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Office of the Inspector General - California Health Care Facility Medical Inspection Results Cycle 5, 2019

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Roy W. Wesley
Inspector General

Office of the Inspector General

California Health Care Facility
Medical Inspection Results
Cycle 5

April 2019

Fairness Integrity Respect
Service Transparency

Medical Inspection Unit

Office of the Inspector General

Page 1

State of California

Office of the Inspector General
CALIFORNIA HEALTH CARE FACILITY
Medical Inspection Results
Cycle 5

Roy W. Wesley
Inspector General
Bryan B. Beyer
Chief Deputy Inspector General
Shaun R. Spillane
Public Information Officer

April 2019

TABLE OF CONTENTS
Foreword ............................................................................................................................................... i
Overall Rating: Inadequate .............................................................................................................iii
Executive Summary ............................................................................................................................iii
Expert Clinician Case Review Results....................................................................................... v
Compliance Testing Results...................................................................................................... vi
Recommendations .................................................................................................................... vii
Population-Based Metrics ........................................................................................................ vii
Introduction.......................................................................................................................................... 1
About the Institution ......................................................................................................................... 1
Objectives, Scope, and Methodology .................................................................................................. 5
Case Reviews .................................................................................................................................... 6
Patient Selection for Retrospective Case Reviews .................................................................... 7
Benefits and Limitations of Targeted Subpopulation Review ................................................... 7
Case Review Sampling Methodology ........................................................................................ 9
Breadth of Case Reviews ........................................................................................................ 10
Case Review Testing Methodology ......................................................................................... 10
Compliance Testing ........................................................................................................................ 12
Sampling Methods for Conducting Compliance Testing ......................................................... 12
Scoring of Compliance Testing Results ................................................................................... 13
Overall Quality Indicator Rating for Case Reviews and Compliance Testing ............................... 13
Population-Based Metrics............................................................................................................... 13
Medical Inspection Results ................................................................................................................ 14
Access to Care ................................................................................................................. 17
Case Review Results ................................................................................................................ 17
Compliance Testing Results..................................................................................................... 20
Diagnostic Services.......................................................................................................... 22
Case Review Results ................................................................................................................ 22
Compliance Testing Results..................................................................................................... 24
Emergency Services ......................................................................................................... 26
Case Review Results ................................................................................................................ 26
Health Information Management..................................................................................... 29
Case Review Results ................................................................................................................ 29
Compliance Testing Results..................................................................................................... 31
Health Care Environment ................................................................................................ 32
Compliance Testing Results..................................................................................................... 32
Inter- and Intra-System Transfers.................................................................................... 36
Case Review Results ................................................................................................................ 36
Compliance Testing Results..................................................................................................... 38
Pharmacy and Medication Management ......................................................................... 40
Case Review Results ................................................................................................................ 40
Compliance Testing Results..................................................................................................... 42
California Health Care Facility, Cycle 5 Medical Inspection

Table of Contents

Office of the Inspector General

State of California

Prenatal and Post-Delivery Services ............................................................................... 46
Preventive Services .......................................................................................................... 47
Compliance Testing Results..................................................................................................... 47
Quality of Nursing Performance .................................................................................... 49
Case Review Results ................................................................................................................ 49
Quality of Provider Performance .................................................................................. 54
Case Review Results ................................................................................................................ 54
Reception Center Arrivals.............................................................................................. 59
Specialized Medical Housing ......................................................................................... 60
Case Review Results ................................................................................................................ 60
Compliance Testing Results..................................................................................................... 64
Specialty Services........................................................................................................... 66
Case Review Results ................................................................................................................ 66
Compliance Testing Results..................................................................................................... 69
Administrative Operations (Secondary)......................................................................... 70
Compliance Testing Results..................................................................................................... 70
Recommendations .............................................................................................................................. 73
Population-Based Metrics .................................................................................................................. 74
Appendix A — Compliance Test Results .......................................................................................... 77
Appendix B — Clinical Data ............................................................................................................. 90
Appendix C — Compliance Sampling Methodology ........................................................................ 94
California Correctional Health Care Services’ Response ................................................................ 101

California Health Care Facility, Cycle 5 Medical Inspection

Table of Contents

Office of the Inspector General

State of California

LIST OF TABLES AND FIGURES
CHCF Executive Summary Table ...................................................................................................... iv
CHCF Health Care Staffing Resources as of November 2017............................................................ 2
CHCF Master Registry Data as of November 6, 2017 ........................................................................ 3
Exhibit 1. Case Review Definitions .................................................................................................... 6
Chart 1. Case Review Sample Selection ............................................................................................. 9
Chart 2. Case Review Testing and Deficiencies ............................................................................... 11
Chart 3. Inspection Indicator Review Distribution............................................................................ 14
CHCF Results Compared to State and National HEDIS Scores ....................................................... 76
Table B-1: CHCF Sample Sets .......................................................................................................... 90
Table B-2: CHCF Chronic Care Diagnoses ...................................................................................... 91
Table B-3: CHCF Event – Program .................................................................................................. 92
Table B-4: CHCF Review Sample Summary .................................................................................... 93

California Health Care Facility, Cycle 5 Medical Inspection
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FOREWORD
Pursuant to California Penal Code Section 6126 et seq., which assigns the Office of the Inspector
General (OIG) responsibility for oversight of the California Department of Corrections and
Rehabilitation (CDCR), the OIG conducts a comprehensive inspection program to evaluate the
delivery of medical care at each of CDCR’s 35 adult prisons. The OIG explicitly makes no
determination regarding the constitutionality of care in the prison setting. That determination is
left to the Receiver and the federal court. The assessment of care by the OIG is just one factor in
the court’s determination whether care in the prisons meets constitutional standards.
The OIG’s inspections are mandated by the Penal Code and not aimed at specifically resolving
the court’s questions on constitutional care. To the degree that they provide another factor for the
court to consider, the OIG is pleased to provide added value to the taxpayers of California.
In Cycle 5, for the first time, the OIG will be inspecting institutions delegated back to CDCR
from the Receivership. There is no difference in the standards used for assessment of a delegated
institution versus an institution not yet delegated. At the time of the Cycle 5 inspection of the
California Health Care Facility, the Receiver had not delegated this institution back to CDCR.
This fifth cycle of inspections will continue evaluating the areas addressed in Cycle 4, which
included clinical case review, compliance testing, and a population-based metric comparison of
selected Healthcare Effectiveness Data Information Set (HEDIS) measures. In agreement with
stakeholders, the OIG made changes to both the case review and compliance components. The
OIG found that in every inspection in Cycle 4, larger samples were taken than were needed to
assess the adequacy of medical care provided. As a result, the OIG reduced the number of case
reviews and sample sizes for compliance testing. Also, in Cycle 4, compliance testing included
two secondary (administrative) indicators (Internal Monitoring, Quality Improvement, and
Administrative Operations; and Job Performance, Training, Licensing, and Certifications). For
Cycle 5, these have been combined into one secondary indicator, Administrative Operations.

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EXECUTIVE SUMMARY
The OIG completed the Cycle 5 medical inspection of the
California Health Care Facility (CHCF) in February 2019. The vast
majority of our inspection findings were based on CHCF’s health
care delivery between February 2017 and December 2017. Our
policy compliance inspectors performed an onsite inspection in
November 2017. After reviewing the institution’s health care
delivery, our case review clinicians performed an onsite inspection
in October 2018 to follow up on their initial findings.

OVERALL RATING:

Inadequate

Our clinician team, consisting of expert physicians and nurse consultants, reviewed cases (patient
medical records) and interpreted our policy compliance results to determine the quality of health
care the institution provided. Our compliance team, consisting of registered nurses, monitored
the institution’s compliance with its medical policies by answering a predetermined set of policy
compliance questions.
Our clinician team reviewed 75 cases that contained 1,977 patient-related events. Our
compliance team tested 87 policy questions by observing CHCF’s processes and examining
400 patient records and 1,527 data points. We distilled the results from both the case review and
compliance testing into 13 health care indicators, and have listed the individual indicators and
ratings applicable for this institution in the CHCF Executive Summary Table on the following
page. Our experts made a considered and measured opinion that the overall quality of health care
at CHCF was inadequate.

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CHCF Executive Summary Table
Case Review
Rating

Compliance
Rating

Cycle 5
Overall
Rating

Cycle 4
Overall
Rating

1—Access to Care

Inadequate

Inadequate

Inadequate

Proficient

2—Diagnostic Services

Inadequate

Inadequate

Inadequate

Inadequate

3—Emergency Services

Adequate

Not Applicable

Adequate

Adequate

4—Health Information
Management

Inadequate

Inadequate

Inadequate

Adequate

Not Applicable

Inadequate

Inadequate

Inadequate

6—Inter- and Intra-System
Transfers

Inadequate

Inadequate

Inadequate

Adequate

7—Pharmacy and Medication
Management

Inadequate

Inadequate

Inadequate

8—Prenatal and Post-Delivery
Services

Not Applicable

Not Applicable

Not Applicable

Not Applicable

9—Preventive Services

Not Applicable

Inadequate

Inadequate

Adequate

10—Quality of Nursing
Performance

Adequate

Not Applicable

Adequate

Adequate

11—Quality of Provider
Performance

Inadequate

Not Applicable

Inadequate

Adequate

Not Applicable

Not Applicable

Not Applicable

Not Applicable

13—Specialized Medical Housing

Inadequate

Adequate

Inadequate

Adequate

14—Specialty Services

Inadequate

Inadequate

Inadequate

Inadequate

Not Applicable

Inadequate

Inadequate

Inadequate*

Inspection Indicators

5—Health Care Environment

12—Reception Center Arrivals

15—Administrative Operations
(Secondary)

I
n
a

Inadequate

* In Cycle 4, there were two secondary (administrative) indicators. This score reflects the average of those
two scores.

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Expert Clinician Case Review Results
Our expert clinicians reviewed cases of patients with many medical needs and included a review
of 1,977 patient care events. 1 The vast majority of our case review covered the period between
July 2017 and December 2017. As depicted on the executive summary table on page iv, we rated
10 of the 13 indicators applicable to CHCF. Of those ten applicable indicators, we rated two
adequate and eight inadequate. When determining the overall adequacy of care, we paid
particular attention to the clinical nursing and provider quality indicators, as adequate health care
staff can sometimes overcome suboptimal compliance or performance with processes and
programs. However, the opposite is not true; inadequate health care staff cannot provide
adequate care, even though the established processes and programs may be adequate. We
identified inadequate medical care based on the risk of significant harm to the patient, not the
actual outcome.
Program Strengths — Clinical
•

CHCF’s Emergency Medical Response Review Committee (EMRRC) identified
deficiencies effectively, while emergency nurse supervisors provided suitable staff
training.

Program Weaknesses — Clinical
•

CHCF could not meet the institution’s demand for medical services because of ongoing
problems with access to care. The institution often delayed provider follow-ups,
especially in the correctional treatment centers (CTCs) and outpatient housing units
(OHUs).

•

CHCF did not provide adequate specialty service follow-ups. Follow-up appointments
requested by specialists often occurred late.

•

CHCF provider performance regressed significantly since Cycle 4. Providers repeatedly
failed to make sound assessments and accurate diagnoses. Poor provider assessments and
misdiagnoses frequently occurred throughout the case reviews, especially in the CTCs
and the OHUs.

•

CHCF providers did not sufficiently review diagnostic or laboratory reports. This finding
was partly due to understaffing at the institution, which created a heavier workload for
providers.

•

CHCF providers performed poorly in addressing hospital discharge recommendations
and new discharge diagnoses for patients.

1

Each OIG clinician team consists of a board-certified physician and a registered nurse consultant with experience in
correctional and community medical settings.
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•

CHCF nursing performance also regressed since Cycle 4. The nurses made incomplete
assessments for patients in all areas of the institution. This problem was especially
notable for patients returning from an offsite hospital.

•

CHCF nurses did not consistently ensure medication continuity for patients during the
transfer-in and transfer-out processes.

•

CHCF medication processes did not ensure medication continuity for the institution’s
patients. Patients often did not receive medications either timely or correctly.

Compliance Testing Results
Of the 13 health care indicators applicable to CHCF, our compliance inspectors 2 evaluated 10.
Of these, we rated one adequate and nine inadequate. The vast majority of our compliance
testing concerned medical care that occurred between February 2017 and November 2017.
Within those ten indicators, 87 individual compliance questions generated 1,527 data points that
tested CHCF’s compliance with California Correctional Health Care Services (CCHCS) policies
and procedures.3 Those 87 questions are detailed in Appendix A — Compliance Test Results.
Program Strengths — Compliance
The following are some of CHCF’s strengths based on its compliance scores on individual
questions in all health care indicators:
•

The institution’s specialized medical housing unit had properly working call buttons, and
medical staff were able to enter patient rooms during emergent events in a timely manner.

•

CHCF’s nursing staff performed well in completing initial assessments on the same day
patients were admitted to specialized medical housing.

•

Providers at CHCF performed well in completing history and physical evaluations within
24 hours of a patient’s admission to the correctional treatment center (CTC).

Program Weaknesses — Compliance
The following are some of the weaknesses identified through CHCF’s low compliance scores on
individual questions in all the health care indicators:
•

Patients did not receive their ordered chronic care medications, hospital discharge
medications, and newly ordered medications within the specified time frames.

2

The OIG’s compliance inspectors are trained deputy inspectors general and registered nurses with expertise in CDCR
policies regarding medical staff and processes.
3
The OIG used its own clinicians to provide clinical expert guidance for testing compliance in certain areas wherein
CCHCS policies and procedures did not specifically address an issue.
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•

Providers at CHCF did not always communicate diagnostic services results to patients in a
timely manner.

•

CHCF did not perform well in ensuring that approved specialty services were provided
timely.

•

The institution did not provide chronic care, specialty services, nursing referrals, and
hospital discharge follow-up appointments within required time frames.

•

CHCF performed poorly in managing patients on tuberculosis (TB) medications. Patients
were not appropriately referred to a provider after missing several doses or refusing
TB medications. In addition, the institution did not complete TB monitoring at required
intervals.

•

CHCF nurses often did not properly account for narcotic medication at medication line
locations based on the record maintained by the licensed nursing staff.

Recommendations
The OIG recommends the following:
•

The chief executive officer (CEO) and the chief support executive (CSE) should ensure
that all CHCF providers have access to and show proficiency using the radiology
information system (RIS) to retrieve and review offsite radiology reports. Alternatively,
CHCF can scan offsite radiology reports directly into the EHRS medical record, which
would be a more efficient method of enabling providers to review offsite reports. During
this inspection, we found that a majority of CHCF providers did not review offsite
radiology reports because they were inaccessible.

•

The CEO and the CSE should identify and fix the processes that resulted in X-rays and
laboratory tests being delayed or that were not completed, which we identified during this
inspection.

•

The CSE and the chief nurse executive (CNE) should rectify the problems we found
whereby standby emergency medical services (SEMS) nurses did not consistently collect
and process laboratory specimens when those tests were performed during weekends.

•

All CHCF executives should analyze why the processing of diagnostic and specialty
reports was delayed and attempt to correct the situation to alleviate future occurrences.
We found delays with both the initial retrieval, and the providers’ review, of those
reports.

•

The CNE should train and improve the clinical performance of nurses in multiple areas.
The training should focus on making thorough assessments, recording complete

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documentation, and administering all medications correctly. We found errors in these
areas throughout the institution.
•

The CEO, the CNE, and the pharmacist-in-charge (PIC) should analyze why problems
occurred with pharmacy and nursing processes, and adjust these processes to correct
problems we found with medication administration and medication continuity.

•

The chief medical executive (CME) should improve the hiring, training, and monitoring
processes the institution used to ensure sufficient provider quality. We found serious
problems with providers’ assessments, misdiagnoses, review of records, and chronic care
performance. Most CHCF staff attributed these problems to severe provider understaffing
during this review period.

•

The CEO and the CNE should adjust specialty scheduling processes to ensure that
patients who require urgent or short-interval specialty follow-ups receive them. During
this inspection, we found that delayed specialty follow-ups occurred more frequently with
urgent or expedited follow-up orders.

Population-Based Metrics
In general, CHCF performed very well compared to other health plans as measured by
population-based metrics. In comprehensive diabetes care, CHCF outperformed most state and
national health care plans in the five diabetic measures. However, CHCF scored lower than four
health care plans regarding diabetic eye exams.
With regard to immunization measures, CHCF scored higher than all other health care plans for
influenza immunizations in both younger and older adults. However, the institution’s score for
pneumococcal immunizations was mixed, exceeding the score for one health care plan, but
scoring lower than one other health care plan. CHCF’s colorectal cancer screening scores were
higher than all other health plans.
CHCF may improve its score for diabetic eye exams by reducing the number of refusals through
educating patients on the benefits of this preventive service.

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INTRODUCTION
Pursuant to California Penal Code Section 6126 et seq., which assigns the Office of the Inspector
General (OIG) responsibility for oversight of the California Department of Corrections and
Rehabilitation (CDCR), and at the request of the federal Receiver, the OIG developed a
comprehensive medical inspection program to evaluate the delivery of medical care at each of
CDCR’s 35 adult prisons. The OIG conducted a clinical case review and a compliance
inspection, ensuring a thorough, end-to-end assessment of medical care within CDCR.
California Health Care Facility (CHCF) was the 35th medical inspection of Cycle 5. During the
inspection process, the OIG assessed the delivery of medical care to patients using the primary
clinical health care indicators applicable to the institution. The Administrative Operations
indicator is secondary because it does not reflect the actual clinical care provided.

ABOUT THE INSTITUTION
The California Health Care Facility is a 1.4 million square foot facility that opened in July 2013.
The 54-building complex is located in Stockton and houses a population of over 2,250 patients,
mostly classified as medium or high medical risk. Medical and psychiatric treatment is delivered
by professional health care staff from CDCR, the Department of State Hospitals, and California
Correctional Health Care Services (CCHCS). CHCF is designated as an “intermediate care
prison”; these institutions are located in predominantly urban areas close to tertiary care centers
and specialty care providers for the most cost-effective care and to complement less acute
treatment provided in other CDCR institutions. At the time of the OIG’s inspection, the
institution had 14 licensed correctional treatment centers (CTCs), which provided inpatient
medical care, diagnostic evaluation, and treatment. There were also 12 outpatient housing units
(OHUs) for patients requiring assistance with daily living activities, as well as inpatient and
outpatient psychiatric treatment units. Mental health crisis bed (MHCB) housing was also
available. CHCF also had multiple outpatient clinics in E facility to handle daily, non-urgent
requests for medical services, as well as a licensed standby emergency medical services (SEMS)
unit to deal with urgent/emergent care issues. This unit is typically referred to as a triage and
treatment area (TTA) at other CDCR institutions. CHCF provided multiple medical services
onsite, including the following: audiology, cardiology, gastroenterology, infectious disease,
nephrology, oncology, orthopedics, ophthalmology, orthotics, ocular prosthesis, physical
therapy, podiatry, radiology, and urology. The institution had licensure for 29 dialysis stations at
the time of the OIG’s inspection. CHCF also used telemedicine for treatment of human
immunodeficiency virus (HIV) patients and specialty services in its E facility and facility shared
services (FSS) buildings.

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Based on staffing data the OIG obtained from CCHCS as identified in the following
CHCF Health Care Staffing Resources as of November 2017 table, CHCF’s vacancies
among nursing staff were 143.6 positions in November 2017, and nursing supervisors had
20.4 vacancies. At the time of the OIG’s inspection, CHCF had 26 nursing staff on
extended leave.

CHCF Health Care Staffing Resources as of November 2017

8.0
8.0
0.0
100.0%

Primary
Care
Providers
41.0
22.0
19.0
53.7%

0.0
0.0%
0.0
0.0%

3.0
7.3%
7.4
18.0%

0.0
0.0%
0.0
0.0%

0.0
0.0%
16.1
1.6%

3.0
0.3%
23.5
2.1%

8.0
100.0%

32.4
78.9%

55.0
72.9%

890.1
87.5%

985.5
86.3%

Appointments in Last 12 Months
Redirected Staff
Staff on Extended Leave^

0.0
0.0
0.0

5.0
0.0
1.0

7.0
0.0
0.0

106.0
2.0
26.0

118.0
2.0
27.0

Adjusted Total: Filled Positions
Adjusted Total: Percentage Filled

8.0
100.0%

31.4
76.5%

55.0
72.9%

862.1
84.7%

956.5
83.8%

Executive
Leadership*
Authorized Positions
Filled by Civil Service
Vacant
Percentage Filled by Civil Service
Filled by Telemed
Percentage Filled by Telemed
Filled by Registry
Percentage Filled by Registry
Total Filled Positions
Total Percentage Filled

Nursing
Supervisors

Nursing
Staff**

Total

75.4
55.0
20.4
72.9%

1,017.6
874.0
143.6
85.9%

1,142.0
959.0
183.0
84.0%

* Executive Leadership includes Chief Physician & Surgeon.
** Nursing Staff includes Senior Psychiatric Technician/Psychiatric Technician.
^ In Authorized Positions.
Note: The OIG did not validate the CHCF Health Care Staffing Resources data.

As of November 6, 2017, the Master Registry for CHCF showed that the institution had a total
population of 2,338. Within that total population, 42.7 percent was designated as high medical
risk, Priority 1 (High 1), and 23.5 percent was designated as high medical risk, Priority 2
(High 2). Patients’ assigned risk levels are based on the complexity of their required medical care
related to their specific diagnoses, frequency of higher levels of care, age, and abnormal
laboratory results and procedures. High 1 has at least two high-risk conditions; High 2 has only
one. Patients at high medical risk are more susceptible to poor health outcomes than those at
medium or low medical risk. Patients at high medical risk also typically require more health care
services than do patients with lower assigned risk levels. The table on the following page
illustrates the breakdown of the institution’s medical risk levels at the start of the OIG medical
inspection.

