appropriate medical interventions. • Similar to Cycle 5, we identified delays in staff calling 9-1-1 and transferring patients to a higher level of care.16 The following cases illustrate these deficiencies: • In case 2, the patient had an altered mental status and a potential head injury. Staff did not call community EMS until 22 minutes after they found the patient. Also, the patient’s departure was delayed for 20 minutes because EMS could not depart without a custody escort. 15. Deficiencies occurred in cases 1, 2, 4, 5, 6, 7, 8, 9, 18, 22, 23, 55, and 57. Significant deficiencies occurred in cases 2, 9, 18, 22, 55, and 57. 16. Delays in emergency medical response occurred in cases 2, 8, and 55. Report Issued: April 2021 Office of the Inspector General, State of California Return to Contents 26 Cycle 6 Medical Inspection Report • In cases 8 and 55, the transportation team was not ready when community EMS arrived, which delayed the patient’s transfer to the community hospital. Provider Performance Providers performed adequately in evaluating patients with urgent or emergent conditions in the TTA. Providers were available for consultation with TTA nursing staff during the day and after hours. The providers usually examined, diagnosed, and triaged these patients appropriately. OIG clinicians identified 12 deficiencies, some related to decision making, but the majority related to documentation lapses.17 The following cases detail some of the deficiencies found: • In case 9, the diabetic patient, who had a history of low and high sugar fluctuations, was evaluated in the TTA. The provider should have scheduled a provider follow-up appointment within five days for this high-risk patient to ensure close follow-up; however, the provider did not. • In case 55, the patient had an elevated heart rate which the provider did not address before medically clearing the patient. Furthermore, when the patient swallowed a razor blade, the provider did not order X-rays to determine the location of the razor blade the same day, but had it performed three days later. • In cases 9, 18, 23, 55, and 57, the providers were consulted on the patients in the TTA, but they did not document complete progress notes. Nursing Performance Nursing performance during medical emergencies had similar deficiencies identified in Cycle 5. First medical responders occasionally did not perform an initial assessment or provide appropriate interventions. When staff transferred patients to the TTA, the TTA nurses sometimes did not properly evaluate and monitor the patients; however, the nursing deficiencies did not significantly affect the patient’s care and outcome, but are opportunities for improvement. Examples of first medical responder deficiencies we identified are illustrated in the following cases: • In case 2, the patient had face and head injuries and received emergency care. The TTA nurse removed a cervical collar prior to the on-site provider clearing the patient. Additionally, neurological checks were not completed every 15 minutes, as required per nursing protocol for this level of consciousness, while the patient was waiting for transfer to a higher level of care. 17. Deficiencies occurred in cases 9, 18, 23, 55, and 57. Significant deficiencies occurred in cases 9 and 55. Office of the Inspector General, State of California Inspection Period: August 2019 – January 2020 Return to Contents California State Prison, Corcoran 27 • In case 5, custody staff found the patient unresponsive and suspected a drug overdose. The nurse did not check the patient’s pulse or pupil size and did not immediately administer naloxone.18 • The following cases show some opportunities for improvement we identified in TTA nursing performance: • In case 9, the diabetic patient reported he had a seizure, which could be caused by significantly low blood sugar; however, the TTA nurse did not check the patient’s blood sugar level. • In case 57, the patient was experiencing back pain and had an abnormally elevated blood pressure; however, the TTA nurse did not perform a back and musculoskeletal assessment prior to discharging the patient. Nursing Documentation Complete and accurate documentation illustrates the quality and timeliness of emergency care. COR nurses continued to have difficulty documenting the proper sequence of events and pertinent information, such as care provided and medications administered during an emergency. These deficiencies occurred in nine cases.19 Examples included the following cases: • In case 6, the first medical responder documented oxygen was delivered via a nonrebreather mask on the patient, who was not breathing. Additionally, the first medical responder did not document the naloxone doses administered to the patient on the medication administration record (MAR). • In case 7, after the patient expired, the nurses documented incorrectly the times naloxone was administered to the patient on the MAR. Emergency Medical Response Review Committee Nursing supervisors and the EMRRC reviewed all emergency cases within the required time frames. Of the nine emergency events we reviewed that were also reviewed by the EMRRC and nursing supervisors, we found reviewers usually recognized lapses in care and implemented corrective actions to address the deficiencies. Clinician On-Site Inspection The TTA was appropriately equipped and well-staffed with two nurses at all times to handle emergency events. A provider was assigned in the TTA during business hours, and an on-call provider was available after hours and on weekends. Custody first responders actively participated during medical emergencies, and other nurses assisted in the TTA when 18. Naloxone is a medication used to rapidly reverse opioid overdose. 19. Incomplete and inaccurate documentation occurred in cases 1, 2, 4, 5, 6, 7, 8, 18, and 55. Report Issued: April 2021 Office of the Inspector General, State of California Return to Contents 28 Cycle 6 Medical Inspection Report needed. The institution partially completed staff training on the new policy for emergency medical responses. Recommendations • Medical leadership should determine the root cause of challenges with providers’ completion of progress notes for emergent events and implement remedial measures as appropriate to ensure they are completed. • The EMRRC should identify and address delays in the transfer of patients to a higher level of care, including delays due to availability of custody staff. • Nursing leadership should identify root causes that prevent nurses from completely and accurately documenting assessments and medication administration in emergent events and implement remedial measures as appropriate. Office of the Inspector General, State of California Inspection Period: August 2019 – January 2020 Return to Contents California State Prison, Corcoran Health Information Management In this indicator, OIG inspectors evaluated the flow of health information, a crucial link in high-quality medical care delivery. Our inspectors examined whether the institution retrieved and scanned critical health information (progress notes, diagnostic reports, specialist reports, and hospital-discharge reports) into the medical record in a timely manner. Our inspectors also tested whether clinicians adequately reviewed and endorsed those reports. In addition, our inspectors checked whether staff labeled and organized documents in the medical record correctly. Results Overview 29 Overall Rating Adequate Case Review Rating Adequate Compliance Score Proficient (89.9%) Compared with Cycle 5, COR’s scores improved in compliance testing for this indicator. COR’s strengths included obtaining hospital discharge reports, scanning and labeling medical records, and reviewing pathology results. The institution had room for improvement in obtaining, scanning, and reviewing specialty reports within the required time frames. Factoring compliance scoring and case reviews, we rated this indicator adequate. Case Review Results We reviewed 958 events and found 55 deficiencies related to health information management. Of these 55 deficiencies, six were significant.20 Hospital-Discharge Reports COR managed hospital records well. Staff retrieved and scanned hospital discharge records within required time frames (MIT 4.003, 95.0%). The institution frequently ensured discharge records included discharge summaries, and the primary care provider reviewed the records within five calendar days of the patient’s discharge (MIT 4.005, 88.0%). OIG case review clinicians reviewed 22 off-site emergency department and hospital events and found one minor deficiency with the retrieval of the discharge summary: • In case 5, the patient was evaluated for a drug overdose in the emergency department. The complete discharge summary was not obtained and scanned into the patient’s electronic medical record. Specialty Reports Compliance testing showed poor performance in scanning specialty reports within required time frames (MIT 4.002, 66.7%). OIG clinicians 20. Deficiencies occurred in cases 1, 5, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 50, 51, 54, 55, 56, and 57. Significant deficiencies occurred in cases 12, 14, 16, 18, 19, and 57. Report Issued: April 2021 Office of the Inspector General, State of California Return to Contents 30 Cycle 6 Medical Inspection Report identified deficiencies in retrieving and scanning dictated specialty reports in six cases, including the following two cases:21 • In case 14, the patient underwent cataract surgery with the ophthalmology specialist; however, the surgical report for the patient was not obtained or scanned. • In case 51, the patient saw the neurosurgeon specialist. The specialty report was not retrieved until six days after the appointment. In compliance testing, COR had variable performance in retrieving specialty reports and reviewing high-priority specialty reports (MIT 14.002, 80.0%), medium-priority specialty reports (MIT 14.005, 46.7%) and routine-priority specialty reports (MIT 14.008, 64.3%). Our case review clinicians found COR providers endorsed specialty reports outside the required time frames in case 21, and the two cases below. • In case 8, the patient had surgery on his right eye. The provider did not endorse the patient’s specialty report until seven days after it was retrieved. • In case 55, the patient had an appointment with the off-site urologist; however, the provider endorsed the urology specialty report five days after it was received. The Specialty Services indicator has additional details regarding COR’s specialty performance. Diagnostic Reports Compliance testing showed COR providers performed well in endorsing pathology results (MIT 2.011, 100%). However, the providers did not send result letters to patients within the required time frames (MIT 2.012, zero). Further analysis of these compliance samples revealed providers did not send result letters to their patients but did discuss pathology results with their patients at subsequent appointments. This correlated with the findings of our case review clinicians. Compliance testing did not have applicable samples to evaluate the management of STAT laboratory test results by the nurse and provider (MIT 2.008, N/A). Case review clinicians did not find any deficiencies in the handling of STAT laboratory test results. Please see the Diagnostic Services indicator for more details. Urgent and Emergent Records OIG clinicians reviewed 55 emergency care events and found the events were generally documented. We found providers had some lapses in fully documenting their emergency care. The Emergency Services indicator has additional information regarding emergency care documentation. 21. Deficiencies occurred in cases 8, 10, 14, 16, 19, and 51. Office of the Inspector General, State of California Inspection Period: August 2019 – January 2020 Return to Contents California State Prison, Corcoran 31 Scanning Performance COR scored well in scanning health care request forms into patients’ electronic health records (MIT 4.001, 100%). Furthermore, compliance testing showed excellent performance in properly scanning, labeling, and including the correct patient file in the medical records (MIT 4.004, 100%). Our clinicians found minor deficiencies in misfiled, mislabeled, or misdated medical records in cases 8, 57, and the following two cases: • In case 15, the patient had an electrocardiogram (EKG), but it was scanned late and misfiled on the wrong date. • In case 22, the patient’s refusal form was incorrectly labeled as discharge instructions in the electronic health record (EHRS). Clinician On-Site Inspection We interviewed health information management supervisors, providers, utilization management nurses, and staff regarding our case review questions and health information processes. The supervisor discussed recent workflows to improve health information management, including holding meetings with a local laboratory to improve communication of laboratory results. COR laboratory staff use a tracker to follow up with results and providers’ reviews. Utilization management nurses also use a tracker to ensure specialist and biopsy reports are retrieved timely. Some staff members were provided access to local hospital medical records in order to obtain reports easily. Recommendations • Medical leadership should determine the root cause of challenges in timely scanning, retrieving, and reviewing specialty service reports and implement remedial measures as appropriate to ensure they are performed within required time frames. Report Issued: April 2021 Office of the Inspector General, State of California Return to Contents 32 Cycle 6 Medical Inspection Report Compliance Testing Results Table 9. Health Information Management Scored Answer Compliance Questions Yes No N/A Yes % Are health care service request forms scanned into the patient’s electronic health record within three calendar days of the encounter date? (4.001) 40 0 0 Are specialty documents scanned into the patient’s electronic health record within five calendar days of the encounter date? (4.002) * 20 10 15 66.7% Are community hospital discharge documents scanned into the patient’s electronic health record within three calendar days of hospital discharge? (4.003) * 19 1 5 95.0% During the inspection, were medical records properly scanned, labeled, and included in the correct patients’ files? (4.004) * 24 0 0 For patients discharged from a community hospital: Did the preliminary or final hospital discharge report include key elements and did a provider review the report within five calendar days of discharge? (4.005) * 22 3 0 100% 100% 88.0% Overall percentage (MIT 4): 89.9% * The OIG clinicians considered these compliance tests along with their case review findings when determining the quality rating for this indicator. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: August 2019 – January 2020 Return to Contents California State Prison, Corcoran 33 Table 10. Other Tests Related to Health Information Management Scored Answer Compliance Questions Yes No N/A Yes % Laboratory: Did the nursing staff notify the health care provider within one (1) hour from receiving the STAT laboratory results? (2.008) * N/A N/A N/A N/A Pathology: Did the health care provider review and endorse the pathology report within specified time frames? (2.011) * 7 0 3 100% Pathology: Did the health care provider communicate the results of the pathology study to the patient within specified time frames? (2.012) 0 7 3 0 Did the institution receive and did the primary care provider review the high-priority specialty service consultant report within the required time frame? (14.002) * 12 3 0 80.0% Did the institution receive and did the primary care provider review the medium-priority specialty service consultant report within the required time frame? (14.005) * 7 8 0 46.7% Did the institution receive and did the primary care provider review the routine-priority specialty service consultant report within the required time frame? (14.008) * 9 5 1 64.3% * The OIG clinicians considered these compliance tests along with their case review findings when determining the quality rating for this indicator. Source: The Office of the Inspector General medical inspection results. Report Issued: April 2021 Office of the Inspector General, State of California Return to Contents 34 Cycle 6 Medical Inspection Report Overall Rating Inadequate Case Review Rating (N/A) Compliance Score Inadequate (45.8%) Health Care Environment In this indicator, OIG compliance inspectors tested clinics’ waiting areas, infection control, sanitation procedures, medical supplies, equipment management, and examination rooms. Inspectors also tested clinics’ ability to maintain auditory and visual privacy for clinical encounters. Compliance inspectors asked the institution’s health care administrators to comment on their facility’s infrastructure and its ability to support health care operations. The OIG rated this indicator solely on the compliance score, using the same scoring thresholds as in the Cycle 4 and Cycle 5 medical inspections. Our case review clinicians do not rate this indicator. Compliance Testing Results For this indicator, COR’s performance declined compared with its performance in Cycle 5. Multiple aspects of COR’s health care environment needed improvement: examination rooms lacked adequate space; multiple clinics and the medical warehouse contained expired medical supplies; emergency medical response bag (EMRB) logs were missing staff verification; and staff did not regularly sanitize their hands before or after examining patients. These factors resulted in an inadequate rating for this indicator. Outdoor Waiting Areas We inspected the outdoor patient waiting areas at COR (see Photo 1, below). There was a cooling sprinkler in the outdoor waiting areas Photo 1. Outdoor waiting area (photographed on March 12, 2020). Office of the Inspector General, State of California Inspection Period: August 2019 – January 2020 Return to Contents California State Prison, Corcoran 35 Photo 2. Indoor waiting area (photographed on March 12, 2020). for comfort in the