CORRECTIONAL MEDICAL AUTHORITY PHYSICAL & MENTAL HEALTH SURVEY of Lowell Correctional Institution in Ocala, Florida on September 11-13, 2018 CMA Staff Members Clinical Surveyors Jane Holmes-Cain, LCSW Lynne Babchuck, LCSW Monica Dodrill, RN Kathy McLaughlin, BS Thomas Chambers, DO Erik Gooch, DO Ashok Manocha, DDS Timothy Garvey, DMD Ron Gironda, PhD Jeffery Bates, PhD Rosemary Bates, APRN Sue Porterfield, APRN Gina Siggia, APRN Joanne Pintacuda, APRN Rizan Yozgat, APRN Suzanne Brown, RN Patricia Meeker, RN Debra Bola, RN Denise Sanfillipo, LCSW Jane Wynn, LCSW Emily Grob, LCSW Distributed on October 15, 2018 CAP Due Date: November 14, 2018 Lowell Correctional Institution Page 1 DEMOGRAPHICS The institution provided the following information in the Pre-survey Questionnaire. INSTITUTIONAL INFORMATION Population Type Custody Level Medical Level 2434 Female Maximum 5 Institutional Potential/Actual Workload Main Unit Capacity 1221 1579 Annex Capacity Satellite Unit(s) Capacity 394 Total Capacity 3194 Current Main Unit Census 838 Annex Census 1306 Current Satellite(s) Census Total Current Census 290 2434 Inmates Assigned to Medical/Mental Health Grades Medical Grade Mental Health Grade (S-Grade) 1 2 3 4 5 Impaired 940 1063 89 3 2 114 Mental Health Outpatient MH Inpatient 1 2 3 4 5 Impaired 851 236 1064 0 0 3 PM CM3 CM2 CM1 N/A 5 15 23 Inmates Assigned to Special Housing Status Confinement/ Close Management DC 96 AC 57 Lowell Correctional Institution Page 2 Medical Staffing: Main Unit Number of Positions Physician Clinical Associate RN LPN Dentist Dental Assistant Dental Hygienists Number of Vacancies 1 0 1 0 7 4 11 3 1 0 1 0 1 1 Mental Health Staffing: Main Unit Number of Positions Number of Vacancies Psychiatrist 1 0 Psychiatric APRN/PA 0 0 Psychological Services Director 1 0 Psychologist 1 0 Mental Health Professional 5 0 Human Services Counselor 0 0 Activity Technician 0 0 Mental Health RN 1 1 Mental Health LPN 0 0 Lowell Correctional Institution Page 3 Medical Staffing: Annex Number of Positions Physician Clinical Associate RN LPN Dentist Dental Assistant Dental Hygienists Number of Vacancies 1 0 2 0 8 2 15 3 1 0 2 0 0 2 Mental Health Staffing: Annex Number of Positions Number of Vacancies Psychiatrist 2 0 Psychiatric APRN/PA 1 0 Psychological Services Director 1 0 Psychologist 1 0 Mental Health Professional 9 0 Human Services Counselor 0 0 Activity Technician 1 0 Mental Health RN 1 0 Mental Health LPN 0 0 Lowell Correctional Institution Page 4 OVERVIEW Lowell Correctional Institution (LOWCI) houses female inmates of minimum, medium, and close custody levels. The facility grades are medical (M) grades 1, 2, 3, 4, 5, and 9, and psychology (S) grades 1, 2, and 3. LOWCI consists of a Main, Annex, and work camp. The overall scope of services provided at LOWCI includes comprehensive medical, dental, mental health, and pharmaceutical services. Specific services include: health education, preventive care, chronic illness clinics, emergency care, and outpatient mental health. The Correctional Medical Authority (CMA) conducted a thorough review of the medical, mental health, and dental systems at LOWCI on September 11-13, 2018. Record reviews evaluating the provision and documentation of care were also conducted. Additionally, a review of administrative processes and a tour of the physical plant were conducted. Exit Conference and Final Report The survey team conducted an exit conference via telephone with institutional personnel to discuss preliminary survey results. The findings and final conclusions presented in this report are a result of further analysis of the information collected during the survey. The suggested corrective actions included in this report should not be construed as the only action required to demonstrate correction, but should be viewed as a guide for developing a corrective action plan. Where recommended corrective actions suggest in-service training. A copy of the curriculum and attendance roster should be included in the corrective action plan files. Additionally, evidence of appropriate biweekly monitoring should be included in the files for each finding. Unless otherwise specified, this monitoring should be conducted by an institutional clinician/peer and documented by a biweekly compilation of the following: 1) The inmate names and DC numbers corresponding to the charts (medical records) reviewed; 2) The criteria/finding being reviewed; 3) An indication of whether the criteria/finding was met for each chart reviewed; 4) The percentage of charts reviewed each month complying with the criteria; 5) Back-up documentation consisting of copies of the relevant sections reviewed from the sampled charts. Lowell Correctional Institution Page 5 PHYSICAL HEALTH FINDINGS – MAIN UNIT Lowell Correctional Institution-Main (LOWCI-Main) provides outpatient physical health services. The following are the medical grades used by the Department to classify inmate physical health needs at LOWCI-Main: • M1 - Inmate requires routine care (periodic screening, sick call, emergency care). • M2 - Inmate is being followed in a chronic illness clinic (CIC) but is stable and requires care at intervals of every six to twelve months. • M3 - Inmate is being followed in a CIC every three months. • M4 - Inmate is being followed in a CIC every three months and requires ongoing visits to the physician more often than every three months. • M5 - Inmate requires long-term care (greater than thirty days) inpatient, infirmary, or other designated housing. • M9 - Inmate who is pregnant. CLINICAL RECORDS REVIEW CHRONIC ILLNESS RECORD REVIEW There were findings requiring corrective action in the general chronic illness clinic review and in seven of the chronic illness clinics. The items to be addressed are indicated in the tables below. EPISODIC CARE REVIEW There were findings requiring corrective action in the review of infirmary services, emergency care, and sick call. The items to be addressed are indicated in the tables below. OTHER MEDICAL RECORD REVIEW There were findings requiring corrective action in the review of consultations, period screenings, and medical inmate requests. The items to be addressed are indicated in the tables below. DENTAL REVIEW There were no findings requiring corrective action in the review of dental care or dental systems. ADMINISTRATIVE PROCESSES REVIEW There were no findings requiring corrective action in the review of the pill line, infection control, or pharmacy services. INSTITUTIONAL TOUR There were no findings as a result of the institutional tour. Lowell Correctional Institution Page 6 Chronic Illness Clinic (CIC) Record Review Finding(s) PH-1: In 3 of 15 records reviewed, inmates were not seen according to their M-grade status. Suggested Corrective Action(s) Provide in-service training to staff regarding the issue(s) identified in the Finding(s) column. Create a monitoring tool and conduct biweekly monitoring of no less than ten records of those enrolled in a chronic illness clinic to evaluate the effectiveness of corrections. Continue monitoring until closure is affirmed through the CMA corrective action plan assessment. Cardiovascular Clinic Record Review Finding(s) PH-2: In 3 of 10 applicable records (17 reviewed), there was no evidence that follow-up after abnormal labs and/or diagnostic testing was completed timely (see discussion). Suggested Corrective Action(s) Provide in-service training to staff regarding the issue(s) identified in the Finding(s) column. Create a monitoring tool and conduct biweekly monitoring of no less than ten records of those enrolled in the cardiovascular clinic to evaluate the effectiveness of corrections. Continue monitoring until closure is affirmed through the CMA corrective action plan assessment. Discussion