CONTRACT FACILITY HEALTH CARE - California · CONTRACT FACILITY HEALTH CARE ... 2 – INTERNAL MONITORING AND QUALITY MANAGEMENT ... Limited Review Sample Size

CONTRACT FACILITY HEALTH CARE MONITORING AUDIT

Limited Review

Central Valley

Modified Community Correctional Facility

August 8-10, 2017

Contract Facility Health Care Monitoring Audit Limited Review

Private Prison Compliance and Health Care Monitoring Audit – Limited Review Page 2 Central Valley Modified Community Correctional Facility August 8-10, 2017

TABLE OF CONTENTS

DATE OF REPORT .................................................................................................................................... 3

INTRODUCTION ....................................................................................................................................... 3

METHODOLOGY ....................................................................................................................................... 5

EXECUTIVE SUMMARY ........................................................................................................................... 6

IDENTIFICATION OF CRITICAL ISSUES ................................................................................................. 8

AUDIT FINDINGS – DETAILED BY QUALITY INDICATOR (COMPONENT) ......................................... 9

2 – INTERNAL MONITORING AND QUALITY MANAGEMENT ............................................................. 9

4 - ACCESS TO CARE .............................................................................................................................. 10

5 – DIAGNOSTIC SERVICES ................................................................................................................... 11

6 – EMERGENCY SERVICES AND COMMUNITY HOSPITAL DISCHARGE .......................................... 11

7 - INITIAL HEALTH ASSESSMENT/HEALTH CARE TRANSER ......................................................... 13

8 - MEDICAL/MEDICATION MANAGEMENT ....................................................................................... 14

10 - SPECIALTY SERVICES .................................................................................................................... 15

11 - PREVENTIVE SERVICES ................................................................................................................ 17

12 - EMERGENCY MEDICAL RESPONSE/DRILLS and EQUIPMENT .................................................. 17

13 - CLINICAL ENVIRONMENT............................................................................................................. 18

CRITICAL ISSUE REVIEW ...................................................................................................................... 19

NEW CRITICAL ISSUES ......................................................................................................................... 21

CONCLUSION ......................................................................................................................................... 22



DATE OF REPORT November 30, 2017

INTRODUCTION

As a result of an increasing inmate population and a limited capacity to house inmates, the California Department of Corrections and Rehabilitation (CDCR) entered into contractual agreements with private prison vendors to house California inmates. Although these inmates are housed in a contracted facility, either in or out-of-state, the California Correctional Health Care Services (CCHCS) is responsible to ensure health care standards equivalent to California’s regulations, CCHCS’s policy and procedure, and court ordered mandates are provided.

As one of several means to ensure the prescribed health care standards are provided, CCHCS staff developed a tool to evaluate and monitor the delivery of health care services provided at the contracted facility through a standardized audit process. This process consists of a review of various documents obtained from the facility; including medical records, monitoring reports, staffing rosters, Disability Placement Program (DPP) list, and other relevant health care documents, as well as an onsite assessment involving staff and patient interviews and a tour of all health care service points within the facility.

This report provides the findings associated with the Limited Review conducted on August 8 through 10, 2017 at Central Valley Modified Community Correctional Facility (CVMCCF), which is located in McFarland, California. At the time of the audit, CDCR’s Weekly Population Count, dated August 11, 2017, indicated that CVMCCF had a design capacity of 700 beds, of which 691 were occupied with CDCR inmates.

Audit Review

In accordance with the Receiver’s directive, the CCHCS Field Operations and Private Prison Compliance and Monitoring Unit’s (PPCMU) management plan on conducting two rounds of audits in a calendar year for the private facilities Modified Community Correctional Facilities (MCCFs) and the out-of-state correctional facilities (COCF) currently in contract with California. During the first six months of the calendar year, the PPCMU audit team will conduct a full audit on all the facilities using the revised Audit Guide and Audit Tools. Based upon the overall audit rating received by the facility in their initial audit (inadequate or adequate), the facility may undergo a second round audit, either a full review or Limited Review. If the facility records a proficient score, there may not be a need to proceed with a second audit during the same calendar year, the determination will be made based upon the overall assessment of each component. The Limited Review will utilize the Audit Guide/Methodology used during the full audit completed in the first six months of the calendar year.



Type of Audit Review

The following guidelines will be used in the determination of the type of review to be performed:

If the facility achieved an overall audit rating of “Proficient” (≥ 90%) on the first round of audit, the facility may not undergo a second round of audit in the same calendar year.

If the facility achieved an overall audit rating of “Adequate” (80.0 - 89.9%), a Limited Review will be conducted during the second half of the calendar year.

If the facility achieved an overall audit rating of “Inadequate” (<80.0%), a second full review will be conducted during the second half of the calendar year.

Limited Review

For a Limited Review, the following guidelines will be followed:

If the overall rating for a specific quality indicator (component), e.g., Access to Care, is “Inadequate,” the CCHCS auditors will perform a review of all sections pertaining to the inadequate indicator (component). The auditors will perform nursing case review, physician case review, and quantitative review which is comprised of onsite and electronic medical record review.

If the overall rating for a specific quality indicator (component) is “Adequate,” the CCHCS auditors will only perform a review of those sections that scored less than 80%. For example, if the Diagnostic Services overall score of 85.0% resulted from the following review scores: physician case review of 70.0%; nursing case review of 90.0%, and the quantitative review of 95.0%, then the only review to be performed is the physician case review and review of any quantitative critical issues identified in the previous audit.

For the quantitative review portion, if the score of a specific quality indicator (component) is equal to or above 80.0%, the CCHCS auditors will only review critical issues identified during the previous audit or specific questions scoring below 80.0% under that specific (component).