hot weather. During our inspection, we did not observe any patients waiting outside for their clinical appointments due to a fog alert. Heath care and custody staff reported the outdoor waiting areas had sufficient seating capacity and provided patients protection from inclement weather. Indoor Waiting Areas Inside the medical clinics, patients had ample seating to wait for their appointments (see Photo 2, above). Depending on the population, patients were either placed in the clinic waiting area or held in individual modules (see Photo 3, right) to wait for their medical appointments. Waiting areas had temperature control, running water, toilets, and hand sanitation items. We interviewed custody and medical staff, who reported the patient waiting areas were never at full capacity. Report Issued: April 2021 Photo 3. Individual waiting module (photographed on March 10, 2020). Office of the Inspector General, State of California Return to Contents 36 Cycle 6 Medical Inspection Report Clinic Environment Thirteen of the 14 clinic environments were sufficiently conducive to medical care; they provided reasonable auditory privacy, appropriate waiting areas, wheelchair accessibility, and nonexamination-room workspace (MIT 5.109, 92.9%). In one clinic, the configuration of the vital check stations did not provide auditory privacy. Of the 11 clinics we observed, only six contained appropriate space, configuration, supplies, and equipment to allow their clinicians to perform proper clinical examinations (MIT 5.110, 54.5%). The remaining five clinics had one or more of the following deficiencies: torn examination table covers; examination rooms measuring under 100 square feet; and cluttered examination rooms. Photos 4, above, and 5, right. Residual water damage (photographed on March 12, 2020). In addition to the above findings, our compliance inspectors observed some notable findings in clinics during their on-site inspection. Several clinics had ceilings with residual water damage, for which staff provided us with copies of work orders and submitted repair requests (see Photos 4 and 5, this page). According to the nursing administrative staff, the plant manager denied their request because the clinic swing spaces were only temporary and construction of the new clinic spaces was nearing completion. Office of the Inspector General, State of California Inspection Period: August 2019 – January 2020 Return to Contents California State Prison, Corcoran 37 The plant manager reported staff were busy completing other tasks at COR to fulfill duties to the best of their abilities. Clinic Supplies None of the 15 clinics followed adequate medical supply storage and management protocols (MIT 5.107, zero). Photo 6. Expired medical supply, dated June 2015 (photographed on March 12, 2020). We found one or more of the following deficiencies in all clinics at COR: expired medical supplies (see Photos 6, 7, and 8, this page); unidentified medical supplies; and compromised sterile medical supplies packaging. Photo 7. Expired medical supply, dated September 2019 (photographed on March 9, 2020). We also found cleaning supplies stored in the same area with medical supplies; and staff’s personal items and food stored in the same area with medical supplies (see Photo 9, page 38). Photo 8. Expired medical supply, dated June 2019 (photographed on March 9, 2020). Report Issued: April 2021 Office of the Inspector General, State of California Return to Contents 38 Cycle 6 Medical Inspection Report Five of the 15 clinics met requirements for essential core medical equipment and supplies (MIT 5.108, 33.3%). The remaining ten clinics lacked medical supplies or had improperly calibrated or nonfunctional equipment. The missing items included a nebulizer, tongue depressor, examination table paper, hemoccult cards, lubricating jelly, and biohazard bag or receptacle bin. Among the improperly calibrated or nonfunctional equipment, we found Snellen charts that either had an inaccurately identified distance line or did not have an identified distance line on the floor or wall, a nonfunctional otoscope, an automatic external defibrillator (AED) without a current calibration sticker, and an expired lubricating jelly (see Photo 10, below). We also noted staff did not accurately log or failed to log the results of the defibrillator performance test within the preceding 30 days. Photo 9. Staff members’ personal items and food stored with medical supplies (photographed on March 12, 2020). We examined EMRBs to determine whether they contained all essential items, and whether staff inspected the bags daily and inventoried them monthly. Only two of the 12 EMRBs passed our test (MIT 5.111, 16.7%). We found one or more of the following deficiencies with 10 EMRBs: staff failed to ensure the EMRBs’ compartments were sealed and intact, and staff had not inventoried the EMRBs when the seal tags were replaced nor inventoried the EMRBs in the previous 30 days. The crash carts in the correction treatment center (CTC) contained several expired medical supplies. During our clinic inspections, we also found multiple expired medical supplies in the emergency stab bags. Stab bags Office of the Inspector General, State of California Photo 10. Expired lubricating jelly dated February 2020 (photographed on March 9, 2020). Inspection Period: August 2019 – January 2020 Return to Contents California State Prison, Corcoran 39 are used with an EMRB when responding to an emergency medical response. The emergency stab bags were not organized or regularly inventoried. Medical Supply Management None of the medical supply storage areas located outside the medical clinics stored medical supplies adequately (MIT 5.106, zero). We found multiple expired medical supplies (see Photos 11 and 12, right and below). According to the chief executive officer (CEO), the institution did not have any concern about the medical supplies process. Health care managers and medical warehouse managers expressed no concerns about the medical supply chain or their communication process with the existing system. Infection Control and Sanitation Staff appropriately disinfected, cleaned, and sanitized 11 of 15 clinics (MIT 5.101, 73.3%). In four clinics, we found one or more of the Photo 11. Expired medical supplies, dated January 31, 2020 (photographed on March 11, 2020). following deficiencies: cleaning logs were not maintained, accumulated dirt and grime on examination room cabinets and a gurney, and accumulated dust on an examination table. Staff in six of 12 applicable clinics properly sterilized or disinfected medical equipment (MIT 5.102, 50.0%). In six other clinics, we found one or more of the following deficiencies: staff did not list disinfecting the examination table as part of their daily start-up protocol; staff did not regularly log sterilized reusable medical equipment; and compromised or no seals on sterilized reusable medical equipment. Photo 12. Expired medical supplies, dated February 29, 2020 (photographed on March 11, 2020). Report Issued: April 2021 Office of the Inspector General, State of California Return to Contents 40 Cycle 6 Medical Inspection Report We found operating sinks and hand hygiene supplies in the examination rooms in nine of 14 applicable clinics (MIT 5.103, 64.3%). In five clinics, patient restrooms either lacked antiseptic soap or disposable hand towels or sinks were nonfunctional for the health care staff or patients, or both. We observed patient encounters in nine clinics. In six clinics, clinicians did not wash their hands before or after examining their patients, before applying gloves, or before performing blood draw (MIT 5.104, 33.3%). Health care staff in 12 of 14 applicable clinics followed proper protocols to mitigate exposure to blood-borne pathogens and contaminated waste (MIT 5.105, 85.7%). In one clinic, we found dried blood on and under two gurney mattresses (see Photo 13, left). In another clinic, the examination room lacked a sharps container. Physical Infrastructure Photo 13. Blood on the gurney mattress (photographed on March 9, 2020). The institution’s health care management and plant operations manager reported all clinical area infrastructures were in good working order and construction of the medical clinic at COR did not hinder health care services. At the time of our medical inspection, the institution’s administrative team reported eight concurrent ongoing health care facility improvement program (HCFIP) construction projects. Some projects were still in the planning phase, while others had already broken ground or were nearing completion. All eight projects were for new medical clinic space. The institution reported multiple setbacks relating to various obstacles causing delays in completion; three clinics were still awaiting inspection approval from the fire marshal, and one clinic had a hot water leak causing extensive damage. The administrative team offered no additional information relating to future health care clinic space renovation plans (MIT 5.999). Recommendations Nursing leadership should consider performing random spot checks to ensure staff follow equipment and medical supply management protocols. • Medical leadership should remind staff to follow universal hand hygiene precautions. Implementing random spot checks could improve compliance. • Nursing leadership should have each clinic nurse supervisor review the monthly EMRB logs to ensure the EMRBs are regularly inventoried and sealed. Office of the Inspector General, State of California Inspection Period: August 2019 – January 2020 Return to Contents California State Prison, Corcoran 41 Compliance Testing Results Table 11. Health Care Environment Scored Answer Compliance Questions Yes No Infection control: Are clinical health care areas appropriately disinfected, cleaned, and sanitary? (5.101) 11 4 0 73.3% Infection control: Do clinical health care areas ensure that reusable invasive and noninvasive medical equipment is properly sterilized or disinfected as warranted? (5.102) 6 6 3 50.0% Infection control: Do clinical health care areas contain operable sinks and sufficient quantities of hygiene supplies? (5.103) 9 5 1 64.3% Infection control: Does clinical health care staff adhere to universal hand hygiene precautions? (5.104) 3 6 6 33.3% Infection control: Do clinical health care areas control exposure to blood-borne pathogens and contaminated waste? (5.105) 12 2 1 85.7% Warehouse, conex, and other nonclinic storage areas: Does the medical supply management process adequately support the needs of the medical health care program? (5.106) 0 1 0 0 Clinical areas: Does each clinic follow adequate protocols for managing and storing bulk medical supplies? (5.107) 0 15 0 0 Clinical areas: Do clinic common areas and exam rooms have essential core medical equipment and supplies? (5.108) 5 10 0 33.3% 13 1 1 92.9% Clinical areas: Are the environments in the clinic exam rooms conducive to providing medical services? (5.110) 6 5 4 54.5% Clinical areas: Are emergency medical response bags and emergency crash carts inspected and inventoried within required time frames, and do they contain essential items? (5.111) 2 10 3 16.7% Clinical areas: Are the environments in the common clinic areas conducive to providing medical services? (5.109) Does the institution’s health care management believe that all clinical areas have physical plant infrastructures that are sufficient to provide adequate health care services? (5.999) N/A Yes % This is a nonscored test. Please see the indicator for discussion of this test. Overall percentage (MIT 5): 45.8% * The OIG clinicians considered these compliance tests along with their case review findings when determining the quality rating for this indicator. Source: The Office of the Inspector General medical inspection results. Report Issued: April 2021 Office of the Inspector General, State of California Return to Contents 42 Cycle 6 Medical Inspection Report Overall Rating Inadequate Case Review Rating Adequate Compliance Score Inadequate (51.2%) Transfers In this indicator, OIG inspectors examined the transfer process for those patients who transferred into the institution, as well as for those who transferred to other institutions. For newly arrived patients, our inspectors assessed the quality of health screenings and the continuity of provider appointments, specialist referrals, diagnostic tests, and medications. For patients who transferred out of the institution, inspectors checked whether staff reviewed patient medical records and determined the patient’s need for medical holds. They also assessed if staff transferred patients with their medical equipment and gave correct medications before patients left. In addition, our inspectors evaluated the ability of staff to communicate vital health transfer information, such as preexisting health conditions, pending appointments, tests, and specialty referrals; and inspectors confirmed if staff sent complete medication transfer packages to the receiving institution. For patients who returned from off-site hospitals or emergency rooms, inspectors reviewed whether staff appropriately implemented the recommended treatment plans, administered necessary medications, and scheduled appropriate followup appointments. Results Overview Similar to Cycle 5, COR performed poorly in completing initial health screening forms, timely receiving previously ordered medications for patients transferring into COR from other institutions, and completing transfer packets for patients transferring from COR to other institutions. Additionally, we found delayed access to approved specialty appointments for newly arrived patients and lapses in medication continuity for patients returning from the hospital. The institution did improve access to the primary care team for newly arrived patients, as well as retrieval, scanning, and provider review of hospital discharge reports. Factoring both compliance and case reviews, we rated this indicator inadequate. Case Review Results Our clinicians reviewed 24 cases in which patients transferred into or out of the institution or returned from an off-site hospital or emergency room, and identified 16 deficiencies, four of which were significant.22 In most cases, COR ensured medical care continued during transfers. There were some lapses, particularly in medication management, but none adversely affected patient care. Transfers In We reviewed eight patients who transferred into COR from another institution. The R&R nurses completed initial health screenings of 22. Deficiencies occurred in cases 1, 4, 5, 8, 9, 17, 24, 28, 50, 51, 52, and 55. Cases 51 and 55 had significant deficiencies. Office of the Inspector General, State of California Inspection Period: August 2019 – January 2020 Return to Contents California State Prison, Corcoran 43 patients upon arrival to the institution. However, compliance testing found R&R nurses scored poorly in completing initial health screening (MIT 6.001, zero). All screenings missed one or more pertinent item of information, such as symptoms in tuberculosis (TB) screening and vital signs within the required time frame.23 Nurse or provider referrals for newly arriving patients occurred within the specified time frames. We found only one case where the R&R nurse did not refer a patient, who returned from a mental health placement, to the RN care manager.24 Compliance testing also showed R&R nurses completed the disposition section of the initial health screening form in 23 of the 24 samples tested (MIT 6.002, 95.8%) and provider appointments for newly arriving patients occurred timely for 20 of the 25 samples tested (MIT 1.002, 80.0%). Our case review clinicians found R&R nurses evaluated newly arriving patients timely and performed adequate assessments. COR performed poorly in ensuring approved specialty appointments for newly arriving patients occurred within the required time frames (MIT 14.010, 65.0%), with appointment delays from 21 to 49 days. Our case review clinicians reviewed two patients transferring into COR with approved specialty appointments and did not identify any lapses. Compliance testing found low scores in medication continuity for patients transferred into COR (MIT 6.003, 58.8%), reassigned to another yard within the institution (MIT 7.005, 64.0%), and patients en route to another institution (MIT 7.006, 40.0%). Patients received their medications either late or not at all. We identified delays in medication administration in two of the transfer-in cases we reviewed.25 The nurses documented medication in the sending institution encounter in three cases,26 and in two cases the patient refused medication. Our clinicians found COR did not ensure medication continuity in one out of the five cases reviewed: • In case 24, the patient transferred into COR from another institution and did not receive his eye drops or intestinal medication for two days. COR provided adequate provider follow-up for patients transferring into the institution (MIT 1.002, 80.0%). However, compliance testing found poor performance in scheduling specialty appointments for patients who transferred into COR with preapproved specialty appointments (MIT 14.010, 65.0%). Our case review clinicians did not identify any missed or delayed preapproved specialty referrals. 23. In April 2020, CCHCS reported having added the symptom of fatigue into the EHRS for TB symptom monitoring. 24. Case 24. 25. Delays in medication administration occurred in cases 24 and 52. 