PH-2: In the first record, there was no follow-up after an abnormal EKG. In the second record, a repeat EKG was ordered but never completed. In the last record, hyponatremia was noted by the clinician who indicated that it was likely related to the use of Tegretol as a psychiatric medication. The clinician indicated that follow-up would be addressed by the psychiatrist but there was no indication that this occurred. Lowell Correctional Institution Page 7 Endocrine Clinic Record Review Finding(s) PH-3: In 2 of 5 applicable records (14 reviewed), inmates with HgbA1c levels over 8% were not seen at the required intervals (see discussion). Suggested Corrective Action(s) Provide in-service training to staff regarding the issue(s) identified in the Finding(s) column. Create a monitoring tool and conduct biweekly monitoring of no less than ten records of those enrolled in the endocrine clinic to evaluate the effectiveness of corrections. Continue monitoring until closure is affirmed through the CMA corrective action plan assessment. Discussion PH-3: These inmates were rescheduled at 180-day intervals instead of the 90 days required by Department policy. Gastrointestinal Clinic Record Review Finding(s) PH-4: In 2 of 4 applicable records (13 reviewed), there was no evidence that inmates were screened for hepatocellular carcinoma at the required intervals. Suggested Corrective Action(s) Provide in-service training to staff regarding the issue(s) identified in the Finding(s) column. Create a monitoring tool and conduct biweekly monitoring of no less than ten records of those enrolled in the gastrointestinal clinic to evaluate the effectiveness of corrections. Continue monitoring until closure is affirmed through the CMA corrective action plan assessment. Lowell Correctional Institution Page 8 Immunity Clinic Record Review Finding(s) A comprehensive review of 13 records revealed the following deficiencies: PH-5: In 2 of 7 applicable records, there was no evidence of hepatitis B vaccination or refusal. PH-6: In 2 of 9 applicable records, there was no evidence of pneumococcal vaccination or refusal. Suggested Corrective Action(s) Provide in-service training to staff regarding the issue(s) identified in the Finding(s) column. Create a monitoring tool and conduct biweekly monitoring of no less than ten records of those enrolled in the immunity clinic to evaluate the effectiveness of corrections. Continue monitoring until closure is affirmed through the CMA corrective action plan assessment. Miscellaneous Clinic Record Review Finding(s) A comprehensive review of 13 records revealed the following deficiencies: Suggested Corrective Action(s) Provide in-service training to staff regarding the issue(s) identified in the Finding(s) column. PH-7: In 4 of 10 applicable records, there was no evidence that abnormal labs were addressed timely. Create a monitoring tool and conduct biweekly monitoring of no less than ten records of those enrolled in the miscellaneous clinic to evaluate the effectiveness of corrections. PH-8: In 2 of 7 applicable records, a referral for specialty services was not completed in a timely manner. Continue monitoring until closure is affirmed through the CMA corrective action plan assessment. Lowell Correctional Institution Page 9 Neurology Clinic Record Review Finding(s) A comprehensive review of 11 records revealed the following deficiencies: PH-9: In 8 of 10 applicable records, there was no evidence that seizures were classified as primary generalized (tonic-clonic, grand mal), primary or simple absence (petit mal), simple partial seizures, or complex partial seizures. PH-10: In 3 records, the physical examination was incomplete (see discussion). Suggested Corrective Action(s) Provide in-service training to staff regarding the issue(s) identified in the Finding(s) column. Create a monitoring tool and conduct biweekly monitoring of no less than ten records of those enrolled in the neurology clinic to evaluate the effectiveness of corrections. Continue monitoring until closure is affirmed through the CMA corrective action plan assessment. PH-11: In 2 of 2 applicable records, there was no evidence that abnormal labs were addressed timely. PH-12: In 1 of 1 applicable record, there was no evidence the inmate was referred to a specialist when necessary (see discussion). Discussion PH-10: The neurological examination was missing in all three records. Discussion PH-12: Documentation by the clinician indicated a neurological consultation was needed. However, there was no evidence that the consultation request was generated. Respiratory Clinic Record Review Finding(s) PH-13: In 3 of 12 records reviewed, reactive airway diseases were not classified as mild, moderate, or severe. Suggested Corrective Action(s) Provide in-service training to staff regarding the issue(s) identified in the Finding(s) column. Create a monitoring tool and conduct biweekly monitoring of no less than then records of those enrolled in the respiratory clinic to evaluate the effectiveness of corrections. Continue monitoring until closure is affirmed through the CMA corrective action plan assessment. Lowell Correctional Institution Page 10 Infirmary Record Review Finding(s) A comprehensive review of 12 records revealed the following deficiencies: PH-14: In 5 of 12 inpatient and outpatient records, patient care orders were incomplete. PH-15: In 1 of 2 applicable outpatient records, weekend and/or holiday phone rounds were not documented as required. PH-16: In 2 of 8 applicable inpatient records, nursing evaluations were not documented at the required intervals. Suggested Corrective Action(s) Provide in-service training to staff regarding the issue(s) identified in the Finding(s) column. Create a monitoring tool and conduct biweekly monitoring of no less than ten records of inmates receiving infirmary services to evaluate the effectiveness of corrections. Continue monitoring until closure is affirmed through the CMA corrective action plan assessment. PH-17: In 2 of 6 applicable inpatient records, daily rounds by the clinician were not documented at the required intervals. PH-18: In 4 of 6 applicable inpatient records, weekend and/or holiday phone rounds were not documented as required. Emergency Care Record Review Finding(s) PH-19: In 5 of 15 records reviewed, vital signs were incomplete. Suggested Corrective Action(s) Provide in-service training to staff regarding the issue(s) identified in the Finding(s) column. Create a monitoring tool and conduct biweekly monitoring of no less than ten records of those receiving emergency care services to evaluate the effectiveness of corrections. Continue monitoring until closure is affirmed through the CMA corrective action plan assessment. Lowell Correctional Institution Page 11 Sick Call Record Review Finding(s) A comprehensive review of 18 records revealed the following deficiencies: PH-20: In 4 of 10 applicable records, vital signs were incomplete. PH-21: In 4 records, patient education was incomplete or missing (see discussion). Suggested Corrective Action(s) Provide in-service training to staff regarding the issue(s) identified in the Finding(s) column. Create a monitoring tool and conduct biweekly monitoring of no less than ten records of those receiving sick call services to evaluate the effectiveness of corrections. Continue monitoring until closure is affirmed through the CMA corrective action plan assessment. Discussion PH-21: In all four records, the educational component of the incidental note was documented as “verbalizes understanding” but did not identify the education provided. Consultations Record Review Finding(s) A comprehensive review of 12 records revealed the following deficiencies: PH-22: In 5 records, the consultation was