The quality indicators (components) “Quality of Nursing Performance” and “Quality of Provider Performance” will be excluded under the Limited Review. CCHCS clinicians will only review patient encounters occurring during the four-month Limited Review audit period that pertain to failed sections for all other quality indicators (components).

Limited Review Sample Size

For sample selection on case reviews, the CCHCS nurse auditor will select a sample of 10 patients that will likely have frequent encounters related to the quality indicator (component) being reviewed. Due to less frequent physician-patient encounters in a month, the CCHCS physician auditor will review a total of 15 patients to obtain sufficient data.

Review Period

The CCHCS auditors will utilize four months of data for both full and Limited Reviews to avoid the overlapping of months previously audited.



The August 2017 Limited Review conducted at the CVMCCF assessed data and records for the review period of March 1 through June 30, 2017. The auditors conducted an assessment of all quality indicators (components) and processes that were identified to be deficient at the time of the previous audit conducted on December 13 through 15, 2016. The deficient items included findings obtained from medical record reviews, pre-audit document reviews, clinician case reviews, and onsite observations and interviews. During all Limited Reviews the auditors utilize the same methodology initially used in the previous full audit to determine compliance with a specific standard/requirement maintaining consistency during each review.

METHODOLOGY

The auditors predominantly utilize three methods to evaluate compliance during the review process:

i. Medical Record Review: All items that were previously found to be deficient following the health record reviews are evaluated by the clinician auditors. The nurse and physician auditors reviewed a sample of patient health records as identified in the Audit Guide (Rev. September 2016) Methodology for a four month audit review period. For limited case reviews, the nurse auditor reviews 10 cases while the physician reviews 15 cases. Under each quality indicator (component), questions that previously did not meet the 80% compliance standard will be separately reviewed by a nurse auditor. Compliance is determined based on the documentation found in the medical records and not in the shadow files kept by the facility. This review is completed remotely by reviewing the electronic medical record. The issues are determined to be resolved only if the quality indicators (components) or the questions under each indicator (component) score above the 80% compliance threshold.

ii. Document Review: The administrative items that were previously identified to be deficient related to the facility’s lack of policies and procedures, absence of training logs, absence of mechanism to track the release of information, health care appeals, licenses and certifications, and contracts are evaluated by the Health Program Specialists I (HPS I). The facilities are requested to submit the pertinent documentation to PPCMU prior to the onsite review. The HPS I auditors review the documents received from the facility and determine compliance.

iii. Onsite observation and interviews with CVMCCF health care staff: The critical issues previously identified resulting from onsite inspections and observations of facility’s various medical processes and staff interviews are evaluated during the onsite visit. The nurse and HPS I auditors conduct inspections of various clinical and housing areas within the facility, interview key facility personnel, which includes medical and custody staff, for the overall purpose of evaluating compliance of the identified critical issues and to identify any new issues.



EXECUTIVE SUMMARY

A full health care monitoring audit was conducted at CVMCCF on December 13 through 15, 2016. The review period for this audit was May 1, 2016 through October 31, 2016. The facility received an overall compliance rating of Adequate (87.7%). The PPCMU audit team conducted a four month Limited Review at CVMCCF on August 8 through 10, 2017, to reassess the failed components and critical issues identified during the December 2016 audit. The Limited Review audit period was March 1, 2017 through June 30, 2017. The audit team consisted of the following personnel:

R. Delgado, Medical Doctor, Retired Annuitant L. Pareja, Nurse Consultant, Program Review R. Brar, HPS I

The scope of the review included:

Re-examination of all questions for all sections of the Emergency Services and Community Hospital Discharge indicator (component);

Review of all quantitative findings (medical record review and nursing onsite review) of the Initial Health Assessment/Health Care Transfer and Specialty Services Indicators (components);

Nursing case review for the Diagnostic Services indicator (component); and physician case review of the Medical/Medication Management indicator (component).

The results of the Limited Review revealed an overall compliance score of 83.3% for Emergency Services and Community Hospital Discharge Quality Indicator (component), which is an increase of 16.6 percentage points from the 66.7% compliance score received for this indicator (component) during the December 2016 audit, as shown in Table 1.1.

Table 1.1

Quality Indicator (Component) Full Review

December 2016 Overall Indicator

(Component) Compliance Score

August 2017 Overall Indicator

(Component) Compliance Score

6. Emergency Services & Community Hospital Discharge

66.7% 83.3%

The CCHCS auditors also reviewed the 17 critical issues identified during the December 2016 audit. The facility successfully resolved 12 out of 17 critical issues as indicated in Table 1.2, with one new critical issue identified in the Specialty Services Quality indicator (component).



Table 1.2

Quality Indicators (Components) Limited Review

Previous Critical Issues

Resolved Unresolved

New Critical Issues

Limited Review

Current Critical Issues

2. Internal Monitoring & Quality Management

4 3 1 0 1

4. Access to Care 3 3 0 0 0

7. Initial Health Assessment/Health Care Transfer

4 4 0 0 0

8. Medical/Medication Management 1 0 1 0 1

10. Specialty Services 1 0 1 1 2

11. Preventative Services 1 0 1 0 1

12. Emergency Medical Response/Drills and Equipment

2 1 1 0 1

13. Clinical Environment 1 1 0 0 0

A discussion of the facility’s progress toward resolution of all Critical Issue items identified during the previous audit is included in the Critical Issue Review section on page 19 of this report.



IDENTIFICATION OF CRITICAL ISSUES The table below reflects the continued quantitative analysis standards in which the facility’s compliance fell below acceptable compliance levels during the August 2017 Limited Review.