26. This occurred in cases 9, 17, and 24. Report Issued: April 2021 Office of the Inspector General, State of California Return to Contents 44 Cycle 6 Medical Inspection Report Transfers Out Our clinicians reviewed eight patients who transferred out of COR into other institutions and identified three deficiencies, one of which was significant.27 R&R nurses performed face-to-face evaluations, sent required transfer documents, and administered prescribed medications when patients transferred. However, the nurses sometimes did not inform the receiving institution of the patient’s pending appointments, tests, and specialty referrals or send prescribed medications with the patients. These deficiencies are illustrated in the cases below: • In case 1, the R&R nurse did not communicate the status of the patient’s hepatitis C treatment. • In case 28, the nurse did not send all medications with the patient. • In case 51, the nurse did not communicate the patient’s recommended specialty follow-up appointment and diagnostic tests to the receiving institution and did not document whether prescribed medications were sent with the patient. Our regional compliance inspectors also confirmed only four of the eight transfer packets they reviewed on-site had the required medications (MIT 6.101, 50.0%). Hospitalizations Patients returning from an off-site hospitalization or emergency room are at high risk for lapses in care. These patients have typically experienced severe illness or injury. They require more care and place strain on the institution’s resources. Because these patients have complex medical issues, the successful transfer of health information is necessary for quality care. Any lapse of care can result in serious consequences for these patients. Our clinicians reviewed 21 hospital or emergency room returns in 13 cases28 and found TTA nurses properly evaluated patients upon return from the hospital or emergency department. The nurses reviewed hospital discharge reports, informed the provider of hospital recommendations, and scheduled provider follow-up appointments. Our case review clinicians identified eight deficiencies, three of which were significant.29 Although providers thoroughly reviewed hospital discharge summaries, they sometimes missed hospital recommendations as in the following cases: • In case 4, the hospital discharge summary recommended diagnostic tests to follow up on the patient’s abnormal diagnostic results; however, the provider did not order the tests. 27. Transfers-out occurred in cases 1, 26, 27, 28, 51, 53, 54, and 55. Deficiencies occurred in cases 1, 28, and 51. A significant deficiency occurred in case 51. 28. Hospital/ED return cases: 1, 2, 4, 5, 8, 17 ,18, 19, 20, 21, 50, 51, and 55. 29. Deficiencies occurred in cases 4, 5, 8, 50, and 55. All significant deficiencies occurred in case 55. Office of the Inspector General, State of California Inspection Period: August 2019 – January 2020 Return to Contents California State Prison, Corcoran 45 • In case 55, the hospital discharge summary recommended the patient receive an antibiotic medication as treatment for infection, but the provider did not order the medication. Compliance testing revealed a low score in the continuity of hospitalrecommended medications (MIT 7.003, 40.0%). When we reviewed these compliance samples we found most medications were not available from one to three days. Some of these medications were antibiotics and inhalers. Our case review clinicians found delayed delivery of medication in two cases.30 Provider follow up after hospital or emergency room return occurred most of the time (MIT 1.007, 78.3%). Hospital discharge summary or emergency room reports were also available (MIT 4.003, 95.0%), complete, and reviewed by providers timely (MIT 4.005, 88.0%). Our case review clinicians found a few hospital reports dated and scanned incorrectly or incompletely.31 Clinician On-Site Inspection Patients arriving to or departing from the institution, en route to another institution, or returning from court appointments were evaluated in the R&R. The R&R clinic had ample space to interview and examine patients privately. An R&R nurse was assigned at all times during the week, and a clerical staff member assisted during business hours. We interviewed a second watch nurse, who was newly hired as the R&R nurse. The nurse was very knowledgeable and familiar with the transfer processes. On average, COR processed 60 to 100 incoming and outgoing transfers weekly. The nurse reported COR had temporarily ceased transfers in and out of the institution, unless necessary, due to the COVID-19 pandemic. The TTA nurses evaluated patients returning from the hospital or mental health crisis bed units located outside of the institution. Recommendations • Nursing leadership should determine the cause of challenges in providing medications to newly arriving patients without interruption and implement remedial measures as appropriate. • The department should consider developing and implementing an electronic alert to ensure nurses in receiving and release (R&R) properly complete initial health screening questions and follow up as needed. 30. Deficiencies occurred in cases 8 and 55. 31. Deficiencies in cases 5 and 8. Report Issued: April 2021 Office of the Inspector General, State of California Return to Contents 46 Cycle 6 Medical Inspection Report Compliance Testing Results Compliance On-Site Inspection Our compliance inspectors found the transfer-out process at COR lacked acceptable elements resulting in several deficiencies. We tested eight patients transferring out of COR to other institutions. COR nursing staff performed face-to-face evaluations before patients were transferred out of the institution. During our on-site inspection, we identified improvement opportunities in this area. COR nurses did not consistently document pertinent information of patients’ current list of missing medications or missing durable medical equipment. The nursing staff also did not ensure each patient transferred with all proper durable medical equipment, or keep-on-person and rescue medications. In addition, nursing staff included insufficient quantities of California Penal Code section 2602 ordered medications32 in patients’ transfer envelopes upon departure to another institution. Table 12. Transfers Scored Answer Yes No 0 25 0 For endorsed patients received from another CDCR institution or COCF: When required, did the RN complete the assessment and disposition section of the initial health screening form; refer the patient to the TTA if TB signs and symptoms were present; and sign and date the form on the same day staff completed the health screening? (6.002) 23 1 1 95.8% For endorsed patients received from another CDCR institution or COCF: If the patient had an existing medication order upon arrival, were medications administered or delivered without interruption? (6.003) * 10 7 8 58.8% 4 4 2 50.0% Compliance Questions For endorsed patients received from another CDCR institution or COCF: Did nursing staff complete the initial health screening and answer all screening questions within the required time frame? (6.001) * For patients transferred out of the facility: Do medication transfer packages include required medications along with the corresponding transfer packet required documents? (6.101) * N/A Yes % 0 Overall percentage (MIT 6): 51.2% * The OIG clinicians considered these compliance tests along with their case review findings when determining the quality rating for this indicator. Source: The Office of the Inspector General medical inspection results. 32. These consist of psychotropic medications involuntarily administered to patients with mental disorders. Office of the Inspector General, State of California Inspection Period: August 2019 – January 2020 Return to Contents California State Prison, Corcoran Table 13. Other Tests Related to Transfers 47 Scored Answer Compliance Questions Yes No N/A Yes % For endorsed patients received from another CDCR institution: Based on the patient’s clinical risk level during the initial health screening, was the patient seen by the clinician within the required time frame? (1.002) * 20 5 0 80.0% Upon the patient’s discharge from the community hospital: Did the patient receive a follow-up appointment with a primary care provider within the required time frame? (1.007) * 18 5 2 78.3% Are community hospital discharge documents scanned into the patient’s electronic health record within three calendar days of hospital discharge? (4.003) * 19 1 5 95.0% For patients discharged from a community hospital: Did the preliminary or final hospital discharge report include key elements and did a provider review the report within five calendar days of discharge? (4.005) * 22 3 0 88.0% Upon the patient’s discharge from a community hospital: Were all ordered medications administered, made available, or delivered to the patient within required time frames? (7.003) * 10 15 0 40.0% Upon the patient’s transfer from one housing unit to another: Were medications continued without interruption? (7.005) * 16 9 0 64.0% For patients en route who lay over at the institution: If the temporarily housed patient had an existing medication order, were medications administered or delivered without interruption? (7.006) * 4 6 0 40.0% For endorsed patients received from another CDCR institution: If the patient was approved for a specialty services appointment at the sending institution, was the appointment scheduled at the receiving institution within the required time frames? (14.010) * 13 7 0 65.0% * The OIG clinicians considered these compliance tests along with their case review findings when determining the quality rating for this indicator. Source: The Office of the Inspector General medical inspection results. Report Issued: April 2021 Office of the Inspector General, State of California Return to Contents 48 Cycle 6 Medical Inspection Report Overall Rating Inadequate Case Review Rating Inadequate Compliance Score Inadequate (51.4%) Medication Management In this indicator, OIG inspectors evaluated the institution’s ability to administer prescription medications on time and without interruption. The inspectors examined this process from the time a provider prescribed medication until the nurse administered the medication to the patient. When rating this indicator, the OIG strongly considered the compliance test results, which tested medication processes to a much greater degree than case review testing. In addition to examining medication administration, our compliance inspectors also tested many other processes, including medication handling, storage, error reporting, and other pharmacy processes. Results Overview COR performed poorly in medication management in both compliance testing and case review. Compliance testing results showed low scores in chronic medication continuity, hospital discharge medications, and medication in specialized medical housing. Our compliance testing illustrated a more robust assessment of the institution’s poor medication administration practices and pharmacy protocols. We also identified more deficiencies in our case reviews than during Cycle 5. After considering all factors, we rated this indicator inadequate. Case Review Results We reviewed 121 events related to medications and found 33 deficiencies, four of which were significant.33 New Medication Prescriptions The nurses did not always administer new medications on time. In most cases, the medication was not available on the date the provider had ordered.34 Compliance testing also showed 68.0 percent of patients received their newly ordered medications within specified time frames (MIT 7.002), which was a decline from the previous Cycle 5 compliance score. Further review of the compliance samples revealed five patients did not receive their medication on time. Also, an additional three patients refused their medication, and the nurses did not document the refusals. Chronic Care Medication Continuity Our case review clinicians found patterns of minor delays in the availability of chronic medications and intermittent gaps in medication administration.35 Compliance testing revealed patients often did not 33. Deficiencies occurred in cases 2, 8, 9, 12, 13, 14, 15, 16, 18, 22, 24, 28, 51, 52, 53, 55, and 57. Significant deficiencies occurred in cases 2, 9, 12, and 55. 34. Deficiencies occurred in cases 8, 16, 22, 24, 53, and 57. 35. These deficiencies occurred in more than once in cases 9, 13, 15, 16, 18, and once in cases 2, 51, and 57. Office of the Inspector General, State of California Inspection Period: August 2019 – January 2020 Return to Contents California State Prison, Corcoran 49 receive their chronic medications as scheduled (MIT 7.001, 10.5%). These delays were generally related to policy compliance and not clinically significant. Our clinicians identified 26 deficiencies of chronic care medication not being administered as prescribed.36 The following cases illustrate these deficiencies: • In case 2, during September 2019, the patient did not receive his keep-on-person (KOP) chronic medications timely. There was a delay of more than five days. • In case 12, the patient’s medication had expired and was not renewed. Therefore, the patient never received the medication. • In case 9, from November 6, 2019 to November 9, 2019, the medication nurse did not follow the primary care provider’s order and administered inaccurate doses of regular insulin. Furthermore, the nurse incorrectly recorded the doses of insulin administered throughout the month. The documentation showed the patient received very small amounts of insulin, less than what was ordered. Hospital Discharge Medications Compliance testing sampled 25 patients, who returned from the hospital with prescribed medications, and found poor performance (MIT 7.003, 40.0%). The patients either received their medications late, or there was no record of the patients receiving their medications. For one patient, who had a recommendation to receive an antibiotic for 10 days, the medication was never ordered and why the antibiotic had not been ordered was not documented.37 This is also discussed in the Transfers indicator. Specialized Medical Housing Medications Patients in the specialized housing units usually received their prescribed medications without delay. Our clinicians found occurrences of patients not receiving medications or receiving prescribed medications late, and in one instance we found involved a provider who did not continue one patient’s chronic medication when it expired.38 Although compliance testing showed medication delays (MIT 13.004, 50.0%), the delays were not clinically significant. 36. Deficient cases occurred in case 2, 9, 12, 13, 14, 15, 16, 50, 51, 52, 53, 55, 57. Significant deficiencies occurred in case 2, 9, and 12. 37. This deficiency occurred in case 55. 38. These deficiencies occurred in cases 12, 51, and 53. Report Issued: April 2021 Office of the Inspector General, State of California Return to Contents 50 Cycle 6 Medical Inspection Report Transfer Medications COR had room for improvement with transfer medications. Compliance testing showed some delays in medication administration for patients arriving into the institution(MIT 6.003, 58.8%). We also identified two deficiencies in our case review.39 Medication continuity for patients transferring from one housing unit to another within the institution scored at 64.0 percent (MIT 7.005). However, only two patients we tested did not receive their medications. Most patients refused their medications, and the nurses did not document the reason for their refusals. Our case review clinicians did not review any cases for transfers within COR. Compliance testing found low medication continuity for patients en route to another institution (MIT 7.006, 40.0%). COR did not always send required medications for patients transferring out of the institution and received a low compliance rate of 50.0 percent (MIT 6.101). Our clinicians found one case where medications were delayed for one day.40 Medication Administration The nurses generally administered medications on time. In a few occurrences, the nurses did not administer medications because they were not available. Our compliance inspectors tested how COR nurses administered and monitored patients taking tuberculosis (TB) medications and found good TB medication continuity (MIT 9.001, 84.6%) but poor TB monitoring (MIT 9.002, zero). We identified significant deficiencies of insulin administration in the case below: • In case 9, the patient had diabetes and received insulin medications. The provider prescribed regular insulin on a sliding scale therapy and Tresiba.41 The nurses administered incorrect doses of insulin, administered medications when not indicated or without checking blood sugar level, and withheld an insulin dose without notifying the provider. These errors could have adversely affected the patient. The nurses also erroneously recorded the amount of insulin administered several times, thus it appeared the patient received the wrong dose. Clinician On-Site Inspection Nurse leadership reported having sufficient medication nurses assigned in each clinic. The nurses usually attend morning huddles and inform the care team of any medication issues. The nurses articulated medication 39. These deficiencies occurred in cases 24 and 52. 40. Deficiency in case 52. 