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CHCF Master Registry Data as of November 6, 2017
Medical Risk Level

Number of Patients

Percentage

High 1
High 2
Medium
Low
Total

999
550
646
143
2,338

42.7%
23.5%
27.6%
6.1%
100%

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OBJECTIVES, SCOPE, AND METHODOLOGY
In designing the medical inspection program, the OIG reviewed CCHCS policies and procedures,
relevant court orders, and guidance developed by the American Correctional Association. The
OIG also reviewed professional literature on correctional medical care; reviewed standardized
performance measures used by the health care industry; consulted with clinical experts; and met
with stakeholders from the court, the Receiver’s office, CDCR, the Office of the Attorney
General, and the Prison Law Office to discuss the nature and scope of the OIG’s inspection
program. With input from these stakeholders, the OIG developed a medical inspection program
that evaluates medical care delivery by combining clinical case reviews of patient files, objective
tests of compliance with policies and procedures, and an analysis of outcomes for certain
population-based metrics.
To maintain a metric-oriented inspection program that evaluates medical care delivery
consistently at each state prison, the OIG identified 15 indicators (14 primary (clinical) indicators
and one secondary (administrative) indicator) of health care to measure. The primary quality
indicators cover clinical categories directly relating to the health care provided to patients,
whereas the secondary quality indicator addresses the administrative functions that support a
health care delivery system. The CHCF Executive Summary Table on page iv of this report
identifies these 15 indicators.
The OIG rates each of the quality indicators applicable to the institution under inspection based
on case reviews conducted by OIG clinicians and compliance tests conducted by OIG registered
nurses. The case review results alone, the compliance test results alone, or a combination of both
these information sources may influence an indicator’s overall rating. For example, the OIG
derives the ratings for the primary quality indicators Quality of Nursing Performance and
Quality of Provider Performance entirely from the case review done by clinicians, while the
ratings for the primary quality indicators Health Care Environment and Preventive Services are
derived entirely from compliance testing done by registered nurse inspectors. As another
example, primary quality indicators such as Diagnostic Services and Specialty Services receive
ratings derived from both sources.
The OIG does not inspect for efficiency or cost-effectiveness of medical operations. Consistent
with the OIG’s agreement with the Receiver, this report only addresses the quality of CDCR’s
medical operations and its compliance with quality-related policies. Moreover, if the OIG learns
of a patient needing immediate care, the OIG notifies the chief executive officer of health care
services and requests a status report. Additionally, if the OIG learns of significant departures
from community standards, it may report such departures to the institution’s chief executive
officer or to CCHCS. Because these matters involve confidential medical information protected
by state and federal privacy laws, the OIG does not include specific identifying details related to
any such cases in the public report.

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In all areas, the OIG is alert for opportunities to make appropriate recommendations for
improvement. Such opportunities may be present regardless of the score awarded to any
particular quality indicator; therefore, recommendations for improvement are not necessarily
indicative of deficient medical care delivery.

CASE REVIEWS
The OIG added case reviews to the Cycle 4 medical inspections at the recommendation of its
stakeholders, which continues in the Cycle 5 medical inspections. The following exhibit provides
definitions that describe this process.

Exhibit 1. Case Review Definitions

Case = Sample = Patient
An appraisal of the medical care provided to one patient over a specific
period, which can comprise detailed or focused case reviews.
Detailed Case Review
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.
Focused Case Review
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.
Case Review 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 non-compliance, elevated risk of
patient harm, or both.
Adverse Deficiency
A medical error that increases the risk of, or results in, serious patient harm.
Most health care organizations refer to these errors as adverse events.

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The OIG’s clinicians perform a retrospective case review of selected patient files to evaluate the
care given by an institution’s primary care providers and nurses. Retrospective case review is a
well-established review process used by health care organizations that perform peer reviews and
patient death reviews. Currently, CCHCS uses retrospective case review as part of its death
review process and in its pattern-of-practice reviews. CCHCS also uses a more limited form of
retrospective case review when performing appraisals of individual primary care providers.

Patient Selection for Retrospective Case Reviews
Because retrospective case review is time consuming and requires qualified health care
professionals to perform it, the OIG must carefully select a sample of patient records for clinician
review. Accordingly, the group of patients the OIG targeted for case review carried the highest
clinical risk and utilized the majority of medical services. The majority of patients selected for
retrospective case review were high-utilizing patients with chronic care illnesses who were
classified as high or medium risk. The reason the OIG targeted these patients for review is
twofold:
1. The goal of retrospective case review is to evaluate all aspects of the health care system.
Statewide, high-utilization patients consume medical services at a disproportionate rate.
Between October 2011 and March 2012, 9 percent of the total statewide adult patient
population was classified as high-risk and accounted for more than half of CCHCS’
pharmaceutical, specialty, community hospital, and emergency costs.4 This
disproportionate utilization of health care resources was consistent with that observed in
the general U.S. population. Based on the 2010 Medical Expenditure Panel Survey data,
5 percent of the U.S. population accounted for 50 percent of health care costs.5 By
May 2018, the proportion of high-risk patients had increased to 13.6 percent of the
statewide adult patient population. 6
2. Selecting this target group for case review provides a significantly greater opportunity to
evaluate all the various aspects of the health care delivery system at an institution.
Underlying the choice of high- and medium-risk patients for detailed case review, the OIG
clinical experts made the following three assumptions:

4

Twenty-first Tri-Annual Report of the Federal Receiver’s Turnaround Plan of Action for May 1 – August 31, 2012,
Appendix 6, High-Risk Patient Performance Report – Appropriate Placement in the CCHCS Primary Care
Environment, August 2012; https://www.clearinghouse.net/chDocs/public/PC-CA-0018-0097.pdf (accessed
3-28-19).
5
S. B. Cohen, The Concentration and Persistence in the Level of Health Expenditures Over Time: Estimates for the
U.S. Population, 2009–2010 (Rockville, MD: Agency for Healthcare Research and Quality, U.S. Department of Health
and Human Services, 2012); https://meps.ahrq.gov/data_files/publications/st392/stat392.shtml (accessed 9-10-18).
6
CCHCS Public Dashboard, Statewide, May 2018; https://cchcs.ca.gov/wp-content/uploads/sites/60/2018/08/
Public-Dashboard-2018-05.pdf (accessed 9-10-18).
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1. If the institution is able to provide adequate clinical care to the most challenging patients
with multiple complex and interdependent medical problems, it is more likely to provide
adequate care to patients with less complicated health care issues. Because clinical expertise
is required to determine whether the institution has provided adequate clinical care, the OIG
utilizes experienced correctional physicians and registered nurses to perform this analysis.
2. The health of less complex patients is more likely to be affected by processes such as timely
appointment scheduling, medication management, routine health screening, and
immunizations. To review these processes, the OIG simultaneously performs a broad
compliance review.
3. Patient cases generated during death reviews, sentinel events (unexpected occurrences
involving death or serious injury, or risk thereof), and hospitalizations are more likely to
comprise high-risk patients.

Benefits and Limitations of Targeted Subpopulation Review
Because the patients selected utilize the broadest range of services offered by the health care
system, the OIG’s retrospective case review provides adequate data for a qualitative assessment
of the most vital system processes (referred to as “primary quality indicators”). Retrospective
case review provides an accurate qualitative assessment of the relevant primary quality indicators
as applied to the targeted subpopulation of high-risk and high-utilization patients. While this
targeted subpopulation does not represent the prison population as a whole, the institution’s
ability to respond with adequate medical care to this subpopulation is a crucial and vital indicator
of how the institution provides health care to its whole patient population. Simply put, if the
institution’s medical system does not respond adequately for those patients needing the most
care, then it is not fulfilling its obligations, even if it takes good care of patients with less
complex medical needs.
Since the targeted subpopulation does not represent the institution’s general prison population,
the OIG cautions against inappropriate extrapolation of medical conditions or outcomes from the
retrospective case reviews to the general population. For example, if the high-risk diabetic
patients reviewed have poorly controlled diabetes, one cannot conclude that all the diabetics’
conditions are poorly controlled. Similarly, if the high-risk diabetic patients under review have
poor outcomes, one cannot conclude that the entire diabetic population is having similarly poor
outcomes. The OIG does not extrapolate conditions or outcomes, but instead extrapolates the
institution’s response for those patients needing the most care because the response yields
valuable system information.
In the above example, if the institution responds by providing appropriate diabetic monitoring,
medication therapy, and specialty referrals for the high-risk patients reviewed, then it is
reasonable to infer that the institution is also responding appropriately to all the diabetics in the
prison. However, if these same high-risk patients needing monitoring, medications, and referrals
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are not getting those needed services, it is likely that the institution is not providing appropriate
diabetic services.

Case Review Sampling Methodology
Using a pre-defined case review sampling algorithm, OIG analysts apply various filters to each
institution’s patient population. The various filters include medical risk status, number of
prescriptions, number of specialty appointments, number of clinic appointments, and other
health-related data. The OIG uses these filters to narrow down the population to those patients
with the highest utilization of medical resources (see Chart 1, below). To prevent selection bias,
the OIG ensures that the same clinicians who perform the case reviews do not participate in the
sample selection process.

Chart 1. Case Review Sample Selection

The OIG’s case sample sizes matched those of other qualitative research. The empirical findings,
supported by expert statistical consultants, showed adequate conclusions after 10 to 15 cases had
undergone comprehensive, or detailed, clinician review. In qualitative statistics, this
phenomenon is known as “saturation.” The OIG found the Cycle 4 medical inspection sample
size of 30 for detailed physician reviews far exceeded the saturation point necessary for an
adequate qualitative review. At the end of Cycle 4 inspections, the OIG re-analyzed the case
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review results using half the number of cases; there were no significant differences in the ratings.
To improve inspection efficiency while preserving the quality of the inspection, the OIG reduced
the number of the samples for Cycle 5 medical inspections to the current levels. For most basic
institutions, the OIG samples 20 cases for detailed physician review. For intermediate institutions
and several basic institutions with larger high-risk populations, the OIG samples 25 cases. For
California Health Care Facility, the OIG samples 30 cases for detailed physician review.

Breadth of Case Reviews
As indicated in Appendix B, Table B-1: CHCF Sample Sets, the OIG clinicians evaluated
medical records for 75 unique cases. Appendix B, Table B-4: CHCF Case Review Sample
Summary clarifies that both nurses and physicians reviewed 23 of those cases, for 98 case
reviews in total. Physicians performed detailed reviews of 30 cases, and nurses performed
detailed reviews of 21 cases, totaling 51 detailed case reviews. Physicians and nurses also
performed a focused review of an additional 47 cases. These reviews generated 1,977 case
review events (Appendix B, Table B-3: CHCF Event – Program).
While the sampling method specifically pulled only 6 chronic care cases, i.e., 3 diabetes cases
and 3 anticoagulation cases (Appendix B, Table B-1: CHCF Sample Sets), the 75 unique cases
sampled included 426 chronic care diagnoses, including 43 additional cases with diabetes (for a
total of 46) and 11 additional anticoagulation cases (for a total of 14) (Appendix B, Table B-2:
CHCF Chronic Care Diagnoses). The OIG’s sample selection tool allowed evaluation of many
chronic care programs because the complex and high-risk patients selected from the different
categories often had multiple medical problems. While the OIG did not evaluate every chronic
disease or health care staff member, the OIG did assess for adequacy the overall operation of the
institution’s system and staff.

Case Review Testing Methodology
A physician, a nurse consultant, or both clinician inspectors review each case. The OIG clinician
inspector can perform one of two different types of case review: detailed or focused (see
Exhibit 1, page 6, and Chart 1, previous page). As the OIG clinician inspector reviews the
medical record for each sample, the inspector records pertinent interactions between the patient
and the health care system. These interactions are also known as case review events. When an
OIG clinician inspector identifies a medical error, the inspector also records these errors as case
review deficiencies. If a deficiency is of such magnitude that it caused, or had the potential to
cause, serious patient harm, then the OIG clinician records it as an adverse deficiency (see
Chart 2, next page).

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Chart 2. Case Review Testing and Deficiencies

When the OIG clinician inspectors have reviewed all cases, they analyze the deficiencies. OIG
inspectors search for similar types of deficiencies to determine if a repeating pattern of errors
existed. When the same type of error occurs multiple times, the OIG inspectors identify those
errors as findings. When the error is frequent, the likelihood is high that the error is regularly
recurring at the institution. The OIG categorizes and summarizes these deficiencies in one or
more health care quality indicators in this report to help the institution focus on areas for
improvement.
Additionally, the OIG physicians also rate each of the detailed physician cases for adequacy
based on whether the institution met the patient’s medical needs and if it placed the patient at
significant risk of harm. The cumulative analysis of these cases gives the OIG clinicians
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additional perspective to help determine whether the institution is providing adequate medical
services or not.7
Based on the collective results of clinicians’ case reviews, the OIG clinicians rated each quality
indicator proficient (excellent), adequate (passing), or inadequate (failing). A separate
confidential CHCF Supplemental Medical Inspection Results: Individual Case Review
Summaries report details the case reviews the OIG clinicians conducted and is available to
specific stakeholders. For further details regarding the sampling methodologies and counts, see
Appendix B — Clinical Data, Table B-1; Table B-2; Table B-3; and Table B-4.

COMPLIANCE TESTING
Sampling Methods for Conducting Compliance Testing
Our registered nurse inspectors obtained answers to 87 objective medical inspection test (MIT)
questions designed to assess the institution’s compliance with critical policies and procedures
applicable to the delivery of medical care. To conduct most tests, inspectors randomly selected
samples of patients for whom the testing objectives were applicable and reviewed their electronic
medical records. In some cases, inspectors used the same samples to conduct more than one test.
In total, inspectors reviewed health records for 400 individual patients and analyzed specific
transactions within their records for evidence that critical events occurred. Inspectors also
reviewed management reports and meeting minutes to assess certain administrative operations.
In addition, during the week of November 27, 2017, registered nurse field inspectors conducted a
detailed onsite inspection of CHCF’s medical facilities and clinics; interviewed key institutional
employees; and reviewed employee records, logs, medical appeals, death reports, and other
documents. This generated 1,527 scored data points to assess care.
In addition to the scored questions, the OIG obtained information from the institution that it did
not score. This included, for example, information about CHCF’s plant infrastructure, protocols
for tracking medical appeals and local operating procedures, and staffing resources.
For details of the compliance results, see Appendix A — Compliance Test Results. For details of
the OIG’s compliance sampling methodology, see Appendix C — Compliance Sampling
Methodology.

7

Regarding individual provider performance, the OIG did not design the medical inspection to be a focused search for
poorly performing providers; rather, the inspection assesses each institution’s systemic health care processes.
Nonetheless, while the OIG does not purposefully sample cases to review each provider at the institution, the cases
usually involve most of the institutions’ providers. Providers should only escape OIG case review if institutional
managers assigned poorly performing providers the care of low-utilizing and low-risk patients, or if the institution had a
relatively high number of providers.
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Scoring of Compliance Testing Results
After compiling the answers to the 87 questions for the ten indicators for which compliance
testing was applicable, the OIG compliance team derived a score for each quality indicator by
calculating the percentage score of all Yes answers for each of the questions applicable to a
particular indicator, then averaging those scores. Based on those results, the OIG assigned a
rating to each quality indicator of proficient (greater than 85 percent), adequate (between
75 percent and 85 percent), or inadequate (less than 75 percent).

OVERALL QUALITY INDICATOR RATING FOR CASE REVIEWS AND COMPLIANCE
TESTING
The OIG derived the final rating for each quality indicator by combining the ratings from the
case reviews and from the compliance testing, as applicable. When combining these ratings, the
case review evaluations and the compliance testing results usually agreed, but there were
instances for this inspection when the rating differed for a particular quality indicator. In those
instances, the inspection team assessed the quality indicator based on the collective ratings from
both components. Specifically, the OIG clinicians and registered nurse inspectors discussed the
nature of individual exceptions found within that indicator category and considered the overall
effect on the ability of patients to receive adequate medical care.
To derive an overall assessment rating of the institution’s medical inspection, the OIG evaluated
the various rating categories assigned to each of the quality indicators applicable to the
institution, giving more weight to the rating results of the primary quality indicators, which
directly relate to the health care provided to patients. Based on that analysis, OIG experts made a
considered and measured overall opinion about the quality of health care observed.

POPULATION-BASED METRICS
The OIG identified a subset of Healthcare Effectiveness Data Information Set (HEDIS) measures
applicable to the CDCR patient population. To identify outcomes for CHCF, the OIG reviewed
some of the compliance testing results, randomly sampled additional patients’ records, and
obtained CHCF data from the CCHCS Master Registry. The OIG compared those results to
HEDIS metrics reported by other statewide and national health care organizations.

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MEDICAL INSPECTION RESULTS
The OIG’s case review and clinician teams use quality indicators to assess the clinical aspects of
health care. The CHCF Executive Summary Table on page iv of this report identifies the
13 indicators applicable to this institution. The following chart depicts their union and
intersection:

Chart 3. Inspection Indicator Review Distribution
The Administrative Operations indicator is a secondary indicator; therefore, the OIG did not rely
upon this indicator when determining the institution’s overall score. Based on the analysis and
results in all the primary indicators, the OIG experts made a considered and measured opinion
that the quality of health care at CHCF was inadequate.

The Administrative Operations indicator is a secondary indicator; therefore, the OIG did not rely
upon this indicator when determining the institution’s overall score. Based on the analysis and
results in all the primary indicators, the OIG experts made a considered and measured opinion
that the quality of health care at CIM was inadequate.
Summary of Case Review Results: The clinical case review component assessed 10 of the
12 primary (clinical) indicators applicable to CHCF. Of these ten indicators, OIG clinicians rated
two adequate and eight inadequate.

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The OIG physicians rated the overall adequacy of care for each of the 30 detailed case reviews
they conducted. Of these 30 cases, 13 were adequate and 17 were inadequate. In the
1,977 events reviewed, there were 665 deficiencies, 250 of which were considered to be of such
magnitude that, if left unaddressed, they would likely contribute to patient harm.
Adverse Deficiencies Identified During Case Review: Adverse deficiencies are medical errors
that markedly increased the risk of, or resulted in, serious patient harm. Medical care is a
complex and dynamic process with many moving parts, subject to human error even within the
best health care organizations. All major health care organizations typically identify and track
adverse deficiencies for quality improvement. Adverse deficiencies are not typically
representative of medical care delivered by the organization. The OIG normally identifies
adverse deficiencies for the dual purposes of quality improvement and the illustration of
problematic patterns of practice found during the inspection. Because of the anecdotal nature of
these deficiencies, the OIG cautions against drawing inappropriate conclusions regarding the
institution based solely on adverse deficiencies. The OIG identified eight adverse deficiencies in
the case reviews at CHCF:
•

In case 1, the patient had an intestinal bleed and low platelet levels. The hospital
physician recommended stopping the patient’s clopidogrel (a blood thinning medication
that decreases platelet function) and prescribing aspirin instead. While the providers
prescribed aspirin to the patient, they failed to stop the patient’s clopidogrel. They
prescribed both of the blood-thinning medications, which significantly increased the
patient’s risk of bleeding again. We also discuss this case in the Quality of Provider
Performance and Specialized Medical Housing indicators.

•

Also in case 1, the patient had low blood levels (anemia). By July 2017, the patient’s
blood levels had decreased to a critically low level. None of the providers reviewed this
abnormal laboratory result. As a result, they did not address the patient’s critically low
blood level until he had dialysis several days later. The following week, the patient’s
blood level decreased even further. Again, none of the providers acted immediately to
address the patient’s dangerously severe anemia. We also discuss this case in the Quality
of Provider Performance indicator.

•

Again in case 1, several providers did not thoroughly review the medical record and did
not recognize the patient’s irregular heart rhythm on two separate electrocardiograms
(EKGs). In failing to diagnose the patient’s irregular heart rhythm, the providers
significantly increased the patient’s risk of having a stroke or developing a blood clot in
his lungs. We also discuss this case in the Specialized Medical Housing indicator.

•

In case 7, the nurse failed to check the unresponsive patient for the presence of a pulse or
breathing. Because of this error, the emergency staff did not start CPR immediately. The
OHU nurse also requested 9-1-1 activation, but failed to direct a specific person to
perform the task, resulting in a delay in contacting EMS. When the nurses noted a pulse,
they stopped CPR, but did not check the patient for breathing. The nurses also failed to

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restart CPR immediately when the patient’s heart stopped beating again. We also discuss
this case in the Emergency Services and the Specialized Medical Housing indicators.
•

In case 8, the patient explained to the provider that in the event of his demise, he did not
want medical staff to perform heroic life-saving measures (i.e., CPR). The provider failed
to enter an order that reflected his wishes. Nurses did not ensure that those orders were
entered. When the patient’s condition deteriorated, medical staff performed CPR and
other emergency measures on the patient despite the patient’s most recent desire to
withhold those interventions.

•

In case 9, the patient had abdominal distention, lethargy, and confusion. A provider
ordered an emergency abdominal X-ray, which revealed the patient had a small bowel
obstruction. However, the provider was offsite and failed to inform the on-call physician
that this X-ray was pending. As a result, a provider never checked the abdominal X-ray.
The patient died five-hours later. The providers may have prevented this patient’s death if
a provider had known of the patient’s bowel obstruction and had promptly sent the
patient to an outside hospital for further management. We also discuss this case in the
Specialized Medical Housing indicator.

•

In case 17, the patient was taking a blood thinning medication, and the provider
inappropriately added aspirin, another blood thinning medication. Consequently, the
patient developed nasal and rectal bleeds.

•

In case 23, the patient had an aggressive bacterial infection in his right leg. CHCF staff
did not retrieve or scan his wound culture report for more than three weeks. The report
showed the bacteria was resistant to multiple antibiotics, including the antibiotic ordered
by the patient’s provider. This delay in critical health information transmission also
delayed the needed change in the patient’s antibiotic treatment. We also discuss this case
in the Diagnostic Services indicator.

Summary of Compliance Results: The compliance component assessed 10 of the 13 indicators
applicable to CHCF. Of these ten indicators, OIG inspectors rated one adequate and nine
inadequate. The results of those assessments are summarized within this section of the report.
Each section of this report summarizes the results of those assessments, whereas Appendix A
provides the details of the test questions used to assess compliance for each indicator.

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ACCESS TO CARE
This indicator evaluates the institution’s ability to provide patients
Case Review Rating:
with timely clinical appointments. Compliance and case review
Inadequate
Compliance Score:
teams review areas specific to patients’ access to care, such as initial
Inadequate
assessments of newly arriving patients, acute and chronic care
(68.2%)
follow-ups, face-to-face nurse appointments when patients request to
Overall Rating:
be seen, provider referrals from nursing lines, and follow-ups after
Inadequate
hospitalization or specialty care. Compliance testing for this
indicator also evaluates whether inmate patients have Health Care
Services Request forms (CDCR Form 7362) available in their housing units.

Case Review Results
We reviewed 410 provider, nursing, specialty, and outside hospital encounters that required
follow-up appointments, and identified 86 deficiencies relating to access to care. Of the
86 deficiencies, 57 were significant and placed the patient at an elevated risk of harm. Poor
health care access affected all aspects of health care delivery at CHCF. The case review rating
for the Access to Care indicator was inadequate.
Provider-to-Provider Follow-up Appointments
CHCF performance in this area remained relatively unchanged from Cycle 4. Failure to ensure
appointment availability can cause lapses in care. The OIG clinicians reviewed 88 outpatient
provider encounters and identified five deficiencies in cases 12, 22, 23, and 78. In these cases,
follow-up appointments occurred late. The following are two examples of such delays:
•

In case 22, the provider ordered a next-day follow-up for the patient to evaluate a right
testicular mass. The follow-up did not occur for seven days, which was a significant lapse
in care as the patient could have had an undiagnosed testicular cancer or an untreated
infection.