Critical Issues – Central Valley Modified Community Correctional Facility

Question 2.7 The facility does not accurately document dates the patient returned to the hub from the emergency department (ED) in the Hospital Stay/Emergency Department monitoring log. This deficiency has been outstanding since the January 2016 audit.

Question 8.5 The facility does not consistently administer anti-Tuberculosis (TB) medication(s) as prescribed to patients on anti-TB medication(s). This deficiency has been outstanding since the December 2016 audit.

Question 10.3 The registered nurse (RN) failed to notify the primary care provider of any immediate medication or follow-up requirements ordered by the specialty consultant upon the patient’s return from the specialty services appointment. This is a new critical issues.

Question 10.4 The facility primary care provider (PCP) does not consistently complete a follow-up appointment with the patient within the required time frame after a specialty appointment. This deficiency has been outstanding since the January 2016 audit.

Question 11.3 The facility does not consistently offer colorectal cancer screening to the patient population 50-75 years of age. This deficiency has been outstanding since the December 2016 audit. This deficiency was not reviewed during the Limited Review.1

Question 12.4 The facility’s Emergency Medical Response Review Committee does not consistently perform timely incident package reviews containing the required review documents. This deficiency has been outstanding since the January 2016 audit.

These critical issues found unresolved during this review process will remain active and will be monitored in subsequent audits. In addition, the newly identified critical issue and each unresolved deficiency will require the facility to take the necessary action to bring the deficiencies into compliance and will be re-examined during the facility’s next scheduled health care audit.

1 This question is reviewed annually during the full audit completed during the months of January through June each year and was not reviewed during the current Limited Review.



AUDIT FINDINGS – DETAILED BY QUALITY INDICATOR (COMPONENT)

2 – INTERNAL MONITORING AND QUALITY MANAGEMENT

Quantitative Review Results

During the December 2016 audit, CVMCCF received an Overall Quality Indicator Rating of adequate for the Internal Monitoring and Quality Management Indicator (component) with four critical issues identified all pertaining to the facility’s monitoring logs. The Sick Call; Specialty Services; Hospital Stay/Emergency Department; and Initial Intake Screening logs were found to have inaccuracies in documentation. During the current Limited Review, the facility resolved three of the four critical issues. Of the four logs listed above, only the Hospital Stay/Emergency Department monitoring log remained non-compliant.

Internal Monitoring & Quality Management

First

Round

Audit

Score

Limited

Review

Audit

Score

Percentage

Point

Change

2.5 Is data documented on the sick call monitoring log accurate? 56.0% 80.0% + 24.0%

2.6 Is data documented on the specialty care monitoring log accurate? 16.2% 92.9% + 76.7%

2.7 Is data documented on the hospital stay/emergency department monitoring log accurate?

50.0% 0.0% - 50.0%

2.9 Is data documented on the initial intake screening monitoring log accurate?

73.3% 95.0% + 21.7%

Comments:

2.5 During the Limited Review, 35 entries on the sick call monitoring log for the audit review period were reviewed for accuracy. Seven of the entries were found to be inaccurate. Seven records failed to have the sick call request form in the medical record to validate the date the sick call was received or reviewed by an RN. Two records failed to have the nursing encounter/protocol form in the medical record as documented on the sick call form. One record had an incorrect date listed for the RN face-to-face, and one record failed to have the date the patient was seen by the PCP documented on the log. This critical issue has been resolved by the facility.

2.6 Fourteen entries were reviewed on the specialty services monitoring log of patients receiving specialty services during the Limited Review audit review period. On one record, the PCP referral date did not match the Physician Order dated February 10, 2017 for the referral. This critical issue has been resolved by the facility.

2.7 Two entries on the hospital stay/emergency department monitoring log met the criteria for review during the Limited Review audit period. For one record, the log failed to show the patient’s return date to CVMCCF and one record failed to have the PCP assessment date documented on the log. There was a progress note found in the medical record and the date should have been documented on the log. This critical issue remains unresolved and will be monitored during subsequent audits for compliance.



2.9 Forty entries were reviewed on the intake screening monitoring log during the Limited Review. Two entries were found to be inaccurate. One date entered on the log for the date of the history and physical did not match the date on the history and physical form in the medical record. The second entry did not have documentation of an initial health assessment in the medical record to confirm the initial health assessment was completed. This critical issue has been resolved by the facility.

4 - ACCESS TO CARE

Quantitative Review Results During the December 2016 audit, the facility received an overall adequate rating in the Access to Care indicator (component). Due to the adequate rating, only the three critical issues identified for this Indicator (component) during the December 2016 audit were reviewed. During the Limited Review, the three critical issues rated proficient, thereby resolving all critical issues for the Access to Care indicator (component).

Access to Care

First

Round

Audit

Score

Limited

Review

Audit

Score

Percentage

Change

4.3 Was the focused subjective/objective assessment conducted based upon the patient’s chief complaint?

70.8% 93.8% + 23.0%

4.5 Did the registered nurse document that effective communication was established and that education was provided to the patient related to the treatment plan?

75.0% 100% + 25.0%

4.8 Did the Care Team regularly conduct and document a Care Team Huddle during business days?

38.1% 90.9% + 52.8%

Comments:

4.3 CCHCS nursing staff reviewed 16 medical records during the Limited Review. Documentation for one record revealed the facility RN failed to conduct a focused subjective/objective assessment of all of patient’s complaints. This critical issue has been resolved by the facility.