41. Insulin is a medication to treat high blood glucose. Regular insulin is a short-acting insulin that starts to work approximately within 30 minutes of administration. A sliding scale therapy is an administration of a prescribed dose based on the blood sugar level of the patient. This requires the nurse to obtain the patient’s blood glucose reading and select the proper dose based on the result. Tresiba is a long-acting insulin that helps control blood sugar throughout the day. Office of the Inspector General, State of California Inspection Period: August 2019 – January 2020 Return to Contents California State Prison, Corcoran 51 administration practices for transfers, hospital returns, medication noncompliance, and KOP medications. COR had recently hired a new pharmacist. COR’s current process for KOP medications includes delivering them two days prior to the medication due date. COR also has implemented stock medications for the 150 most commonly prescribed medications, including both nurse administered and direct observed therapy medications, in 25 locations. Compliance Testing Results Medication Practices and Storage Controls The institution adequately stored and secured narcotic medications in all applicable clinic and medication line locations (MIT 7.101, 100%). COR appropriately stored and secured nonnarcotic medications in nine of 14 clinic and medication line locations (MIT 7.102, 64.3%). In five locations, we identified one or more of the following deficiencies: crash cart logs missing daily security check entries or having inaccurate security check entries; no clearly identifiable designated area for medications to be returned to the pharmacy; and disorganized medication storage. Staff kept medications protected from physical, chemical, and temperature contamination in seven of the 14 clinic and medication line locations (MIT 7.103, 50.0%). In seven locations, we found one or more of the following deficiencies: staff did not store oral and topical medications separately; staff did not consistently record the room and refrigerator temperatures; logs indicated medications were not stored within acceptable temperature range; accumulated grime on the medication refrigerator; and staff stored medications with disinfectant. Staff successfully stored valid unexpired medications in ten of the 14 applicable clinic and medication line locations (MIT 7.104, 71.4%). In four locations, we found one or more of the following deficiencies: medication nurses did not label the multiple-use medication; inhalation solutions were not stored within the manufacturers’ guidelines; and medication was stored beyond the expiration date. Nurses exercised proper hand hygiene and contamination control protocols in four of seven applicable locations (MIT 7.105, 57.1%). In three locations, some nurses neglected to wash or sanitize their hands before donning gloves or before each subsequent regloving. In four of seven medication preparation and administration areas, staff demonstrated appropriate administrative controls and protocols (MIT 7.106, 57.1%). In three locations, nurses did not maintain nonissued medication in its original labeled packaging. In three of seven medication areas, staff used appropriate administrative controls and protocols when distributing medications to their patients (MIT 7.107, 42.9%). In four locations, medication nurses did not reliably Report Issued: April 2021 Office of the Inspector General, State of California Return to Contents 52 Cycle 6 Medical Inspection Report observe patients while they swallowed direct observation therapy medications or did not appropriately administer medication as ordered by the provider, or both. According to nursing administration, COR utilizes only one specific glucometer model for patient care, the Assure Platinum Meter which self-calibrates. However, during our inspection we found additional glucometer models in several clinic areas, which nursing staff reported using as back-ups. In multiple locations, we interviewed medication administration nurses, who were unable to describe circumstances when a glucometer should be control tested. The nurses reported glucometer control testing occurred rarely or never at all, which was corroborated by our finding during our on-site inspection. In some locations, we found incomplete quality control logs, while in other locations, we found no logs at all. The logs we reviewed included inconsistent data and data reflecting uncalibrated glucometers. We did not find any remedial measures taken to fix the uncalibrated glucometers. The nursing staff reported that even with abnormal control readings, insulin medications for multiple patients continued to be regularly administered daily. We also found multiple medication prescriptions with expired labels for specific patients that nursing staff continued to administer to these patients. The nursing staff did not consistently request updated medication labels for new medications from the pharmacy when needed. Pharmacy Protocols Pharmacy staff followed general security, organization, and cleanliness management protocols in the institution’s main and remote pharmacies (MIT 7.108, 100%). In its main pharmacy, staff did not properly store nonrefrigerated medications. We found expired medications stored in the pharmacy. Additionally, staff stored bulk food items within the medication preparation area. As a result, COR scored zero for this test (MIT 7.109). The institution properly stored refrigerated or frozen medications in the pharmacy (MIT 7.110, 100%). The pharmacist in charge (PIC) did not correctly review monthly inventories of controlled substances in the institution’s clinic and medication storage locations. Specifically, the PIC did not correctly complete several medication area inspection checklists (CDCR Form 7477). These errors resulted in a score of zero in this test (MIT 7.111). We examined 24 medication error reports. The PIC timely and correctly processed only two of these 24 reports (MIT 7.112, 8.3%). For 22 reports, one or more of the following deficiencies were identified: the PIC did not complete the pharmacy follow-up review form within the three business days from the error’s reported date; the form was missing pertinent data related to the error, including documentation of medication error notification to the patient or prescribing physician, determinations or findings; and recommended changes to correct the medication error. Office of the Inspector General, State of California Inspection Period: August 2019 – January 2020 Return to Contents California State Prison, Corcoran 53 Nonscored Tests In addition to testing the institution’s self-reported medication errors, our inspectors also followed up on any significant medication errors found during compliance testing. We do not score this test; we provide these results for informational purposes only. We did not find any applicable medication errors for COR (MIT 7.998). The OIG interviewed patients in isolation units to determine whether they had immediate access to their prescribed rescue medications. Sixteen of 17 applicable patients interviewed indicated they had access to their rescue medications. One patient reported he finished his medication a few days prior and had requested a refill. We promptly notified the CEO of this concern, and health care management immediately reissued a replacement rescue inhaler to the patient (MIT 7.999). Recommendations • Medical leadership should determine the cause of challenges related to medication continuity for chronic care, transferin, hospital discharge, and en route patients and implement remedial measures as appropriate. Report Issued: April 2021 Office of the Inspector General, State of California Return to Contents 54 Cycle 6 Medical Inspection Report Table 14. Medication Management Scored Answer Yes No 2 17 6 10.5% Did health care staff administer, make available, or deliver new order prescription medications to the patient within the required time frames? (7.002) 17 8 0 68.0% Upon the patient’s discharge from a community hospital: Were all ordered medications administered, made available, or delivered to the patient within required time frames? (7.003) * 10 15 0 40.0% For patients received from a county jail: Were all medications ordered by the institution’s reception center provider administered, made available, or delivered to the patient within the required time frames? (7.004) * N/A N/A N/A Upon the patient’s transfer from one housing unit to another: Were medications continued without interruption? (7.005) * 16 9 0 64.0% 4 6 0 40.0% 13 0 2 All clinical and medication line storage areas for nonnarcotic medications: Does the institution properly secure and store nonnarcotic medications in the assigned storage areas? (7.102) 9 5 1 64.3% All clinical and medication line storage areas for nonnarcotic medications: Does the institution keep nonnarcotic medication storage locations free of contamination in the assigned storage areas? (7.103) 7 7 1 50.0% 10 4 1 71.4% Medication preparation and administration areas: Do nursing staff employ and follow hand hygiene contamination control protocols during medication preparation and medication administration processes? (7.105) 4 3 8 57.1% Medication preparation and administration areas: Does the institution employ appropriate administrative controls and protocols when preparing medications for patients? (7.106) 4 3 8 57.1% Medication preparation and administration areas: Does the institution employ appropriate administrative controls and protocols when administering medications to patients? (7.107) 3 4 8 42.9% Pharmacy: Does the institution employ and follow general security, organization, and cleanliness management protocols in its main and remote pharmacies? (7.108) 1 0 0 100% Pharmacy: Does the institution’s pharmacy properly store nonrefrigerated medications? (7.109) 0 1 0 0 Pharmacy: Does the institution’s pharmacy properly store refrigerated or frozen medications? (7.110) 1 0 0 100% Pharmacy: Does the institution’s pharmacy properly account for narcotic medications? (7.111) 0 1 0 0 Pharmacy: Does the institution follow key medication error reporting protocols? (7.112) 2 22 0 8.3% Compliance Questions Did the patient receive all chronic care medications within the required time frames or did the institution follow departmental policy for refusals or no‑shows? (7.001) * For patients en route who lay over at the institution: If the temporarily housed patient had an existing medication order, were medications administered or delivered without interruption? (7.006) * All clinical and medication line storage areas for narcotic medications: Does the institution employ strong medication security controls over narcotic medications assigned to its storage areas? (7.101) All clinical and medication line storage areas for nonnarcotic medications: Does the institution safely store nonnarcotic medications that have yet to expire in the assigned storage areas? (7.104) N/A Yes % N/A 100% Pharmacy: For Information Purposes Only: During compliance testing, did the OIG find that medication errors were properly identified and reported by the institution? (7.998) This is a nonscored test. Please see the indicator for discussion of this test. Pharmacy: For Information Purposes Only: Do patients in isolation housing units have immediate access to their KOP prescribed rescue inhalers and nitroglycerin medications? (7.999) This is a nonscored test. Please see the indicator for discussion of this test. Overall percentage (MIT 7): 51.4% * The OIG clinicians considered these compliance tests along with their case review findings when determining the quality rating for this indicator. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: August 2019 – January 2020 Return to Contents California State Prison, Corcoran 55 Table 15. Other Tests Related to Medication Management Scored Answer Compliance Questions Yes No N/A Yes % For endorsed patients received from another CDCR institution or COCF: If the patient had an existing medication order upon arrival, were medications administered or delivered without interruption? (6.003) * 10 7 8 58.8% For patients transferred out of the facility: Do medication transfer packages include required medications along with the corresponding transfer-packet required documents? (6.101) * 4 4 2 50.0% Patients prescribed TB medication: Did the institution administer the medication to the patient as prescribed? (9.001) * 11 2 0 84.6% Patients prescribed TB medication: Did the institution monitor the patient per policy for the most recent three months he or she was on the medication? (9.002) * 0 13 0 Upon the patient’s admission to specialized medical housing: Were all medications ordered, made available, and administered to the patient within required time frames? (13.004) * 5 5 0 0 50.0% * The OIG clinicians considered these compliance tests along with their case review findings when determining the quality rating for this indicator. Source: The Office of the Inspector General medical inspection results. Report Issued: April 2021 Office of the Inspector General, State of California Return to Contents 56 Cycle 6 Medical Inspection Report Overall Rating Inadequate Case Review Rating (N/A) Compliance Score Inadequate (59.8%) Preventive Services In this indicator, OIG compliance inspectors tested whether the institution offered or provided cancer screenings, tuberculosis (TB) screenings, influenza vaccines, and other immunizations. If the department designated the institution as high risk for coccidioidomycosis (valley fever), we tested the institution’s ability to transfer out patients quickly. The OIG rated this indicator solely based on the compliance score, using the same scoring thresholds as in the Cycle 4 and Cycle 5 medical inspections. Our case review clinicians do not rate this indicator. Recommendations • Medical leadership should remind nursing staff to perform weekly monitoring and address the symptoms of patients taking TB medications. Table 16. Preventive Services Scored Answer Compliance Questions Yes No N/A Yes % Patients prescribed TB medication: Did the institution administer the medication to the patient as prescribed? (9.001) 11 2 0 Patients prescribed TB medication: Did the institution monitor the patient per policy for the most recent three months he or she was on the medication? (9.002) 0 13 0 0 Annual TB screening: Was the patient screened for TB within the last year? (9.003) 0 25 0 0 Were all patients offered an influenza vaccination for the most recent influenza season? (9.004) 25 0 0 100% All patients from the age of 50 through the age of 75: Was the patient offered colorectal cancer screening? (9.005) 22 3 0 Female patients from the age of 50 through the age of 74: Was the patient offered a mammogram in compliance with policy? (9.006) N/A N/A N/A N/A Female patients from the age of 21 through the age of 65: Was patient offered a pap smear in compliance with policy? (9.007) N/A N/A N/A N/A Are required immunizations being offered for chronic care patients? (9.008) 12 2 11 85.7% Are patients at the highest risk of coccidioidomycosis (valley fever) infection transferred out of the facility in a timely manner? (9.009) 3 2 0 60.0% 84.6% 88.0% Overall percentage (MIT 9): 59.8% * The OIG clinicians considered these compliance tests along with their case review findings when determining the quality rating for this indicator. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: August 2019 – January 2020 Return to Contents California State Prison, Corcoran Nursing Performance In this indicator, the OIG clinicians evaluated the quality of care delivered by the institution’s nurses, including registered nurses (RNs), licensed vocational nurses (LVNs), psychiatric technicians (PTs), and certified nursing assistants (CNAs). Our clinicians evaluated nurses’ ability to make timely and appropriate assessments and interventions. We also evaluated the institution’s nurses’ documentation for accuracy and thoroughness. Clinicians reviewed nursing performance in many clinical settings and processes, including sick call, outpatient care, care coordination and management, emergency services, specialized medical housing, hospitalizations, transfers, specialty services, and medication management. The OIG assessed nursing care through case review only and performed no compliance testing for this indicator. 57 Overall Rating Inadequate Case Review Rating Inadequate Compliance Score (N/A) When summarizing overall nursing performance, our clinicians understand that nurses perform numerous aspects of medical care. As such, specific nursing quality issues are discussed in other indicators, such as Emergency Services, Specialty Services, and Specialized Medical Housing. Results Overview COR nurses delivered poor nursing care. Compared with Cycle 5, we identified fewer nursing deficiencies; however, we noted more significant opportunities for improvement in nursing performance. Care management of high-risk diabetic patients, including medication management, notification of abnormal results, and timely appointments for symptomatic patients, placed patients at risk for delay of necessary medical services. Nursing assessments and documentation remained a challenge in emergency and outpatient care. Nurses did not always inform providers of specialists’ recommendations, which contributed to delayed or missed interventions. While these nursing deficiencies illustrated poor performances, they can be improved with quality improvement strategies. We considered the overall quality of nursing care and rated this indicator inadequate. Case Review Results Our case review clinicians reviewed 302 nursing encounters in 56 cases. Of the nursing encounters we reviewed, 136 were in the outpatient setting. Most outpatient nursing encounters were for sick call requests and nurse follow-up visits. We identified 88 nursing performance deficiencies, 20 of which were significant.42 Nursing Assessment All phases of the nursing process depend on the accurate and complete collection of data. When incomplete data is documented, the overall 42. Significant deficiencies occurred in cases 2, 8, 9, 11, 14, 15, 19, 34, 51, 55, and 57. Report Issued: April 2021 Office of the Inspector General, State of California Return to Contents 58 Cycle 6 Medical Inspection Report care of the patient could be affected, including incorrect diagnosis and inappropriate treatment. COR nurses generally performed appropriate assessments, including patient interviews and physical examinations. However, nurses did not always capture all components of focused assessments.43 We found a few occurrences in which nurses did not obtain vital signs when evaluating the patient or examine the patient’s body part related to the medical complaint.44 During emergency care, nurses sometimes failed to sufficiently examine the patient at the scene or evaluate the patient after providing emergency treatment.45 We discuss these nursing deficiencies in more detail in the specific indicators. Nursing Intervention Nursing interventions are actions nurses perform to provide safe and effective patient care. Nurses can perform interventions independently, use nursing protocols, or follow orders from the provider. Patient outcome could be affected when nurses fail to intervene appropriately. COR nurses neglected to properly intervene or follow provider orders in 13 cases.46 Some nursing deficiencies resulted in delays or lapses in care. Significant deficiencies are discussed in the Emergency Services, Medication Management, Specialized Medical Housing, and Specialty Services indicators. The following cases also illustrate the deficiencies we found with nursing interventions: • In case 9, the diabetic patient had significantly low and high blood sugar levels on numerous occasions. During the fivemonth review period, medication nurses did not assess the patient for signs and symptoms or notify the provider when the patient’s blood sugar was either very low or very high. Nurses also did not provide appropriate interventions, such as administering correct insulin doses, providing the patient glucose or snacks when his blood sugar was low, or rechecking the patient’s blood sugar level. When the provider ordered blood sugar checks, nurses failed to follow the provider’s order. • In case 22, the patient had an infected wound. The clinic nurse urgently (same day) referred the patient to the TTA but did not communicate with the TTA nurse. As a result, the patient was not seen in the TTA until the following day. Nursing staff should improve communicating patient status, specialists’ recommendations, and hospital discharge instructions to other medical staff and receiving institutions.47 43. These deficiencies occurred in cases 2, 8, 13, 16, 34, 45, 48, 49, and 57. 