•

In case 78, the patient had a rash and right lower extremity swelling. The on-call provider
requested a two-day follow-up, but the appointment did not occur.

RN Sick Call Access
CHCF performed satisfactorily with sick call access. The OIG clinicians reviewed 122 RN sick
call encounters and identified only one significant deficiency:
•

In case 26, a nurse received a patient’s sick call requesting an urgent examination of a
lower extremity ulcer. However, the nurse evaluation did not occur until four days later.

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RN-to-Provider Referrals
Sick call nurses assess patients and make referrals to a provider when needed. CHCF performed
poorly with these appointments, as we found seven significant deficiencies in cases 21, 24, 25,
52, 104, and 107. The following examples show missed or delayed nurse-requested provider
appointments:
•

In case 24, a nurse requested a patient follow-up with a provider in 14 days to assess an
open head wound. However, the appointment never occurred.

•

In case 52, a nurse requested a same-day provider appointment because the patient had
testicular pain. However, the appointment did not occur until four days later.

•

In case 107, the patient complained of right-sided neck pain. Although the nurse
requested a one-day follow-up with the provider, the appointment did not occur until
seven days later.

Provider Follow-Up After Specialty Service
CHCF failed to consistently provide patients with provider follow-up appointments after
receiving specialty services. We reviewed 166 specialty diagnostic and consultative services and
found many instances in which follow-ups were delayed or did not occur. This pattern of delayed
follow-ups markedly increased the risk of lapses or delays in patient care. We found these
deficiencies in cases 5, 10, 15, 25, 28, 30, 32, and in the following cases:
•

In case 18, the provider requested an urgent appointment with an endocrinologist (a
doctor who treats hormonal imbalances) because the patient had uncontrolled diabetes.
After the patient returned from his endocrinology appointment, the nurse requested a
14-day follow-up with his provider. This appointment did not occur for nearly two
months, which increased the patient’s risk of developing diabetic complications.

•

In case 22, the patient returned after he had received an urgent urological procedure. The
provider requested a follow-up in three days. This appointment occurred 15 days outside
the requested time interval, which resulted in a significant delay in the patient’s medical
care.

•

In case 23, the patient had scarring of his cornea (the clear front surface of the eye)
resulting from a viral infection. The onsite eye doctor recommended an urgent referral to
an ophthalmologist (a specialty surgeon who diagnoses and treats eye diseases). The
nurse requested a three-day follow-up with the patient’s provider to process this urgent
recommendation, but that appointment occurred 22 days later (19 days late), a delay that
meant an ophthalmologist did not see the patient for nearly one month. This lapse in care
was significant as the patient’s eye infection could have worsened and caused blindness.

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Intra-System Transfers
Nurses assessed newly transferred patients correctly and typically referred them to a provider
timely. We reviewed three transfer-in patients and found no deficiencies with access to care in
this area.
Follow-up After Hospitalization
CHCF performance in patient follow-ups after hospitalizations was sufficient, similar to that
observed during Cycle 4. We reviewed 53 hospitalization and outside emergency events, and
identified only one deficiency with access to care in this area:
•

In case 26, the patient returned from an outside emergency department after he was
diagnosed with a lower extremity infection. Per CCHCS policy, a provider should have
seen the patient within five days. This follow-up occurred 13 days later (8 days late),
which increased the patient’s risk of developing complications due to his infection.

Follow-up After Urgent or Emergent Care
CHCF demonstrated substandard performance when scheduling provider follow-ups after
patients returned from the standby emergency medical services (SEMS) unit. The OIG reviewed
64 urgent or emergent encounters, 25 of which required a provider follow-up. We identified
deficiencies in three cases: 24, 29, and the following case:
•

In case 18, the patient had an abnormal EKG that showed he was having a possible
cardiac event. SEMS staff initially monitored the patient and then released him back to
his general housing unit. The SEMS provider requested a 14-day follow-up for additional
evaluation. This follow-up did not occur for approximately five weeks, resulting in a
significant lapse in care because this patient demonstrated risk factors for a heart attack,
and a provider did not see him for more than a month.

Specialized Medical Housing
CHCF performed poorly with provider access both during and after admission to the correctional
treatment center (CTC) and outpatient housing unit (OHU). Providers did not always see their
patients in the CTC and OHU within appropriate time intervals. CHCF possessed a license
waiver that allowed its providers to see patients every seven days once a provider was in place
who designated the patient as a long-term-care (LTC) patient in the CTC. Despite the allowance
granted by this waiver, we found that providers still did not see their patients within the sevenday interval and often saw the patients every two to three weeks instead. The OIG clinicians
reviewed six CTC admissions with 375 CTC provider encounters. We identified this pattern of
delay for both OHU and CTC patients in cases 4, 5, 9, 14, 16, 17, 19, 29, and 35.

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Specialty Access
CHCF performed poorly ensuring patients received appropriate access to specialty services. We
discuss this performance further in the Specialty Services indicator.
Clinician Onsite Inspection
Problems with access to care were primarily due to a lack of providers. We discuss this problem
further in the Quality of Provider Performance indicator. As noted in that indicator, we found 19
provider vacancies out of the 45 designated positions during our review period. This lack of
providers posed significant challenges for the institution to provide sufficient care quality.
CHCF also converted to the electronic health record system (EHRS) on July 11, 2017, which
contributed to the significant backlog of patients. During this process, CHCF scheduled fewer
patients for each provider because providers were learning and adapting to this new system.
This meant that on average, most providers saw only eight patients per day. The institution
gradually increased the number of patients scheduled to 14 patients in C yard, approximately 8
to 14 patients in D yard, and 14 patients in E yard.
At the time of the onsite inspection, CHCF reduced the patient backlog throughout the
institution by using telemedicine providers and registry providers (temporary physicians).
Case Review Conclusion
CHCF experienced problems providing patients with sufficient access to care during the review
period. We identified a significant backlog of patients during this review period. Although
implementing the EHRS exacerbated this backlog, CHCF providers saw more patients as they
became accustomed to the new system. CHCF also took steps to improve these access issues by
recruiting telemedicine providers and new registry physicians. While the OIG acknowledges this
institution’s ongoing efforts to improve access to care, many of these improvements either
occurred late or after this review period. Therefore, the results of these changes are not reflected
in the Cycle 5 rating. The OIG rated this indicator inadequate.

Compliance Testing Results
The institution performed in the inadequate range, with a score of 68.2 percent in the Access to
Care indicator. The following tests received scores in the inadequate range:
•

We sampled 25 patients with chronic care conditions and found that 14 (56.0 percent)
received timely provider follow-up appointments. Three patients’ follow-up
appointments were two to six days late. Four patients’ follow-up appointments were 45 to
76 days late. One patient’s follow-up appointment was 135 days late. For the remaining
three patients, a follow-up appointment never occurred (MIT 1.001).

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•

Among 25 patients sampled who transferred into CHCF and whom nurses referred to a
provider based on their initial health screening, only 9 were seen timely (36.0 percent).
For 15 patients, provider appointments occurred between 4 and 82 days late. One
patient’s provider visit never occurred at all (MIT 1.002).

•

We sampled 21 health care services request forms on which the nurse referred the patient
for a provider appointment. Thirteen patients (61.9 percent) received a timely
appointment. Four patients received their appointments between 4 and 18 days late. Two
patients received their appointments 40 and 79 days late, and two other patients did not
receive a provider visit at all (MIT 1.005).

•

Of the seven applicable sampled patients whom nursing staff referred to a provider and
for whom the provider subsequently ordered follow-up appointments, five patients
(71.4 percent) received timely follow-up appointments. For two patients, follow-up
appointments occurred one and 66 days late (MIT 1.006).

•

We tested 25 patients discharged from a community hospital to determine whether they
received provider follow-up appointments at CHCF within five calendar days of
returning to the institution. Thirteen patients (52.0 percent) received a timely provider
follow-up appointment. Twelve patients received their appointments between one and
66 days late (MIT 1.007).

•

Of 24 sampled patients who received a high-priority or routine specialty service, 12 of
them (50.0 percent) received a timely provider follow-up appointment with a CHCF
provider. Of those 12 patients who did not receive a timely follow-up appointment,
5 patients’ high-priority specialty service follow-up appointments were one to 45 days
late; 2 patients’ routine specialty service follow-up appointments were 9 and 30 days late;
and the remaining 5 patients’ routine specialty services follow-up appointments never
occurred (MIT 1.008).

Three tests received scores in the proficient range:
•

We reviewed 30 health care services request forms (CDCR Form 7362) submitted by
patients across all facility clinics. Nursing staff reviewed this form for 28 patients on the
same day the forms were collected (93.3 percent). For two patients, nursing staff
reviewed this form one day beyond the required time frame (MIT 1.003).

•

Nursing staff timely completed face-to-face triage encounters for 28 of 30 sampled
patients (93.3 percent). For one patient, nursing staff failed to complete documentation in
the Subjective, Objective, Assessment, Plan, and Education (SOAPE) format. For the
remaining patient, a face-to-face encounter never occurred (MIT 1.004).

•

Patients had access to health care services request forms at all six housing units we
inspected (MIT 1.101).

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DIAGNOSTIC SERVICES
This indicator addresses several types of diagnostic services.
Case Review Rating:
Specifically, it addresses whether radiology and laboratory services
Inadequate
Compliance Score:
were timely provided to patients, whether primary care providers
Inadequate
timely reviewed results, and whether providers communicated
(62.8%)
results to the patient within required time frames. In addition, for
Overall Rating:
pathology services, the OIG determines whether the institution
Inadequate
received a final pathology report and whether the provider timely
reviewed and communicated the pathology results to the patient.
The case reviews also factor in the appropriateness, accuracy, and quality of the diagnostic test(s)
ordered and the clinical response to the results.

Case Review Results
We reviewed 368 diagnostic events and found 63 deficiencies, of which 31 were significant. Of
those 63 deficiencies, we found 50 related to health information management and 13 related to
the noncompletion of ordered tests. For health information management, we considered test
reports that were never retrieved or reviewed just as severe of a problem as tests that were not
performed. The case review rating for this indicator was inadequate.
Test Completion
As we found in Cycle 4, CHCF continued to perform poorly with most diagnostic services.
CHCF often did not perform diagnostic services promptly. The institution also failed to
consistently perform diagnostic tests the providers ordered. Not completing diagnostic tests is a
serious deficiency that might lead to lapses in medical care. We found noncompleted laboratory
tests or diagnostic scans in cases 1, 5, 16, 18, 24, and 108. We discuss the following examples
for quality improvement purposes:
•

In case 16, the provider ordered an urgent, same-day chest X-ray to evaluate an elderly
patient with shortness of breath and cough. However, the chest X-ray was not performed
until four days later. This delay placed the patient at risk of having an undiagnosed and
untreated lung infection.

•

In case 24, the provider ordered laboratory tests to further monitor the patient’s
hepatitis C (a viral liver infection). CHCF never performed these tests, which potentially
delayed the patient’s hepatitis C treatment.

•

In case 108, the patient had right leg swelling and pain that caused concern for a blood
clot in his leg. While the provider did order an urgent ultrasound within two days, CHCF
never completed this diagnostic scan. This failure placed the patient at risk of developing
a stroke or cardiac arrest from an undiagnosed blood clot.

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We also found that SEMS nurses on the weekends often did not perform needed laboratory tests.
In cases 19, 22, and 29, during a weekend, the provider ordered urgent laboratory tests. The
nurses neither collected the specimens nor performed the tests. We also discuss these errors in
the Emergency Services indicator.
Health Information Management
CHCF performed poorly in retrieving and scanning diagnostic reports. We found delays in
scanning diagnostic and laboratory reports as well as failing to retrieve and scan in cases 5, 10,
22, 23, 34, and 35. These failures increased the risk of patient harm because pertinent
information was unavailable to subsequent providers. We provide the following examples for
quality improvement purposes:
•

In case 22, clinical staff evaluated an elderly patient in the SEMS unit for
lightheadedness. Although staff performed an EKG, this diagnostic test was not scanned
into the EHRS. This lapse in medical care was significant because this pertinent
information was unavailable to subsequent providers.

•

In case 23, the patient had a dangerous bacterial infection of his right leg. His wound
culture showed bacteria resistant to multiple antibiotics, including the antibiotic the
provider had ordered. This report was not retrieved or scanned into the EHRS for more
than three weeks, delaying a change in the patient’s antibiotic treatment.

•

In case 35, the patient had a slow-growing brain tumor. Although the patient had a
magnetic resonance imaging (MRI) scan, the results were not available in the EHRS or
the radiology information system-picture archive and communication system (RISPACS). This was a significant lapse in medical care because the MRI scan was not
available to guide the patient’s treatment plan.

We also found that CHCF providers failed to sign diagnostic or laboratory reports in cases 1, 2,
11, 14, 16, 18, 19, 26, 28, 30, 31, 32, and 34. CHCF providers also did not consistently review
diagnostic and laboratory results promptly. We identified delays in test review in cases 12, 15,
17, 18, 19, 21, 23, and 30.
Clinician Onsite Inspection
We learned that although reports generated from onsite radiology tests flowed directly into the
EHRS for the providers to review, the reports from offsite radiology tests were scanned into the
radiology information system (RIS) instead. Unfortunately, we discovered that a majority of the
providers could not access the radiology reports from the RIS. As a result, these providers could
not review multiple offsite diagnostic reports. To efficiently review these offsite radiology
reports and to provide necessary patient care, the providers strongly recommended that the
institution should scan these offsite reports directly into the EHRS. The OIG agrees that while
the most efficient method would be for the institution to scan the reports directly into the EHRS,

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we recommend that CHCF should at least ensure the providers have access to the RIS and can
show proficiency retrieving offsite radiology reports.
Case Review Conclusion
During this review period, CHCF performed poorly in most aspects of diagnostic services that
involved laboratory services. We identified deficiencies in the collecting and processing of
diagnostic tests ordered by providers. Also, we found a pattern whereby providers did not review
laboratory and diagnostic reports. A majority of providers had difficulty accessing offsite
radiology reports in the RIS. Because of these problems, we rated this indicator inadequate.

Compliance Testing Results
The institution received an inadequate compliance score of 62.8 percent in the Diagnostic
Services indicator, which encompasses radiology, laboratory, and pathology services. For clarity,
each type of diagnostic service is discussed separately below:
Radiology Services
•

CHCF timely performed radiology services for nine of ten sampled patients
(90.0 percent). For one patient, the institution provided radiology services two days late
(MIT 2.001). Providers timely reviewed the corresponding diagnostic services reports for
only two of ten patients (20.0 percent). For eight patients, we found no evidence the
providers reviewed their reports at all (MIT 2.002). Providers timely communicated the
diagnostic results to only three of ten patients (30.0 percent). Of the remaining seven, for
three patients, providers communicated the results between 3 to 26 days late; and for four
patients, providers did not communicate the results at all (MIT 2.003).

Laboratory Services
•

CHCF timely performed all ten sampled laboratory services, and providers also reviewed
the laboratory results promptly (MIT 2.004, 2.005). Providers timely communicated the
results to only two of the nine sampled patients (22.2 percent). For six patients, the
written communication received from the provider failed to identify the specific
laboratory test referenced. For the remaining patient, the provider did not communicate
the result at all (MIT 2.006).

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Pathology Services
•

The institution received final pathology reports in a timely manner for seven of ten
sampled patients (70.0 percent). For two patients, the institution received the reports
10 and 20 days late; and for one other patient, the institution did not obtain the final
pathology report (MIT 2.007). Providers properly showed evidence of their review of the
pathology results for eight of nine patients (88.9 percent). One report was reviewed one
day late (MIT 2.008). Finally, while providers timely communicated the pathology results
to four of the nine patients (44.4 percent), for five patients, providers communicated the
pathology results between one and 20 days late (MIT 2.009).

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EMERGENCY SERVICES
An emergency medical response system is essential to providing
Case Review Rating:
effective and timely emergency medical response, assessment,
Adequate
treatment, and transportation 24 hours per day. Provision of
Compliance Score:
urgent/emergent care is based on a patient’s emergency situation,
Not Applicable
clinical condition, and need for a higher level of care. The OIG
Overall Rating:
reviews emergency response services including first aid, basic life
Adequate
support (BLS), and advanced cardiac life support (ACLS) consistent
with the American Heart Association guidelines for cardiopulmonary
resuscitation (CPR) and emergency cardiovascular care, and the provision of services by
knowledgeable staff appropriate to each individual’s training, certification, and authorized scope
of practice.
The OIG evaluates this quality indicator entirely through clinicians’ reviews of case files and
conducts no separate compliance testing element.

Case Review Results
We reviewed 64 urgent/emergent events and found 44 deficiencies in various aspects of urgent
and emergent medical care. We found eight significant deficiencies that occurred in cases 3, 10,
11, 19, 22, and 27. The case review rating for the Emergency Services indicator was adequate.
CPR Response
We reviewed eight CPR events. Two CPR events occurred in the outpatient yard (E yard).
During these events, custody staff promptly notified medical staff and began CPR. First medical
responders (FMRs) from the SEMS unit arrived on scene in a timely manner, and custody
officers and nurses worked together to provide coordinated resuscitation attempts. Six other CPR
events occurred in the specialized medical housing areas where CTC and OHU nurses usually
responded quickly and intervened appropriately in emergency CPR situations. One OHU event
occurred during which the CPR response was subpar. The institution should use the following
exception for quality improvement purposes:
•

In case 7, the nurse failed to check the unresponsive patient for the presence of a pulse
and respiration. Because of this error, emergency staff did not start CPR promptly. The
OHU nurse also requested 9-1-1 activation, but failed to direct a specific person to
perform the task, resulting in a delay in contacting EMS. When the nurses noted a pulse,
they stopped CPR, but did not check the patient for breathing. The nurses also failed to
restart CPR immediately when the patient’s heart stopped beating again. We also discuss
this case in the Specialized Medical Housing indicator.

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Provider Performance
CHCF providers generally made appropriate assessments and created proper treatment plans
when patients presented emergently to the SEMS unit. The providers were frequently available
for immediate consultation. The following two case examples were not representative of most
SEMS provider care, but should be used for quality improvement purposes:
•

In case 3, a provider evaluated the patient for a seizure, but did not perform a head or
neurological examination to assess for possible head trauma.

•

In case 11, the patient with multiple cardiac risk factors complained of chest pain and
became unresponsive during dialysis. When a provider subsequently evaluated the patient
in the SEMS unit, the provider did not consider heart disease as a possible explanation for
the patient’s symptoms and did not address the patient’s elevated blood pressure.

CHCF providers did not consistently document their SEMS assessments and decision-making in
cases 10, 11, 19, 28, 34, and the following:
•

In case 12, the patient had a cardiac arrest, and a SEMS provider performed appropriate
clinical interventions; however, the provider did not document the emergent event.

Nursing Performance
SEMS nurses usually conducted appropriate assessments and interventions, and notified
providers promptly. Most deficiencies were minor and occurred in cases 10, 19, 22, 27, and 29.
Nonetheless, there was room for improvement in this area. The following examples illustrated
some of these concerns:
•

In case 10, the patient was short of breath, and his oxygen saturation level was very low.
He was also wheezing and coughing up bloody sputum. The nurse gave the patient a low
dose of oxygen, but failed to check whether the patient’s breathing improved. Almost one
hour later, the patient remained in respiratory distress and was sent to the hospital.

•

In case 27, the patient had severe abdominal pain. The nurse did not monitor the patient’s
condition while awaiting his transfer to a community hospital.

•

In cases 19, 22, and 29, during a weekend, the provider ordered urgent laboratory tests.
The nurses neither collected the specimens nor performed the tests. We also discussed
this issue in the Diagnostic Services indicator.

Nursing Documentation
While SEMS nurses assessed and intervened appropriately during emergent events, they usually
failed to record accurate sequential timelines and other pertinent information concerning the
event. We identified poor nursing documentation, mostly discrepancies in recording timelines of
emergent events, as well as incomplete documentation of nursing care. These deficiencies
occurred in cases 1, 3, 5, 9, 10, 11, 12, 13, 23, 27, 29, and 30.
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Emergency Medical Response Review Committee
The Emergency Medical Response Review Committee (EMRRC) met regularly and discussed
emergent events. The committee properly identified clinical deficiencies and provided nursing
training when deficiencies were identified.
Clinician Onsite Inspection
In most California state prisons, medical staff typically deliver urgent medical care in an
unlicensed triage and treatment area (TTA). Unlike most prisons, the SEMS unit at CHCF is a
California state-licensed emergency care area. SEMS medical providers are physically present in
the unit 16 hours each weekday and are “on-call” overnight. Providers are also present for a full
24 hours on both weekend days. Registered nurses (RNs), licensed vocational nurses (LVNs),
and certified nursing assistants (CNAs) staff the SEMS unit during each shift.
During our onsite inspection, the SEMS unit had four bays; each was spacious, well-stocked, and
was fully visible from the nurse’s station. The staff explained that one RN and one LVN were
always ready to respond to emergencies in the housing units and clinics. They also explained that
in addition to urgent and emergent care, the SEMS staff evaluated patients after they returned
from specialty appointments, community emergency departments, and offsite hospitalizations. In
all, the staff reported an average of 700 SEMS patient encounters each month.
Case Review Conclusion
CHCF provided appropriate emergency care. The EMRRC successfully identified care deficits,
and SEMS supervisors trained their staff appropriately. However, we found that nurse and
provider documentation discrepancies affected the ability to thoroughly assess the sequence of
events, an area that could be improved. Nonetheless, clinically significant problems were
relatively rare, and we rated the Emergency Services indicator adequate.

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HEALTH INFORMATION MANAGEMENT
Health information management is a crucial link in the delivery of
Case Review Rating:
medical care. Medical personnel require accurate information in
Inadequate
Compliance Score:
order to make sound judgments and decisions. This indicator
Inadequate
examines whether the institution adequately manages its health care
(63.8%)
information. This includes determining whether the information is
correctly labeled and organized and available in the electronic
Overall Rating:
Inadequate
medical record; whether the various medical records (internal and
external, e.g., hospital and specialty reports and progress notes) are
obtained and scanned timely into the patient’s electronic medical record; whether records routed
to clinicians include legible signatures or stamps; and whether hospital discharge reports include
key elements and are timely reviewed by providers.

Case Review Results
The OIG clinicians reviewed 1,977 events and found 99 deficiencies related to health
information management. Of those 99 deficiencies, 32 were significant. The case review rating
for this indicator was inadequate.
Hospital Records
We reviewed 53 offsite emergency department and hospital visits. CHCF staff timely retrieved
hospital records, scanned them into the medical record, and reviewed them appropriately. We
found no deficiencies in this area.
Specialty Services
CHCF performed adequately concerning specialty reports. The institution retrieved specialty
reports and scanned them into the medical record promptly. However, we identified a pattern in
which CHCF staff scanned specialty reports into the EHRS without evidence of review. We also
discuss these findings in the Specialty Services indicator.
Diagnostic Reports
CHCF performed poorly with its diagnostic report processing. We found delays in scanning
diagnostic and laboratory reports, and noted the institution’s failure in retrieving and scanning
these reports in cases 5, 10, 22, 23, 34, and 35. Most CHCF providers could not access or review
offsite radiology reports because they did not have functioning access to the RIS. We discussed
these findings in the Diagnostic Services indicator.