4.8 Documentation of 22 days of Daily Care Team Huddles were reviewed by the CCHCS nurse auditor for the Limited Review. Two days’ documentation was inadequate. On June 7, 2017, new intakes were discussed, but there was no documentation of any monitoring to be done, no documentation of any new intake who needs to be seen earlier or if they have an appointment to be seen. Additionally, on June 29, 2017, there was no documentation of the reason a patient was transferred to a higher level of care and no discussion of what preparations are needed upon the patient’s return. This critical issue has been resolved by the facility.



5 – DIAGNOSTIC SERVICES

For the August 2017 Limited Review, the nurse case review was the only section reviewed. No physician case reviews were required as the overall compliance rating for the indicator (component) was adequate during the December 2016 audit. Additionally, there were no quantitative or qualitative critical issues identified for this indicator (component).

Audit Date NCPR

Compliance Score

Physician Provider

Score

Quantitative Score

Critical Issues

December 2016 50.0% 100% 97.1% 0

Limited Review August 2017 81.8% N/A N/A 0

Current Critical Issues 0

During the Limited Review, CVMCCF received a compliance score of 81.8% for the nurse case reviews in the Diagnostic Services Indicator (component), which is an improvement from the 50.0% score received during the December 2016 audit. Specific findings related to the Limited Review nurse case reviews for this indicator (component) are documented below.

Case Review Results

During the December 2016 audit, there were four nursing encounters reviewed during the nurse case review. Of the four encounters, two deficiencies were identified related to inadequate nursing education on how to properly connect a patient to a 12-lead EKG. During the Limited Review, 11 nursing encounters for Diagnostic Services were reviewed. Nine of the 11 encounters were found to be appropriate and two were found to be deficient. The nursing deficiencies identified are listed below:

In Case 20, there was no documentation that the patient’s Vitamin D Level test was completed as ordered.

In Case 24, the patient’s routine lab orders were not completed within 14 days of being ordered. The PCP ordered labs on April 24, 2017 and they were not collected until May 10, 2017 which is outside the required 14 day time frame.

6 – EMERGENCY SERVICES AND COMMUNITY HOSPITAL DISCHARGE

Audit Date NCPR

Compliance Score

Physician Provider

Score

Quantitative Score

Critical Issues

December 2016 50.0% N/A2 100% 0

Limited Review August 2017 50.0% 100% 100% 0


2 There were no physician encounters identified for the Emergency Services and Community Hospital Discharge review during

the December 2016 Audit



The facility received an Overall Quality Indicator (component) rating of inadequate (66.7%) in the Emergency Services and Community Hospital Discharge indicator (component) during the December 2016 audit. Due to the overall quality indicator (component) rating of inadequate, all sections of this indicator were reviewed during the Limited Review. During the current review, CVMCCF received a compliance rating of adequate (83.3%). Specific findings related to the provider and nurse case reviews. Case Review Results

The CCHCS nurse auditor assessed a total of six urgent and emergent encounters during the December 2016 audit and found three deficiencies related to nursing performance. All three deficiencies were found to be related to the same case; nursing staff failed to utilize the appropriate nursing protocol; failed to contact the facility PCP immediately when patient complained of a pain scale3 of 10/10 for chest pain and failed to connect the 12-lead electrocardiogram (EKG)4 properly, thereby delaying diagnostic data. During the Limited Review, the CCHCS nurse auditor reviewed four urgent and emergent nursing encounters. Of the four encounters, two were found appropriate and two were found deficient resulting in a compliance score of 50.0%. Nursing staff has failed to improve on this critical indicator as one deficiency was again related to the emergency care provided to a patient complaining of chest pain with an abnormal EKG result. The nursing deficiencies identified are documented below:

In Case 19, the patient complained of chest pain with an abnormal EKG result. Nursing staff failed to notify the PCP STAT5 and administer STAT medications to the patient. The patient was sent to the emergency department the following day by the PCP.

In Case 21, there was no documentation of a nursing assessment when the patient presented with a pain scale of 9/10 for severe leg pain with swelling; inability to walk; inability to move the leg or put pressure on it. The only documentation related to this event was the PCP documentation.

There were no encounters reviewed by the CCHCS physician auditor during the December 2016 audit for Emergency Services and Community Hospital Discharge case review. During the Limited Review, the physician auditor reviewed seven encounters related to this indicator (component). All seven encounters were found appropriate, resulting in a 100% compliance score.

3 Pain Scale: A pain scale measures a patient's pain intensity or other features. Pain scales are based on self-report,

observational (behavioral), or physiological data. Self-report is considered primary and should be obtained if possible. Pain measurements help determine the severity, type, and duration of the pain, and are used to make an accurate diagnosis. A 10/10 pain sale would indicate the patient is in extreme pain at the top of the scale. 4 Electrocardiogram – a test to show how fast the heart is beating, whether the rhythm of the heartbeats is steady or irregular,

and the strength and timing of the electrical impulses passing through each part of the heart. 5 STAT - A common medical abbreviation for urgent or rush. From the Latin word statum, meaning 'immediately.'

https://en.wikipedia.org/wiki/Patient

https://en.wikipedia.org/wiki/Pain



7 -INITIAL HEALTH ASSESSMENT/HEALTH CARE TRANSER

The facility received failing scores for four of the eight quantitative questions reviewed. Due to the inadequate rating for the quantitative section this indicator (component), CCHCS auditors reviewed all eight quantitative review questions during the Limited Review. Specific findings related to the review of the quantitative section and the progress in resolution of the four critical issues identified are documented below. Quantitative Review Results In December 2016, the facility received an inadequate quantitative review rating for the Initial Health Assessment/Health Care Transfer indicator (component). During the Limited Review, the facility received three proficient and one adequate rating for the failing questions, thereby resolving all four critical issues for this indicator.