44. These deficiencies occurred in cases 9, 52, and 55. 45. These deficiencies occurred in cases 1, 2, 5, 8, 18, and 55. 46. These deficiencies occurred in cases 8, 9, 11, 14, 15, 18, 19, 22, 24, 34, 52, 55, and 57. 47. These deficiencies occurred in cases 1, 2, 8, 9, 14, 18, 22, 51, and 55. Office of the Inspector General, State of California Inspection Period: August 2019 – January 2020 Return to Contents California State Prison, Corcoran 59 Nursing Documentation Proper documentation enables the transmission of complete and accurate information among health care staff, preventing lapses in care. Inconsistent and incomplete nursing documentation at COR occurred primarily during emergency events.48 In the outpatient clinics and specialized medical housing units, there were occurrences of nurses not recording care provided to patients, such as vital sign results, weight, dietary intake, or wound description.49 Nursing Sick Call The nursing sick call process involves reviewing each sick call request, then determining whether the patient’s medical symptoms require urgent or routine evaluation. We reviewed 98 sick call requests, 71 of which resulted in face-to-face appointments with nurses. COR nurses timely reviewed sick call requests and often made appropriate decisions. However, in one case we found the nurse did not recognize the patient’s symptoms as potentially urgent: • In case 15, the diabetic patient complained of dizziness, nausea, and vomiting on two separate sick call requests. Because these symptoms could indicate significantly low or high blood sugar levels, the nurse should have evaluated the patient the same day; however, the patient was not evaluated until the following day. We found nursing assessments generally lacked thoroughness50 and occasionally failed to address the patient’s medical request.51 Care Management/ Coordination Nurses had poor performance in chronic care management, including caring for patients with diabetes. We found nursing care lacked appropriate interventions for patients who presented with acute symptoms or abnormally low blood sugars, specifically in reviewing blood sugar readings of symptomatic patients and notifying providers of patients with blood sugars which were abnormally low. The nurses did not provide sufficient care coordination for high-risk diabetic patients. • In case 9, the lapse of care coordination placed the patient at increased risk of harm. The providers and nurses did not manage the patient well as the patient had multiple emergency evaluations for abnormal low and high sugar levels. 48. Incomplete and inconsistent documentations occurred in cases 1, 2, 4, 5, 6, 7, 8, 18, 53, and 55). 49. These deficiencies occurred in cases 9, 18, 19, 31, 33, 40, 50, 52, 53, 55, and 56. 50. Incomplete assessments occurred in cases 2, 8, 13, 16, 31, 34, 45, 48, and 49. 51. The nurses did not address the patient’s medical requests in cases 1, 14, and 18. Report Issued: April 2021 Office of the Inspector General, State of California Return to Contents 60 Cycle 6 Medical Inspection Report Wound Care We reviewed five cases in which the nurses provided wound care52 and found one nurse missed a few wound care assessments and documentation. Overall, COR nurses provided good wound care. Emergency Services While there were opportunities for improvement in nursing performance and documentation, COR nurses provided adequate emergency care. Specific details are provided in the Emergency Services indicator. Transfers R&R nurses conducted initial health screenings timely and referred newly arriving patients to appropriate care team members within the specified time frames. When patients transferred out of COR, R&R nurses completed the transfer process but sometimes did not communicate pertinent medical information to the receiving institution. Additional details are provided in the Transfers indicator. Overall, the R&R nurses provided satisfactory care. Specialized Medical Housing The correctional treatment center (CTC) and OHU nurses completed timely assessments, provided essential care, and documented care properly. We identified nursing intervention and documentation deficiencies; however, they did not significantly affected patient outcomes. More specific details are provided in the Specialized Medical Housing indicator. Specialty Services COR nurses examined patients upon return from off-site specialty appointments. We found nurses sometimes did not properly review patients’ specialty reports or inform providers of specialists’ recommendations. This is detailed further in the Specialty Services indicator. Medication Management Nurses administered most medications timely. However, we found examples of poor insulin administration practices performed by nurses. The Medication Management indicator provides further information. Clinician On-Site Inspection Clinic nurses attended well-prepared huddles. Morning huddles were organized and ran smoothly. Most clinic staff actively participated 52. Cases 9, 10, 22, 53, and 56. Office of the Inspector General, State of California Inspection Period: August 2019 – January 2020 Return to Contents California State Prison, Corcoran 61 in huddle discussions, which included essential information the care team needed to provide patient care. Clinic staff were familiar with clinic processes, such as nursing sick calls, care management and coordination, and care team referrals. The new clinics were spacious and clean. Protocol medications which nurses can administer in emergency situations without provider orders were available for immediate administration. Emergency equipment used by first medical responders was easily accessible. The chief nurse executive (CNE) was new to the position but had been a nursing manager in COR for many years. The CNE and nursing managers actively participated in our discussion and acknowledged the nursing issues we identified during our case reviews. The line nurses reported responding to emergency events in their area. During our on-site visit we observed the institution’s response to COVID-19. Most staff and patients were wearing face masks and practicing social distancing when possible. Custody staff limited the number of patients in the clinic to ensure social distancing. A month before our on-site inspection, the Incident Command Post had been activated. Nursing leadership also initiated a nursing command center to monitor patients and provide guidance to staff. Nurses assigned to the nursing command center tracked new cases, monitored patients in isolation and patients quarantined throughout the institution, and coordinated with the Incident Command Post to disseminate information to all institutional staff. This dedicated system relieved outpatient clinic staff of daily patient screenings and evaluations so they could continue with their regular tasks. The nurse instructor, public health nurses, and supervisors provided regular training on the proper use of personal protective equipment and reminded nurses of safety practices. Although we provide this information for context, we did not assess the efficacy of COR’s nursing command center during this inspection. Recommendations • Nursing leadership should consider implementing a performance review to ensure nurses properly intervene when patients present with acute medical symptoms and notify providers of abnormal values timely. • Nursing leadership should review the cause of lapses in chronic care coordination for diabetic patients and implement remedial measures as appropriate. • Nursing leadership should determine the root cause of challenges that prevent outpatient and special housing nurses from performing complete assessments and documentation of care accurately and implement remedial measures as appropriate. Report Issued: April 2021 Office of the Inspector General, State of California Return to Contents 62 Cycle 6 Medical Inspection Report Overall Rating Inadequate Case Review Rating Inadequate Compliance Score (N/A) Provider Performance In this indicator, OIG case review clinicians evaluated the quality of care the institution’s providers (physicians, physician assistants, and nurse practitioners) delivered. Our clinicians assessed the institution’s providers’ ability to evaluate, diagnose, and manage their patients properly. We examined provider performance across several clinical settings and programs, including sick call, emergency services, outpatient care, chronic care, specialty services, intake, transfers, hospitalizations, and specialized medical housing. The OIG assessed provider care through case review only and performed no compliance testing for this indicator. Results Overview COR provider performance was mixed. Providers usually assessed appropriately, made good decisions, and ensured continuity of care in the outpatient and specialized medical housing. However, providers faltered in other areas. Compared with Cycle 5, there were more deficiencies in this indicator during this medical inspection. Providers did not always fully document their emergency medical care in the TTA, completely review medical records including hospital and specialty records, or consistently follow through with the specialists’ recommendations. We also identified some lapses in diabetic management. These areas can be improved with reminders and education. Taking all provider performance into consideration, we rated this indicator inadequate. Case Review Results The OIG clinicians reviewed 148 provider encounters and identified 62 deficiencies related to provider performance, 14 of which were significant.53 The clinicians performed 20 detailed physician case reviews, of which 14 were adequate and six inadequate. Assessment and Decision-Making COR providers generally made good assessments and sound decisions. Providers sufficiently addressed patients’ complaints, ordered correct tests, and arranged appropriate follow-up appointments. Our clinicians identified room for improvement in case 22 and the following case: • In case 12, the provider evaluated the patient who was taking opioids and sedative medications. The provider showed poor decision making by not reevaluating the patient for chronic opioid use when patient was sleepy during an exam. Additionally, the provider did not assess the patient’s need for chronic opioid usage during the review period. 53. Cycle 6 deficiencies occurred in cases 4, 8, 9, 10, 11, 12, 13, 14, 15, 16, 18, 19, 20, 21, 22, 23, 50, 51, 55, 56, and 57. Significant deficiencies occurred in cases 8, 9, 12, 19, 55, and 57. Office of the Inspector General, State of California Inspection Period: August 2019 – January 2020 Return to Contents California State Prison, Corcoran 63 Review of Records The review of records is an essential component of a provider’s evaluation, and is especially important for patients who had recent testing, saw a specialist, or returned from a higher level of care. Providers must also review records for unfamiliar patients. Our clinicians identified eight deficiencies involving review of hospital discharge records, specialty reports, and the medication administration record.54 The following cases illustrate the deficiencies identified: • In case 4, the provider did not thoroughly review the patient’s hospital discharge records and did not see the recommendation to order a follow-up test for magnesium level. The provider did not order the magnesium level test. • In case 12, the provider did not review the medication administration record carefully and did not see the patient’s prescription for tamsulosin medication had expired. As a result, the provider did not renew the medication. Two other providers did not renew the medication while the patient was in the CTC. Emergency Care Providers were available for consultation with TTA nursing staff. We identified 11 deficiencies,55 most of which were related to documentation with a few related to decision making. Lapses in documentation can lead to errors in communication, decision making, and care management. The following cases illustrate opportunities for improvement: • In case 9, the diabetic patient with a history of low and high sugar fluctuations went to the TTA on three occasions. The provider did not order a provider follow-up appointment within five days for this high-risk patient. • In case 18, the provider was consulted for a patient with shortness of breath in the TTA. The provider did not document a progress note. • In case 55, in the TTA, the provider evaluated and cleared the patient for admission to the mental health crisis bed, but did not document a progress note. The provider did not address the patient’s elevated heart rate before medically clearing the patient. When the patient swallowed a razor blade, the provider ordered X-rays to be completed three days later to check the razor blade’s location, instead of the same day. The Emergency Services indicator has additional discussion on emergency care. 54. The deficiencies occurred in cases 4, 8, 10, 12, 19, 20, and 22. 55. Deficiencies occurred in cases 9, 18, 23, 55, and 57. Report Issued: April 2021 Office of the Inspector General, State of California Return to Contents 64 Cycle 6 Medical Inspection Report Chronic Care Providers gave appropriate care to patients with chronic medical conditions such as hypertension, hepatitis C, and asthma. In case 55, the provider did not address the patient’s high blood pressure. However, case review clinicians found providers needed to improve with diabetic management. Clinicians found five deficiencies in four cases with diabetic care.56 The following cases illustrate these deficiencies: • In case 9, the provider followed up with the diabetic patient after recent TTA evaluations for a low sugar reading. Instead of ordering a prompt follow-up to reassess the low sugar, the provider ordered a follow-up in 30 days, putting the patient at risk for another low sugar episode. • In case 15, the provider evaluated the patient for a chronic care appointment and noted the increased diabetic HgbA1c test level. The provider did not adjust the patient’s diabetic medication to lower rising sugar level or order a sooner appointment to closely monitor the patient’s diabetes. COR did not have any case review samples for anticoagulation management. Specialty Services The providers generally referred patients for specialty consultations and followed up with the patients after the consultations. Our clinicians found occurrences in which providers did not follow through on specialists’ recommendations and did not arrange for follow-up specialty appointments appropriately. The following cases illustrate these deficiencies: • In case 19, the urologist recommended X-rays to evaluate for kidney stones for the patient. The provider reviewed the recommendations, but did not order the X-rays. • In case 8, the provider evaluated the patient and reviewed the ophthalmologist’s eye drop medication recommendations. The provider did not follow the specialist’s recommendations to adjust the patient’s eye drop medication. We discuss the providers’ specialty performance further in the Specialty Services indicator. Specialized Medical Housing The providers delivered adequate care in the CTC. Our case review clinicians found providers performed a written history and physical examination for patients within the required time frames and delivered clinically appropriate intervals. The deficiencies we identified were mainly related to incomplete review of the medical records and 56. Deficiencies in diabetic care occurred in cases 9, 10, 11, and 15. Office of the Inspector General, State of California Inspection Period: August 2019 – January 2020 Return to Contents California State Prison, Corcoran 65 documentation errors. Further details on the provider performance are discussed in the Specialized Medical Housing indicator. Documentation Quality Our clinicians found many instances of insufficient provider documentation in the case reviews. In nine cases, we identified deficiencies in which lapses in documentation can affect patient care, including emergency care, diagnoses, treatment, and specialty care.57 The following cases show the poor documentation: • In cases 9, 18, 23, 55, and 57, providers did not record TTA progress notes. • In case 8, the provider evaluated the patient after a hospital discharge. The patient’s abdominal CT was abnormal and showed fatty infiltration of the liver and a borderline large spleen. However, the provider documented that the abdominal CT was normal. • In case 19, the provider documented for two months that the patient’s urinary suprapubic catheter was draining even though it was not functional. Provider Continuity COR maintained provider continuity in the outpatient and CTC settings. Clinician On-Site Inspection During our on-site inspection, we observed well organized morning huddles attended by providers, supervisors, nurses, office technicians, and medical assistants. During the huddles, the team discussed appointment lines, specialty referrals, hospitalizations, medications, and backlogs. We noticed staff practiced social distancing and used personal protective equipment, such as face masks. We met with chief medical executive (CME), chief physician and surgeon (CP&S), and providers. According to the CME, COR’s provider vacancy was 1.5 positions. COR’s eight providers included two telemedicine physicians, two nurse practitioners, and one physician assistant. The CME and CP&S review cases with the providers and offer feedback throughout the year, as well as providing regular performance evaluations. COR providers generally expressed good morale and job satisfaction. Providers noticed COVID-19’s impact on specialty services because the off-site specialists closed practices and were not seeing patients. During the previous three months, the providers have used e-consult, an electronic specialty service, to help improve access to the specialists. 