not completed in a timely manner (see discussion). PH-23: In 7 records, the diagnosis was not recorded on the problem list. PH-24: In 3 of 9 applicable records, the consultant’s treatment recommendations were not incorporated into the treatment plan (see discussion). Suggested Corrective Action(s) Provide in-service training to staff regarding the issue(s) identified in the Finding(s) column. Create a monitoring tool and conduct biweekly monitoring of no less than ten records of those receiving consultation services to evaluate the effectiveness of corrections. Continue monitoring until closure is affirmed through the CMA corrective action plan assessment. PH-25: In 4 of 9 applicable records, additional diagnostic and/or laboratory testing was not completed as required (see discussion). Discussion PH-22: In the first record, an abnormal mammogram completed in September 2017 was not biopsied until June 2018. In the second record, an inmate with cervical cancer was seen by the oncologist on 3/29/18 who indicated the patient should be seen by gynecologicaloncologist “ASAP” to check for progression of the disease. The inmate was not seen until 5/8/18. In the third record, an ultrasound of the neck was completed in October 2017. The report Lowell Correctional Institution Page 12 recommended biopsy and clinical follow-up. There was no documented action taken until March 2018 when an “urgent” biopsy was requested. In the fourth record, a biopsy completed in February 2018 indicated invasive breast cancer. Although institutional staff reported multiple attempts to obtain the clinical pathology, it was not reviewed for more than six weeks after it was issued. In the last record, an inmate with a remote history of cervical cancer had her yearly Pap smear returned indicating the specimen was insufficient for evaluation. No new Pap smear was ordered. Discussion PH-24: In the first record, an inmate was seen by the urologist for a possible urethral mass on 7/16/18. The consultant requested the inmate return for follow-up in three weeks. The consultation was not reviewed by a site clinician until 8/17/18 and the inmate was not returned for her follow-up visit. In the second record, the inmate was returned to the gynecological-oncologist outside of the recommended time frame. In the last record, the inmate was supposed to return to the general surgeon within one month but the appointment was never scheduled. She has been waiting since April 2018. Discussion PH-25: In the first record, the general surgeon recommended a repeat biopsy in April 2018 which was never scheduled. In the second record, a colposcopy was completed in February 2018. The gynecologist requested a repeat Pap smear in four months. This was never completed. In the third record, a follow-up mammogram to recheck an abnormality was due in March 2018 but not completed. In the last record, the gynecological-oncologist recommended a PET scan on 5/8/18. The consultation was completed on 5/8/18 but not reviewed by a site clinician until 6/7/18. The inmate returned to the clinic in mid-June without a completed PET scan. Medical Inmate Requests Finding(s) A comprehensive review of 15 records indicated the following deficiencies: PH-26: In 3 of 14 applicable records, the response to the inmate request did not address the stated need. PH-27: In 5 of 7 applicable records, the response to the inmate request did not occur as intended. Suggested Corrective Action(s) Provide in-service training to staff regarding the issue(s) identified in the Finding(s) column. Create a monitoring tool and conduct biweekly monitoring of no less than ten medical inmate requests to evaluate the effectiveness of corrections. Continue monitoring until closure is affirmed through the CMA corrective action plan assessment. Lowell Correctional Institution Page 13 Periodic Screenings Finding(s) A comprehensive review of 14 records revealed the following deficiencies: PH-28: In 4 records, there was no evidence that inmates were provided with lab results at the time of screening. PH-29: In 3 records, Pap smears were not completed at the required intervals (see discussion). Suggested Corrective Action(s) Provide in-service training to staff regarding the issue(s) identified in the Finding(s) column. Create a monitoring tool and conduct biweekly monitoring of no less than ten periodic screenings to evaluate the effectiveness of corrections. Continue monitoring until closure is affirmed through the CMA corrective action plan assessment. Discussion PH-29: In two records, no Pap smears or refusals were found. In the last record, there was no evidence of a Pap smear since 2012. Additional Administrative Issues Finding(s) PH-30: Inmates with a history of malignancy were not enrolled in the oncology clinic (see discussion). Suggested Corrective Action(s) Provide in-service training to staff regarding the issue(s) identified in the Finding(s) column. Create a monitoring tool and conduct biweekly monitoring to evaluate the effectiveness of corrections. Continue monitoring until closure is affirmed through the CMA corrective action plan assessment. Discussion PH-30: The first inmate had a history of lymphoma. The second inmate was undergoing treatment for stage IIIb cervical cancer. The last inmate recently completed radiation treatment for breast cancer. Lowell Correctional Institution Page 14 CONCLUSION – PHYSICAL HEALTH The physical health staff at LOWCI-Main serves a difficult population that includes inmates with medical and psychiatric comorbidities. Physical health care is provided on an inpatient and outpatient basis. In addition to providing routine physical health care and inmate education, medical staff participates in continuing education and infection control activities. A physical inspection revealed that all areas of the compound were clean. Interviews with institutional personnel and inmates revealed that all were familiar with how to obtain both routine and emergency services. The majority of inmates described the health care services as inadequate. CMA surveyors identified several areas in which the provision of clinical services were found to be deficient. Notably, there were multiple incidents of abnormal labs not addressed, medical orders or requests for specialty services that were noted but never implemented, as well as medical appointments that were not scheduled within the appropriate clinical time frame. Clinical surveyors were concerned that long wait times or missed opportunities for follow-up could have serious and adverse effects on inmate health. Based on the findings listed above, it is clear that the institution will benefit from the corrective action plan (CAP) process. Staff indicated that they were appreciative of the CMA review and would use the results of the survey report to improve physical health services. Lowell Correctional Institution Page 15 MENTAL HEALTH FINDINGS – MAIN UNIT Lowell Correctional Institution-Main (LOWCI-Main) provides outpatient mental health services. The following are the mental health grades used by the Department to classify inmate mental health needs at LOWCI-Main: • S1 - Inmate requires routine care (sick call or emergency). • S2 - Inmate requires ongoing services of outpatient psychology (intermittent or continuous). • S3 - Inmate requires ongoing services of outpatient psychiatry (case management, group and/or individual counseling, as well as psychiatric care). CLINICAL RECORDS REVIEW SELF INJURY/SUICIDE PREVENTION REVIEW There were no episodes of psychiatric restraints or Self-Harm Observation Status (SHOS) at LOWCI-Main. If an inmate requires these safety precautions, they are moved to LOWCI-Annex. USE OF FORCE REVIEW There were no applicable episodes in the review of use of force. ACCESS