Initial Health Assessment/Health Care Transfer

First

Round

Audit

Score

Limited

Review

Audit

Score

Percentage

Change

7.1 Did the patient receive an initial health screening upon arrival at the receiving facility by licensed health care staff?

100% 100% 0.0%

7.2 If YES was answered to any of the questions on the Initial Health Screening form (CDCR 7277/7277A or similar form), did the registered nurse document an assessment of the patient?

42.9% 100% + 57.1%

7.3 If the patient required referral to an appropriate provider based on the registered nurses disposition, was the patient seen within the required time frame.

N/A N/A 0.0%

7.4 If upon arrival, the patient had a scheduled or pending medical, dental, or a mental health appointment, was the patient seen within the time frame specified by the sending facility’s provider?

72.7% 100% + 27.3%

7.5 Did the patient receive a complete screening for the signs and symptoms of tuberculosis upon arrival?

100% 100% 0.0%

7.6 Did the patient receive a complete initial health assessment upon arrival at the facility?

100% 100% 0.0%

7.7 When a patient transfers out of the facility, are all pending appointments that were not completed, documented on a CDCR Form 7371, Health Care Transfer Information Form, or a similar form?

58.3% 83.3% + 25.0%

7.8 Does the Inter-Facility Transfer Envelope contain all the required transfer documents and medications?

66.7% 100% + 33.3%

Overall Percentage Score and Percentage Change: 77.2% 97.6% 20.4%



Comments:

7.3 N/A. There were no patients identified who met the criteria for this question during the Limited Review.

7.7 The CCHCS nurse auditor reviewed six medical records meeting the criteria for this question during the Limited Review period. Five records were compliant, but one record was found non-compliant. The CDCR Form 7371, Health Care Transfer Information Form did not document a pending follow-up appointment scheduled with the PCP. This critical issue has been resolved by the facility.

8 - MEDICAL/MEDICATION MANAGEMENT

Audit Date NCPR

Compliance Score

Physician Provider

Score

Quantitative Score

Critical Issues

December 2016 95.0% 70.8% 95.1% 1

Limited Review August 2017 N/A 88.0% N/A 0


The facility received an Overall Quality Indicator Rating of adequate in the Medical/Medication Management indicator (component) during the December 2016 audit. Based on the inadequate (70.8%) compliance rating for Physician Case Reviews for this indicator (component), physician case reviews were conducted. There was also one critical issue identified which was also reviewed during the Limited Review. Nurse case reviews were not completed as the nurse case review compliance rating was found to be proficient during the December 2016. Specific findings related to the physician case review and review of the critical issue identified are documented below. Case Review Results

During the Limited Review, the CCHCS physician auditor reviewed 27 physician encounters related to the Medical/Medication Management indicator (component) and found three deficiencies which are documented below:

In Case 8, the patient was scheduled to be seen by Dermatology for an unexplained, severe rash. Patient refused the appointment for unclear reasons. The PCP failed to schedule a follow-up appointment to discuss the refusal and its possible implications.

In Case 10, the patient was evaluated for a scalp rash. The patient refused the referral to Dermatology; the lesions were documented as mild and causing few symptoms. There was inadequate documentation of medical necessity of referral or systemic treatment.

In Case 13, the patient was seen at sick call on May 12, 2017 with a heart rate of 79 and blood pressure of 101/63. Patient seen on May 18, 2017 for allergic rhinosinusitis6. Vitals initially noted a heart rate of 43 and blood pressure of 96/65. Nursing staff’s recheck of heart rate and blood pressure noted 45 and 105/68 respectively. Provider failed to mention abnormal vital signs or

6 Rhinosinusitis – an inflammation of the sinuses and nasal cavity.



exploration of possible symptoms or follow-up. Abnormal vital signs should always be addressed and assessment of such should follow. Follow-up as needed is not appropriate.

Recommendations: Patient refusals need to be followed by a provider visit to review the issues and generate a new

plan if the refusal persists.

The PCP should carefully review the Title 15 and specifically seek to avoid workups and treatments which are not medically necessary and only order routine laboratory testing as suggested by the United States Preventative Services Task Force.


The critical issue identified in the Medical/Medication Management indicator (component) during the December 2016 audit was the facility failed to consistently administer anti-Tuberculosis (TB) medication(s) as prescribed to the patients on anti-TB medications(s). During the Limited Review period (March through June 2017) there were no patients housed at CVMCCF receiving anti-TB medications, therefore this critical issue was unable to be evaluated and is considered unresolved. This critical issue will be monitored for compliance during subsequent audits.

Medical/Medication Management

First

Round

Audit

Score

Limited

Review

Audit

Score

Percentage

Change

8.5 For patients prescribed anti-Tuberculosis medication(s): Did the facility administer the medication(s) to the patient as

prescribed?

42.1% N/A 0.0%

Comments:

8.5 N/A. There were no patients housed at CVMCCF who were prescribed anti-TB medications during the Limited Review period, therefore this question could not be evaluated. This critical issue remains unresolved and will be monitored during subsequent audits for compliance.

10 - SPECIALTY SERVICES


The facility received an Overall Quantitative Review Rating of inadequate (78.0%) in the Specialty Services indicator (component) during the December 2016 audit. Two of the four quantitative questions for this (component) were evaluated during the December 2016 audit with one critical issue identified. Question 10.1 was not reviewed for either the December 2016 audit or Limited Review as it does not pertain to the MCCF facilities and Question 10.3 was not scored during the December 2016 audit as there were no samples identified as meeting the criteria for that question. Based on the inadequate score for the quantitative portion of the Specialty Services Indicator (component), all quantitative questions pertaining to the MCCFs were reviewed during the Limited Review.