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Urgent/Emergent Records
CHCF providers usually performed sufficiently when documenting their SEMS encounters with
patients. However, we noted room for improvement in this area. The Emergency Services
indicator provides additional details.
Scanning Performance
CHCF performed poorly in this area. We identified mistakes in the document scanning process
in which documents were either mislabeled or misfiled (filed in the wrong chart). Erroneously
scanned documents can create delays or lapses in care by hindering providers’ ability to find
relevant clinical information. We found mislabeled or misfiled documents in the electronic unit
health record (eUHR) and the EHRS in cases 2, 4, 9, 17, 21, 23, 25, 42, 43, 47, 48, 58, 99, and
104.
Legibility
Legibility was not an issue after CHCF transitioned to the EHRS. CHCF required all onsite staff to
type or dictate their entries into the EHRS after the transition.
Clinician Onsite Inspection
The OIG clinicians observed clinical information transmission during the morning huddles. All
units used a standardized CCHCS huddle agenda. Staff displayed clinical information on a large
monitor for ease of information dissemination and discussion. They also reviewed and renewed
expiring medications during the morning huddle. Despite using the standard CCHCS huddle
agenda, however, the quality of the huddles varied significantly among different units. Some
teams were unfamiliar with their patients or the care being delivered. These teams were only
superficially aware of important after-hours clinical information, and they used the huddles
primarily as a scheduling tool only. However, in other huddles, care teams were fully cognizant
of their patients’ care needs. Besides ensuring appropriate appointment scheduling, these wellperforming teams transmitted important information and developed staff-specific care plans.
Those plans included monitoring and contingency interventions for patients returning from the
SEMS unit or other higher levels of care.
Case Review Conclusion
CHCF’s performance in the Health Information Management indicator was variable compared to
Cycle 4. The institution performed well with retrieving outside emergency department reports
and hospital discharge summaries. However, diagnostic report processing was poor. Providers
did not perform well with signing laboratory and diagnostic reports, and they rarely had access to
any offsite radiology reports. Scanning performance was poor. Documents were frequently
mislabeled in the electronic medical record. Huddle quality was inconsistent. Overall, CHCF
performed poorly in several important areas in Health Information Management, and we rated
this indicator inadequate.
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Compliance Testing Results
The institution scored in the inadequate range with a score of 63.8 percent in the Health
Information Management indicator. The following tests were inadequate:
•

CHCF scored zero on labeling and filing of documents scanned into patients’ electronic
medical records. For this test, once the OIG identifies 24 mislabeled or misfiled
documents, we deduct the maximum amount of points, which resulted in a score of zero
for this test (MIT 4.006).

•

We reviewed electronic medical records for 25 patients who were admitted to a
community hospital and returned to the institution; providers timely reviewed
16 corresponding hospital discharge reports within three calendar days of the patient’s
discharge (64.0 percent). For seven patients, providers reviewed their hospital discharge
reports one to 11 days late. For two remaining patients, providers reviewed reports 61 and
67 days late (MIT 4.007).

Two tests received adequate scores:
•

Of 20 sampled specialty service consultant reports (75.0 percent), 15 were scanned into
the patient’s electronic medical records within five calendar days. Five documents were
scanned one to two days late (MIT 4.003).

•

CHCF medical records staff timely scanned patients’ discharge reports into 16 of the
20 sampled patients’ electronic medical records (80.0 percent). Four reports were
scanned between one and seven days late (MIT 4.004).

One test received a proficient score:
•

The institution timely scanned all ten sampled health care documents into patients’
electronic medical records within three calendar days of the patient’s encounter
(MIT 4.001).

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HEALTH CARE ENVIRONMENT
This indicator addresses the general operational aspects of the
institution’s clinics, including certain elements of infection control
and sanitation, medical supplies and equipment management, the
availability of both auditory and visual privacy for patient visits, and
the sufficiency of facility infrastructure to conduct comprehensive
medical examinations. The OIG rates this component entirely on the
compliance testing results from the visual observations inspectors
make at the institution during their onsite visit. There is no case
review portion.

Case Review Rating:
Not Applicable
Compliance Score:
Inadequate
(69.5%)
Overall Rating:
Inadequate

Compliance Testing Results
The institution received scores in the inadequate range in the following five tests:

•

CHCF appropriately disinfected, cleaned,
and sanitized 18 of 35 clinic locations
inspected (51.4 percent). In 17 clinic
locations, the staff did not maintain the
cleaning log. In addition, we found one
clinic’s gurney stretcher exhibited
extensive dirt and built-up dust
(MIT 5.101) (Figure 1).

•

The non-clinic bulk medical supply
storage areas did not follow the supply
management process and did not support
Figure 1: Unsanitary gurney
the needs of the health care program,
resulting in a score of zero for this test.
During our interview at the time of inspection, the warehouse managers expressed their
concerns regarding the lack of training for nursing staff in following the approved supply
management protocols. In addition, medical supplies were found stored beyond
manufacturers’ guidelines and were found sitting directly on the floor (MIT 5.106).

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•

Only 23 of the 35 clinics inspected followed
adequate medical supply storage and
management protocols (65.7 percent). We
found 10 clinics stored germicidal wipes in the
same area with medical supplies. In addition,
two clinics stored medical supplies beyond
manufacturers’ guidelines (Figure 2)
(MIT 5.107).

Figure 2: Expired medical supplies

•

Among 35 clinic locations, 25 (71.4 percent)
met compliance requirements for essential
core medical equipment and supplies. The
remaining 10 clinics were missing one or
more functional pieces of properly calibrated
core equipment or other medical supplies
necessary to conduct a comprehensive
examination. The missing items included a
peak flow meter, gloves, lubricating jelly, an
automated external defibrillator, and
examination table disposable paper. A blood
pressure machine and nebulization units did
not have current calibration stickers, an
otoscope was not operational, and tongue
depressors were stored in an unsanitary
container (Figure 3) (MIT 5.108).

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Figure 3: Tongue depressor stored in
an unsanitary container

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•

We examined emergency medical response bags (EMRBs) to determine if staff inspected
the bags daily and inventoried them monthly and whether they contained all essential
items. EMRBs were compliant in only one of four applicable clinical locations (25.0
percent). We found one or more of the following deficiencies at three locations: staff
failed to verify that the bag’s compartments were sealed and intact; an EMRB was
missing two different sizes of blood pressure cuffs: a regular (adult) and an extra-large;
and the emergency crash cart had medical supplies stored beyond manufacturers’
guidelines (MIT 5.111).

Two tests received scores in the adequate range:
•

We observed clinician encounters with patients in 35 clinics. Clinicians followed good
hygiene practices in 29 clinic locations (82.9 percent). At six clinic locations, clinicians
failed to wash their hands before or after patient contact, or before applying gloves
(MIT 5.104).

•

Of the 35 clinics we observed, 29 had appropriate space, configuration, supplies, and
equipment to allow clinicians to perform a proper clinical examination (82.9 percent).
The remaining six clinics had one or more of the following deficiencies: examination
tables had torn vinyl covers; an examination room did not provide visual privacy; and
confidential medical records were easily accessible by unauthorized individuals
(MIT 5.110).

Four tests received scores in the proficient range:
•

Clinical health care staff at 31 of the 35 applicable clinics (88.6 percent) ensured that they
properly sterilized or disinfected reusable invasive and non-invasive medical equipment.
Clinical staff in four clinics failed to mention disinfecting examination tables before the
start of the shift as part of their daily start-up protocol (MIT 5.102).

•

Of the 35 clinics inspected, 34 of them had operating sinks and sufficient quantities of
hand hygiene supplies in the examination areas (97.1 percent). One clinic’s examination
room did not have antiseptic soap (MIT 5.103).

•

Health care staff at all 35 clinics followed proper protocols to mitigate exposure to
bloodborne pathogens and contaminated waste (MIT 5.105).

•

All 35 clinics had environments conducive to providing medical services; they provided
reasonable auditory privacy, appropriate waiting areas, wheelchair accessibility, and
sufficient non-exam room workspace (MIT 5.109).

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Non-Scored Results
The OIG gathered information to determine whether CHCF staff maintained the institution’s
physical infrastructure in a manner that supported health care management’s ability to provide
timely or adequate healthcare. We did not score this question.
•

When we interviewed health care managers, they did not express concerns about the
facility’s infrastructure or its effect on the staff’s ability to provide adequate health care.
At the time of inspection, CHCF did not have any infrastructure projects (MIT 5.999).

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INTER- AND INTRA-SYSTEM TRANSFERS
This indicator focuses on the management of patients’ medical needs
Case Review Rating:
and continuity of patient care during the inter- and intra-facility
Inadequate
Compliance Score:
transfer process. The patients reviewed for this indicator include
Inadequate
those received from, as well as those transferring out to, other CDCR
(46.3%)
institutions. The OIG review includes evaluation of the institution’s
ability to provide and document health screening assessments,
Overall Rating:
Inadequate
initiation of relevant referrals based on patient needs, and the
continuity of medication delivery to patients arriving from another
institution. For those patients, the OIG clinicians also review the timely completion of pending
health appointments, tests, and requests for specialty services. For patients who transfer out of
the institution, the OIG evaluates the ability of the institution to document transfer information
that includes pre-existing health conditions, pending appointments, tests and requests for
specialty services, medication transfer packages, and medication administration prior to transfer.
The OIG clinicians also evaluate the care provided to patients returning to the institution from an
outside hospital and check to ensure appropriate implementation of the hospital assessment and
treatment plans.

Case Review Results
We reviewed 63 inter and intra-system transfer events, including information from both the
sending and receiving institutions. These included 53 hospitalization and offsite emergency
department events, each of which resulted in a transfer back to the institution. There were
36 deficiencies, 13 of which were significant. We identified significant deficiencies in cases 1,
23, 29, 30, 37, and 39. The case review rating for this indicator was inadequate.
Transfers In
We reviewed three transfer-in cases, which yielded five relevant events. CHCF nurses initiated
appropriate provider referrals, but did not consistently make appropriate nursing assessments. In
cases 36 and 38, both patients had risk factors for valley fever, but the receiving and release
(R&R) nurses did not recognize or identify them. We also found mislabeled records in two cases
and one significant deficiency as noted in the following:
•

In case 37, the nurse did not administer the newly transferred patient’s bedtime
medications, which included his insulin and seizure medications. This error placed the
patient at risk for diabetic and seizure complications. When the provider performed a
history and physical examination, the provider did not recognize or process the patient’s
pending cardiology appointment. The provider’s error resulted in a lapse in
specialty care.

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Transfers Out
We found the transfer-out process acceptable. We reviewed four cases in which patients
transferred out to other CDCR institutions. In all of them, CHCF nurses performed face-to-face
evaluations before the patients transferred out of the institution. However, we found
improvement opportunities in this area. CHCF nurses did not always record pertinent
information such as where the patient was transferred to, or if CHCF sent medications and
medical equipment with the patient. We also considered one deficiency significant:
•

In case 39, the patient had a history of seizures, hypertension, and abdominal infection.
CHCF transferred the patient to another CDCR institution without his seizure,
hypertension, antibiotics, or other medications. This error placed the patient at elevated
risk for a lapse in medication continuity and other medical complications.

Hospitalizations
Patients returning from hospitalizations are some of the highest-risk encounters because of two
factors. First, these patients are generally hospitalized for severe illness or injury. Second, they
are at risk because of potential lapses in care that can occur during any transfer.
CHCF performed poorly for patients returning from an offsite hospital or emergency department.
We reviewed 53 hospital events that occurred in 22 cases and identified 26 deficiencies. Nurses
frequently failed to complete essential portions of the nursing assessment, such as basic vital sign
measurements, pain levels, or assessment of the affected body part. Also, nurses frequently did
not give patients their medications in a timely manner or gave incorrect doses. Providers also
sometimes failed to address new hospital diagnoses and recommendations (cases 1, 30, and 31).
The following examples illustrate these problems with CHCF’s hospital return process:
•

In case 1, the patient had an intestinal bleed and low platelet (a component of the blood
that helps control bleeding) levels. During two hospitalizations, the hospital physician
repeatedly recommended stopping a blood thinning medication. Despite those
recommendations, the CHCF provider continued prescribing the blood thinner. These
errors placed the patient at an increased risk of bleeding. The hospital physician also
recommended that providers avoid prescribing aspirin (a drug that disables platelets)
unless the platelet level increased to a safe, specified level; however, the provider
prescribed the aspirin without checking the platelet level, which also placed the patient at
risk of further bleeding.

•

In case 4, the patient had severe lung disease and depended on supplemental oxygen. He
returned after a 10-day hospitalization and complained of shortness of breath. The nurse
gave the patient a breathing treatment, but did not evaluate his response to the treatment
and failed to determine whether the treatment was effective.

•

In case 23, the patient returned from the hospital where physicians had diagnosed him
with severe blood and leg infections. The nurse failed to examine the patient’s leg. Also,

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upon return from the hospital, the provider prescribed important antibiotics to continue to
treat the leg infection. The patient received the medications several days later, creating a
lapse in medication continuity and increasing the patient’s risk for infection
complications.
•

In case 30, the hospital physician recommended getting an MRI scan of the heart to test
for specific heart disease and a computed tomography (CT) scan of the chest to evaluate a
lung nodule. The provider failed to address those recommendations.

•

In case 31, the hospital physician recommended specific dosages of the patient’s heart
medications. When the patient returned from the hospital, a CHCF provider failed to
prescribe the medications at the recommended dosages. Fortunately, a nurse recognized
the errors and sent a message to a different provider the following day to correct
the error.

Clinician Onsite Inspection
The R&R nurses were knowledgeable about their job duties and the transfer process. We met
with medical, nursing, and pharmacy management to discuss some of the case review findings.
CHCF managers explained that some of their institution’s deficiencies occurred due to
implementing the EHRS and their staff’s unfamiliarity with the attendant new documentation
and medication ordering processes. The managers reported that they provided their staff with
additional training regarding the transfer process.
Case Review Conclusion
CHCF did not perform well for patients returning from an offsite hospital. Providers made
critical errors when addressing new diagnoses and recommendations. We also found important
lapses in medication continuity. At times, nurses’ evaluations and supporting documentation
were missing pertinent information. Nurses also did not consistently ensure medication
continuity for patients who transferred into or out of the institution. The transfer process is one
area the institution should target for quality improvement. We rated the Inter- and Intra-System
Transfers indicator inadequate.

Compliance Testing Results
The institution scored in the inadequate range for this indicator, with a score of 46.3 percent,
with inadequate scores in the following tests:
•

Only 7 of 25 sampled patients (28.0 percent) who transferred into CHCF from other
CDCR institutions had an initial health screening (CDCR Form 7277) completed on the
same day the patient arrived. For 18 patients, nursing staff neglected to record an answer
to one or more of the screening form questions (MIT 6.001).

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•

Of 25 sampled patients who transferred into CHCF, 14 had an existing medication order
that required nursing staff to issue or administer medications upon arrival. Ten patients
(71.4 percent) received their medications without interruption. Four patients incurred
medication interruptions of one or more dosing periods upon arrival (MIT 6.003).

•

Among 20 sampled patients who transferred out of CHCF to another CDCR institution,
only 8 (40.0 percent) had their scheduled specialty service appointments properly
documented on the health care transfer form. For 12 patients, CHCF failed to document
specialty service appointments on the transfer forms (MIT 6.004).

•

CHCF received a score of zero when we tested four patients transferring out of the
institution to determine whether their transfer packages included required medications
and related documentation. All four transfer packages were missing the medication
administration record and the required transfer checklist forms (MIT 6.101).

One test received a proficient score:
•

For 23 of 25 sampled patients (92.0 percent) who transferred into CHCF, nursing staff
timely completed the assessment and disposition sections of the initial health screening
form (CDCR Form 7277) on the same day that they performed the patient’s initial health
care screening. For two patients, nursing staff failed to complete the assessment and
disposition section of the screening form (MIT 6.002).

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PHARMACY AND MEDICATION MANAGEMENT
This indicator is an evaluation of the institution’s ability to provide
Case Review Rating:
appropriate pharmaceutical administration and security management,
Inadequate
Compliance Score:
encompassing the process from the written prescription to the
Inadequate
administration of the medication. By combining both a quantitative
(51.9%)
compliance test with case review analysis, this assessment identifies
issues in various stages of the medication management process,
Overall Rating:
Inadequate
including ordering and prescribing, transcribing and verifying,
dispensing and delivering, administering, and documenting and
reporting. Because numerous entities across various departments affect medication management,
this assessment considers internal review and approval processes, pharmacy, nursing, health
information systems, custody processes, and actions taken by the prescriber, staff, and patient.

Case Review Results
We reviewed 31 cases related to medications and found 24 medication deficiencies, 19 of which
were significant. We identified significant deficiencies in cases 1, 2, 3, 4, 5, 10, 12, 17, 21, 22,
23, 24, 28, 29, 30, 32, 37, 39, and 82. We found lapses in medication continuity and medications
that were not administered or prescribed correctly. The case review rating for this indicator was
inadequate.
Medication Continuity
During this review period, CHCF performed poorly with chronic medication continuity due to
delayed medication refills, unavailable medications, and interruptions related to the transfer
process. These lapses in medication continuity increased the patients’ risk for medical
complications. We also discussed several of these cases in the Inter- and Intra-System Transfers
indicator. These deficiencies occurred in 14 cases: 1, 3, 4, 11, 24, 25, 29, 30, 37, 39, 82, and the
following:
•

In case 2, the patient submitted a refill request for his diabetic medication, but did not
receive this medication. A week later, he submitted a second request. After not receiving
the medication, he submitted a third request. The patient received the medication two
weeks after his initial request. This lapse placed him at risk for diabetic complications.

•

In case 21, the provider renewed the patient’s blood pressure medication improperly. The
provider entered an incorrect start date, resulting in a five-day delay. This lapse in
medication continuity placed the patient at an increased risk for complications such as
stroke or heart attack.

•

In case 23, the patient did not receive aspirin for one month because the nurses recorded
the medication was “not available.” The OIG doubts the validity of the nurses’
documentation, as this medication is commonly available over-the-counter.

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Medication Administration
We also found several problems with medication administration. Nurses frequently failed to
administer medications timely or at all, gave incorrect doses, or recorded inaccurate
administration, or failed to record administration at all. The nurses did not properly administer
medications in cases 4, 5, 10, 11, 12, 21, 22, 23, 26, 28, 29, 30, 32, and 37. Nurses delayed
administering newly prescribed medications, including critical antibiotics for infections, in cases
11, 16, 21, 22, 23, 24, 28, 29, 30, 32, and 114. The nurses also gave incorrect medication doses
in cases 5, 23, 28, and 29. We also found inaccurate or missing documentation of medication
orders and administration in cases 5, 10, 11, 21, 23, 26, 28, 30, 32, and 94. The following cases
are only a few examples of these problems:
•

In case 10, the provider ordered nurses to not administer the patient’s blood pressure
medication if the patient’s blood pressure or heart rate was below a specific value. On
numerous occasions, the nurses administered the patient’s blood pressure medications
even when the patient’s heart rate was too low. Furthermore, the nurses failed to
consistently check the patient’s blood pressure and heart rate before giving the blood
pressure medication, despite instructions to do so.

•

In cases 5, 23, and 28, the nurses administered the wrong dosage of insulin. This error
placed the patients at risk for diabetic complications.

•

In case 29, the patient had a history of blood clots in his legs and lungs. The provider
ordered a blood thinning medication to prevent clot formation. The nurse gave the patient
double the prescribed dose for two days. This error placed the patient at an increased risk
of bleeding and other complications.

•

In case 30, the patient had a history of high blood pressure. The provider ordered a blood
pressure medication to be given when the patient’s blood pressure was elevated. On
numerous occasions, nurses failed to administer the medication when the patient’s blood
pressure was elevated.

Clinician Onsite Inspection
We met with pharmacy and nursing managers to discuss our case review findings. CHCF
managers attributed some deficiencies to the implementation of the new EHRS and their staff
being unfamiliar with the new system. For example, if a provider prescribed keep-on-person
(KOP) medications after the pharmacy had closed (e.g., on Friday evenings, weekends, or
holidays), the pharmacy could not verify or fill the prescription. Without pharmacy verification,
the EHRS could not alert the nurse to issue the medication, and the nurse would remain unaware
of the new prescription until the pharmacy re-opened. CHCF does not have enough pharmacy
staff to keep the pharmacy open on the weekends. Because of these issues, many patients did not
receive medications prescribed on the weekends in a timely manner. At the time of our onsite
inspection, CHCF was still developing a solution to resolve this concern. Managers also

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attributed some errors to insufficient training of nursing staff, but explained that they had since
provided additional training and education to their staff.
Case Review Conclusion
We found evidence of significant problems with medication continuity and administration. The
institution also struggled with ensuring medication continuity for patients who received chronic
medications, those transferring into or out of the institution, and those returning from an offsite
hospital. Nurses also struggled with proper medication administration and documentation.
Medication management remains an area CHCF should continue to target for quality
improvement. We rated the Pharmacy and Medication Management indicator inadequate.

Compliance Testing Results
The institution received a score of 51.9 percent in the Pharmacy and Medication Management
indicator. For discussion purposes below, this indicator is divided into three sub-indicators:
medication administration, observed medication practices and storage controls, and pharmacy
protocols.
Medication Administration
For this sub-indicator, the institution received an inadequate score of 51.0 percent. The following
tests were inadequate:
•

CHCF administered chronic care medications in a timely manner to 11 of the 23
applicable sampled patients (47.8 percent). For five patients, we found no evidence that
they received or refused nurse-administered medications. Four patients did not receive
their KOP medications per CCHCS policy requirements. Two patients’ medications were
not made available timely as ordered by the provider. For one patient, nursing staff
administered a medication outside the provider’s blood-pressure parameter order and also
withheld another medication without a physician’s order to do so (MIT 7.001).

•

CHCF timely administered or delivered newly prescribed medications to 16 of the
25 sampled patients (64.0 percent). Six patients’ medications were not made available
timely to the patients. Two patients received their medication two days late. For one
patient, nursing staff administered the wrong insulin dosage (MIT 7.002).

•

Clinical staff timely provided new and previously prescribed medications to only 3 of
25 sampled patients (12.0 percent) who transferred from a community hospital and
returned to the institution. Specifically, 17 patients’ medications were not made available
or administered timely as prescribed. For two patients, we found no evidence whether
they received or refused their medications. Three patients did not receive required
counseling for missed doses (MIT 7.003).