57. Deficiencies occurred in cases 8, 9, 16, 18, 19, 21, 23, 55, and 57. Report Issued: April 2021 Office of the Inspector General, State of California Return to Contents 66 Cycle 6 Medical Inspection Report Recommendations • Medical leadership should ascertain causative factors in the timely provider review of hospital and specialty reports and with provider follow through of recommendations. Medical leadership should implement remedial measures as appropriate. Office of the Inspector General, State of California Inspection Period: August 2019 – January 2020 Return to Contents California State Prison, Corcoran Specialized Medical Housing In this indicator, OIG inspectors evaluated the quality of care in the specialized medical housing units. We evaluated the performance of the medical staff in assessing, monitoring, and intervening for medically complex patients requiring close medical supervision. Our inspectors also evaluated the timeliness and quality of provider and nursing intake assessments and care plans. We considered staff members’ performance in responding promptly when patients’ conditions deteriorated and looked for good communication when staff consulted with one another while providing continuity of care. At the time of our inspection, COR’s specialized medical housing is an outpatient housing unit (OHU) and correctional treatment center (CTC). 67 Overall Rating Adequate Case Review Rating Adequate Compliance Score Proficient (85.0%) Results Overview COR providers and nurses delivered good care to their CTC and OHU patients. Providers ensured timely admission history and physicals and rounding on patients. Nurses performed routine patient assessments and provided interventions appropriately. Compared with Cycle 5, COR still has opportunities for improvement with wound and catheter care, providers’ review of medical records, and administration of admission medications within the required time frames. Overall, we rated this indicator adequate. Case Review Results We reviewed four cases that occurred in the correctional treatment center (CTC) and three cases that occurred in the outpatient housing unit (OHU).58 We also evaluated the medical care of patients admitted for short-term medical observations in the specialized medical housing units.59 These cases included 62 provider events and 40 nursing events. Because of the high care volume that occurs in specialized medical housing units, each provider and nursing event represents up to one month of provider care and one week of nursing care. We identified 26 deficiencies, seven of which were significant.60 Provider Performance COR providers delivered adequate care in the cases we reviewed. We found that providers performed well in completing admission history and physical examinations for patients within the required time frames. Compliance testing also showed good performance, with a score of 100 percent (MIT 13.002). We also noted providers checked on patients at clinically appropriate intervals without any delays. 58. Deficiencies occurred in cases 9, 12, 18, 19, 20, 50, 51, 52, and 53. 59. Deficiencies occurred in cases 1, 9, 17, 18, and 20. 60. Deficiencies found in cases 9, 12, 18, 19, 20, 50, 51, 52, and 53. Significant deficiencies found in cases 12 and 19. Report Issued: April 2021 Office of the Inspector General, State of California Return to Contents 68 Cycle 6 Medical Inspection Report The deficiencies we found with providers, primarily were related to poor review of the medical records, not following through with specialists’ recommendations, and documentation errors. We identified 12 deficiencies,61 six of which occurred in case 19. This case was not representative of the overall provider care in the specialized medical housing. The following are cases with identified deficiencies: • In case 19, providers did not follow through with the urologist’s recommendations, did not follow up on a urine test results, and erroneously documented that a nonfunctioning catheter was working. • In case 50, the provider did not order the medication as recommended in the hospital discharge report. Nursing Performance CTC nurses performed admission assessments on the day the patient was admitted (MIT 13.001, 100%). Case review clinicians confirmed nurses completed an initial assessment upon the patient’s admission in all the CTC and OHU cases they reviewed. The CTC nurses regularly checked on patients and generally provided good care. However, we did find occurrences of incomplete assessment and documentation as well as orders that were not carried out as requested. The following cases illustrate these findings: • In case 19, during the review period, the CTC nurses sometimes did not document the color and description of the patient’s urine or the gastric tube’s intake and residual amount. • In case 52, the patient had an elevated blood pressure. On another occasion, the patient complained of stomach discomfort for several days. The OHU LVN did not inform the RN or provider of these abnormalities to determine appropriate interventions. Also, OHU nurses did not regularly assess the patient’s condition or check his vital signs as the provider ordered. • In case 53, the patient had a scalp wound. The OHU nurses did not evaluate the patient’s wound for three days or regularly check the patient’s vital signs. Medication Administration CTC and OHU nurses generally administered prescribed medications timely. We identified three deficiencies in our case reviews, one of which was significant: • In case 12, during the review period, the patient’s chronic medication had expired and was not renewed. 61. Deficiencies occurred in cases 12, 19, 20, 50, and 51. Severe deficiencies occurred in cases 12 and 19. Office of the Inspector General, State of California Inspection Period: August 2019 – January 2020 Return to Contents California State Prison, Corcoran 69 Compliance testing showed nurses often failed to administer the patients’ medication within the ordered time frames (MIT 13.004, 50.0%). When our clinicians reviewed the compliance data, four of the five samples showed no evidence the patients received their medications. In the fifth sample, the provider did not order the medications at the time of admission. Clinician On-Site Inspection COR had a 50-bed CTC assigned to medical patients and a 15-bed OHU. Two beds were in isolation rooms in Hub A, and 26 medical beds were in Hub B. The institution also had a 25-bed mental health crisis bed unit. During our inspection, the CTC and OHU beds were almost full. These specialized medical housing units are in close proximity to the TTA. The CTC and OHU had dedicated providers who checked daily on patients. CTC staffing included two RNs, a shift lead RN, and two LVNs on the second and third watches. One RN was on first watch for Hub A and one for Hub B. The shift lead and the CTC provider were responsible for reviewing recommendations from specialty appointments and hospital returns. Additional nursing aides assisted with patient care and medical observation when needed. In the OHU, an RN was assigned during the day and LVNs were assigned in the evenings and nights. At the time of inspection, 14 beds were occupied. Staffing consisted of one RN on second watch and one LVN on third and first watches. In this unit, several patients needed wound care due to chronic conditions. We observed the CTC huddles during our on-site inspection. The shift lead nurse demonstrated thorough knowledge of the patients’ conditions and health needs. Other staff did not participate. Our interview revealed that the shift lead nurse and the providers primarily managed and coordinated patient care. Our regional inspectors tested call lights in the CTC and OHU. All call lights were functional with the exception of one light (MIT 13.101, 75.0%). Health care staff performed patient safety checks according to the institution’s local operating procedure or within the required time frames (MIT 13.102, 100%). Recommendations • Nursing leadership should determine the root cause of challenges in ensuring patients who are admitted into the CTC and OHU receive their medications timely upon admission and implement remedial measures as appropriate. Report Issued: April 2021 Office of the Inspector General, State of California Return to Contents 70 Cycle 6 Medical Inspection Report Compliance Testing Results Table 17. Specialized Medical Housing Scored Answer Compliance Questions Yes No N/A Yes % For OHU, CTC, and SNF: Prior to 4/2019: Did the registered nurse complete an initial assessment of the patient on the day of admission, or within eight hours of admission to CMF’s Hospice? Effective 4/2019: Did the registered nurse complete an initial assessment of the patient at the time of admission? (13.001) *‡ 10 0 0 100% For CTC and SNF only (effective 4/2019, include OHU): Was a written history and physical examination completed within the required time frame? (13.002) * 10 0 0 100% For OHU, CTC, SNF, and Hospice (applicable only for samples prior to 4/2019): Did the primary care provider complete the Subjective, Objective, Assessment, and Plan notes on the patient at the minimum intervals required for the type of facility where the patient was treated? (13.003) *,† N/A N/A N/A Upon the patient’s admission to specialized medical housing: Were all medications ordered, made available, and administered to the patient within required time frames? (13.004) * 5 5 0 50.0% For OHU and CTC only: Do inpatient areas either have properly working call systems in its OHU & CTC or are 30-minute patient welfare checks performed; and do medical staff have reasonably unimpeded access to enter patient’s cells? (13.101) * 3 1 0 75.0% For specialized health care housing (CTC, SNF, Hospice, OHU): Do health care staff perform patient safety checks according to institution’s local operating procedure or within the required time frames? (13.102) * 1 0 3 N/A 100% Overall percentage (MIT 13): 85.0% * The OIG clinicians considered these compliance tests along with their case review findings when determining the quality rating for this indicator. † CCHCS changed its policies and removed mandatory minimum rounding intervals for patients located in specialized medical housing. After April 2, 2019, MIT 13.003 only applied to CTCs that still have state-mandated rounding intervals. OIG case reviewers continued to test the clinical appropriateness of provider follow-ups within specialized medical housing units through case reviews. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: August 2019 – January 2020 Return to Contents California State Prison, Corcoran Specialty Services In this indicator, OIG inspectors evaluated the quality of specialty services. The OIG clinicians focused on the institution’s ability to provide needed specialty care. Our clinicians also examined specialty appointment scheduling, providers’ specialty referrals, and medical staff’s retrieval, review, and implementation of any specialty recommendations. Results Overview COR provided satisfactory specialty services for their patients. The institution generally arranged timely appointments for specialty services, specialty follow-up, and provider follow-up. Providers referred appropriately and nurses adequately assessed patients. We identified some occurrences of late retrieval of specialty reports and staff not following through with specialists’ recommendations. Our compliance tests showed both provider review and specialty reports scanning needed improvement. Balancing compliance testing and case reviews, we determined a borderline adequate rating for this indicator. 71 Overall Rating Adequate Case Review Rating Adequate Compliance Score Inadequate (71.6%) Case Review Results We reviewed 147 events related to this indicator, which included 76 specialty consultations and procedures. Deficiencies increased from Cycle 5, We found 39 deficiencies, 14 of the deficiencies which were significant.62 However, 41 percent of the deficiencies we found were in three cases. Access to Specialty Services COR had good performance with access to specialty services. In compliance testing, COR performed well in providing access to specialty services for patients at the institution, and scored notably in meeting policy-required time frames for routine-priority (MIT 14.007, 100%), medium-priority (MIT 14.004, 80.0%), and highpriority (MIT 14.001, 93.3%) appointments. Case review clinicians found deficiencies in six cases, and the following case:63 • In case 53, the provider ordered an urgent orthopedic appointment for a hip procedure, but the patient did not receive the appointment within the urgent time frame. However, in our compliance testing, COR did not perform well with access to preapproved specialty services when patients transferred 62. Deficiencies occurred in cases 8, 9, 10, 13, 14, 15, 16, 17, 18, 19, 21, 51, 52, 53, 55, and 57. Significant deficiencies occurred in cases 8, 14, 15, 16, 19, 51, 53, and 55. Case 8 had seven deficiencies, case 9 had four deficiencies, and case 19 had five deficiencies. 63. Deficiencies occurred in cases 15, 16, 19, 21, 51, 53, and 55. Significant deficiencies in cases 15, 16, 19, 51, 53, and 55. Report Issued: April 2021 Office of the Inspector General, State of California Return to Contents 72 Cycle 6 Medical Inspection Report into the institution (MIT 14.010, 65.0%). Our clinicians did not find any deficiencies in this area. Provider Performance COR providers performed well with specialty care and referred patients to specialists appropriately. Providers followed up with patients after they saw the specialists. Our clinicians found providers should have arranged for specialty consultations sooner in two instances in one case.64 We also found two instances in which providers did not always follow the specialists’ recommendations: • In case 8, the provider reviewed the ophthalmologist’s eye drop recommendations, but did not follow through with the orders. • In case 19, the provider reviewed the urologist’s recommendations, but not follow through with the orders. COR providers generally arranged appropriate follow-up care after specialty consultations. Compliance testing found providers saw their patients promptly following a specialty appointment (MIT 1.008, 81.0%). Our case review clinicians found provider follow-up visits occurred within the required time frames and identified no deficiencies. Nursing Performance We reviewed 11 cases, including 34 events in which nurses assessed patients who returned from off-site specialty appointments. We identified eight nursing deficiencies, four of which were significant.65 The nurses usually examined the patient, with the exception of case 8, in which the nurse did not assess a patient who had eye surgery. Significant deficiencies occurred when patients returned from specialty appointments and nurses did not properly review the specialists’ recommendations. While it is ultimately the provider’s responsibility to review the specialist’s findings and recommendations, the nurses should communicate recommendations to the provider. In the following cases, lapses in communication resulted in delays in care: • In case 8, the specialist recommended a new medication for the patient; however, the nurse did not inform the provider. As a result, the patient received the new medication late. When the specialist recommended changes in previous medication orders, the nurses also did not inform the provider of these recommendations. 64. Minor deficiencies occurred in case 9. 65. Nursing deficiencies identified in cases 8, 14, 19, 51, 52, and 55. Significant deficiencies occurred in cases 8, 14, 19, and 55. Office of the Inspector General, State of California Inspection Period: August 2019 – January 2020 Return to Contents California State Prison, Corcoran 73 • In case 14, the dermatologist recommended a new medication for the patient, but the nurse did not inform the provider. The patient received the medication two weeks late. • In case 19, the urologist recommended frequent catheter irrigation, kidney, ureter, and bladder X-rays, and a follow-up with the specialist in one month for the patient. The nurses did not inform the provider and the recommendations were not ordered. • In case 55, the urologist recommended a new medication and urine culture for the patient. The nurse did not inform the provider, resulting in a delay ordering the recommendations. Health Information Management COR showed room for improvement with managing specialty reports and documents. In compliance testing, specialty documents were scanned into the patient’s electronic health record within five calendar days of the encounter date 66.7 percent of the time (MIT 4.002). Similarly, in case reviews, we identified late retrieval or nonretrieval of specialty reports in four cases and the two cases below:66 • In case 16, the orthopedic specialist injected a steroid medication into the patient’s right hand. This specialist report was not retrieved or scanned into the patient’s electronic health record. • In case 19, the urologist saw the patient for a consultation. This specialist report was retrieved and scanned six days after the appointment. In compliance testing, COR had a varied performance in specialty reports retrieval and provider review of high-priority specialty reports (MIT 14.002, 80.0%), medium-priority specialty reports (MIT 14.005, 46.7%) and routine-priority specialty reports (MIT 14.008, 64.3%). Our case review clinicians found COR providers endorsed specialty reports outside the required time frames in case 55 and the following cases: • In case 8, the provider endorsed the eye specialty report six days after it was scanned into the patient’s electronic health record. • In case 21, the provider endorsed the orthopedic specialty report six days after it was scanned into the patient’s electronic health record. We also found when patients refused specialty appointments, staff sometimes did not retrieve and scan the refusal forms.67 • In case 17, the patient refused an optometry appointment. COR did not obtain a signed refusal form. A refusal form was not scanned into the patient’s electronic health record. 