TO MENTAL HEALTH SERVICES REVIEW There were findings requiring corrective action in the review of inmate requests and psychological emergencies. The items to be addressed are indicated in the tables below. There are no special housing units at LOWCI-Main. OUTPATIENT SERVICES REVIEW There were no findings in the review of outpatient mental health services. There were findings requiring corrective action in the review of psychotropic medication practices. The items to be addressed are indicated in the tables below. AFTERCARE PLANNING REVIEW There was a finding requiring corrective action in the review of aftercare planning. The item to be addressed is indicated in the table below. MENTAL HEALTH SYSTEMS REVIEW There was a finding requiring corrective action in the review of mental health systems. The item to be addressed is indicated in the table below. Lowell Correctional Institution Page 16 Inmate Requests Finding(s) Suggested Corrective Action(s) MH-1: In 2 of 10 records reviewed, the interview or referral did not occur as intended in response to an inmate request (see discussion). Provide in-service training to staff regarding the issue(s) identified in the Finding(s) column. Create a monitoring tool and conduct biweekly monitoring of no less than ten inmate requests to evaluate the effectiveness of corrections. Continue monitoring until closure is affirmed through the CMA corrective action plan assessment. Discussion MH-1: In one record, an inmate reported a medical problem due to change in psychotropic medication. There was no indication that a referral was made to psychiatry or that the inmate was assessed by nursing. In the other record, the response to the inmate was that she would be seen within two weeks. However, the inmate was not seen by mental health for nineteen days. Psychological Emergencies Finding(s) Suggested Corrective Action(s) MH-2: In 3 of 13 applicable records (17 reviewed), there was no evidence that the clinician fully assessed suicide risk. Provide in-service training to staff regarding the issue(s) identified in the Finding(s) column. Create a monitoring tool and conduct biweekly monitoring of no less than ten psychological emergencies to evaluate the effectiveness of corrections. Continue monitoring until closure is affirmed through the CMA corrective action plan assessment. Lowell Correctional Institution Page 17 Outpatient Psychotropic Medication Practices Finding(s) A comprehensive review of 16 outpatient records revealed the following deficiencies: Suggested Corrective Action(s) Provide in-service training to staff regarding the issue(s) identified in the Finding(s) column. MH-3: In 1 of 4 applicable records, initial laboratory studies were not conducted as required prior to initiating psychotropic medications. Create a monitoring tool and conduct biweekly monitoring of no less than ten applicable outpatient records to evaluate the effectiveness of corrections. MH-4: In 4 of 15 applicable records, clinician’s orders were not timed, dated, stamped and/or signed per protocol. Continue monitoring until closure is affirmed through the CMA corrective action plan assessment. MH-5: In 7 of 15 applicable records, the inmate did not receive medications as prescribed (see discussion). MH-6: In 7 records, psychiatry follow-up was not provided per protocol (see discussion). Discussion MH-5: In four records, there were one or more blanks on the Medication Administration Record (MAR) indicating the inmate was not offered medication on that date. In one record, MARs for May 2018 and August 2018 were unable to be located by staff. In one record, the inmate received an incorrect dose of Buspar for 11 days before the problem was noted and corrected. Lastly, in one record an order was written at another institution on 3/30/18 for 90 days’ worth of psychotropic medications. The inmate was transferred to Lowell on 4/20/18; however, the medications were not continued upon her arrival. She eventually decompensated, resulting in an admission to SHOS on 5/01/18, at which time the medications were finally restarted. Discussion MH-6: According to HSB 15.05.19, follow-up visits shall be scheduled, and appropriate progress notes written by the psychiatrist or other qualified prescribing clinician as needed at least once every two weeks upon initiation of any new psychotropic medication for a period of four weeks. Thereafter, psychotropic medication therapy and progress of the inmate shall be reviewed and documented at least every 90 days. In all seven records, a new psychotropic medication was prescribed; however, it was approximately 60 days until the inmate was evaluated again by the clinician. Lowell Correctional Institution Page 18 Aftercare Planning Finding(s) MH-7: In 1 of 1 applicable records (7 reviewed), there was no evidence that assistance with social security benefits was provided 30-45 days prior to expiration of sentence (EOS) (see discussion). Suggested Corrective Action(s) Provide in-service training to staff regarding the issue(s) identified in the Finding(s) column. Create a monitoring tool and conduct biweekly monitoring of no less than ten applicable records of inmates within 180 days EOS to evaluate the effectiveness of corrections. Continue monitoring until closure is affirmed through the CMA corrective action plan assessment. Discussion MH-7: In the record reviewed, mental health documentation stated, “Inmate already received SSD and does not need to re-apply for benefits”. Due to the inmate’s length of incarceration, any social security benefits would have been terminated and the inmate would be required to reapply. There was no evidence that assistance was offered to the inmate. Mental Health Systems Finding(s) MH-8: There was no evidence that mental health group therapy was being provided as required (see discussion). Suggested Corrective Action(s) Provide in-service training to staff regarding the issue(s) identified in the Finding(s) column. Create a monitoring tool and conduct biweekly monitoring of no less than ten medical records to evaluate the effectiveness of corrections. Continue monitoring until closure is affirmed through the CMA corrective action plan assessment. Discussion MH-8: According to HSB 15.05.18, each permanent institution will offer group interventions, as clinically indicated, that are designed to meet the needs of the inmates who are eligible for ongoing outpatient services. At the time of the survey, no therapeutic groups were being offered at LOWCI-Main. Lowell Correctional Institution Page 19 CONCLUSION – MENTAL HEALTH The staff at LOWCI-Main serves a difficult population that includes inmates with multiple medical and psychiatric comorbidities. Mental health outpatient services, including case management and individual counseling, are provided to over 545 inmates. In addition to providing services to inmates on the mental health caseload, staff answer inmate requests, respond to psychological emergencies, and perform sex offender screenings when needed. Staff also provide aftercare planning for eligible inmates. Reportable findings requiring corrective action are outlined in the tables above. Half of the findings noted were in the area of psychotropic medication practices. Laboratory studies and psychiatric follow-up were not completed timely, physician orders were not appropriately timed, dated, stamped and/or signed. Of greatest concern to CMA surveyors was that inmates were not consistently being given psychotropic medications, as was the case in over 45% of the records reviewed. Additionally, there were no therapeutic groups being offered to the inmates at LOWCI-Main. Incomplete assessments, and a lack of appropriate interventions or follow-up was noted in the areas of inmate requests