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One test earned an adequate score:
•

CHCF ensured that 20 of 25 sampled patients (80.0 percent) received their medications
without interruption when they transferred from one housing unit to another. Five
patients did not receive their medications at the proper dosing interval (MIT 7.005).

Observed Medication Practices and Storage Controls
The institution scored 61.8 percent in this sub-indicator, with the following tests scoring in the
inadequate range:
•

The institution employed adequate security controls over narcotic medications in 6 of the
34 applicable clinic and medication line locations where narcotics were stored
(17.7 percent). At 28 locations, one or more of the following deficiencies occurred: the
Omnicell inventory receipt and narcotics logbook showed that on multiple occasions,
controlled substance inventory counts were not performed by two licensed nursing staff;
nursing staff were unable to give a verbal account of the medication error reporting
process; nurses waited until the end of the medication administration line to update the
narcotics logbook; and nurses did not counter-sign the narcotics logbook to verify the
proper destruction of controlled substances (MIT 7.101).

•

We observed the medication preparation and administration processes at eight applicable
medication line locations. Nursing staff were compliant regarding proper hand hygiene
and contamination control protocols at five locations (62.5 percent). At three locations,
not all nursing staff washed or sanitized their hands when required, such as before putting
on gloves, after intentionally touching a patient’s skin, before subsequent re-gloving, and
before preparing and administering medications (MIT 7.104).

•

Only two of eight inspected medication preparation and administration areas
demonstrated appropriate administrative controls and protocols (25.0 percent). At six
different locations, we observed one or more of the following deficiencies: medication
nurses did not always ensure that patients swallowed direct observation therapy
medications, and medication nurses did not follow manufacturers’ guidelines related to
the proper administration of insulin to diabetic patients. Those guidelines require
medication nurses to verify the patient’s blood glucose level from his KOP glucometer
before administering medication, to disinfect previously opened multi-use insulin vials
before withdrawing and administering medication, and to refrigerate insulin medication
vials when not in active use (MIT 7.106).

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One test received an adequate score:
•

CHCF properly stored non-narcotic medications that did not require refrigeration in 27 of
36 applicable clinic and medication line storage locations (75.0 percent). In nine
locations, we observed one or more of the following deficiencies: there was no
established system to return expired medication prescriptions to the pharmacy; staff did
not label multi-use medication with the date it was opened; staff did not properly separate
external and internal medications when stored; the medication area lacked a designated
area for return-to-pharmacy medications; the clinic’s medication drawer was not sanitary;
and a medication was stored beyond its expiration date (MIT 7.102).

Two tests received scores in the proficient range:
•

The institution properly stored non-narcotic medications that required refrigeration in
30 of the 33 applicable clinics and medication line locations (90.9 percent). At one clinic,
there was no established system to return paroled patient medication to the pharmacy. At
one clinic, the medication refrigerator was found unsanitary. Another clinic stored
expired medications (MIT 7.103).

•

Nursing staff at all eight of the inspected medication line locations employed appropriate
administrative controls and followed appropriate protocols during medication preparation
(MIT 7.105).

Pharmacy Protocols
CHCF scored 40.8 percent in this sub-indicator. The following four tests were inadequate:
•

In its main pharmacy, CHCF properly stored non-refrigerated medication. However, in its
satellite pharmacy we found stored medications not clearly labeled for easy identification.
As a result, the institution scored 50.0 percent for this test (MIT 7.108).

•

The institution properly stored refrigerated or frozen medications in one of two
pharmacies (50.0 percent). In the satellite pharmacy, the staff did not complete the
temperature logbook (MIT 7.109).

•

The institution’s pharmacist-in-charge (PIC) did not properly account for narcotic
medications stored in CHCF’s pharmacy or review monthly inventories of controlled
substances in the institution’s clinical and medication line storage locations, resulting in a
score of zero in this test. Specifically, the PIC did not properly complete multiple
medication area inspection checklists (CDCR Form 7477) and had missed names,
signatures, or dates on each inventory record (MIT 7.110).

•

We examined 25 medication errors follow-up reports and five monthly medication error
statistical reports generated by the institution’s PIC. Only one of the PIC’s 25 reports was
timely or correctly processed (4.0 percent). The PIC at CHCF did not complete

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24 medication error follow-up reports within the required period. The institution’s PIC
completed the reports between one and 20 days late (MIT 7.111).
One test received a proficient score:
•

CHCF followed general security, organization, and cleanliness management protocols in
its main and satellite pharmacies (7.107).

Non-Scored Tests
•

In addition to the testing of reported medication errors, we follow up on any significant
medication errors that were found during the case reviews or compliance testing to
determine whether the errors were properly identified and reported. We provide those
results for information purposes only. At CHCF, we found two reported severity level 4
medication errors: one was in March 2017 and the other was in August 2017. Both
medication errors for the patients had already been identified in MIT 7.111 (MIT
7.998).

•

We interviewed patients in isolation units to determine whether they had immediate
access to their prescribed KOP rescue inhalers and nitroglycerin medications. One
applicable sampled patient had access to his asthmatic inhaler (MIT 7.999).

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PRENATAL AND POST-DELIVERY SERVICES
This indicator evaluates the institution’s capacity to provide timely
and appropriate prenatal, delivery, and postnatal services to pregnant
patients. This includes the ordering and monitoring of indicated
screening tests, follow-up visits, referrals to higher levels of care,
e.g., high-risk obstetrics clinic, when necessary, and postnatal
follow-up.

Case Review Rating:
Not Applicable
Compliance Score:
Not Applicable
Overall Rating:
Not Applicable

As CHCF does not have female patients, this indicator does not
apply.

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PREVENTIVE SERVICES
This indicator assesses whether the institution offered or provided
various preventive medical services to patients. These include cancer
screenings, tuberculosis screenings, and influenza and chronic care
immunizations. This indicator also assesses whether certain
institutions take preventive actions to relocate patients identified as
being at higher risk for contracting coccidioidomycosis
(valley fever).

Case Review Rating:
Not Applicable
Compliance Score:
Inadequate
(69.7%)
Overall Rating:
Inadequate

The OIG rates this indicator entirely through the compliance testing component; the case review
process does not include a separate qualitative analysis for this indicator.

Compliance Testing Results
The institution scored in the inadequate range for this indicator at 69.7 percent. The following
two tests were in the inadequate range:
•

CHCF timely administered TB medications to four of the nine (44.4 percent) sampled
patients. Nursing staff neglected to refer three patients to a provider for required
counseling after they had missed a dose of medication. A provider did not see two other
patients after they refused TB treatment (MIT 9.001).

•

We reviewed CHCF’s monitoring of nine sampled patients who received TB medications
and noted that the institution was compliant for only one of them (11.1 percent). For eight
patients, the institution either failed to complete monitoring at all required intervals or
failed to document weight changes (MIT 9.002).

One test received an adequate score:
•

Of 30 sampled patients, 23 of them (76.7 percent) received their annual tuberculosis (TB)
screenings within the last year and during their birth month, as required by policy. Four
patients’ TB screenings did not occur during their birth months. Nursing staff did not
properly complete the annual TB screening form for two patients. Nursing staff did not
refer one patient who refused the TB screening for provider counseling (MIT 9.003).

Three tests were proficient:
•

All 25 sampled patients timely received or were offered influenza vaccinations during the
most recent influenza season (MIT 9.004).

•

CHCF offered colorectal cancer screenings to all 25 sampled patients subject to the
annual screening requirement (MIT 9.005).

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•

We tested whether patients who suffered from chronic care conditions were offered
vaccinations for influenza, pneumonia, and hepatitis. At CHCF, 12 of the 14 sampled
patients (85.7 percent) received all recommended vaccinations at required intervals. For
two patients, the institution failed to document whether the patients had received or
refused one or more of the required vaccinations (MIT 9.008).

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QUALITY OF NURSING PERFORMANCE
The Quality of Nursing Performance indicator is a qualitative
Case Review Rating:
evaluation of the institution’s nursing services. The evaluation is
Adequate
completed entirely by OIG nursing clinicians within the case review
Compliance Score:
process and does not have a score under the OIG compliance testing
Not Applicable
component. Case reviews include face-to-face encounters and
Overall Rating:
indirect activities performed by nursing staff on behalf of the patient.
Adequate
Review of nursing performance includes all nursing services
performed onsite, such as outpatient, inpatient, urgent/emergent,
patient transfers, care coordination, and medication management. The key focus areas for
evaluation of nursing care include appropriateness and timeliness of patient triage and
assessment, identification and prioritization of health care needs, use of the nursing process to
implement interventions, and accurate, thorough, and legible documentation. Although the OIG
reports nursing services provided in specialized medical housing units in the Specialized Medical
Housing indicator, and those provided in the TTA or related to emergency medical responses in
the Emergency Services indicator, this Quality of Nursing Performance indicator summarizes all
areas of nursing services.

Case Review Results
Most CHCF patients lived in specialized medical housing units. We reviewed 604 nursing
encounters within 73 cases. Among the nursing encounters reviewed, 188 were in the outpatient
setting, or in the institution’s E yard. We identified 227 deficiencies related to nursing care
performance, 41 of which were significant. The case review rating for the Quality of Nursing
Performance indicator was adequate.
Nursing Assessment
A major part of providing appropriate nursing care involves the quality of nursing assessment,
which includes both the subjective (patient interview) and objective (observation and
examination) portions of the evaluation. CHCF nurses generally performed satisfactory nursing
assessments. We discovered some incomplete nursing assessments, which included missing
elements from the subjective or objective portions of the documentation. We found four cases (5,
23, 24, and 97) in which the nurses did not obtain the necessary vital signs or examine the
affected area of the patient’s body.
Nursing Intervention
In most cases, CHCF nurses made timely and appropriate interventions for their patients. They
usually provided care based on a nursing care plan or nursing protocol. When the patient’s
condition changed, the nurses usually notified a provider or transferred the patient to the SEMS

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unit for further evaluation. We identified this pattern of good care in cases 3, 24, 29, 108, 109,
112, and the examples below:
•

In case 2, custody staff reported the patient was unable to function independently. The
SEMS nurse evaluated the patient and found the patient with an acute change in mental
status. The nurse contacted the provider promptly, who then ordered the patient
transferred immediately to the CTC for appropriate monitoring and treatment.

•

In case 6, the CTC nurse immediately contacted the provider after recognizing the
patient’s difficulty with breathing and abnormal vital signs. The same nurse also
appropriately provided oxygen supplementation to the patient and transferred the patient
to the SEMS unit.

•

In case 13, custody staff brought a patient to the clinic after the patient reported feeling
weak and had trouble with breathing. The clinic nurse promptly assessed the patient,
started him on oxygen, and notified the provider who directed the patient to the SEMS
unit.

•

In case 27, the patient complained of abdominal pain, nausea, and vomiting. The nurse
noted there was no output in the patient’s ileostomy (an opening in the abdomen made
during surgery) and promptly notified the provider who sent the patient to an outside
hospital. Hospital physicians successfully diagnosed and treated the patient’s bowel
obstruction.

Although nurses usually intervened for their patients satisfactorily, they did not always do so.
We found occasions in which the nurses delayed or did not contact a provider, did not follow
providers’ orders correctly, or did not provide appropriate care. These instances occurred in
cases 4, 19, 28, 37, and the following cases:
•

In case 10, the hypertensive patient complained of chest pain, which could have been an
emergency. The nurse did not perform an EKG, recheck the patient’s elevated blood
pressure, or notify the provider. Instead, the nurse inappropriately referred the patient for
a routine (within 14 days) provider appointment.

•

In case 18, the patient had a history of poorly controlled diabetes. He complained of
severe bilateral foot and back pain. The nurse did not refer the patient to the provider to
consider evaluation for nerve pain (a common symptom associated with diabetes).

•

In case 22, the patient had severe scrotal pain and swelling. The nurse should have
urgently referred the patient for a provider appointment. Instead, the nurse made a 14-day
referral. This error placed the patient at risk of harm. The patient then submitted a second
sick call request because the symptoms were getting worse. This time, the nurse failed to
examine the patient. When the patient submitted a third sick call request, the nurse again
made a routine, 14-day referral. Eventually, a provider ordered a one-day follow-up, but

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because of the lack of provider availability, the institution still failed to schedule an
appointment until seven days after the provider’s order.
Nursing Documentation
Complete and accurate nursing documentation is another essential component of patient care. This
documentation communicates the patient’s medical history and identifies any change in the
patient’s medical condition. While outpatient nurses satisfactorily recorded their care, nurses in the
specialized medical housing and the emergency services areas did not perform well with
documentation. We discuss documentation in those areas in their respective indicators.
Nursing Sick Call
We reviewed 122 sick call requests. The nurses processed most sick call requests promptly.
Sometimes the outpatient nurses failed to examine their symptomatic patients and required the
patients to wait for a future provider appointment for an evaluation. We found these nursing
errors in cases 22, 24, 25, and the case below:
•

In case 23, the patient complained of right ear pain, swelling, and bleeding. Instead of
examining the patient, the nurse recorded “outside the scope of nursing practice” and
scheduled a provider appointment without first examining the patient and determining the
severity of the patient’s condition. On another occasion, the patient complained of eye
pain with associated redness and vision changes. Once again, the nurse failed to examine
the patient.

Urgent/Emergent Care
The SEMS nurses and the first medical responders (FMRs) provided good care during
emergency medical responses. However, the nurses’ documentation of emergency timelines was
problematic. We also discussed these findings in the Emergency Services indicator.
Care Management
The role of a nursing care manager includes monitoring high-risk patients or those with chronic
conditions, assessing them, starting appropriate interventions, and following treatment plans.
At CHCF, the primary care nurse also served as the nursing care manager. During our onsite
visit, the care managers stated that by accessing the CCHCS Quality Management Master
Registry, they could identify new care management patients. Care managers also found new
patients by using the automatically generated morning huddle agenda. Health care teams then
scheduled these patients for their initial care manager and provider visits. The care manager then
performed assessments, discussed laboratory test results, reviewed medications, and provided
education and teaching based on the patients’ chronic care diagnoses and conditions.
Sometimes, CHCF nursing care managers performed well. The following cases showed effective
care management:
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•

In case 13, the nursing care manager appropriately reviewed the patient’s recent
laboratory results, noted the patient had no abnormally high or low blood sugar levels,
checked for medication compliance, and assessed the patient for diabetic complications.
The nurse also discussed these results with the provider.

•

In case 22, the nursing care manager evaluated the patient’s asthma. The nurse assessed
the patient’s respiratory status and provided proper patient education.

In other cases, the performance of nursing care managers showed room for improvement:
•

In cases 10 and 11, the nurse scheduled a care management visit for the patients’ asthma
condition, but failed to perform a complete assessment.

•

In cases 12 and 28, the nurse failed to review recent laboratory results.

•

In cases 21 and 24, the patients could have benefited from nursing care management to
monitor their chronic issues, but they did not receive these services.

Wound Care
CHCF used two RNs, certified in wound care, to evaluate and treat patient wounds. Each nurse
managed approximately 48 patients. Since Cycle 4, the institution formalized its wound care
program by implementing new policies and procedures. A wound care nurse checked patients
weekly to ensure consistent management of wounds. CHCF providers referred their patients to
telemedicine wound care specialists, who gave additional support to the institution’s wound care
program. The specialists also conferred with the wound care nurses weekly and offered
additional training to improve the wound care program.
Although the CHCF wound care program had improved since Cycle 4, we found problems. We
reviewed 17 cases related to wound care and found nursing deficiencies in nine cases. In cases
24, 26, 28, 57, and 99, the nurses did not perform wound care as frequently as the provider
ordered. We also identified failures to document the appearance of wounds in cases 4, 8, 21, and
28. Nurses also failed to educate their patients regarding wound care in cases 23 and 28.
Post-Hospital Returns
SEMS nurses performed poorly for patients returning from hospitalizations. We discussed these
findings in the Inter- and Intra-System Transfers indicator.
Specialized Medical Housing
Nurses in the CTC and the OHU assessed and intervened for their patients acceptably. Although
nursing performance in these areas was generally sufficient, we found nursing assessments that
were unfocused, as well as failures to re-evaluate patients after providing treatments and
incomplete nursing documentation. We discuss these findings further in the Specialized Medical
Housing indicator.

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Intra-System Transfers
The R&R nurses appropriately referred newly transferred patients to providers, but still made
assessment errors. For patients leaving the institution, the nurses did not always record pertinent
information. We described our findings in additional detail in the Inter-and Intra-System
Transfer indicator.
Offsite Specialty Services Returns
SEMS nurses regularly performed sufficient assessments when evaluating patients returning
from offsite specialty evaluations. We found one significant deficiency whereby the nurse failed
to obtain a specialist recommendation in case 28. We discuss this case further in the Specialty
Services indicator.
Clinician Onsite Inspection
We visited several clinical areas and spoke with nursing administration and staff in the PMU
(Patient Management Unit), SEMS, OHU, CTC, outpatient clinics, specialty service area, and
medication administration areas. We attended morning huddles in the primary clinics, OHUs,
and CTCs. We discussed huddle performance in the Health Information Management
indicator. The nurses we interviewed were knowledgeable about their patient population, duties,
and responsibilities. Most nurses stated that morale was good, and they felt supported by their
supervisors.
Both the CNE and nursing managers were receptive to us and were prepared to discuss our
questions. They had also identified some nursing deficiencies we found before our onsite
inspection and had already implemented quality improvement measures. They shared education
and training records, which showed evidence of their efforts to improve the quality of care they
provided. The various training programs included proper nursing assessments, documentation,
and sick-call triage. The nursing managers started additional audits to monitor the quality of
nursing care throughout the institution.
Case Review Conclusion
We found that compared to Cycle 4, the quality of nursing care at CHCF declined due to
incomplete nursing assessments in both outpatient and inpatient areas. Also, we found errors in
nursing performance, especially for those patients returning from an offsite hospitalization.
Although we found nursing errors that impacted care, CHCF nursing performance was still
barely sufficient to offset the deficiencies noted during this inspection. We, therefore, rated the
Quality of Nursing Performance indicator adequate.

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QUALITY OF PROVIDER PERFORMANCE
In this indicator, the OIG physicians provide a qualitative evaluation
of the adequacy of provider care at the institution. Appropriate
evaluation, diagnosis, and management plans are reviewed for
programs including, but not limited to, nursing sick call, chronic care
programs, TTA, specialized medical housing, and specialty services.
The assessment of provider care is performed entirely by OIG
physicians. There is no compliance testing component associated
with this quality indicator.

Case Review Rating:
Inadequate
Compliance Score:
Not Applicable
Overall Rating:
Inadequate

Case Review Results
We reviewed 521 medical provider encounters and found one or more provider errors in 115 of
those encounters. We identified an additional 57 provider deficiencies in other aspects of our
inspection, for a total of 172 deficiencies. Of those 172 deficiencies, 75 were significant. Our
physicians also rated the adequacy of care for 30 individual patients. Of these 30 cases, we rated
13 adequate and 17 inadequate. The case review rating for the Quality of Provider Performance
indicator was inadequate.
Assessment and Decision-Making
CHCF providers repeatedly failed to make sound assessments or accurate diagnoses. Poor
assessments and misdiagnoses frequently occurred throughout the cases reviewed. We found
these errors in cases 1, 3, 5, 9, 11, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29,
30, 31, 32, 34, and 82. The following are a few examples found during our case review:
•

In case 1, the patient had several hospitalizations for altered mental status because of his
end-stage liver disease. During one of these hospitalizations, the hospital physician
recommended stopping the patient’s clopidogrel (a blood thinner) as the patient had a
high risk of bleeding due to his severe liver disease. The provider ignored the hospital’s
recommendation and restarted the medication, which placed the patient at an unnecessary
risk for bleeding.

•

In case 4, the patient had a history of end-stage lung disease that required oxygen.
However, the provider failed to assess the patient’s oxygen levels during a routine
provider visit in the CTC.

•

In case 14, the OHU nurse notified the provider of the patient’s abdominal pain. The
provider failed to consider the possible diagnoses and prescribed medication with the
potential to worsen the patient’s condition.

•

In case 27, the OHU provider was scheduled to examine the patient after he sustained a
fall. However, the provider instead focused the evaluation on the patient’s complaint of a
sore toe and failed to examine the patient for his fall.

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•

In case 28, the patient had several blood tests that showed critically low blood levels
(severe anemia), but the provider failed to address these results. These errors placed the
patient at risk for developing complications of anemia, such as palpitations, shortness of
breath, weakness, and falls due to dizziness.

Review of Records
CHCF providers did not sufficiently review their patients’ medical records. Insufficient record
review occurred in cases 3, 16, 17, and the following:
•

In case 1, the patient had recurring anemia. By July 2017, the patient’s blood levels had
decreased to a critically low level. None of the providers reviewed this abnormal
laboratory result. As a result, providers did not address the patient’s critically low blood
level until he had dialysis several days later. The following week, the patient’s blood
level decreased even further. Again, none of the providers acted immediately to address
the patient’s dangerously severe anemia.

•

In case 5, the provider failed to do a thorough review of the medical record and did not
realize the patient’s thyroid ultrasound scan revealed two large nodules. The provider did
not address this abnormal finding, resulting in a delayed evaluation of the thyroid
nodules.

•

In case 15, the provider failed to perform a thorough chart review of the medical record
and also did not recognize the patient did not have immunity to the hepatitis B virus. As a
result, the provider did not offer the hepatitis B vaccine to the patient. Because of this
oversight, the provider placed the patient at risk of contracting this serious viral infection.

•

In case 19, the SEMS physician ordered an antibiotic for a presumed urinary tract
infection. A nurse’s note recorded the provider’s order for the antibiotic. At a subsequent
follow-up visit, a different provider failed to review the medical record carefully and was
unaware the patient was taking an antibiotic for an infection.

•

In case 22, multiple providers failed to review the medical record thoroughly. As a result,
the providers prescribed the patient two separate medicated eye drops that contained the
same drug. Because of this lapse in medical care, the providers placed the patient at risk
of developing side effects such as an abnormally slow heart rate and hypotension
(abnormally low blood pressure) because the patient was taking duplicate medications.

Emergency Care
Both the SEMS and on-call providers usually made accurate assessments and triage decisions.
Patients requiring a higher level of care were appropriately sent to outside hospitals. CHCF
emergency care provider performance was sufficient, as we also observed in Cycle 4. We
provided further details in the Emergency Services indicator.

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Chronic Care
As we found in Cycle 4, chronic care performance was poor. Providers continued to struggle
with chronic care, especially with diabetic care. Providers failed to follow CCHCS guidelines
and also ordered inappropriate follow-up intervals when treating uncontrolled blood sugar levels
in diabetic patients. Furthermore, CHCF providers managed high blood pressure poorly. Overall,
we found problems with chronic care in cases 10, 11, 12, 18, 19, 20, 25, and the following:
•

In case 14, the provider failed to address the patient’s elevated blood pressure even
though the patient had a history of stroke. The patient required careful monitoring and
treatment of his blood pressure, but did not receive these interventions.