66. Deficiencies occurred in cases 8, 10, 14, 16, 19, and 51. Major deficiencies occurred in cases in 14 and 16. 67. Deficiencies occurred in cases 9, 13, 17, and 18. Report Issued: April 2021 Office of the Inspector General, State of California Return to Contents 74 Cycle 6 Medical Inspection Report Clinician On-Site Inspection Our clinicians met with COR’s nursing managers, the utilization management nurse, and specialty nurses and discussed specialty referral management and communication of specialty recommendations. Onsite specialty services included optometry, podiatry, physical therapy, and audiology. COR utilized both telemedicine and off-site specialty services. The telemedicine nurse reported an average of 25 specialty appointments weekly. Some specialty services had limited access, such as cardiology and infectious disease. Some specialty services had challenges, such as orthopedics specialists who were located further away in San Diego. During the preceding three months, the institution used an e-consult referral system to quickly access specialists with a turnaround time of less than three days. Since some specialist clinics had closed due to COVID-19, the e-consult referral system really helped COR with specialty access. Recently health information management and utilization management have utilized trackers to follow up on specialty reports. Office technicians have direct access to the electronic medical records of the local contracted hospital, enabling access to some specialty reports. Recommendations • Nursing leadership should determine the root cause of challenges in nurses’ review of specialty reports and challenges of informing providers of specialists’ recommendations and implement remedial measures as appropriate. • Medical leadership should identify the root cause in timely provision of ordered specialty services and implement remedial measures as appropriate. Office of the Inspector General, State of California Inspection Period: August 2019 – January 2020 Return to Contents California State Prison, Corcoran 75 Compliance Testing Results Table 18. Specialty Services Scored Answer Compliance Questions Yes No Did the patient receive the high-priority specialty service within 14 calendar days of the primary care provider order or the Physician Request for Service? (14.001) * 14 1 0 93.3% Did the institution receive and did the primary care provider review the high-priority specialty service consultant report within the required time frame? (14.002) * 12 3 0 80.0% 8 2 5 80.0% Did the patient receive the medium-priority specialty service within 15-45 calendar days of the primary care provider order or Physician Request for Service? (14.004) * 12 3 0 80.0% Did the institution receive and did the primary care provider review the medium-priority specialty service consultant report within the required time frame? (14.005) * 7 8 0 46.7% Did the patient receive the subsequent follow-up to the mediumpriority specialty service appointment as ordered by the primary care provider? (14.006) * 6 2 7 75.0% Did the patient receive the routine-priority specialty service within 90 calendar days of the primary care provider order or Physician Request for Service? (14.007) * 15 0 0 Did the institution receive and did the primary care provider review the routine-priority specialty service consultant report within the required time frame? (14.008) * 9 5 1 64.3% Did the patient receive the subsequent follow-up to the routinepriority specialty service appointment as ordered by the primary care provider? (14.009) * 7 3 5 70.0% For endorsed patients received from another CDCR institution: If the patient was approved for a specialty services appointment at the sending institution, was the appointment scheduled at the receiving institution within the required time frames? (14.010) * 13 7 0 65.0% Did the institution deny the primary care provider’s request for specialty services within required time frames? (14.011) 8 12 0 40.0% Following the denial of a request for specialty services, was the patient informed of the denial within the required time frame? (14.012) 11 6 3 64.7% Did the patient receive the subsequent follow-up to the high-priority specialty service appointment as ordered by the primary care provider? (14.003) * N/A Yes % 100% Overall percentage (MIT 14): 71.6% * The OIG clinicians considered these compliance tests along with their case review findings when determining the quality rating for this indicator. Source: The Office of the Inspector General medical inspection results. Report Issued: April 2021 Office of the Inspector General, State of California Return to Contents 76 Cycle 6 Medical Inspection Report Table 19. Other Tests Related to Specialty Services Scored Answer Compliance Questions Yes No N/A Yes % Specialty service follow-up appointments: Did the clinician follow-up visits occur within required time frames? (1.008) *, † 34 8 3 81.0% Are specialty documents scanned into the patient’s electronic health record within five calendar days of the encounter date? (4.002) * 20 10 15 66.7% * The OIG clinicians considered these compliance tests along with their own case review findings when determining the quality rating for this indicator. † CCHCS changed its specialty policies in April 2019, removing the requirement for primary care physician follow-up visits following most specialty services. As a result, we test 1.008 only for high-priority specialty services or when the staff orders PCP or PC RN follow-ups. The OIG continues to test the clinical appropriateness of specialty follow-ups through its case review testing. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: August 2019 – January 2020 Return to Contents California State Prison, Corcoran Administrative Operations In this indicator, OIG compliance inspectors evaluated health care administrative processes. Our inspectors examined the timeliness of the medical grievance process and checked whether the institution followed reporting requirements for adverse or sentinel events and patient deaths. Inspectors checked whether the Emergency Medical Response Review Committee (EMRRC) met and reviewed incident packages. We evaluated and determined if the institution conducted the required emergency response drills. Inspectors also assessed whether the Quality Management Committee (QMC) met regularly and addressed program performance adequately. In addition, the inspectors examined if the institution provided training and job performance reviews for its employees. They checked whether staff possessed current, valid professional licenses, certifications, and credentials. The OIG rated this indicator solely based on the compliance score, using the same scoring thresholds as in the Cycle 4 and Cycle 5 medical inspections. Our case review clinicians do not rate this indicator. 77 Overall Rating Inadequate Case Review Rating (N/A) Compliance Score Inadequate (71.9%) Because none of the tests in this indicator affected clinical patient care directly (it is a secondary indicator), the OIG did not consider this indicator’s rating when determining the institution’s overall quality rating. Nonscored Results We obtained California Correctional Health Care Services’ (CCHCS) Death Review Committee (DRC) reporting data and found nine unexpected (Level 1) deaths occurred during our review period. The DRC must complete its death review summary report within 60 calendar days of the death. When the DRC completes the death review summary report, it must submit the report to the institution’s CEO within seven calendar days after completion. In our inspection, we found the DRC did not complete any death review reports within the required time frames. The DRC finished nine reports between 11 to 145 days late and submitted the reports to the institution’s CEO between 5 to 152 days later (MIT 15.998). Recommendations • The medical and nursing leadership should ensure clinical competency evaluations and performance appraisals are completed timely. Report Issued: April 2021 Office of the Inspector General, State of California Return to Contents 78 Cycle 6 Medical Inspection Report Table 20. Administrative Operations Scored Answer Yes No For health care incidents requiring root cause analysis (RCA): Did the institution meet RCA reporting requirements? (15.001) 0 0 1 N/A Did the institution’s Quality Management Committee (QMC) meet monthly? (15.002) 6 0 0 100% For Emergency Medical Response Review Committee (EMRRC) reviewed cases: Did the EMRRC review the cases timely, and did the incident packages the committee reviewed include the required documents? (15.003) 9 3 0 75.0% For institutions with licensed care facilities: Did the Local Governing Body (LGB) or its equivalent, meet quarterly and discuss local operating procedures and any applicable policies? (15.004) 2 2 0 50.0% Did the institution conduct medical emergency response drills during each watch of the most recent quarter, and did health care and custody staff participate in those drills? (15.101) 2 1 0 66.7% 10 0 0 Did the medical staff review and submit initial inmate death reports to the CCHCS Death Review Unit on time? (15.103) 9 1 0 90.0% Did nurse managers ensure the clinical competency of nurses who administer medications? (15.104) 2 8 0 20.0% Did physician managers complete provider clinical performance appraisals timely? (15.105) 3 6 0 33.3% Did the providers maintain valid state medical licenses? (15.106) 14 0 0 100% Did the staff maintain valid Cardiopulmonary Resuscitation (CPR), Basic Life Support (BLS), and Advanced Cardiac Life Support (ACLS) certifications? (15.107) 2 0 1 100% Did the nurses and the pharmacist-in-charge (PIC) maintain valid professional licenses and certifications, and did the pharmacy maintain a valid correctional pharmacy license? (15.108) 6 0 1 100% Did the pharmacy and the providers maintain valid Drug Enforcement Agency (DEA) registration certificates? (15.109) 1 0 0 100% Did nurse managers ensure their newly hired nurses received the required onboarding and clinical competency training? (15.110) 0 1 0 0 Compliance Questions Did the responses to medical grievances address all of the inmates’ grieved issues? (15.102) N/A Yes % 100% Did the CCHCS Death Review Committee process death review reports timely? (15.998) This is a nonscored test. Please refer to the discussion in this indicator. What was the institution’s health care staffing at the time of the OIG medical inspection? (15.999) This is a nonscored test. Please refer to Table 4 for CCHCSprovided staffing information. Overall percentage (MIT 15): 71.9% Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: August 2019 – January 2020 Return to Contents California State Prison, Corcoran 79 Appendix A: Methodology In designing the medical inspection program, the OIG met with stakeholders to review CCHCS policies and procedures, relevant court orders, and guidance developed by the American Correctional Association. We also reviewed professional literature on correctional medical care; reviewed standardized performance measures used by the health care industry; consulted with clinical experts; and met with stakeholders from the court, the receiver’s office, the department, the Office of the Attorney General, and the Prison Law Office to discuss the nature and scope of our inspection program. With input from these stakeholders, the OIG developed a medical inspection program that evaluates the delivery of medical care by combining clinical case reviews of patient files, objective tests of compliance with policies and procedures, and an analysis of outcomes for certain population-based metrics. We rate each of the quality indicators applicable to the institution under inspection based on case reviews conducted by our clinicians or compliance tests conducted by our registered nurses. Figure A–1 below depicts the intersection of case review and compliance. Figure A–1. Inspection Indicator Review Distribution for COR SE CA Emergency Services Diagnostic Services Health Care Environment Health Information Management Nursing Performance Transfers Preventive Services Medication Management Provider Performance Specialized Medical Housing Administrative Operations MPLIANCE CO REVIE W Access to Care Specialty Services Source: The Office of the Inspector General medical inspection results. Report Issued: April 2021 Office of the Inspector General, State of California Return to Contents 80 Cycle 6 Medical Inspection Report Case Reviews The OIG added case reviews to the Cycle 4 medical inspections at the recommendation of its stakeholders, which continues in the Cycle 6 medical inspections. Below, Table A–1 provides important definitions that describe this process. Table A–1. Case Review Definitions Case, Sample, or Patient Comprehensive Case Review Focused Case Review The medical care provided to one patient over a specific period, which can comprise detailed or focused case reviews. A review that includes all aspects of one patient’s medical care assessed over a six-month period. This review allows the OIG clinicians to examine many areas of health care delivery, such as access to care, diagnostic services, health information management, and specialty services. A review that focuses on one specific aspect of medical care. This review tends to concentrate on a singular facet of patient care, such as the sick call process or the institution’s emergency medical response. Event A direct or indirect interaction between the patient and the health care system. Examples of direct interactions include provider encounters and nurse encounters. An example of an indirect interaction includes a provider reviewing a diagnostic test and placing additional orders. Case Review Deficiency A medical error in procedure or in clinical judgment. Both procedural and clinical judgment errors can result in policy noncompliance, elevated risk of patient harm, or both. Adverse Event Office of the Inspector General, State of California An event that caused harm to the patient. Inspection Period: August 2019 – January 2020 Return to Contents California State Prison, Corcoran 81 The OIG eliminates case review selection bias by sampling using a rigid methodology. No case reviewer selects the samples he or she reviews. Because the case reviewers are excluded from sample selection, there is no possibility of selection bias. Instead, nonclinician analysts use a standardized sampling methodology to select most of the case review samples. A randomizer is used when applicable. For most basic institutions, the OIG samples 20 comprehensive physician review cases. For institutions with larger high‑risk populations, 25 cases are sampled. For the California Health Care Facility, 30 cases are sampled. Case Review Sampling Methodology We obtain a substantial amount of health care data from the inspected institution and from CCHCS. Our analysts then apply filters to identify clinically complex patients with the highest need for medical services. These filters include patients classified by CCHCS with high medical risk, patients requiring hospitalization or emergency medical services, patients arriving from a county jail, patients transferring to and from other departmental institutions, patients with uncontrolled diabetes or uncontrolled anticoagulation levels, patients requiring specialty services or who died or experienced a sentinel event (unexpected occurrences resulting in high risk of, or actual, death or serious injury), patients requiring specialized medical housing placement, patients requesting medical care through the sick call process, and patients requiring prenatal or postpartum care. After applying filters, analysts follow a standardized protocol and select samples for clinicians to review. Samples are obtained per the case review methodology shared with stakeholders in prior cycles. Our physician and nurse reviewers test the samples by performing comprehensive or focused case reviews. Case Review Testing Methodology An OIG physician, a nurse consultant, or both review each case. As the clinicians review medical records, they record pertinent interactions between the patient and the health care system. We refer to these interactions as case review events. Our clinicians also record medical errors, which we refer to as case review deficiencies. Deficiencies can be minor or significant, depending on the severity of the deficiency. If a deficiency caused serious patient harm, we classify the error as an adverse event. On the next page, Figure A–2 depicts the scenarios that can lead to these different events. After the clinician inspectors review all the cases, they analyze the deficiencies, then summarize their findings in one or more of the health care indicators in this report. Report Issued: April 2021 Office of the Inspector General, State of California Return to Contents 82 Cycle 6 Medical Inspection Report Figure A–2. Case Review Testing The OIG clinicians examine the chosen