and psychological emergencies. Overall, the quality of individualized service plans and summaries was adequate and notwithstanding the timeliness of psychiatric follow-up, the documentation of mental health encounters was complete and informative. When reviewing records, the course and progress of treatment was clear. It should be noted that there were no findings requiring corrective action in the review of outpatient mental health services. The staff at LOWCI-Main was helpful throughout the survey process and presented as knowledgeable and dedicated to the inmates they serve. Medical charts were well organized and documents were filed in a timely manner. Interviews conducted by surveyors and CMA staff indicated inmates and correctional officers were familiar with the process for accessing routine medical and emergency services. Although there were relatively few findings identified in the report, LOWCI-Main staff indicated they would use the CMA corrective action process to improve mental health services. Lowell Correctional Institution Page 20 PHYSICAL HEALTH FINDINGS – ANNEX Lowell Correctional Institution-Annex (LOWCI-Annex) provides outpatient physical health services. The following are the medical grades used by the Department to classify inmate physical health needs at LOWCI-Annex: • M1 - Inmate requires routine care (periodic screening, sick call, emergency care). • M2 - Inmate is being followed in a chronic illness clinic (CIC) but is stable and requires care at intervals of every six to twelve months. • M3 - Inmate is being followed in a CIC every three months. • M4 - Inmate is being followed in a CIC every three months and requires ongoing visits to the physician more often than every three months. • M5 - Inmate requires long-term care (greater than thirty days) inpatient, infirmary, or other designated housing. CLINICAL RECORDS REVIEW CHRONIC ILLNESS RECORD REVIEW There were no findings requiring corrective action in the general chronic illness clinic review. There were findings requiring corrective action in five of the chronic illness clinics. The items to be addressed are indicated in the tables below. EPISODIC CARE REVIEW There were no findings requiring corrective action in the review of emergency care or sick call services. There were findings requiring corrective action in the review of infirmary care. The items to be addressed are indicated in the table below. OTHER MEDICAL RECORD REVIEW There were no findings requiring corrective action in the review of consultations, medication administration, periodic screenings, or inmate requests. There were findings requiring corrective action in the review of intra-system transfers. The items to be addressed are indicated in the table below. DENTAL REVIEW There were no findings requiring corrective action in the review of dental systems or dental care. ADMINISTRATIVE PROCESSES REVIEW There were no findings requiring corrective action in the review of pharmacy services, the pill line, or infection control. INSTITUTIONAL TOUR There was a finding requiring corrective action as a result of the institutional tour. The item to be addressed is indicated in the table below. Lowell Correctional Institution Page 21 Cardiovascular Clinic Record Review Finding(s) PH-1: In 3 of 15 applicable records (18 reviewed), there was no evidence of pneumococcal vaccination or refusal. Suggested Corrective Action(s) Provide in-service training to staff regarding the issue(s) identified in the Finding(s) column. Create a monitoring tool and conduct biweekly monitoring of no less than ten records of those enrolled in the cardiovascular clinic to evaluate the effectiveness of corrections. Continue monitoring until closure is affirmed through the CMA corrective action plan assessment. Endocrine Clinic Record Review Finding(s) PH-2: In 3 of 6 applicable records (17 reviewed), there was no evidence that inmates with HgbA1c over 8% were seen every 3 months as required. Suggested Corrective Action(s) Provide in-service training to staff regarding the issue(s) identified in the Finding(s) column. Create a monitoring tool and conduct biweekly monitoring of no less than ten records of those enrolled in the endocrine clinic to evaluate the effectiveness of corrections. Continue monitoring until closure is affirmed through the CMA corrective action plan assessment. Gastrointestinal Clinic Record Review Finding(s) PH-3: In 4 of 9 applicable records (17 reviewed), there was no evidence inmates were screened for hepatocellular carcinoma as required (see discussion). Suggested Corrective Action(s) Provide in-service training to staff regarding the issue(s) identified in the Finding(s) column. Create a monitoring tool and conduct biweekly monitoring of no less than ten Lowell Correctional Institution Page 22 Gastrointestinal Clinic Record Review Finding(s) Suggested Corrective Action(s) records of those enrolled in the gastrointestinal clinic to evaluate the effectiveness of corrections. Continue monitoring until closure is affirmed through the CMA corrective action plan assessment. Discussion PH-3: In all four records, the inmates were staged at Fibrosis 1 or 2 but had not received an annual abdominal ultrasound. Immunity Clinic Record Review Finding(s) PH-4: In 3 of 10 applicable records (13 reviewed), there was no evidence of hepatitis B vaccination or refusal. Suggested Corrective Action(s) Provide in-service training to staff regarding the issue(s) identified in the Finding(s) column. Create a monitoring tool and conduct biweekly monitoring of no less than ten records of those enrolled in the immunity clinic to evaluate the effectiveness of corrections. Continue monitoring until closure is affirmed through the CMA corrective action plan assessment. Lowell Correctional Institution Page 23 Tuberculosis Clinic Record Review Finding(s) PH-5: In 2 of 2 records reviewed, there was no evidence that nursing assessments were completed monthly as required. Suggested Corrective Action(s) Provide in-service training to staff regarding the issue(s) identified in the Finding(s) column. Create a monitoring tool and conduct biweekly monitoring of no less than ten records of those enrolled in the tuberculosis clinic to evaluate the effectiveness of corrections. Continue monitoring until closure is affirmed through the CMA corrective action plan assessment. Infirmary Care Record Review Finding(s) A comprehensive review of 15 records revealed the following deficiencies: PH-6: In 5 inpatient and outpatient records, there was no evidence that orders were received and implemented accordingly (see discussion). PH-7: In 3 of 13 applicable records, the nursing discharge note was incomplete (see discussion). Suggested Corrective Action(s) Provide in-service training to staff regarding the issue(s) identified in the Finding(s) column. Create a monitoring tool and conduct biweekly monitoring of no less than ten records of those receiving infirmary care to evaluate the effectiveness of corrections. Continue monitoring until closure is affirmed through the CMA corrective action plan assessment. PH-8: In 2 of 8 applicable inpatient records, there was no evidence that nursing evaluations occurred at the required intervals. PH-9: In 2 of 7 applicable inpatient records, there was no evidence of weekend telephone rounds as required. Discussion PH-6: In three records, documentation of wound care was either limited to “open to air” or did not occur for all days as ordered. In one record, the clinician ordered elevation of the arm with ice, but there was no indication this occurred. In the last record, abdominal girth was not recorded for an inmate with ascites. Lowell Correctional Institution Page 24 Discussion PH-7: Per Health Services Bulletin (HSB) 15.03.26, the