CVMCCF failed to resolve the critical issue (Question 10.4) identified during the December 2016 audit and one new critical issue (Question 10.4) was identified during the current audit. Specific findings related to the review of the three quantitative questions are documented below.

Specialty Services

First

Round

Audit

Score

Limited

Review

Audit

Score

Percentage

Change

10.1 Was the patient seen by the specialist for a specialty services referral within the specified time frame? (COCF Only)

N/A N/A 0.0%

10.2 Upon the patient’s return from the specialty service appointment, did the registered nurse complete a face-to-face assessment prior to the patient’s return to the assigned housing unit?

81.0% 87.5% 6.5%

10.3

Upon the patient’s return from the specialty services appointment, did the registered nurse notify the primary care provider of an immediate medication or follow-up requirements provided by the specialty consultant?

N/A 0.0% 0.0%

10.4 Did the primary care provider review the specialty consultant’s report/discharge summary and complete a follow-up appointment with the patient within the required time frame?

75.0% 35.7% - 39.3%

Comments:

10.1 N/A. This question pertains to out-of-state facilities only.

10.2 Sixteen medical records were reviewed by the CCHCS nurse auditor for the Limited Review period. Fourteen medical records were found to have documentation of the RN completing a face-to-face assessment of the patient upon his return from a specialty appointment prior to him returning to his housing unit. Two medical records failed to have the required documentation.

10.3 Four medical records were reviewed by the CCHCS nurse auditor during the Limited Review for this question. All four records failed to have documentation that RN notified the PCP of an immediate medication or follow-up requirements provided by the specialty consultant upon patient’s return from a specialty services appointment. This is a new critical issue.

10.4 Fourteen medical records were reviewed regarding by the CCHCS nurse auditor during the Limited Review for this question. Nine records were found to be non-compliant. Seven patients were not seen by the PCP for a follow-up appointment within the required time frame upon return from a specialty appointment; one record failed to have documentation the PCP reviewed the specialty consultant’s documentation and failed to complete a follow-up appointment; and one record failed to have documentation the PCP completed a follow-up appointment. The critical issue remains unresolved and will be monitored during subsequent audits to determine compliance.

Recommendation:

Nursing staff assigned to schedule the patient’s PCP visits should be trained on IMSP&P guidelines related to the time frames for patient’s PCP follow-up appointment post specialty services and other returns from outside services.



11 - PREVENTIVE SERVICES

During the December 2016 Audit, CVMCCF was found deficient in offering colorectal cancer screening to the patient population 50-75 years of age.

Preventive Services

First

Round

Audit

Score

Limited

Review

Audit

Score

Percentage

Change

11.3 For all patients 50 to 75 years of age: Were the patients offered colorectal cancer screening?

55.0% N/A 0.0%

Comments:

11.3 This question was not evaluated during the Limited Review as the review for this question is only completed annually to avoid duplicate selection from the sample pool. The critical issue remains unresolved and will be monitored during subsequent audits to determine compliance.

12 - EMERGENCY MEDICAL RESPONSE/DRILLS and EQUIPMENT

Emergency Medical Response/Drills & Equipment

First

Round

Audit

Score

Limited

Review

Audit

Score

Percentage

Change

12.4 Did the Emergency Medical Response Review Committee perform timely incident package reviews that included the use of required review documents?

33.3% 50.0% + 16.7%

12.6

Emergency Medical Equipment: If the emergency medical response and/or drill warranted an opening of the Emergency Medical Response Bag, was it re-supplied and re-sealed before the end of the shift?

66.7% 100% + 33.3%

Comments:

12.4 Eight medical records were reviewed during the Limited Review audit period. Four records were found compliant and four were found non-compliant. There was no documentation that the actual medical emergencies that occurred on March 9, 2017, April 6, 2017, May 12, 2017, and June 18, 2017, were discussed during the Emergency Medical Response Review Committee Meetings (EMRRC).The critical issue remains unresolved and will be monitored during subsequent audits to determine compliance.

12.6 The CCHCS nurse auditor reviewed three emergency medical responses and/or drills that warranted an opening of the Emergency Medical Response Bag, there was documentation that the emergency bags were resupplied and resealed before the end of the shift. This critical issue has been resolved by the facility.

Recommendation:

The facility should assign an emergency medical coordinator to keep track of emergency medical responses, evaluate each incident, report the incidents to the health services administrator, and



submit the reports to the EMRRC. The emergency medical coordinator should be a member of the EMRRC and regularly participate in the EMRRC meetings.

13 - CLINICAL ENVIRONMENT

There was one critical issue identified during the December 2016 audit. CVMCCF received a compliance rating of proficient during the December 2016 Audit, with question 13.2 (Appendix A) falling below the 80.0% compliance rating having received a compliance score of 75.0%.

Clinical Environment

First

Round

Audit

Score

Limited

Review

Audit

Score

Percentage

Change

13.2 If autoclave sterilization is used, is there documentation showing weekly spore testing?

75.0% 100% + 25.0%

Comments:

13.2 During the Limited Review, Question 13.2 was evaluated and found to be 100% compliant. The facility provided documentation showing they consistently completed weekly spore7 testing for their autoclave sterilization, thereby resolving this critical issue.

7 Spore testing – a requirement of weekly spore testing to ensure proper sterilization of medical devices, surgical instruments, supplies and equipment utilized in patient care. Spore testing is a critical aspect of health care that directly impacts patient safety through infection control.