•

In case 15, the OHU provider stopped the patient’s insulin and started an oral medication
for diabetes. CCHCS guidelines recommend a short interval follow-up to monitor the
patient’s blood sugar closely, but the provider failed to order a close follow-up. As a
result, the provider failed to review the patient’s fasting blood sugar levels timely, and the
patient’s diabetes became uncontrolled.

•

In case 23, the provider increased the patient’s insulin because his diabetes was
uncontrolled. The provider ordered a 30-day follow-up instead of the 3-to-7-day followup recommended by CCHCS guidelines. Also, the provider failed to review the patient’s
fasting blood sugar levels; the provider needed to review those levels to adjust the
patient’s insulin dose appropriately.

•

Also in case 23, a different provider saw the patient for follow-up and did not review the
patient’s fasting blood sugar levels. As a result, the provider was unaware of the patient’s
uncontrolled diabetes and failed to adjust his insulin dose.

•

In case 26, the provider increased the patient’s insulin and added an oral medication
because of the patient’s poorly controlled diabetes. The provider ordered a 30-day
follow-up instead of a short interval follow-up as recommended by CCHCS guidelines.
After changing the patient’s diabetic medications, the provider also failed to review the
patient’s fasting blood sugar levels and did not make proper adjustments to his
medications.

•

Also in case 26, the same provider repeatedly failed to review the patient’s elevated
blood pressure level. The patient had multiple cardiac risk factors that required close
monitoring and treatment of his blood pressure.

Specialty Services
CHCF providers often failed to review or implement specialists’ recommendations properly.
They also failed to submit specialty referrals with the proper priority level. The Specialty
Services indicator offers further details.

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Documentation Quality
Provider documentation was extremely poor as there were numerous instances of insufficient
documentation identified during this review period. Providers commonly wrote incomplete
progress notes containing references to either a partial physical exam or none at all having been
conducted, or that lacked a thorough and subjective narrative account. Providers often failed to
record sufficient justification to support their medical decisions and sometimes failed to record
anything at all. Insufficient documentation occurred in cases 1, 3, 5, 11, 14, 15, 16, 19, 21, 22,
24, 26, and the following case:
•

In case 9, outside hospital physicians discharged the patient after they treated him for a
critically low sodium level. The hospital physician observed that the patient had swelling
of both legs upon discharge. However, the CHCF provider incorrectly recorded that the
patient had normal lower extremities when the patient returned to the institution that
same day.

We also found evidence of “cloned” progress notes, in which providers inappropriately copied
outdated medical information and moved it forward into a current progress note. We identified
these “cloned” progress notes in cases 1, 16, 21, and 26.
Provider Continuity
We observed problems with provider continuity mostly in the institution’s outpatient yard clinic
(E yard). We identified these problems in cases 1, 11, 14, 18, 20, 21, 22, 23, 24, 25, and 27.
Provider continuity was sufficient in the CTC and the OHU.
Clinician Onsite Inspection
During our case review period, CHCF was extremely short-staffed with 19 provider vacancies.
The chief medical executive (CME) acknowledged that this significant provider shortage had
negatively impacted patient care. By the time of the onsite inspection, the CME stated that
CHCF’s provider shortage had improved, but the institution still had seven provider vacancies.
Medical managers at CHCF felt that physician recruitment had improved when the managers reimplemented a flexible working schedule (10 hours per day, four days per week). The managers
also attributed the improved staffing, in part, to the 15 percent recruitment and retention
differential pay increase that this institution has offered over the past several years.
The medical managers could not explain many of the OIG’s concerns about the providers’
assessment and decision-making capabilities, however, because approximately half the providers
we reviewed during this inspection were no longer working at CHCF.
The physician management team remained stable and unchanged from Cycle 4. This executive
team comprised three chief physician and surgeons and one CME. CHCF providers described
their physician executive team as fair, approachable, and willing to listen to their concerns.
Provider morale had recently improved; providers directly attributed the improvement to stable
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medical leadership and increased physician staffing. However, a few of the more experienced
CHCF providers expressed frustration with having to learn and adapt to the new EHRS.
Case Review Conclusion
As a whole, CHCF provider performance was poor. Our case reviews showed strong patterns of
deficiencies with provider assessment and decision-making, insufficient documentation, the
cursory review of records, and mismanagement of chronic medical conditions. CHCF managers
attributed these provider deficiencies to the high number of provider vacancies present during
this review period. We do not reasonably expect a severely understaffed institution to provide
adequate care. While CHCF has increased the number of providers on staff, thus mitigating this
severe personnel concern, the improvement occurred after our review period concluded.
Therefore, any benefit from the improved provider staffing is not reflected in this inspection. We
rated CHCF’s Quality of Provider Performance indicator inadequate.

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RECEPTION CENTER ARRIVALS
This indicator focuses on the management of medical needs and
Case Review Rating:
continuity of care for patients arriving from outside the CDCR
Not Applicable
system. The OIG review includes evaluation of the ability of the
Compliance Score:
institution to provide and document initial health screenings, initial
Not Applicable
health assessments, continuity of medications, and completion of
Overall Rating:
required screening tests; address and provide significant
Not Applicable
accommodations for disabilities and health care appliance needs; and
identify health care conditions needing treatment and monitoring.
The patients reviewed for reception center cases are those received from non-CDCR facilities,
such as county jails.
CHCF does not have a reception center; therefore, this indicator does not apply.

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SPECIALIZED MEDICAL HOUSING
This indicator addresses whether the institution follows
appropriate policies and procedures when admitting patients to
onsite inpatient facilities, including completion of timely nursing
and provider assessments. The case review assesses all aspects of
medical care related to these housing units, including quality of
provider and nursing care. CHCF medical housing units comprise
correctional treatment centers (CTCs) and outpatient housing units
(OHUs).

Case Review Rating:
Inadequate
Compliance Score:
Adequate
(85.0%)
Overall Rating:
Inadequate

For this indicator, the case review and compliance review processes yielded different results,
with the case reviewers assigning an inadequate rating and the compliance testing resulting in an
adequate score. The main reason for the inadequate case review rating was that OHU and CTC
providers demonstrated poor quality care that increased their patients’ risk of harm. We
determined that the overall rating for this indicator was inadequate.

Case Review Results
CHCF’s medical facilities include 12 OHU and 14 CTC housing units where staff manage
medically complex patients. CHCF designates the OHU units as medical housing areas that
provide supportive services to patients who need help with daily living activities or short-term
observations. The CTC units provide extensive nursing care and other inpatient health services to
patients who need close medical supervision. We reviewed 20 CTC and nine OHU cases, and
found 259 deficiencies, 85 of which were significant. The case review rating for this indicator
was inadequate.
Provider Performance
Provider care was poor in specialized medical housing as we found 96 deficiencies related to
provider performance. We found 45 significant deficiencies in cases 1, 3, 4, 9, 14, 15, 16, 17, 19,
27, 28, 29, and 30. The following are examples showing poor provider assessment:
•

In case 3, a nurse notified the provider that the patient’s left leg was showing skin
breakdown and fluid leakage. The provider not only delayed ordering dressing changes
and an antibiotic, but also never documented conducting an examination of the patient’s
lower extremity. This error increased the patient’s risk of infection.

•

In case 9, the patient had abdominal distention, lethargy, and confusion. The offsite
provider ordered an abdominal X-ray immediately, which revealed the patient had a
bowel obstruction, a medical emergency. However, the offsite provider did not
inform the on-call physician that this X-ray was pending. As a result, a provider never
checked the abdominal X-ray, and the patient died five hours later. This patient’s death
may have been prevented if a provider had checked the X-ray, had known of the patient’s

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bowel obstruction, and had promptly sent the patient to an outside hospital for further
management of his condition.
•

In case 30, a provider evaluated the patient for persistent swelling of his scrotum.
However, there was no evidence that the provider examined the patient’s scrotum.

Provider care was superficial and incomplete. In addition, the providers were at times unaware of
diagnostic and laboratory results. The following are examples of this type of insufficient record
review:
•

In case 1, several providers failed to review the medical record thoroughly and did not
recognize the patient’s irregular heart rhythm on two separate EKGs. Because the
patient’s irregular heart rhythm went undiagnosed, the providers increased the patient’s
risk of having a stroke or developing a blood clot in his lung.

•

In case 16, the provider did not thoroughly review the prior progress note and therefore,
was unaware the radiology department never performed a chest X-ray in response to the
patient’s shortness of breath.

Providers did not adequately address hospital recommendations after patients were discharged.
In addition, providers performed poorly when addressing specialists’ recommendations. The
following cases are such examples:
•

In case 1, the patient had an intestinal bleed and low platelet levels. The hospital
physician recommended stopping the patient’s clopidogrel (a blood thinning medication
that decreases platelet function) and prescribing aspirin instead. While the providers
prescribed aspirin for the patient, they did not stop the patient’s clopidogrel. This failure
to stop prescribing the patient’s blood-thinning medications significantly increased the
his risk of bleeding again.

•

In case 30, the specialist made recommendations that the patient receive a CT scan of the
chest to assess a lung nodule. However, the providers did not address these
recommendations.

Nursing Performance
CTC and OHU nursing performance was barely sufficient. Although nurses admitted their
patients timely and started care plans based on their patients’ needs, we found a pattern of
incomplete nursing assessment and documentation. We were most concerned when nurses failed
to implement providers’ orders and their failure to recognize whenever patients’ symptoms
warranted nursing interventions. We also observed most of these significant nursing deficiencies
in Cycle 4 as well. We identified 103 nursing deficiencies in 15 cases. Eight cases showed an
elevated risk of patient harm (cases 4, 5, 7, 11, 19, 27, 30, and 37). The following examples in
the areas of nursing assessment, intervention, implementation, and documentation show room for
significant improvement.

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Assessment
In eight cases, we identified absent or incomplete nursing assessments that could have
significantly impacted the patient’s medical care. These assessment deficiencies included partial
vital signs, a lack of focused assessment of the affected body part or wound, and a missed
evaluation before and after administering treatment or medications, as noted in the following
examples:
•

In case 4, the patient often had difficulty breathing. The CTC nurses administered
breathing treatments, but failed to listen to the patient’s lung sounds before and after each
treatment. Therefore, the nurses did not assess if the patient’s lung sounds had improved
following each treatment. On another occasion, the patient again complained of shortness
of breath. The nurse failed to administer a breathing treatment and also did not
re-evaluate the patient.

•

In case 5, the patient had a chronic breathing condition and required hospitalization for
low oxygen levels. When the patient returned to the institution, the CTC nurses failed to
assess the patient’s respiratory status. The patient continued to have difficulty breathing
and required another hospitalization for his continued low oxygen levels.

•

Also, in case 5, CHCF staff transferred the patient to a different CTC unit. None of the
CTC nurses monitored the patient’s respiratory status sufficiently to determine if his
symptoms had worsened. Six weeks later, the patient required hospitalization for
respiratory distress.

Despite the above examples, nurses usually made adequate nursing assessments as demonstrated
in the example below:
•

In case 27, the patient was noncompliant and usually refused his medications and nursing
assessments. Despite these refusals, the nurse appropriately assessed the patient when he
developed symptoms and notified the provider. Also, the OHU nurse counseled the
patient extensively regarding his noncompliance with his diabetic care. When he returned
to CHCF after being hospitalized for a small bowel obstruction, the CTC nurse reliably
assessed the patient and immediately informed the provider of any changes in the
patient’s condition.

Intervention and Implementation
CHCF nurses had problems reliably following the providers’ orders and intervening when
appropriate. These deficiencies included the following failures: check vital signs, monitor the
patient as frequently as the provider ordered, inform the CTC RN or provider of abnormal
findings, or administer the prescribed treatment or medication. We found these problems in
12 cases, some of which are depicted in the following:

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•

In case 11, the OHU nurse failed to correctly obtain orthostatic blood pressures
(positional blood pressure measurements) by placing the patient in both a reclining and
an upright position. Instead, the nurse only checked the patient’s blood pressure in a
sitting or upright position.

•

In case 19, the diabetic patient had an extremely high blood sugar level. The provider
ordered the nurse to recheck the patient’s blood sugar and administer additional insulin if
the patient’s result remained elevated. The nurse did not follow the provider’s order.
Frequently, the CTC nurses identified critically elevated blood sugars, but did not inform
the provider of the abnormal findings. Elevated blood sugars placed the patient at risk for
diabetic complications.

•

In case 30, the patient had a history of high blood pressure. A provider prescribed a blood
pressure medication for nurses to administer when the patient’s blood pressure rose above
a specific level. On numerous occasions, nurses failed to administer the medication, and
the patient’s blood pressure remained elevated. These errors placed the patient at risk for
a heart attack or stroke. Also, the nurses did not consistently record the patient’s intake
and output levels despite a provider’s order to do so.

•

In case 37, the provider ordered orthostatic vital signs for three days in addition to a
urinalysis. The OHU nurses did not follow the provider’s order. Also, on a different
occasion, the nurses did not inform a provider of abnormal orthostatic vital signs. These
errors placed the patient at risk for a possible missed diagnosis or wrong treatment.

CTC and OHU nurses also acted as first medical responders during an emergency in these areas.
The nurses responded quickly and intervened appropriately. We found one instance in which the
nurses made errors with their emergency interventions:
•

In case 7, the nurse failed to check the unresponsive patient for the presence of a pulse or
breathing. Because of this error, the emergency staff did not start CPR promptly. The
OHU nurse also requested 9-1-1 activation, but failed to direct a specific person to
perform the task, resulting in a delay in contacting EMS. When the nurses noted a pulse,
they stopped CPR, but did not check the patient for breathing. The nurses also failed to
restart CPR immediately when the patient’s heart stopped beating again. We also
discussed this case in the Emergency Service indicator.

Documentation
We identified a pattern of incomplete nursing documentation. As a result, this pertinent
information was not available to subsequent nurses or medical providers and could have led to
additional medical errors. The following are examples:
•

In case 3, the patient had two seizures, and the OHU nurse documented, “See notes for
full details.” However, no additional notes detailed the seizure events.

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•

In case 4, the CTC nurse withheld the patient’s blood pressure medication due to low
blood pressure. However, the nurse did not document the actual blood pressure reading.

•

In case 8, the CTC nurse neither completed the CPR record nor documented interventions
such as the use of an automated external defibrillator (AED), intravenous fluid and
medication administration, airway interventions if provided, or the patient’s blood sugar
results.

Clinician Onsite Inspection
During the onsite inspection, patients occupied most of the available 420 CTC medical and the
592 OHU beds. Most patients were long-term residents, with each unit having assigned primary
care providers. The staff performed daily huddles. In addition, nursing supervisors were present
at all times in the CTC and the OHU. The nursing supervisors said they had recently conducted a
quality improvement audit and had been increasing the number of reviews performed. Since their
most recent audit, they had provided training and education to the nurses regarding the
specialized medical housing admission processes, and were focusing on nurse assessments and
proper documentation.
Case Review Conclusion
Patients living in specialized medical housing areas need close monitoring and in-depth medical
care. Patients returning from hospitalization or specialty visits also require a thorough review of
their medical records to address all new diagnoses and recommendations. The specialized
medical housing providers showed poor medical judgments, demonstrated superficial patient
care, and provided an inadequate review of hospital and specialty records. Provider errors
increased their patients’ risk of harm. Nursing assessments only bordered on the acceptable.
Nurses struggled to follow providers’ orders and recorded incomplete nursing documentation.
Due to the poor performance of CHCF’s medical providers as well as the problems we observed
with nursing care, we rated the Specialized Medical Housing indicator inadequate.

Compliance Testing Results
The institution received a score of 85.0 percent in this indicator, with the following three tests
scoring in the adequate range:
•

Nursing staff completed an initial assessment on the date patients were admitted to the
CTC and the OHU for all 41 patients whose records we sampled (MIT 13.001).

•

Providers evaluated 21 of the 24 sampled patients (87.5 percent) within 24 hours of
admission to the CTC, and also completed the required history and physical
examinations. For two patients, providers did not conduct this examination. For one
patient, the provider evaluated the patient one day late (MIT 13.002).

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•

When we observed the working order of sampled call buttons in CTC and OHU patient
rooms, we found all working properly. In addition, according to staff members
interviewed, custody officers and clinicians could expeditiously access patients’ locked
rooms when emergent events occurred (MIT 13.101).

One test scored in the inadequate range:
•

When we tested whether providers completed their SOAPE notes at required 3-day
intervals for the CTC and 14-day intervals for the OHU, we discovered SOAPE notes
were timely and accurately completed for 21 of the 40 sampled patients (52.5 percent).
For 17 patients, provider notes were one to 18 days late. For the remaining two patients,
providers did not complete their required notes (MIT 13.003).

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SPECIALTY SERVICES
This indicator focuses on specialist care from the time a physician
Case Review Rating:
completes a request for services or a physician’s order for specialist
Inadequate
Compliance Score:
care to the time of receipt of related recommendations from
Inadequate
specialists. This indicator also evaluates the providers’ timely review
(65.7%)
of specialist records and documentation reflecting the patients’ care
plans, including the course of care when specialist recommendations
Overall Rating:
Inadequate
were not ordered, and whether the results of specialists’ reports are
communicated to the patients. For specialty services denied by the
institution, the OIG determines whether the denials are timely and appropriate, and whether the
provider updates the patient on the plan of care.

Case Review Results
We reviewed 272 events related to Specialty Services, mostly specialty consultations and
procedures. We found 65 deficiencies in this category, 33 of which were significant. The case
review rating for this indicator was inadequate.
Access to Specialty Services
We found that most of the initial referrals at CHCF were completed within acceptable time
frames except in cases 3, 14, 23, 30, and 34. However, we also found recurrent delays in
specialty follow-ups in cases 9, 18, 30, 31, 32, and 34. The following are a few examples of
these types of deficiencies:
•

In case 18, the provider requested an urgent 14-day appointment with an endocrinologist
(a doctor who treats hormonal imbalances) because the patient had uncontrolled diabetes.
This appointment did not occur for more than one month, which placed the patient at risk
for developing diabetic ketoacidosis (a life-threatening diabetic complication).

•

In case 23, the provider requested an urgent evaluation with an ophthalmologist (an eye
surgeon) due to concern for an acute eye infection that may have required expedited
treatment. However, the patient did not see the ophthalmologist until after a 20-day delay,
and he was diagnosed with a serious viral infection of his eye. This delay was significant
because this eye infection could have led to permanent vision loss.

•

In case 30, the provider requested a follow-up appointment with a cancer specialist to
address the patient’s lung nodule. This follow-up never occurred, and the patient was not
evaluated for possible lung cancer.

•

In case 31, the patient had abdominal surgery for a bowel obstruction. The surgeon was
concerned that the patient’s chronic kidney and liver diseases would prevent proper
wound healing. The surgeon requested a short-interval follow-up to monitor the patient’s
wound, but the follow-up occurred two weeks late.

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•

In case 34, the patient had a history of multiple myeloma (a type of bone marrow cancer),
which required close monitoring. The provider requested a follow-up with the cancer
specialist within 28 days, but the appointment occurred three weeks outside the requested
time interval. This error was significant as the cancer specialist recommended additional
chemotherapy that was delayed by this lapse in medical care.

Nursing Performance
CHCF nurses performed acceptably for patients returning from offsite specialty appointments.
Generally, nurses provided patient assessments, reviewed specialists’ findings and
recommendations, and communicated those results to providers. We found 14 nursing
deficiencies in several cases. These were mostly minor deficiencies that included partial
assessments, incomplete documentation, and failures to provide patient education. The following
examples demonstrate opportunities for improvement:
•

In case 23, the patient returned from the eye specialist who recommended discontinuing
the eye drops. The nurse failed to notify the provider, and the patient continued to selfadminister the eyedrops. The provider stopped the eye drops two days later.

•

In case 28, the patient returned from the specialist without proper paperwork, and the
nurse did not attempt to retrieve the specialist’s urgent recommendation. As a result, the
patient’s pre-operative cardiology appointment did not occur timely.

Provider Performance
CHCF providers did not properly review or implement specialists’ recommendations, or request
referrals to occur within appropriate time frames in cases 18, 22, 23, 25, and 30. We identified
six significant deficiencies. The following are examples of poor provider performance as it
related to specialty services:
•

In case 18, the patient had uncontrolled diabetes before his evaluation with the
endocrinologist. Although the endocrinologist saw the patient and recommended a threemonth follow-up, the provider instead ordered a four-month specialist follow-up.

•

In case 22, the patient saw a urologist (a genito-urinary tract specialist) because his
urinary incontinence medical device had malfunctioned. The urologist recommended the
patient have a different medical device placed at a “special care clinic,” but the provider
failed to specify that location in the referral. As a result, the urologist was unable to
perform the procedure, which further delayed the patient’s medical care.

•

In case 23, the provider evaluated a suspicious lesion on the patient’s ear, which could
have been cancerous. The provider inappropriately submitted a 92-day, routine-priority
referral for a dermatologist. This lengthy referral time was not appropriate given the
patient could have had undiagnosed cancer.

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•

In case 25, the patient saw the kidney specialist for his chronic kidney disease. The
provider failed to order the iron supplementation that the specialist recommended for the
patient’s anemia.

Health Information Management
As we also saw in Cycle 4, CHCF performed satisfactorily with processing specialty reports.
Staff usually retrieved and scanned offsite specialty reports into the EHRS promptly, except in
cases 4 and 35. The following is an example of these rare deficiencies and should be used for the
purpose of quality improvement:
•

In case 35, CHCF staff failed to retrieve and scan the patient’s offsite specialty visits into
the EHRS for more than one year. This oversight resulted in a significant lapse in medical
care because the patient had an inoperable brain tumor, and an important report was not
available to guide the provider’s care at the follow-up visit.

We identified a pattern wherein CHCF staff scanned specialty reports into the EHRS without
appropriate provider review. We found specialty reports that were not signed or initialed by
providers in cases 3, 23, 32, and 35.
Clinician Onsite Inspection
The Utilization Management nurses scheduled specialty appointments and used the EHRS
message center to communicate pertinent information to providers. The telemedicine nurse kept
an organized tracking and scheduling system for all telemedicine appointments. CHCF staff
reported it was challenging at times to ensure specialist appointments were scheduled within the
ordered time frames, but they reported only a minimal backlog of appointments. The specialty
nurses were responsible for handling the offsite specialty reports and ensuring specialists’
recommendations were obtained. The specialty nurses were also responsible for retrieving these
offsite specialty reports if the reports did not return with the patient. CHCF also provided onsite
specialty services with three nurses assigned to assist specialists during visits. These nurses also
informed the provider once an appointment was completed and when to expect the specialty
report.
Case Review Conclusion
CHCF did not perform well with specialty services. While providers did an adequate job
identifying and initially referring patients when needed, we still found issues with delays in
specialist follow-ups that affected patient care. The providers also did not thoroughly review or
implement specialists’ recommendations. Furthermore, a pattern was found in which specialty
reports were scanned into the EHRS without evidence of provider review. We rated the Specialty
Services indicator inadequate.