nurse is to write a discharge note indicating the patient’s condition on discharge, means of discharge (ambulating, wheelchair, crutches, etc.), patient education and discharge instructions, and disposition (transfer to outside hospital or discharged back to dorm). At least one of these items was missing in all the deficient records. Intra-System Transfers Record Review Finding(s) A comprehensive review of 16 records revealed the following deficiencies: PH-10: In 2 of 5 applicable records, there was no evidence that a pending consultation was added to the consultation log and occurred as intended (see discussion). PH-11: In 4 of 13 applicable records, there was no evidence the clinician reviewed the record within 7 days of arrival (see discussion). Suggested Corrective Action(s) Provide in-service training to staff regarding the issue(s) identified in the Finding(s) column. Create a monitoring tool and conduct biweekly monitoring of no less than ten records of those transferring into the institution to evaluate the effectiveness of corrections. Continue monitoring until closure is affirmed through the CMA corrective action plan assessment. Discussion PH-10: In one record, an optometry consult was requested on 8/20/16 and the inmate had an appointment on 2/8/17. Per the consult log, glasses were still pending as of the time of the survey. In the other record, the inmate transferred to Lowell CI on 4/5/18 and then to the Annex on 4/20/18. A pending optometry consult was in her record but was not placed on the log. The consult was to have been completed in March. Discussion PH-11: Three records were not reviewed within 7 days of arrival. The fourth record was signed off as being reviewed, however an abnormal Pap smear was overlooked and further testing was not completed. The Pap smear was done on 8/8/17 at another institution and was reviewed by the clinician there on 9/21/17. Rather than a medical hold being placed on the inmate, she was transferred to Lowell CI on 9/22/17 and then subsequently transferred between the main unit, work camp, and annex. A colposcopy was done on 1/5/18 which revealed high grade squamous intraepithelial lesions involving the glands at 12 o’clock and 6 o’clock. The inmate submitted a request on 2/12/18 asking for her Pap smear results and the answer given was “you do not have the money for copies. You can sign up for SC to review.” There was no record of further testing or consultation until the inmate’s annual gynecological examination on 8/2/18. A progress note dated 8/3/18 indicated an urgent request for a consult with gynecology was submitted to Utilization Management (UM) but the appointment did not occur until 8/23/18. The inmate submitted another request on 8/8/18 asking for her biopsy results and was answered “if abnormal you would’ve received a call out.” A cone biopsy was requested on 8/30/18 and again marked as urgent. It was still pending as of the date of the survey. CMA surveyors expressed concern that a significant delay in care resulted due to the incomplete record review upon transfer. Additionally, there were several missed opportunities where staff could have intervened to address this access to care issue. Lowell Correctional Institution Page 25 Institutional Tour Finding(s) A tour of the facility revealed the following deficiency: PH-12: Over-the-counter (OTC) medications were not logged or secured correctly in all dorms (see discussion). Suggested Corrective Action(s) Include documentation in the closure file that appropriate in-service training has been provided to staff regarding the issues in the Finding(s) column. Provide evidence in the closure file that the issue described has been corrected. This may be in the form of documentation, invoice, etc. Continue monitoring until closure is affirmed through the CMA corrective action plan assessment. Discussion PH-12: OTC medications were distributed without documenting who received the medication, therefore the logs did not match the count of medications on hand. Officers were carrying medications around on their person so this may have contributed to the issue as logs weren’t readily available when medications were given. Lowell Correctional Institution Page 26 CONCLUSION – PHYSICAL HEALTH The physical health staff at LOWCI-Annex serves a difficult population that includes inmates with multiple medical and psychiatric comorbidities. Physical health care is provided on an inpatient and outpatient basis. In addition to providing routine physical health care and inmate education, medical staff participates in continuing education and infection control activities. Reportable findings requiring corrective action are outlined in the tables above. Overall, medical charts were organized and documents were filed in a timely manner. The staff at LOWCI-Annex was helpful throughout the survey process and presented as knowledgeable and dedicated to the inmates they serve. Interviews conducted by surveyors and CMA staff indicated inmates and correctional officers were familiar with the process for accessing routine medical and emergency services. Inmates were inconsistent regarding the care received with some indicating the medical care was adequate and others expressing dissatisfaction. There were several clinical concerns identified in the review of the medical records. Inmates were not consistently receiving pneumococcal or hepatitis B vaccinations. Those enrolled in the gastrointestinal clinic were not receiving annual ultrasounds, and those with elevated blood sugar were not seen as often as required. Required nursing evaluations were missing in both the tuberculosis clinic and the infirmary. Additionally, infirmary clinician orders were not implemented as received and discharge notes were incomplete. There were also several issues with intra-system transfers, most importantly the missed abnormal Pap smear that still has no resolution after a year. Although it did not rise to the level of a finding, two transfer forms were blank and one was missing from the record and could not be located by staff. Based on the findings of this survey, it is clear that the corrective action process will be beneficial to LOWCI-Annex as they strive to meet the health care needs of the inmate population and improve care in areas that were found to be deficient. Lowell Correctional Institution Page 27 MENTAL HEALTH FINDINGS – ANNEX Lowell Correctional Institution-Annex (LOWCI-Annex) provides outpatient mental health services. The following are the mental health grades used by the Department to classify inmate mental health needs at LOWCI-Annex: • S1 - Inmate requires routine care (sick call or emergency). • S2 - Inmate requires ongoing services of outpatient psychology (intermittent or continuous). • S3 - Inmate requires ongoing services of outpatient psychiatry (case management, group and/or individual counseling, as well as psychiatric care). CLINICAL RECORDS REVIEW SELF INJURY/SUICIDE PREVENTION REVIEW There were findings requiring corrective action in the review of Self-Harm Observation Status (SHOS). The items to be addressed are indicated in the table below. There were no episodes of restraints at LOWCI-Annex. USE OF FORCE REVIEW There were no findings requiring corrective action in the review of use of force episodes. ACCESS TO MENTAL HEALTH SERVICES REVIEW There were no findings requiring corrective action in the review of inmate requests. There were findings requiring corrective action in the review of psychological emergencies and special housing. The items to be addressed are indicated in the tables below. OUTPATIENT SERVICES REVIEW There were findings requiring corrective action in the review of outpatient mental health services and psychotropic medication practices. The