CRITICAL ISSUE REVIEW

The Contract Facility Health Care Monitoring Audit in December 2016 resulted in the identification of 17 quantitative critical issues. During the current Limited Review, auditors found 12 of the 17 items resolved, with the remaining five unresolved within acceptable standards. Below is a discussion of each critical issue.

Critical Issue Status Comment

Question 2.5 – THE FACILITY DOES NOT ACCURATELY DOCUMENT THE PATIENT CDCR NUMBERS; THE DATES OF RECEIPT AND REVIEW OF THE CDCR FORM 7362; HEALTH CARE SERVICES REQUEST(S); PATIENT’S CHIEF COMPLAINT; PROVIDER APPOINTMENT DATES, REFERRAL PRIORITY AND DATES OF NURSING ASSESSMENTS ON THE SICK CALL MONITORING LOG.

Resolved This has been an outstanding critical issue since the January 2016 audit. CVMCCF received a compliance score of 56.0% during the December 2016 audit. A review of the sick call monitoring log during the Limited Review, revealed the facility received a compliance score of 80.0%. This critical issue has been resolved by the facility.

Question 2.6 – THE FACILITY DOES NOT ACCURATELY DOCUMENT DATES PROVIDER REFERRED PATIENTS FOR SPECIALTY APPOINTMENTS, APPOINTMENT DISPOSITIONS, AND PROVIDER AND RN ASSESSMENTS IN THE SPECIALTY SERVICES MONITORING LOG.

Resolved This has been an outstanding critical issue since the January 2016 audit. CVMCCF received a compliance score of 16.2% during the December 2016 audit. A review of the specialty services monitoring log during the Limited Review, revealed the facility received a compliance score of 92.9%. This critical issue has been resolved by the facility.

Question 2.7 – THE FACILITY DOES NOT ACCURATELY DOCUMENT DATES THE PATIENT RETURNED TO THE HUB FROM THE EMERGENCY DEPARTMENT (ED) IN THE HOSPITAL STAY/EMERGENCY DEPARTMENT MONITORING LOG.

Unresolved This has been an outstanding critical issue since the January 2016 audit. CVMCCF received a compliance score of 50.0% during the December 2016 audit. A review of the hospital stay/emergency department monitoring log during the Limited Review, revealed the facility received a compliance score of 0.0%. This critical issue is unresolved and will be monitored during subsequent audits for compliance.

Question 2.9 – THE FACILITY DOES NOT ACCURATELY DOCUMENT THE DATE OF PATIENTS’ ARRIVAL AT CVMCCF, DATE OF INITIAL ASSESSMENT, AND/OR FAILED TO INPUT THE DATE OF THE INITIAL HEALTH ASSESSMENT BY PCP IN THE INTIAL INTAKE SCREENING MONITORING LOG.

Resolved This has been an outstanding critical issue since the January 2016 audit. CVMCCF received a compliance score of 73.3% during the December 2016 audit. A review of the initial intake screening monitoring log during the Limited Review, revealed the facility received a compliance score of 95.0%. This critical issue has been resolved by the facility.

Question 4.3 – THE RN DOES NOT CONSISTENTLY CONDUCT A FOCUSED SUBJECTIVE/OBJECTIVE ASSESSMENT BASED ON THE PATIENT’S CHIEF COMPLAINT.

Resolved This has been an outstanding critical issue since the January 2016 audit. The facility received a 70.8% compliance score during the December 2016 Audit. During the Limited Review the facility received a compliance score of 93.8%. This critical issue has been resolved by the facility.



Question 4.5 – THE RN DOES NOT CONSISTENTLY DOCUMENT EFFECTIVE COMMUNICATION IS ESTABLISHED AND EDUCATION WAS PROVIDED TO THE PATIENT RELATED TO THE TREATMENT PLAN.

Resolved This has been an outstanding critical issue since the January 2016 audit. The facility received a 75.0% compliance score during the December 2016 Audit. During the Limited Review, the facility received a compliance score of 100%. This critical issue has been resolved by the facility.

Question 4.8 – THE FACILITY HEALTH CARE STAFF (CARE TEAM) DID NOT REGULARLY CONDUCT AND DOCUMENT A CARE TEAM HUDDLE DURING BUSINESS DAYS.

Resolved This critical issue was identified during the December 2016 audit. The facility received a 38.1% compliance score during the December 2016 Audit. During the Limited Review, the facility received a compliance score of 90.9%. This critical issue has been resolved by the facility.

Question 7.2 – THE RN DID NOT DOCUMENT AN ASSESSMENT OF THE PATIENT IF HE ANSWERED “YES” TO ANY QUESTIONS ON THE INITIAL HEALTH SCREENING FORM (CDCR FORM 7277/7277A OR SIMILAR FORM).


Question 7.4 – PATIENT’S WHO ARRIVED AT CVMCCF AND HAD A SCHEDULED OR PENDING MEDICAL, DENTAL, OR MENTAL HEALTH APPOINTMENT WERE NOT CONSISTENTLY SEEN WITHIN THE TIME FRAME SPECIFIED BY THE SENDING FACILTY’S PROVIDER.


Question 7.7 – THE FACILITY DOES NOT CONSISTENTLY DOCUMENT ALL PENDING APPOINTMENTS ON THE CDCR FORM 7371, HEALTH CARE TRANSFER INFORMATION FORM, WHEN A PATIENT TRANSFERS OUT OF CVMCCF.

Resolved This critical issue was identified during the December 2016 audit. The facility received a 58.3% compliance score during the December 2016 Audit. During the Limited Review, the facility received a compliance score of 83.3%. This critical issue has been resolved by the facility.