samples, performing either a comprehensive case review or a focused case review, to determine the events that occurred. Sample = Patient = Case Sample No Deficiency or Minor Deficiency Events Significant Deficiency * A sample leading to events Deficiencies Not all events lead to deficiencies (medical errors); however, if errors did occur, then the OIG clinicians determine whether any were adverse. Sample Significant Deficiency * Events A sample leading to events that could cause harm Did the event cause harm to the patient? * If an event (in this case, a significant deficiency) caused harm, the OIG clinician labels it adverse. Yes Adverse Event No Significant Deficiency Source: The Office of the Inspector General medical inspection analysis. Office of the Inspector General, State of California Inspection Period: August 2019 – January 2020 Return to Contents California State Prison, Corcoran 83 Compliance Testing Compliance Sampling Methodology Our analysts identify samples for both our case review inspectors and compliance inspectors. Analysts follow a detailed selection methodology. For most compliance questions, we use sample sizes of approximately 25 to 30. Figure A–3 below depicts the relationships and activities of this process. Figure A–3. Compliance Sampling Methodology Total Patient Population Filters Subpopulation Sample Randomize Flagging Source: The Office of the Inspector General medical inspection analysis. Compliance Testing Methodology Our inspectors answer a set of predefined medical inspection tool (MIT) questions to determine the institution’s compliance with CCHCS policies and procedures. Our nurse inspectors assign a Yes or a No answer to each scored question. Report Issued: April 2021 Office of the Inspector General, State of California Return to Contents 84 Cycle 6 Medical Inspection Report OIG headquarters nurse inspectors review medical records to obtain information, allowing them to answer most of the MIT questions. Our regional nurses visit and inspect each institution. They interview health care staff, observe medical processes, test the facilities and clinics, review employee records, logs, medical grievances, death reports, and other documents, and also obtain information regarding plant infrastructure and local operating procedures. Scoring Methodology Our compliance team calculates the percentage of all Yes answers for each of the questions applicable to a particular indicator, then averages the scores. The OIG continues to rate these indicators based on the average compliance score using the following descriptors: proficient (85.0 percent or greater), adequate (between 84.9 percent and 75.0 percent), or inadequate (less than 75.0 percent). Indicator Ratings and the Overall Medical Quality Rating To reach an overall quality rating, our inspectors collaborate and examine all the inspection findings. We consider the case review and the compliance testing results for each indicator. After considering all the findings, our inspectors reach consensus on an overall rating for the institution. Office of the Inspector General, State of California Inspection Period: August 2019 – January 2020 Return to Contents California State Prison, Corcoran 85 Appendix B: Case Review Data Table B–1. Case Review Sample Sets Sample Set Total CTC / OHU 5 Death Review / Sentinel Events 3 Diabetes 3 Emergency Services – CPR 5 Emergency Services – Non-CPR 3 High Risk 4 Hospitalization 4 Intrasystem Transfers In 3 Intrasystem Transfers Out 3 RN Sick Call Specialty Services 21 3 57 Report Issued: April 2021 Office of the Inspector General, State of California Return to Contents 86 Cycle 6 Medical Inspection Report Table B–2. Case Review Chronic Care Diagnoses Diagnosis Total Anemia 2 Arthritis/Degenerative Joint Disease 2 Asthma 6 COPD 1 Cardiovascular Disease 1 Chronic Pain 3 Cirrhosis/End-Stage Liver Disease 10 Coccidioidomycosis 2 Deep Venous Thrombosis/Pulmonary Embolism 2 Diabetes 1 Gastroesophageal Reflux Disease 5 Hepatitis C 9 Hyperlipidemia 27 Hypertension 11 Mental Health 17 Migraine Headaches 20 Seizure Disorder 1 Sleep Apnea 5 Thyroid Disease 1 129 Office of the Inspector General, State of California Inspection Period: August 2019 – January 2020 Return to Contents California State Prison, Corcoran 87 Table B–3. Case Review Events by Program Diagnosis Diagnostic Services Total 140 Emergency Care 73 Hospitalization 37 Intrasystem Transfers In 9 Intrasystem Transfers Out 9 Not Specified 1 Outpatient Care 390 Specialized Medical Housing 151 Specialty Services 147 957 Table B–4. Case Review Sample Summary Report Issued: April 2021 MD Reviews Detailed 20 MD Reviews Focused 3 RN Reviews Detailed 15 RN Reviews Focused 41 Total Reviews 79 Total Unique Cases 57 Overlapping Reviews (MD & RN) 22 Office of the Inspector General, State of California Return to Contents 88 Cycle 6 Medical Inspection Report Appendix C: Compliance Sampling Methodology California State Prison, Corcoran Quality Indicator Sample Category No. of Samples Data Source Filters Access to Care MIT 1.001 Chronic Care Patients 25 Master Registry • • Chronic care conditions (at least one condition per patient — any risk level) Randomize MIT 1.002 Nursing Referrals 25 OIG Q: 6.001 • See Transfers MITs 1.003 – 006 Nursing Sick Call (6 per clinic) 40 MedSATS • • • Clinic (each clinic tested) Appointment date (2 – 9 months) Randomize MIT 1.007 Returns From Community Hospital 25 OIG Q: 4.005 • See Health Information Management (Medical Records) (returns from community hospital) MIT 1.008 Specialty Services Follow-Up 45 OIG Q: 14.001, 14.004 & 14.007 • See Specialty Services MIT 1.101 Availability of Health Care Services Request Forms 6 OIG on-site review • Randomly select one housing unit from each yard Radiology Logs • • • Appointment date (90 days – 9 months) Randomize Abnormal Quest • • • • Appt. date (90 days – 9 months) Order name (CBC or CMPs only) Randomize Abnormal Quest • • • • Appt. date (90 days – 9 months) Order name (CBC or CMPs only) Randomize Abnormal InterQual • • • Appt. date (90 days – 9 months) Service (pathology related) Randomize Diagnostic Services MITs 2.001 – 003 Radiology MITs 2.004 – 006 Laboratory MITs 2.007 – 009 Laboratory STAT MITs 2.010 – 012 Pathology Office of the Inspector General, State of California 10 10 N/A at this institution 10 Inspection Period: August 2019 – January 2020 Return to Contents California State Prison, Corcoran Quality Indicator Sample Category No. of Samples Data Source 89 Filters Health Information Management (Medical Records) MIT 4.001 Health Care Services Request Forms 40 OIG Qs: 1.004 • • Nondictated documents First 20 IPs for MIT 1.004 MIT 4.002 Specialty Documents 40 OIG Qs: 14.002, 14.005 & 14.008 • • Specialty documents First 10 IPs for each question MIT 4.003 Hospital Discharge Documents 20 OIG Q: 4.005 • Community hospital discharge documents First 20 IPs selected MIT 4.004 Scanning Accuracy 24 Documents for any tested inmate • Any misfiled or mislabeled document identified during OIG compliance review (24 or more = No) MIT 4.005 Returns From Community Hospital 25 CADDIS off-site Admissions • • Date (2 – 8 months) Most recent 6 months provided (within date range) Rx count Discharge date Randomize • • • • Health Care Environment MITs 5.101 – 105 Clinical Areas MITs 5.107 – 111 15 OIG inspector on-site review • Identify and inspect all on-site clinical areas. 25 SOMS • • • • Arrival date (3 – 9 months) Arrived from (another departmental facility) Rx count Randomize • R&R IP transfers with medication Transfers MITs 6.001 – 003 Intrasystem Transfers MIT 6.101 Transfers Out Report Issued: April 2021 10 OIG inspector on-site review Office of the Inspector General, State of California Return to Contents 90 Cycle 6 Medical Inspection Report Quality Indicator Sample Category No. of Samples Data Source Filters Pharmacy and Medication Management See Access to Care • At least one condition per patient — any risk level • Randomize MIT 7.001 Chronic Care Medication 25 OIG Q: 1.001 MIT 7.002 New Medication Orders 25 Master Registry • • • Rx count Randomize Ensure no duplication of IPs tested in MIT 7.001 MIT 7.003 Returns From Community Hospital 25 OIG Q: 4.005 • See Health Information Management (Medical Records) (returns from community hospital) MIT 7.004 RC Arrivals — Medication Orders N/A at this OIG Q: 12.001 • See Reception Center MIT 7.005 Intrafacility Moves 25 MAPIP transfer data • • Date of transfer (2 – 8 months) To location/from location (yard to yard and to/from ASU) Remove any to/from MHCB NA/DOT meds (and risk level) Randomize institution • • • MIT 7.006 En Route 10 SOMS • • • • Date of transfer (2– 8 months) Sending institution (another departmental facility) Randomize NA/DOT meds MITs 7.101 – 103 Medication Storage Areas Varies by test OIG inspector on-site review • Identify and inspect clinical & med line areas that store medications MITs 7.104 – 107 Medication Preparation and Administration Areas Varies by test OIG inspector on-site review • Identify and inspect on-site clinical areas that prepare and administer medications OIG inspector on-site review • Identify & inspect all on-site pharmacies Medication error reports • All medication error reports with Level 4 or higher Select total of 25 medication error reports (recent 12 months) On-site active medication listing • MITs 7.108 – 111 Pharmacy 1 MIT 7.112 Medication Error Reporting 24 MIT 7.999 Isolation Unit KOP Medications 17 Office of the Inspector General, State of California • KOP rescue inhalers & nitroglycerin medications for IPs housed in isolation units Inspection Period: August 2019 – January 2020 Return to Contents California State Prison, Corcoran Quality Indicator Sample Category No. of Samples Data Source 91 Filters Prenatal and Postpartum Care MITs 8.001 – 007 Recent Deliveries N/A at this OB Roster • • Delivery date (2 – 12 months) Most recent deliveries (within date range) Pregnant Arrivals N/A at this OB Roster • • Arrival date (2 – 12 months) Earliest arrivals (within date range) Maxor • • Dispense date (past 9 months) Time period on TB meds (3 months or 12 weeks) Randomize institution institution Preventive Services MITs 9.001 – 002 TB Medications 13 • MIT 9.003 TB Evaluation, Annual Screening 25 MIT 9.004 Influenza Vaccinations 25 MIT 9.005 Colorectal Cancer Screening 25 MIT 9.006 Mammogram MIT 9.007 Pap Smear SOMS • • • SOMS • • • SOMS • • • N/A at this institution N/A at this institution MIT 9.008 Chronic Care Vaccinations 25 MIT 9.009 Valley Fever (number will vary) 5 SOMS • • • SOMS • • • OIG Q: 1.001 • • • Cocci transfer status report • • • • Report Issued: April 2021 Arrival date (at least 1 year prior to inspection) Birth month Randomize Arrival date (at least 1 year prior to inspection) Randomize Filter out IPs tested in MIT 9.008 Arrival date (at least 1 year prior to inspection) Date of birth (51 or older) Randomize Arrival date (at least 2 yrs. prior to inspection) Date of birth (age 52 – 74) Randomize Arrival date (at least three yrs. prior to inspection) Date of birth (age 24 – 53) Randomize Chronic care conditions (at least 1 condition per IP — any risk level) Randomize Condition must require vaccination(s) Reports from past 2 – 8 months Institution Ineligibility date (60 days prior to inspection date) All Office of the Inspector General, State of California Return to Contents 92 Cycle 6 Medical Inspection Report Quality Indicator Sample Category No. of Samples Data Source Filters Reception Center MITs 12.001 – 008 RC N/A at this institution SOMS • • • Arrival date (2 – 8 months) Arrived from (county jail, return from parole, etc.) Randomize Specialized Medical Housing MITs 13.001 – 004 Specialized Health Care Housing Unit MIT 13.101 Call Buttons 10 CADDIS • • • • • Admit date (2 – 8 months) Type of stay (no MH beds) Length of stay (minimum of 5 days) Rx count Randomize All OIG inspector on-site review • • Specialized Health Care Housing Review by location 15 MedSATS • • Approval date (3 – 9 months) Remove consult to gynecology, consult to public health/Specialty RN, dialysis, ECG 12-Lead (EKG), mammogram, occupational therapy, ophthalmology, optometry, oral surgery, physical therapy, or podiatry Randomize Specialty Services MITs 14.001 – 003 High-Priority Initial and Follow-Up RFS • MITs 14.004 – 006 Medium-Priority Initial and Follow-Up RFS 15 MedSATS • • • MITs 14.007 – 009 Routine-Priority Initial and Follow-Up RFS 15 MedSATS • • • MIT 14.010 Specialty Services Arrivals MITs 14.011–012 Denials 20 20 N/A Office of the Inspector General, State of California MedSATS • Approval date (3 – 9 months) Remove consult to gynecology, consult to public health/Specialty RN, dialysis, ECG 12-Lead (EKG), mammogram, occupational therapy, ophthalmology, optometry, oral surgery, physical therapy, or podiatry Randomize Approval date (3 – 9 months) Remove consult to gynecology, consult to public health/Specialty RN, dialysis, ECG 12-Lead (EKG), mammogram, occupational therapy, ophthalmology, optometry, oral surgery, physical therapy, or podiatry Randomize • • Arrived from (other departmental institution) Date of transfer (3 – 9 months) Randomize InterQual • • Review date (3 – 9 months) Randomize IUMC/MAR Meeting Minutes • • • Meeting date (9 months) Denial upheld Randomize Inspection Period: August 2019 – January 2020 Return to Contents California State Prison, Corcoran Quality Indicator Sample Category No. of Samples Data Source 93 Filters Administrative Operations MIT 15.001 Adverse/sentinel events 1 Adverse/sentinel events (ASE) report • Adverse/Sentinel events (2 – 8 months) MIT 15.002 QMC Meetings 6 Quality Management Committee meeting minutes • Meeting minutes (12 months) 12 EMRRC meeting minutes • Monthly meeting minutes (6 months) MIT 15.003 EMRRC MIT 15.004 LGB 4 LGB meeting minutes • Quarterly meeting minutes (12 months) MIT 15.101 Medical Emergency Response Drills 3 On-site summary reports & documentation for ER drills • • Most recent full quarter Each watch MIT 15.102 Institutional Level Medical Grievances 10 On-site list of grievances/closed grievance files • Medical grievances closed (6 months) MIT 15.103 Death Reports 10 Institution-list of deaths in prior 12 months • • Most recent 10 deaths Initial death reports MIT 15.104 Nursing Staff Validations 10 On-site nursing education files • • • On duty one or more years Nurse administers medications Randomize MIT 15.105 Provider Annual Evaluation Packets 9 On-site provider evaluation files • All required performance evaluation documents MIT 15.106 Provider Licenses 14 Current provider listing (at start of inspection) • Review all MIT 15.107 Medical Emergency Response Certifications All On-site certification tracking logs • All staff ◦ Providers (ACLS) ◦ Nursing (BLS/CPR) Custody (CPR/BLS) MIT 15.108 Nursing Staff and Pharmacist in Charge Professional Licenses and Certifications All On-site tracking system, logs, or employee files • Report Issued: April 2021 • All required licenses and certifications Office of the Inspector General, State of California Return to Contents 94 Cycle 6 Medical Inspection Report Quality Indicator Sample Category No. of Samples Data Source Filters Administrative Operations MIT 15.109 Pharmacy and Providers’ Drug Enforcement Agency (DEA) Registrations All On-site listing of provider DEA registration #s & pharmacy registration document • All DEA registrations MIT 15.110 Nursing Staff New Employee Orientations All Nursing staff training logs • New employees (hired within last 12 months) MIT 15.998 Death Review Committee 10 OIG summary log: deaths • Between 35 business days & 12 months prior Health Care Services death reviews Office of the Inspector General, State of California • Inspection Period: August 2019 – January 2020 Return to Contents California State Prison, Corcoran 95 California Correctional Health Care Services’ Response March 11, 2021 Roy Wesley, Inspector General Office of the Inspector General 10111 Old Placerville Road, Suite 110 Sacramento, CA 95827 Dear Mr. Wesley: The Office of the Receiver has reviewed the draft report of the Office of the Inspector General (OIG) Medical Inspection Results for California State Prison, Corcoran (COR) conducted from August 2019 to January 2020. California Correctional Health Care Services (CCHCS) acknowledges the OIG findings. Thank you for preparing the report. Your efforts have advanced our mutual objective of ensuring transparency and accountability in CCHCS operations. If you have any questions or concerns, please contact me at (916) 691‐3284. Sincerely, Amanda Oltean Digitally signed by Amanda Oltean Date: 2021.03.11 12:40:37 -08'00' Amanda Oltean Associate Director (A) Risk Management Branch California Correctional Health Care Services cc: Diana Toche, D.D.S., Undersecretary, Health Care Services, CDCR Clark Kelso, Receiver Richard Kirkland, Chief Deputy Receiver Katherine Tebrock, Chief Assistant Inspector General, OIG Doreen Pagaran, R.N., Nurse Consultant Program Review, OIG Directors, CCHCS Roscoe Barrow, Chief Counsel, CCHCS Office of Legal Affairs Jackie Clark, Deputy Director (A), Institution Operations, CCHCS DeAnna Gouldy, Deputy Director (A), Policy and Risk Management Services, CCHCS Renee Kanan, M.D., Deputy Director, Medical Services, CCHCS Barbara Barney‐Knox, R.N., Deputy Director (A), Nursing Services, CCHCS Annette Lambert, Deputy Director, Quality Management, CCHCS Regional Health Care Executive, Region III, CCHCS Regional Deputy Medical Executive, Region III, CCHCS Regional Nursing Executive, Region III, CCHCS Chief Executive Officer, COR Misty Polasik, Staff Services Manager I, OIG P.O. Box 588500 Elk Grove, CA 95758 Report Issued: April 2021 Office of the Inspector General, State of California Return to Contents 96 Cycle 6 Medical Inspection Report (This page left blank for reproduction purposes.) Office of the Inspector General, State of California Inspection Period: August 2019 – January 2020 Return to Contents Cycle 6 Medical Inspection Report for California State Prison, Corcoran OFFICE of the INSPECTOR GENERAL Roy W. Wesley Inspector General Bryan B. Beyer Chief Deputy Inspector General STATE of CALIFORNIA April 2021 OIG