items to be addressed are indicated in the tables below. AFTERCARE PLANNING REVIEW There was a finding requiring corrective action in the review of aftercare planning. The item to be addressed is indicated in the table below. MENTAL HEALTH SYSTEMS REVIEW There were no findings requiring corrective action in the review of mental health systems. Lowell Correctional Institution Page 28 Self-harm Observation Status (SHOS) Finding(s) Suggested Corrective Action(s) A comprehensive review of 19 Selfharm Observation Status (SHOS) admissions revealed the following deficiencies: MH-1: In 7 records, an emergency evaluation was not completed by mental health or nursing staff prior to an SHOS admission (see discussion). MH-2: In 4 records, the “Infirmary Admission Nursing Evaluation” (DC4732) was not completed as required. Provide in-service training to staff regarding the issue(s) identified in the Finding(s) column. Create a monitoring tool and conduct biweekly monitoring of no less than ten SHOS episodes to evaluate the effectiveness of corrections. Continue monitoring until closure is affirmed through the CMA corrective action plan assessment. Discussion MH-1: In six records, the evaluation could not be located. In the remaining record, the medical history and diagnosis were blank. Psychological Emergencies Finding(s) Suggested Corrective Action(s) A comprehensive review of 11 psychological emergencies revealed the following deficiencies: Provide in-service training to staff regarding the issue(s) identified in the Finding(s) column. MH-3: In 5 records, there was no evidence the clinician considered the inmate’s mental health history and past suicide attempts. Create a monitoring tool and conduct biweekly monitoring of no less than ten psychological emergencies to evaluate the effectiveness of corrections. MH-4: In 3 records, there was no evidence that suicide risk was fully assessed. Continue monitoring until closure is affirmed through the CMA corrective action plan assessment. MH-5: In three records, the disposition was not appropriate (see discussion). Discussion MH-5: In one record, plans for self-injury were not addressed, therefore surveyors were unable to determine if the disposition was appropriate. In the second record, the inmate declared two psychological emergencies within 24 hours and expressed thoughts of harming herself and others. There was not adequate documentation indicating why placement in SHOS was not considered. In the remaining record, surveyors were unable to determine if the disposition was appropriate because the evaluation was incomplete. Lowell Correctional Institution Page 29 Special Housing Finding(s) Suggested Corrective Action(s) MH-6: In 2 of 8 applicable records (13 reviewed), follow-up mental status exams did not occur within the required time frame. Provide in-service training to staff regarding the issue(s) identified in the Finding(s) column. Create a monitoring tool and conduct monthly monitoring of no less than ten records of inmates in special housing to evaluate the effectiveness of corrections. Continue monitoring until closure is affirmed through the CMA corrective action plan assessment. Outpatient Mental Health Services Finding(s) A comprehensive review of 17 outpatient records revealed the following deficiencies: Suggested Corrective Action(s) Provide in-service training to staff regarding the issue(s) identified in the Finding(s) column. MH-7: In 2 of 9 applicable records, the “Health Information Arrival/Transfer Summary” (DC4-760A) was not completed within 24 hours of arrival to the institution. Create a monitoring tool and conduct biweekly monitoring of no less than ten applicable outpatient records to evaluate the effectiveness of corrections. MH-8: In 9 records, the Individualized Service Plan (ISP) was not signed by all relevant parties. Continue monitoring until closure is affirmed through the CMA corrective action plan assessment. MH-9: In 3 of 14 applicable records, the ISP was not reviewed and revised within 180 days. MH-10: In 5 records, problems were not recorded on the problem list. MH-11: In 2 of 9 applicable records, the Behavioral Risk Assessment was not completed within the required time frame. Lowell Correctional Institution Page 30 Outpatient Mental Health Services Finding(s) MH-12: In 2 of 8 applicable records, the ISP was not updated within 14 days of placement in Close Management. Suggested Corrective Action(s) MH-13: In 4 of 9 applicable records, the inmate was not receiving one hour of group or individual counseling per week as required in Close Management. Psychotropic Medication Practices Finding(s) A comprehensive review of 12 outpatient records revealed the following deficiencies: Suggested Corrective Action(s) Provide in-service training to staff regarding the issue(s) identified in the Finding(s) column. MH-14: In 3 records, physician’s orders were not timed, dated and/or signed. Create a monitoring tool and conduct biweekly monitoring of no less than ten applicable outpatient records to evaluate the effectiveness of corrections. MH-15: In 6 records, follow-up psychiatry services were not conducted at appropriate intervals (see discussion). Continue monitoring until closure is affirmed through the CMA corrective action plan assessment. MH-16: In 2 of 8 applicable records, the Abnormal Involuntary Movements Scale (AIMS) was not completed as required. MH-17: In 1 of 2 applicable records, an order for medications without inmate consent was not documented as an Emergency Treatment Order (ETO) (see discussion). Discussion MH-15: According to HSB 15.05.19, follow-up visits shall be scheduled, and appropriate progress notes written by the psychiatrist or other qualified prescribing clinician as needed at least once every two weeks upon initiation of any new psychotropic medication for a period of four weeks. Thereafter, psychotropic medication therapy and progress of the inmate shall be reviewed and documented at least every 90 days. In these records, a new psychotropic medication was prescribed. In three of the records, the inmate was seen within the first two weeks; however, she was not seen again within the required time frame. In the remaining three records, the inmate was not seen for the initial follow-up visit within the required time frame. Lowell Correctional Institution Page 31 Discussion MH-17: In this record, the order was not specified as an ETO. Instead it was written “Stat. May use force as necessary.” Aftercare Planning Finding(s) MH-18: In 5 of 13 records reviewed, aftercare plans were not addressed (see discussion). Suggested Corrective Action(s) Provide in-service training to staff regarding the issue(s) identified in the Finding(s) column. Create a monitoring tool and conduct biweekly monitoring of no less than ten applicable records of inmates within 180 days EOS to evaluate the effectiveness of corrections. Continue monitoring until closure is affirmed through the CMA corrective action plan assessment. Discussion MH-18: In these records, aftercare planning was added to the ISP; however, there was no documentation that these plans were discussed with the inmate. Additional Administrative Issues Finding(s) MH-19: Medical records were disorganized (see discussion). Suggested Corrective Action(s) Provide in-service training to staff regarding the issue(s) identified in the Finding(s) column. Create a monitoring tool and conduct biweekly monitoring of no less than ten medical records to evaluate the effectiveness of corrections. Continue monitoring until closure is affirmed through the CMA corrective action plan assessment. MH-20: There were safety concerns in the cells used for SHOS (see discussion). Provide evidence in the closure file that the issue described has been