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State of California

Compliance Testing Results
The institution received a score of 65.7 percent in this indicator, with the following four tests
scoring in the inadequate range:
•

Providers timely received and reviewed high-priority specialists’ reports for 10 of the 15
sampled patients (66.7 percent). One patient’s report was received four days late. For four
other patients, we found no evidence that the institution had ever received the specialists’
reports (MIT 14.002).

•

Providers timely received and reviewed the specialists’ reports following routine specialty
service appointments for 9 of 13 sampled patients (69.2 percent). For two patients,
providers reviewed the specialist reports one and 17 days late. For the remaining two
patients, we found no evidence that CHCF ever received the report (MIT 14.004).

•

Among 20 sampled patients who transferred into CHCF with an approved specialty
service, five patients (25.0 percent) received it within the required time frame. Eight
patients received their specialty services between 4 and 43 days late. Six other patients
had two or more approved services; for these, CHCF provided specialty services between
4 and 87 days late, while other specialty services were not provided. One other patient
also never received his specialty service (MIT 14.005).

•

For 18 sampled patients who had a specialty service denied by CHCF’s health care
management, only four patients (22.2 percent) received timely notification of this denial,
including the provider meeting with the patient within 30 days to discuss alternate
treatment strategies. For five patients, providers communicated the denials between 3 and
27 days late. For the other nine patients, providers did not communicate the denial status
at all (MIT 14.007).

Three tests received scores in the proficient range:
•

For 13 of 15 sampled patients (86.7 percent), high-priority specialty services
appointments occurred within 14 calendar days of the provider’s order. Two patients
received their high-priority specialty services three and seven days late (MIT 14.001).

•

CHCF provided routine specialty service appointments for all 15 sampled patients within
the required time frame (MIT 14.003).

•

CHCF health care management denied providers’ specialty service requests in a timely
manner for 18 of 20 sampled patients (90.0 percent). Management denied two specialty
service requests one and 21 days late (MIT 14.006).

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State of California

ADMINISTRATIVE OPERATIONS (SECONDARY)
This indicator focuses on the institution’s administrative health care
Case Review Rating:
oversight functions. The OIG evaluates whether the institution
Not Applicable
Compliance Score:
promptly processes patient medical appeals and addresses all
Inadequate
appealed issues. Inspectors also verify that the institution follows
(71.1%)
reporting requirements for adverse/sentinel events and patient deaths.
The OIG verifies that the Emergency Medical Response Review
Overall Rating:
Inadequate
Committee (EMRRC) performs required reviews and that staff
perform required emergency response drills. Inspectors also assess
whether the Quality Management Committee (QMC) meets regularly and adequately addresses
program performance. For those institutions with licensed facilities, inspectors also verify that
required committee meetings are held. In addition, the OIG examines whether the institution
adequately manages its health care staffing resources by evaluating whether job performance
reviews are completed as required; specified staff possess current, valid credentials and
professional licenses or certifications; nursing staff receive new employee orientation training
and annual competency testing; and clinical and custody staff have current emergency medical
response certifications. The Administrative Operations indicator is a secondary indicator;
therefore, it was not considered at all when we determined the institution’s overall rating.

Compliance Testing Results
The institution received a score of 71.1 percent in this indicator with six tests scoring in the
inadequate range:
•

We reviewed, but did not validate, medical appeals data provided by the institution.
CHCF processed only 5 of the 12 months’ appeals timely (41.7 percent). Seven months
of appeals were not processed timely (MIT 15.001).

•

We reviewed the one reported adverse/sentinel event (ASE) that occurred at CHCF
during the prior 12-month period that required a root cause analysis and four monthly
status reports per policy. The institution’s ASE was reported to the CCHCS ASE
committee 29 days late. In addition, the institution submitted only two status reports
during the four-month period. As a result, CHCF received a score of zero for this test
(MIT 15.002).

•

Of the 12 sampled incident packages for emergency medical responses reviewed by the
institution’s EMRRC during the prior six-month period, only 2 of 12 packages
(16.7 percent) complied with CCHCS policy. Ten incident packages did not include the
required EMRRC checklist (MIT 15.005).

•

We reviewed 12 months of CHCF’s local governing body (LGB) meeting minutes and
determined that the LGB met at least quarterly; however, CHCF’s CEO did not timely

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approve two of the four quarterly meeting minutes (50.0 percent), which were 28 and
68 days late (MIT 15.006).
•

Inspectors reviewed the summary reports and related documentation for three medical
emergency response drills conducted during the prior quarter. CHCF did not conduct a
comprehensive response drill for these three watches. We found one or more of the
following deficiencies: there was no indication of custody participation; multiple required
forms were missing; and necessary drill elements were also missing. As a result, the
institution received a score of zero for this test (MIT 15.101).

•

Supervisors completed a proper clinical performance appraisal for only 8 of 20 CHCF
providers (40.0 percent). Twelve other providers did not have either timely or properly
completed appraisals, including the following (MIT 15.106):
o Twelve providers had a unit health record clinical appraisal (UCA) completed, but
the reviewers’ results were not discussed with the providers.
o Two providers’ performance reviews were missing the required PCP 360-degree
evaluation.
o One provider’s PCP 360-degree evaluation was 32 days late.
o One provider’s Individual Development Plan (IDP) was missing the reviewer’s
date.
o Two providers’ IDPs were 18 and 56 days late.

Ten tests earned proficient scores:
•

CHCF’s Quality Management Committee (QMC) met monthly, evaluated program
performance, and acted when management identified areas for improvement
(MIT 15.003).

•

CHCF took adequate steps to ensure the accuracy of its Dashboard data reporting
(MIT 15.004).

•

Based on a sample of ten second-level medical appeals, the institution’s responses
addressed all of the patients’ appealed issues (MIT 15.102).

•

Medical staff reviewed and timely submitted the Initial Inmate Death Report to CCHCS’
Death Review Unit for nine of ten cases tested, resulting in a score of 90.0 percent. For
one death report packet, the institution submitted the death report nine minutes late
(MIT 15.103).

•

All ten sampled nurses were current with their clinical competency validations
(MIT 15.105).

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State of California

•

All providers at the institution were current with their professional licenses. Similarly, all
nursing staff and the PIC were current with their professional licenses and certification
requirements (MIT 15.107, 15.109).

•

All active-duty providers and nurses were current with their emergency response
certifications (MIT 15.108).

•

All pharmacy staff and providers who prescribed controlled substances had current Drug
Enforcement Agency registrations (MIT 15.110).

•

All nursing staff hired within the last year timely received new employee orientation
training (MIT 15.111).

Non-Scored Results
•

We gathered non-scored data regarding the completion of death review reports by
CCHCS’ Death Review Committee (DRC). Ten deaths occurred during our review
period: three unexpected (Level 1) deaths and seven expected (Level 2) deaths. The DRC
is required to complete death review summary reports within 60 days from the date of
death for the Level 1 deaths and within 30 days from the date of death for the Level 2
deaths; these reports must be submitted to the institution’s CEO within 7 calendar days
thereafter. None of the death reviews at CHCF met CCHCS’ reporting guidelines. For
three of the Level 1 deaths, the DRC completed one report 11 days late and submitted it
to CHCF’s CEO 18 days late; for two other Level 1 deaths, we found no evidence that the
final Death Review summary reports had been completed at the time of our inspection.
For seven of the Level 2 deaths that occurred at CHCF, the DRC completed its reports
from 9 to 43 days late and submitted them to the CEO between 17 and 51 days late
(MIT 15.998).

•

The OIG discusses the institution’s health care staffing resources in the About the
Institution section of this report (MIT 15.999).

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RECOMMENDATIONS
The OIG recommends the following:
•

The chief executive officer (CEO) and the chief support executive (CSE) should ensure
that all CHCF providers have access to and show proficiency using the radiology
information system (RIS) to retrieve and review offsite radiology reports. Alternatively,
CHCF can scan offsite radiology reports directly into the EHRS medical record, which
would be a more efficient method of enabling providers to review offsite reports. During
this inspection, we found that a majority of CHCF providers did not review offsite
radiology reports because they were inaccessible.

•

The CEO and the CSE should identify and fix the processes that resulted in X-rays and
laboratory tests being delayed or that were not completed, which we identified during this
inspection.

•

The CSE and the chief nurse executive (CNE) should rectify the problems we found
whereby standby emergency medical services (SEMS) nurses did not consistently collect
and process laboratory specimens when those tests were performed during weekends.

•

All CHCF executives should analyze why the processing of diagnostic and specialty
reports was delayed and attempt to correct the situation to alleviate future occurrences.
We found delays with both the initial retrieval, and the providers’ review, of those
reports.

•

The CNE should train and improve the clinical performance of nurses in multiple areas.
The training should focus on making thorough assessments, recording complete
documentation, and administering all medications correctly. We found errors in these
areas throughout the institution.

•

The CEO, the CNE, and the pharmacist-in-charge (PIC) should analyze why problems
occurred with pharmacy and nursing processes, and adjust these processes to correct
problems we found with medication administration and medication continuity.

•

The chief medical executive (CME) should improve the hiring, training, and monitoring
processes the institution used to ensure sufficient provider quality. We found serious
problems with providers’ assessments, misdiagnoses, review of records, and chronic care
performance. Most CHCF staff attributed these problems to severe provider understaffing
during this review period.

•

The CEO and the CNE should adjust specialty scheduling processes to ensure that
patients who require urgent or short-interval specialty follow-ups receive them. During
this inspection, we found that delayed specialty follow-ups occurred more frequently with
urgent or expedited follow-up orders.

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State of California

POPULATION-BASED METRICS
The compliance testing and the case reviews give an accurate assessment of how the institution’s
health care systems are functioning with regard to the patients with the highest risk and
utilization. This information is vital to assess the capacity of the institution to provide
sustainable, adequate care. However, one significant limitation of the case review methodology
is that it does not give a clear assessment of how the institution performs for the entire
population. For better insight into this performance, the OIG has turned to population-based
metrics. For comparative purposes, the OIG has selected several Healthcare Effectiveness Data
and Information Set (HEDIS) measures for disease management to gauge the institution’s
effectiveness in outpatient health care, especially chronic disease management.
The Healthcare Effectiveness Data and Information Set is a set of standardized performance
measures developed by the National Committee for Quality Assurance with input from over
300 organizations representing every sector of the nation’s health care industry. It is used by over
90 percent of the nation’s health plans as well as many leading employers and regulators. HEDIS
was designed to ensure that the public (including employers, the Centers for Medicare and
Medicaid Services, and researchers) has the information it needs to accurately compare the
performance of health care plans. Healthcare Effectiveness Data and Information Set data is
often used to produce health plan report cards, analyze quality improvement activities, and create
performance benchmarks.

Methodology
For population-based metrics, we used a subset of HEDIS measures applicable to the CDCR
patient population. Selection of the measures was based on the availability, reliability, and
feasibility of the data required for performing the measurement. We collected data utilizing
various information sources, including the electronic medical record, the Master Registry
(maintained by CCHCS), as well as a random sample of patient records analyzed and abstracted
by trained personnel. We did not independently validate the data obtained from the CCHCS
Master Registry and Diabetic Registry, and we presume it to be accurate. For some measures, we
used the entire population rather than statistically random samples. While the OIG is not a
certified HEDIS compliance auditor, we use similar methods to ensure that measures are
comparable to those published by other organizations.

Comparison of Population-Based Metrics
For the California Health Care Facility, nine HEDIS measures were selected and are listed in the
following CHCF Results Compared to State and National HEDIS Scores table. Multiple health
plans publish their HEDIS performance measures at the state and national levels. The OIG has
provided selected results for several health plans in both categories for comparative purposes.

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State of California

Results of Population-Based Metric Comparison
Comprehensive Diabetes Care
For chronic care management, the OIG chose measures related to the management of diabetes.
Diabetes is the most complex common chronic disease requiring a high level of intervention on
the part of the health care system in order to produce optimal results. CHCF performed very well
with its management of diabetes.
When compared statewide, CHCF outperformed Medi-Cal in all five diabetic measures, and
outperformed or matched Kaiser in four of the five diabetic measures. The institution scored
lower than Kaiser (North and South) in diabetic eye exams.
When compared nationally, CHCF outperformed Medicaid and commercial plans in all five
diabetic measures, and outperformed Medicare in four of the five measures. CHCF outperformed
the United States Department of Veterans Affairs (VA) in three of the four applicable measures.
The institution scored lower than Medicare and the VA in diabetic eye exams.
Immunizations
Comparative data for immunizations was only fully available for the VA and partially available
for Kaiser, commercial plans, Medicaid, and Medicare. With respect to administering influenza
vaccinations to younger adults and older adults, CHCF scored higher than all reporting health
plans. With regard to administering pneumococcal vaccines to older adults, CHCF scored higher
than Medicare and lower than the VA.
Cancer Screening
With respect to colorectal cancer screening, CHCF outperformed all reporting health plans.
Summary
CHCF performed very well with regard to population-based metrics in comparison to the other
health care plans reviewed. The institution may improve its score for diabetic eye exams by
reducing the number of refusals through patient education regarding the benefits of this
preventive service.

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State of California

CHCF Results Compared to State and National HEDIS Scores
California

CHCF

Clinical Measures

Cycle 5
Results1

National

HEDIS
Medi-Cal
20172

HEDIS
Kaiser
(No.
CA)
20163

HEDIS
Kaiser
(So.
CA)
20163

HEDIS
Medicaid
20174

HEDIS
Commercial
20174

HEDIS
VA
Medicare Average
20174
20165

Comprehensive Diabetes Care
HbA1c Testing (Monitoring)

100%

87%

94%

94%

87%

91%

94%

99%

Poor HbA1c Control (>9.0%)6, 7

10%

38%

20%

23%

43%

33%

26%

18%

78%

52%

70%

63%

47%

56%

63%

-

83%

63%

83%

83%

60%

62%

64%

76%

63%

57%

68%

81%

55%

54%

70%

89%

Influenza Shots – Adults (18–64)

76%

-

56%

57%

39%

48%

-

52%

Influenza Shots – Adults (65+)

80%

-

-

-

-

-

71%

72%

Immunizations: Pneumococcal

88%

-

-

-

-

-

74%

93%

95%

-

79%

82%

-

62%

67%

82%

HbA1c Control (<8.0%)
Blood Pressure Control
(<140/90)
Eye Exams

6

Immunizations

Cancer Screening
Colorectal Cancer Screening

1. Unless otherwise stated, data was collected in November 2017 by reviewing medical records from a sample
of CHCF’s population of applicable patients. These random statistical sample sizes were based on a 95 percent
confidence level with a 15 percent maximum margin of error.
2. HEDIS Medi-Cal data was obtained from the California Department of Health Care Services Medi-Cal
Managed Care External Quality Review Technical Report (July 1, 2016 – June 30, 2017).
3. Data was obtained from Kaiser Permanente November 2016 reports for the Northern and Southern
California regions.
4. National HEDIS data for Medicaid, commercial plans, and Medicare was obtained from the 2017 State of
Health Care Quality Report, available on the NCQA website: www.ncqa.org. The results for commercial plans
were based on data received from various health maintenance organizations.
5. The Department of Veterans Affairs (VA) data was obtained from the VA’s website, www.va.gov. For the
Immunizations: Pneumococcal measure only, the data was obtained from the VHA Facility Quality and Safety
Report – Fiscal Year 2012 Data.
6. For this indicator, the entire applicable CHCF population was tested.
7. For this measure only, a lower score is better. For Kaiser, the OIG derived the poor HbA1c control indicator
using the reported data for the <9.0% HbA1c control indicator.

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State of California

APPENDIX A — COMPLIANCE TEST RESULTS
California Health Care Facility
Range of Summary Scores: 46.3% – 85.0%
Indicator

Compliance Score (Yes %)

1 – Access to Care

68.2%

2 – Diagnostic Services

62.8%

3 – Emergency Services

Not Applicable

4 – Health Information Management (Medical Records)

63.8%

5 – Health Care Environment

69.5%

6 – Inter- and Intra-System Transfers

46.3%

7 – Pharmacy and Medication Management

51.9%

8 – Prenatal and Post-Delivery Services
9 – Preventive Services

Not Applicable
69.7%

10 – Quality of Nursing Performance

Not Applicable

11 – Quality of Provider Performance

Not Applicable

12 – Reception Center Arrivals

Not Applicable

13 – Specialized Medical Housing (OHU, CTC, SNF, Hospice)

85.0%

14 – Specialty Services

65.7%

15 – Administrative Operations

71.1%

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State of California

Scored Answers

1 – Access to Care

Yes

No

Yes
+
No

1.001

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?

14

11

25

56.0%

0

1.002

For endorsed patients received from another CDCR institution: If
the nurse referred the patient to a provider during the initial health
screening, was the patient seen within the required time frame?

9

16

25

36.0%

0

1.003

Clinical appointments: Did a registered nurse review the patient’s
request for service the same day it was received?

28

2

30

93.3%

0

1.004

Clinical appointments: Did the registered nurse complete a faceto-face visit within one business day after the CDCR Form 7362
was reviewed?

28

2

30

93.3%

0

1.005

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?

13

8

21

61.9%

9

1.006

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?

5

2

7

71.4%

23

1.007

Upon the patient's discharge from the community hospital: Did
the patient receive a follow-up appointment within the required
time frame?

13

12

25

52.0%

0

1.008

Specialty service follow-up appointments: Do specialty service
primary care physician follow-up visits occur within required time
frames?

12

12

24

50.0%

6

1.101

Clinical appointments: Do patients have a standardized process to
obtain and submit health care services request forms?

6

0

6

100.0%

0

Reference
Number

Overall percentage:

California Health Care Facility, Cycle 5 Medical Inspection
Office of the Inspector General

Yes %

N/A

68.2%

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State of California

Scored Answers

Reference
Number

2 – Diagnostic Services

Yes

No

Yes
+
No

Yes %

N/A

2.001

Radiology: Was the radiology service provided within the time
frame specified in the provider's order?

9

1

10

90.0%

0

2.002

Radiology: Did the primary care provider review and initial the
diagnostic report within specified time frames?

2

8

10

20.0%

0

2.003

Radiology: Did the primary care provider communicate the results
of the diagnostic study to the patient within specified time frames?

3

7

10

30.0%

0

2.004

Laboratory: Was the laboratory service provided within the time
frame specified in the provider's order?

10

0

10

100.0%

0

2.005

Laboratory: Did the primary care provider review and initial the
diagnostic report within specified time frames?

10

0

10

100.0%

0

2.006

Laboratory: Did the primary care provider communicate the
results of the diagnostic study to the patient within specified time
frames?

2

7

9

22.2%

1

2.007

Pathology: Did the institution receive the final diagnostic report
within the required time frames?

7

3

10

70.0%

0

2.008

Pathology: Did the primary care provider review and initial the
diagnostic report within specified time frames?

8

1

9

88.9%

1

2.009

Pathology: Did the primary care provider communicate the results
of the diagnostic study to the patient within specified time frames?

4

5

9

44.4%

1

Overall percentage:

62.8%

3 – Emergency Services
This indicator is evaluated only by case review clinicians. There is no compliance testing component.

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State of California

Scored Answers

4 – Health Information Management

Yes

No

Yes
+
No

4.001

Are non-dictated healthcare documents (provider progress notes)
scanned within 3 calendar days of the patient encounter date?

10

0

10

4.002

Are dictated/transcribed documents scanned into the patient’s
electronic health record within five calendar days of the encounter
date?

4.003

Are High-Priority specialty notes (either a Form 7243 or other
scanned consulting report) scanned within the required time
frame?

15

5

20

75.0%

0

4.004

Are community hospital discharge documents scanned into the
patient’s electronic health record within three calendar days of
hospital discharge?

16

4

20

80.0%

0

4.005

Are medication administration records (MARs) scanned into the
patient’s electronic health record within the required time frames?

4.006

During the inspection, were medical records properly scanned,
labeled, and included in the correct patients’ files?

0

24

24

0.0%

0

4.007

For patients discharged from a community hospital: Did the
preliminary hospital discharge report include key elements and
did a primary care provider review the report within three
calendar days of discharge?

16

9

25

64.0%

0

Reference
Number

Overall percentage:

California Health Care Facility, Cycle 5 Medical Inspection
Office of the Inspector General

Yes %

N/A

100.0%

0

Not Applicable

Not Applicable

63.8%

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State of California

Scored Answers

5 – Health Care Environment

Yes

No

Yes
+
No

5.101

Are clinical health care areas appropriately disinfected, cleaned
and sanitary?

18

17

35

51.4%

0

5.102

Do clinical health care areas ensure that reusable invasive and
non-invasive medical equipment is properly sterilized or
disinfected as warranted?

31

4

35

88.6%

0

5.103

Do clinical health care areas contain operable sinks and sufficient
quantities of hygiene supplies?

34

1

35

97.1%

0

5.104

Does clinical health care staff adhere to universal hand hygiene
precautions?

29

6

35

82.9%

0

5.105

Do clinical health care areas control exposure to blood-borne
pathogens and contaminated waste?

35

0

35

100.0%

0

5.106

Warehouse, Conex and other non-clinic storage areas: Does the
medical supply management process adequately support the needs
of the medical health care program?

0

1

1

0.0%

0

5.107

Does each clinic follow adequate protocols for managing and
storing bulk medical supplies?

23

12

35

65.7%

0

5.108

Do clinic common areas and exam rooms have essential core
medical equipment and supplies?

25

10

35

71.4%

0

5.109

Do clinic common areas have an adequate environment conducive
to providing medical services?

35

0

35

100.0%

0

5.110

Do clinic exam rooms have an adequate environment conducive
to providing medical services?

29

6

35

82.9%

0

5.111

Emergency response bags: Are TTA and clinic emergency
medical response bags inspected daily and inventoried monthly,
and do they contain essential items?

1

3

4

25.0%

31

Reference
Number

Overall percentage:

California Health Care Facility, Cycle 5 Medical Inspection
Office of the Inspector General

Yes %

N/A

69.5%

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State of California

Scored Answers

Yes

No

Yes
+
No

6.001

For endorsed patients received from another CDCR institution or
COCF: Did nursing staff complete the initial health screening and
answer all screening questions on the same day the patient arrived
at the institution?

7

18

25

28.0%

0

6.002

For endorsed patients received from another CDCR institution or
COCF: When required, did the RN complete the assessment and
disposition section of the health screening form; refer the patient
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?

23

2

25

92.0%

0

6.003

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?

10

4

14

71.4%

11

6.004

For patients transferred out of the facility: Were scheduled
specialty service appointments identified on the patient’s health
care transfer information form?