Question 7.8 – THE FACILITY DOES NOT CONSISTENTLY PLACE ALL REQUIRED TRANSFER DOCUMENTS AND MEDICATIONS IN THE INTER-FACILITY TRANSFER ENVELOPE WHEN A PATIENT TRANSFERS OUT OF CVMCCF.

Resolved This critical issue was identified during the December 2016 audit. The facility received a 66.7% compliance score during the December 2016 Audit. During the Limited Review, the facility received a compliance score of 100%. This critical issue has been resolved by the facility.

Question 8.5 – THE FACILITY DOES NOT CONSISTENTLY ADMINISTER ANTI-TUBERCULOSIS (TB) MEDICATION(S) TO PATIENTS PRESCRIBED ANTI-TB MEDICATION(S).

Unresolved This critical issue was identified during the December 2016 audit. The facility received a 42.1% compliance score during the December 2016 Audit. There were no patients meeting the criteria for this question during the Limited Review audit review period, therefore compliance could not be evaluated. This critical issue is unresolved and will be monitored during subsequent audits for compliance.

Question 10.4 – THE FACILITY PCP DOES NOT CONSISTENTLY COMPLETE A FOLLOW-UP APPOINTMENT WITH THE PATIENT WITHIN THE REQUIRED TIME FRAME AFTER A SPECIALTY APPOINTMENT.

Unresolved This has been an outstanding critical issue since the January 2016 audit. The facility received a 75.0% compliance score during the December 2016 Audit. During the Limited Review, the facility received a compliance score of 35.7%. This critical issue is unresolved and will be monitored during subsequent audits for compliance.



Question 11.3 – THE FACILITY DOES NOT CONSISTENTLY OFFER COLORECTAL CANCER SCREENING TO THE PATIENT POPULATION 50-75 YEARS OF AGE.

Unresolved This critical issue was identified during the December 2016 audit. The facility received a 55.0% compliance score during the December 2016 audit. This question was not reviewed during the Limited Review as it is reviewed annually to avoid duplication review of the sample pool. Therefore compliance was unable to be evaluated. This critical issue is unresolved and will be monitored during subsequent audits for compliance.

Question 12.4 – THE FACILITY’S EMERGENCY MEDICAL RESPONSE REVIEW COMMITTEE DOES NOT CONSISTENTLY PERFORM TIMELY INCIDENT PACKAGE REVIEW CONTAINING THE REQUIRED REVIEW DOCUMENTS.

Unresolved This has been an outstanding critical issue since the January 2016 audit. The facility received a 33.3% compliance score during the December 2016 Audit. During the Limited Review, the facility received a compliance score of 50.0%. This critical issue is unresolved and will be evaluated during subsequent audits for compliance.

Question 12.6 – THE FACILITY DOES NOT CONSISTENTLY RESUPPLY AND RESEAL THE EMERGENCY MEDICAL RESPONSE BAGS FOLLOWING USE DURING MEDICAL EMERGENCIES AND/OR DRILLS.


Question 13.2 – THE FACILITY DOES NOT HAVE DOCUMENTATION TO SHOW THEY CONSISTENTLY COMPLETE WEEKLY SPORE TESTING FOR THEIR AUTOCLAVE STERILIZATION.


NEW CRITICAL ISSUES

New Critical Issues Identified – Central Valley Modified Community Correctional Facility

Question 10.3 The RN failed to notify the primary care provider of any immediate medication or follow-up requirements ordered by the specialty consultant upon the patient’s return from the specialty services appointment.



CONCLUSION During the August 2017 Limited Review, the Emergency Services and Community Hospital Discharge Indicator was reviewed in its entirety. CVMCCF received an Overall Quality Indicator Score of adequate (83.3%) which is a marked improvement from the 66.7% compliance score received during the December 2016 audit. The facility management and health care staff should be commended for resolving 12 out of the 17 critical issues previously identified. However, three out of the five unresolved critical issues have been deficient since the January 2016 audit. The continuation of these three unresolved critical issues from the January 2016 audit and two from the December 2016 audit, combined with the identification of one new critical issue, further accentuates the importance of the facility management’s active involvement in resolution of all identified systemic issues in order to maintain the quality of health care services delivered to California patients at a satisfactory level. While the CCHCS clinician auditors found the overall delivery of health care to be adequate, continued deficiencies within the Emergency Services and Community Hospital Discharge indicator related to emergency services, continues to raise a concern for patient safety, if a patient is experiencing an emergency event. It is strongly recommended that the facility nursing staff receive frequent and ongoing emergency response and nursing protocol training, specifically the Chest Pain Nursing Protocol. In addition, CVMCCF also failed to resolve critical issues identified in the Internal Monitoring and Quality Management; Medical/Medication Management; Specialty Services; and Emergency Medical Response/Drills and Equipment indicators with a new Critical Issue identified in the Specialty Services indicator during the Limited Review. If these critical issues are left unaddressed, they may create barriers preventing the patients from receiving an adequate level of health care. In addition to the emergency services training recommendations above, CCHCS auditors also recommend CVMCCF collaborate with their hub institution, North Kern State Prison (NKSP), to devise a process to expedite the return of patients to CVMCCF once the PCP at NKSP advises the patient is medically clear to return. The deficiencies mentioned in this report are easily correctable and are within the management’s scope of control to ensure compliance.

Documents

CONTRACT FACILITY HEALTH CARE - California · CONTRACT FACILITY HEALTH CARE ... 2 – INTERNAL MONITORING AND QUALITY MANAGEMENT ... Limited Review Sample Size