corrected. This may be in the form of documentation via work order or completed work signed off by regional staff. Lowell Correctional Institution Page 32 Additional Administrative Issues Finding(s) Suggested Corrective Action(s) Continue monitoring until closure is affirmed through the CMA corrective action plan assessment. Discussion MH-19: Medical records were disorganized with items frequently filed out of chronological order or in the wrong section of the file. Some records contained loose filing. Staff were unable to locate documents including emergency assessments, MARs and inmate requests. Additionally, two records contained information belonging to another inmate. Discussion MH-20: Paint was peeling from the walls of the cells used for SHOS in S-dorm and T-dorm. CONCLUSION – MENTAL HEALTH The staff at LOWCI-Annex serves a difficult population that includes inmates with multiple medical and psychiatric comorbidities. In addition to providing services to inmates on the mental health caseload, staff answer inmate requests, respond to psychological emergencies, and perform weekly rounds in confinement. Staff also perform sex offender screenings when needed, provide aftercare planning for eligible inmates, and provide daily counseling for inmates on SHOS. Reportable findings requiring corrective action are outlined in the tables above. Many of the findings noted in this report are related to missing, late or incomplete evaluations. Psychological emergency evaluations were either missing or incomplete, making it difficult determine if the responses provided were appropriate. Nursing assessments including emergency evaluations were missing or incomplete for inmates on SHOS. Follow-up psychiatric assessments for inmates who were prescribed a new psychotropic medication were not completed timely. Additionally, surveyors had difficulty reading the clinician’s handwriting, which caused a delay in the record review. Surveyors were concerned that illegible handwriting could cause errors in patient care. Case management and counseling services were provided timely and documentation was thorough and informative. However, ISPs were not updated to include the extra interventions required for inmates housed in Close Management. Behavioral Risk Assessments were not completed timely and inmates were not receiving the required additional one hour of counseling or group therapy per week. Some of the findings noted above may be related to the disorganization of medical records. Documents were misfiled, loose in the record, or missing. Although staff were able to locate many of the documents not contained in the record, some were never found. Staff indicated that the vacant mental health clerk position had recently been filled. Surveyors expressed concern that disorganized medical records could lead to lapses in patient care. Staff indicated they were appreciative of the CMA survey and would use the corrective action process to improve services in the areas found to be deficient. Lowell Correctional Institution Page 33 SURVEY PROCESS The goals of every survey performed by the CMA are: 1) to determine if the physical, dental, and mental health care provided to inmates in all state public and privately operated correctional institutions is consistent with state and federal law, conforms to standards developed by the CMA, is consistent with the standards of care generally accepted in the professional health care community at large; 2) to promote ongoing improvement in the correctional system of health services; and, 3) to assist the Department in identifying mechanisms to provide cost effective health care to inmates. To achieve these goals, specific criteria designed to evaluate inmate care and treatment in terms of effectiveness and fulfillment of statutory responsibility are measured. They include determining: • • • • • • • • • • • If inmates have adequate access to medical and dental health screening and evaluation and to ongoing preventative and primary health care. If inmates receive adequate and appropriate mental health screening, evaluation and classification. If inmates receive complete and timely orientation on how to access physical, dental, and mental health services. If inmates have adequate access to medical and dental treatment that results in the remission of symptoms or in improved functioning. If inmates receive adequate mental health treatment that results in or is consistent with the remission of symptoms, improved functioning relative to their current environment and reintegration into the general prison population as appropriate. If inmates receive and benefit from safe and effective medication, laboratory, radiology, and dental practices. If inmates have access to timely and appropriate referral and consultation services. If psychotropic medication practices are safe and effective. If inmates are free from the inappropriate use of restrictive control procedures. If sufficient documentation exists to provide a clear picture of the inmate’s care and treatment. If there are sufficient numbers of qualified staff to provide adequate treatment. To meet these objectives, the CMA contracts with a variety of licensed community and public health care practitioners such as physicians, psychiatrists, dentists, nurses, psychologists, and licensed mental health professionals. The survey process includes a review of the physical, dental and mental health systems, specifically, the existence and application of written policies and procedures, staff credentials, staff training, confinement practices, and a myriad of additional administrative issues. Individual case reviews are also conducted. The cases selected for review are representative of inmates who are receiving mental and/or physical health services (or who are eligible to receive such services). Conclusions drawn by members of the survey team are based on several methods of evidence collection: • Physical evidence – direct observation by members of the survey team (tours and observation of evaluation/treatment encounters) Lowell Correctional Institution Page 34 • Testimonial evidence – obtained through staff and inmate interviews (and substantiated through investigation) • Documentary evidence – obtained through reviews of medical/dental records, treatment plans, schedules, logs, administrative reports, physician orders, service medication administration reports, meeting minutes, training records, etc. • Analytical evidence – developed by comparative and deductive analysis from several pieces of evidence gathered by the surveyor Administrative (system) reviews generally measure whether the institution has policies in place to guide and direct responsible institutional personnel in the performance of their duties and if those policies are being followed. Clinical reviews of selected inmate medical, dental and mental health records measure if the care provided to inmates meets the statutorily mandated standard. Encounters of an episodic nature, such as sick call, an emergency, an infirmary admission, restraints, or a suicide episode, as well as encounters related to a long-term chronic illness or on-going mental health treatment are reviewed. Efforts are also made to confirm that administrative documentation (e.g., logs, consultation requests, medication administration reports, etc.) coincides with clinical documentation. Findings identified as a result of the survey may arise from a single event or from a trend of similar events. They may also involve past or present events that either had or may have the potential of compromising inmate health care. A deficiency rate of 80% or below requires in-service training, monitoring and corrective action by institutional staff. Lowell Correctional Institution Page 35