8

12

20

40.0%

0

6.101

For patients transferred out of the facility: Do medication transfer
packages include required medications along with the
corresponding transfer packet required documents?

0

4

4

0.0%

0

Reference
Number

6 – Inter- and Intra-System Transfers

Overall percentage:

California Health Care Facility, Cycle 5 Medical Inspection
Office of the Inspector General

Yes %

N/A

46.3%

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State of California

Scored Answers

Reference
Number

7 – Pharmacy and Medication
Management

Yes

No

Yes
+
No

Yes %

N/A

7.001

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?

11

12

23

47.8%

2

7.002

Did health care staff administer, make available, or deliver new
order prescription medications to the patient within the required
time frames?

16

9

25

64.0%

0

7.003

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?

3

22

25

12.0%

0

7.004

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?

7.005

Upon the patient’s transfer from one housing unit to another:
Were medications continued without interruption?

7.006

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?

7.101

All clinical and medication line storage areas for narcotic
medications: Does the Institution employ strong medication
security over narcotic medications assigned to its clinical areas?

6

28

34

17.7%

3

7.102

All clinical and medication line storage areas for non-narcotic
medications: Does the Institution properly store non-narcotic
medications that do not require refrigeration in assigned clinical
areas?

27

9

36

75.0%

1

7.103

All clinical and medication line storage areas for non-narcotic
medications: Does the institution properly store non-narcotic
medications that require refrigeration in assigned clinical areas?

30

3

33

90.9%

4

7.104

Medication preparation and administration areas: Do nursing staff
employ and follow hand hygiene contamination control protocols
during medication preparation and medication administration
processes?

5

3

8

62.5%

29

7.105

Medication preparation and administration areas: Does the
institution employ appropriate administrative controls and
protocols when preparing medications for patients?

8

0

8

100.0%

29

7.106

Medication preparation and administration areas: Does the
Institution employ appropriate administrative controls and
protocols when distributing medications to patients?

2

6

8

25.0%

29

7.107

Pharmacy: Does the institution employ and follow general
security, organization, and cleanliness management protocols in
its main and satellite pharmacies?

2

0

2

100.0%

0

California Health Care Facility, Cycle 5 Medical Inspection
Office of the Inspector General

Not Applicable

20

5

25

80.0%

0

Not Applicable

Page 83
State of California

Scored Answers

Reference
Number

7 – Pharmacy and Medication
Management

Yes

No

Yes
+
No

Yes %

N/A

7.108

Pharmacy: Does the institution’s pharmacy properly store nonrefrigerated medications?

1

1

2

50.0%

0

7.109

Pharmacy: Does the institution’s pharmacy properly store
refrigerated or frozen medications?

1

1

2

50.0%

0

7.110

Pharmacy: Does the institution’s pharmacy properly account for
narcotic medications?

0

2

2

0.0%

0

7.111

Does the institution follow key medication error reporting
protocols?

1

24

25

4.0%

0

Overall percentage:

51.9%

8 – Prenatal and Post-Delivery Services
The institution has no female patients, so this indicator is not applicable.

California Health Care Facility, Cycle 5 Medical Inspection
Office of the Inspector General

Page 84
State of California

Scored Answers

Reference
Number

9 – Preventive Services

Yes

No

Yes
+
No

Yes %

N/A

9.001

Patients prescribed TB medication: Did the institution administer
the medication to the patient as prescribed?

4

5

9

44.4%

0

9.002

Patients prescribed TB medication: Did the institution monitor the
patient monthly for the most recent three months he or she was on
the medication?

1

8

9

11.1%

0

9.003

Annual TB Screening: Was the patient screened for TB within the
last year?

23

7

30

76.7%

0

9.004

Were all patients offered an influenza vaccination for the most
recent influenza season?

25

0

25

100.0%

0

9.005

All patients from the age of 50 - 75: Was the patient offered
colorectal cancer screening?

25

0

25

100.0%

0

9.006

Female patients from the age of 50 through the age of 74: Was the
patient offered a mammogram in compliance with policy?

Not Applicable

9.007

Female patients from the age of 21 through the age of 65: Was
patient offered a pap smear in compliance with policy?

Not Applicable

9.008

Are required immunizations being offered for chronic care
patients?

9.009

Are patients at the highest risk of coccidioidomycosis (valley
fever) infection transferred out of the facility in a timely manner?

12

2

14

85.7%

11

Not applicable

Overall percentage:

69.7%

10 – Quality of Nursing Performance
This indicator is evaluated only by case review clinicians. There is no compliance testing component.

11 – Quality of Provider Performance
This indicator is evaluated only by case review clinicians. There is no compliance testing component.

California Health Care Facility, Cycle 5 Medical Inspection
Office of the Inspector General

Page 85
State of California

12 – Reception Center Arrivals
The institution has no reception center, so this indicator is not applicable.

Scored Answers

13 – Specialized Medical Housing

Yes

No

Yes
+
No

13.001

For OHU, CTC, and SNF: 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?

41

0

41

100.0%

0

13.002

For CTC and SNF only: Was a written history and physical
examination completed within the required time frame?

21

3

24

87.5%

17

13.003

For OHU, CTC, SNF, and Hospice: Did the primary care provider
complete the Subjective, Objective, Assessment, Plan, and
Education (SOAPE) notes on the patient at the minimum intervals
required for the type of facility where the patient was treated?

21

19

40

52.5%

1

13.101

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?

25

0

25

100.0%

0

Reference
Number

Overall percentage:

California Health Care Facility, Cycle 5 Medical Inspection
Office of the Inspector General

Yes %

N/A

85.0%

Page 86
State of California

Scored Answers

14 – Specialty Services

Yes

No

Yes
+
No

14.001

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?

13

2

15

86.7%

0

14.002

Did the primary care provider review the high priority specialty
service consultant report within the required time frame?

10

5

15

66.7%

0

14.003

Did the patient receive the routine specialty service within 90
calendar days of the primary care provider order or Physician
Request for Service?

15

0

15

100.0%

0

14.004

Did the primary care provider review the routine specialty service
consultant report within the required time frame?

9

4

13

69.2%

2

14.005

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?

5

15

20

25.0%

0

14.006

Did the institution deny the primary care provider request for
specialty services within required time frames?

18

2

20

90.0%

0

14.007

Following the denial of a request for specialty services, was the
patient informed of the denial within the required time frame?

4

14

18

22.2%

2

Reference
Number

Overall percentage:

California Health Care Facility, Cycle 5 Medical Inspection
Office of the Inspector General

Yes %

N/A

65.7%

Page 87
State of California

Scored Answers
Reference
Number

15 – Administrative Operations

Yes

No

Yes
+
No

Yes %

N/A

15.001

Did the institution promptly process inmate medical appeals
during the most recent 12 months?

5

7

12

41.7%

0

15.002

Does the institution follow adverse / sentinel event reporting
requirements?

0

1

1

0.0%

0

15.003

Did the institution Quality Management Committee (QMC) meet
at least monthly to evaluate program performance, and did the
QMC take action when improvement opportunities were
identified?

6

0

6

100.0%

0

15.004

Did the institution’s Quality Management Committee (QMC) or
other forum take steps to ensure the accuracy of its Dashboard
data reporting?

1

0

1

100.0%

0

15.005

Does the Emergency Medical Response Review Committee
perform timely incident package reviews that include the use of
required review documents?

2

10

12

16.7%

0

15.006

For institutions with licensed care facilities: Does the Local
Governing Body (LGB), or its equivalent, meet quarterly and
exercise its overall responsibilities for the quality management of
patient health care?

2

2

4

50.0%

0

15.101

Did the institution complete a medical emergency response drill
for each watch and include participation of health care and
custody staff during the most recent full quarter?

0

3

3

0.0%

0

15.102

Did the institution’s second level medical appeal response address
all of the patient's appealed issues?

10

0

10

100.0%

0

15.103

Did the institution's medical staff review and submit the initial
inmate death report to the Death Review Unit in a timely manner?

9

1

10

90.0%

0

15.104

Does the institution's Supervising Registered Nurse conduct
periodic reviews of nursing staff?

15.105

Are nursing staff who administer medications current on their
clinical competency validation?

10

0

10

100.0%

0

15.106

Are structured clinical performance appraisals completed timely?

8

12

20

40.0%

0

15.107

Do all providers maintain a current medical license?

25

0

25

100.0%

0

15.108

Are staff current with required medical emergency response
certifications?

2

0

2

100.0%

1

6

0

6

100.0%

1

15.109

Are nursing staff and the Pharmacist-in-Charge current with their
professional licenses and certifications, and is the pharmacy
licensed as a correctional pharmacy by the California State Board
of Pharmacy?

California Health Care Facility, Cycle 5 Medical Inspection
Office of the Inspector General

Not Applicable

Page 88
State of California

Scored Answers
Reference
Number

15 – Administrative Operations

Yes

No

Yes
+
No

Yes %

N/A

15.110

Do the institution’s pharmacy and authorized providers who
prescribe controlled substances maintain current Drug
Enforcement Agency (DEA) registrations?

1

0

1

100.0%

0

15.111

Are nursing staff current with required new employee orientation?

1

0

1

100.0%

0

Overall percentage:

California Health Care Facility, Cycle 5 Medical Inspection
Office of the Inspector General

71.1%

Page 89
State of California

APPENDIX B — CLINICAL DATA
Table B-1: CHCF Sample Sets
Sample Set

Total

Anticoagulation

3

Death Review/Sentinel Events

5

Diabetes

3

Emergency Services – CPR

4

Emergency Services – Non-CPR

5

High Risk

5

Hospitalization

5

Intra-system Transfers-In

3

Intra-system Transfers-Out

3

RN Sick Call

35

Specialty Services

4
75

California Health Care Facility, Cycle 5 Medical Inspection
Office of the Inspector General

Page 90
State of California

Table B-2: CHCF Chronic Care Diagnoses
Diagnosis

Total

Anemia

12

Anticoagulation

14

Arthritis/Degenerative Joint Disease

13

Asthma

12

COPD

22

Cancer

11

Cardiovascular Disease

26

Chronic Kidney Disease

21

Chronic Pain

31

Cirrhosis/End Stage Liver Disease

11

Coccidioidomycosis

1

DVT/PE

1

Deep Venous Thrombosis/Pulmonary Embolism

6

Diabetes

46

Gastroesophageal Reflux Disease

25

Hepatitis C

23

Hyperlipidemia

38

Hypertension

63

Mental Health

19

Seizure Disorder

10

Sleep Apnea

8

Thyroid Disease

13
426

California Health Care Facility, Cycle 5 Medical Inspection
Office of the Inspector General

Page 91
State of California

Table B-3: CHCF Event – Program
Diagnosis

Total

Diagnostic Services

375

Emergency Care

81

Hospitalization

84

Intra-system Transfers-In

5

Intra-system Transfers-Out

5

Not Specified

1

Outpatient Care

362

Specialized Medical Housing

786

Specialty Services

278
1,977

California Health Care Facility, Cycle 5 Medical Inspection
Office of the Inspector General

Page 92
State of California

Table B-4: CHCF Review Sample Summary

Total
MD Reviews Detailed

30

MD Reviews Focused

2

RN Reviews Detailed

21

RN Reviews Focused

45

Total Reviews

98

Total Unique Cases

75

Overlapping Reviews (MD & RN)

23

California Health Care Facility, Cycle 5 Medical Inspection
Office of the Inspector General

Page 93
State of California

APPENDIX C — COMPLIANCE SAMPLING METHODOLOGY
California Health Care Facility (CHCF)
Quality
Indicator

Sample Category
(number of
samples)

Data Source

Chronic Care Patients

Master Registry

•

OIG Q: 6.001

•
•

Filters

Access to Care
MIT 1.001

MIT 1.002
MITs 1.003–006

MIT 1.007
MIT 1.008
MIT 1.101

(25)
Nursing Referrals
(25)
Nursing Sick Call
(3 per clinic)
(30)
Returns from
Community Hospital
(25)
Specialty Services
Follow-up
(30)
Availability of Health
Care Services
Request Forms
(6)

Chronic care conditions (at least one condition per
patient—any risk level)
Randomize
See Intra-system Transfers

•
•
•
•

Clinic (each clinic tested)
Appointment date (2–9 months)
Randomize
See Health Information Management (Medical
Records) (returns from community hospital)

OIG Q: 14.001 &
14.003

•

See Specialty Services

OIG onsite
review

•

Randomly select one housing unit from each yard

•
•
•
•
•
•
•
•
•
•

Appointment date (90 days–9 months)
Randomize
Abnormal
Appt. date (90 days–9 months)
Order name (CBC or CMPs only)
Randomize
Abnormal
Appt. date (90 days–9 months)
Service (pathology related)
Randomize

MedSATS

OIG Q: 4.007

Diagnostic Services
MITs 2.001–003

Radiology

Radiology Logs

MITs 2.004–006

(10)
Laboratory

Quest

MITs 2.007–009

(10)
Pathology

InterQual

(10)

California Health Care Facility, Cycle 5 Medical Inspection
Office of the Inspector General

Page 94
State of California

Quality
Indicator

Sample Category
(number of
samples)

Data Source

Filters

Health Information Management (Medical Records)
MIT 4.001

Timely Scanning
(10)

MIT 4.002

OIG Qs: 1.001,
1.002, & 1.004
OIG Q: 1.001

(0)
MIT 4.003
(20)
MIT 4.004

OIG Qs: 14.002
& 14.004
OIG Q: 4.007

(20)
MIT 4.005

OIG Q: 7.001
(0)

MIT 4.006
MIT 4.007

(24)
Returns From
Community Hospital

Documents for
any tested inmate
Inpatient claims
data

•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•

(25)

Non-dictated documents
1st 10 IPs MIT 1.001, 1st 5 IPs MITs 1.002, 1.004
Dictated documents
First 20 IPs selected
Specialty documents
First 10 IPs for each question
Community hospital discharge documents
First 20 IPs selected
MARs
First 20 IPs selected
Any misfiled or mislabeled document identified
during OIG compliance review (24 or more = No)
Date (2–8 months)
Most recent 6 months provided (within date range)
Rx count
Discharge date
Randomize (each month individually)
First 5 patients from each of the 6 months (if not
5 in a month, supplement from another, as needed)

Health Care Environment
MIT 5.101–105
MIT 5.107–111

Clinical Areas
(35)

OIG inspector
onsite review

•

Identify and inspect all onsite clinical areas.

SOMS

•
•
•
•

Arrival date (3–9 months)
Arrived from (another CDCR facility)
Rx count
Randomize

MedSATS

•
•

Date of transfer (3–9 months)
Randomize

OIG inspector
onsite review

•

R&R IP transfers with medication

Inter- and Intra-System Transfers
MIT 6.001–003

MIT 6.004
MIT 6.101

Intra-System
Transfers
(25)
Specialty Services
Send-Outs
(20)
Transfers Out
(4)

California Health Care Facility, Cycle 5 Medical Inspection
Office of the Inspector General

Page 95
State of California

Quality
Indicator

Sample Category
(number of
samples)

Data Source

Filters

OIG Q: 1.001

See Access to Care
• At least one condition per patient—any risk level
• Randomize

Master Registry

OIG Q: 4.007

•
•
•
•

Rx count
Randomize
Ensure no duplication of IPs tested in MIT 7.001
See Health Information Management (Medical
Records) (returns from community hospital)

OIG Q: 12.001

•

See Reception Center Arrivals

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
Date of transfer (2–8 months)
Sending institution (another CDCR facility)
Randomize
NA/DOT meds
Identify and inspect clinical & med line areas that
store medications

Pharmacy and Medication Management
MIT 7.001

MIT 7.002

MIT 7.003
MIT 7.004

MIT 7.005

Chronic Care
Medication
(25)
New Medication
Orders
(25)
Returns from
Community Hospital
(25)
RC Arrivals –
Medication Orders
(N/A at this
institution)
Intra-Facility Moves

(25)
MIT 7.006

MITs 7.101–103
MITs 7.104–106

MITs 7.107–110
MIT 7.111
MIT 7.999

En Route
(0)
Medication Storage
Areas
(varies by test)
Medication
Preparation and
Administration Areas
(varies by test)
Pharmacy
(2)
Medication Error
Reporting
(25)
Isolation Unit KOP
Medications
(1)

SOMS

OIG inspector
onsite review

•
•
•
•
•
•
•
•

OIG inspector
onsite review

•

Identify and inspect onsite clinical areas that
prepare and administer medications

OIG inspector
onsite review
Monthly
medication error
reports
Onsite active
medication
listing

•

Identify & inspect all onsite pharmacies

•
•

All monthly statistic reports with Level 4 or higher
Select a total of 5 months

•

KOP rescue inhalers & nitroglycerin medications
for IPs housed in isolation units

Recent Deliveries
(N/A at this
institution)

OB Roster

•
•

Delivery date (2–12 months)
Most recent deliveries (within date range)

Pregnant Arrivals
(N/A at this
institution)

OB Roster

•
•

Arrival date (2–12 months)
Earliest arrivals (within date range)

Prenatal and Post-Delivery Services
MIT 8.001–007

California Health Care Facility, Cycle 5 Medical Inspection
Office of the Inspector General

Page 96
State of California

Quality
Indicator

Sample Category
(number of
samples)

Data Source

Filters

TB Medications

Maxor

•
•
•
•
•
•
•
•
•
•
•
•
•
•
•

Dispense date (past 9 months)
Time period on TB meds (3 months or 12 weeks)
Randomize
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

Preventive Services
MITs 9.001–002

MIT 9.003

MIT 9.004

MIT 9.005

MIT 9.006

(9)
TB Evaluation,
Annual Screening
(30)
Influenza
Vaccinations
(25)
Colorectal Cancer
Screening
(25)
Mammogram
(N/A at this
institution)

SOMS

SOMS

SOMS

SOMS

MIT 9.007

Pap Smear
(N/A at this
institution)

SOMS

•
•
•

Arrival date (at least three yrs prior to inspection)
Date of birth (age 24–53)
Randomize

MIT 9.008

Chronic Care
Vaccinations

OIG Q: 1.001

•

Cocci transfer
status report

•
•
•
•
•
•

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

MIT 9.009

(25)
Valley Fever
(number will vary)
(N/A at this
institution)

California Health Care Facility, Cycle 5 Medical Inspection
Office of the Inspector General

Page 97
State of California

Quality
Indicator

Sample Category
(number of
samples)

Data Source

Filters

SOMS

•
•
•

Arrival date (2–8 months)
Arrived from (county jail, return from parole, etc.)
Randomize

OHU & CTC

CADDIS

(41)
Call Buttons
CTC
(all)

OIG inspector
onsite review

•
•
•
•
•

Admit date (1–6 months)
Type of stay (no MH beds)
Length of stay (minimum of 5 days)
Randomize
Review by location

•
•
•
•
•
•
•
•
•
•
•
•
•

Approval date (3–9 months)
Randomize
Approval date (3–9 months)
Remove optometry, physical therapy or podiatry
Randomize
Arrived from (other CDCR institution)
Date of transfer (3–9 months)
Randomize
Review date (3–9 months)
Randomize
Meeting date (9 months)
Denial upheld
Randomize

Reception Center Arrivals
MITs 12.001–008

RC
(N/A at this
institution)

Specialized Medical Housing
MITs 13.001–003

MIT 13.101

Specialty Services
MITs 14.001–002
MITs 14.003–004

MIT 14.005

MIT 14.006–007

High-Priority
(15)
Routine
(15)
Specialty Services
Arrivals
(20)
Denials
(15)

MedSATS
MedSATS

MedSATS

InterQual
IUMC/MAR
Meeting Minutes

(5)

California Health Care Facility, Cycle 5 Medical Inspection
Office of the Inspector General

Page 98
State of California

Quality
Indicator

Sample Category
(number of
samples)

Data Source

Filters

Monthly medical
appeals reports
Adverse/sentinel
events report

•

Medical appeals (12 months)

•

Adverse/sentinel events (2–8 months)

Quality
Management
Committee
meeting minutes
EMRRC meeting
minutes
LGB meeting
minutes
Onsite summary
reports &
documentation
for ER drills
Onsite list of
appeals/closed
appeals files
Institution-list of
deaths in prior 12
months
Onsite supervisor
periodic RN
reviews

•

Meeting minutes (12 months)

•

Monthly meeting minutes (6 months)

•

Quarterly meeting minutes (12 months)

•
•

Most recent full quarter
Each watch

•

Medical appeals denied (6 months)

•
•

Most recent 10 deaths
Initial death reports

•
•

RNs who worked in clinic or emergency setting
six or more days in sampled month
Randomize

Onsite nursing
education files

•
•
•
•

On duty one or more years
Nurse administers medications
Randomize
All required performance evaluation documents

•

Review all

•

All staff
o Providers (ACLS)
o Nursing (BLS/CPR)
Custody (CPR/BLS)
All required licenses and certifications

Administrative Operations
MIT 15.001
MIT 15.002

MITs 15.003–004

MIT 15.005
MIT 15.006
MIT 15.101

MIT 15.102
MIT 15.103
MIT 15.104

MIT 15.105

MIT 15.106
MIT 15.107
MIT 15.108

MIT 15.109

Medical Appeals
(all)
Adverse/Sentinel
Events
(1)
QMC Meetings
(6)
EMRRC
(12)
LGB
(4)
Medical Emergency
Response Drills
(3)
2nd Level Medical
Appeals
(10)
Death Reports
(10)
RN Review
Evaluations
(N/A)
Nursing Staff
Validations
(10)
Provider Annual
Evaluation Packets
(20)
Provider licenses
(25)
Medical Emergency
Response
Certifications
(all)
Nursing staff and
Pharmacist in
Charge Professional
Licenses and
Certifications
(all)

Onsite
provider
evaluation files
Current provider
listing (at start of
inspection)
Onsite
certification
tracking logs
Onsite tracking
system, logs, or
employee files

California Health Care Facility, Cycle 5 Medical Inspection
Office of the Inspector General

•
•

Page 99
State of California

Quality
Indicator

Sample Category
(number of
samples)

Data Source

Filters

Onsite listing of
provider DEA
registration #s &
pharmacy
registration
document
Nursing staff
training logs

•

All DEA registrations

•
•

New employees (hired within last 12 months)

OIG summary log
- deaths

•
•

Between 35 business days & 12 months prior
CCHCS death reviews

Administrative Operations
MIT 15.110

MIT 15.111

MIT 15.998

Pharmacy and
Providers’ Drug
Enforcement Agency
(DEA) Registrations
(all)
Nursing Staff New
Employee
Orientations
(all)
Death Review
Committee
(10)

California Health Care Facility, Cycle 5 Medical Inspection
Office of the Inspector General

Page 100
State of California

CALIFORNIA CORRECTIONAL
HEALTH CARE SERVICES’
RESPONSE

California Health Care Facility, Cycle 5 Medical Inspection
Office of the Inspector General

Page 101
State of California

 

 

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