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Evaluation of Medical and Other Health Services at
Wyoming Department of Corrections Facilities
January 9-13, 2006

Consultants in Correctional Care
54 Balsa Road
Santa Fe, NM 87508

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Evaluation of Medical Services at Wyoming Department of Corrections'
Facilities
January 9-13, 2006
Introduction
On January 9-13, 2006, Consultants in Correctional Care conducted cm-site
audits of the health care services provided by Prison Health Services (PSIS) at the
Wyoming State Penitentiary (WSP) in Rawlins, the Wyoming Honor Farm (WHY)
in Riverton, the Wyoming Honor Conservation Camp (WHCC) and Boot Camp in
Newcastle, and the Wyoming Women's Center (WWC) in Lusk. The audits were
performed by B. Jaye Anna, PhD, CCIP-A, Marshall B, Bischoff; MD, COIF, and .
Reinhold, MD. Dr. Anno is the owner and principle of Consultants in
Correctional Care. Dr. Bischoff is an independent health care consultant with
extensive experience in auditing the quality of medical care in correctional facilities.
Dr. Reinhold is a correctional psychiatrist, who works at the prison in Angola,
Louisiana.
Dr. Anna managed the audits and reviewed logs, records, and other
documentation relating to the contract requirements for providing sick call (MD, DDS,
PA, and nurse), off-site referrals for specialty care, informal and formal grievances,
current staffing and the adequacy of licenses and certification, the adequacy of the quality
assurance program, and meetings of staff including the cooperation of management,
custody, and health services personnel.
Dr. Bischoff reviewed a number of aspects of the medical care provided including
the medical intake process reviewing the Medical History & Screening Form and the
Physical Assessment Form; the sick call process; the chronic care clinics, specifically
those patients with diabetes, hypertension, seizure disorder, and/or astinna/chronic
obstructive lung disease; and the inpatient care at WSP. He also reviewed the charts of
the two inmates who died during the quarter.
Dr. Reinhold reviewed the mental health care provided at all four facilities. His
comments are appended as a separate report.
This report includes findings, observations, conclusions and recommendations
regarding the aspects of care cited above provided at the four Wyoming Department of
corrections (WY DOC) facilities during October, November, and December of 2005.

Wyoming State Penitentiary (WSP)
Average Daily Population 587
Consultants in Correctional Care conducted this on-site medical audit on
January 9-10, 2006. This audit reviewed the health care provided during the months

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of October – December 2005, During that time period, medical services were
contracted to Prison Health Services,
Staffing: The WSP has a total of 48.9 regular fill-time equivalent (FTE)
health staff positions (including the sex offender program) of which 88% were filled
at the time of our on-site audit. The 6.25 vacant positions include .a 1.0 PhD
psychologist, 2.4 licensed professional counselors, a 1.0 psychiatric RN, and a 1.0
medical records supervisor. The remaining .85 positions are generally related to
nursing vacancies, which are currently filled by agency personnel.
Professional licenses and certifications were reviewed for currency, and all
were up-to-date. CPR certification for professional staff was also reviewed. All
were current except for the medical director, the optometrist, and one RN.
Staff meeting minutes and statistical reports were reviewed for October
through December. .Nurses meetings, staff meetings, and MAC meetings were all
held monthly. Statistical reports were also generated monthly.
Medical Intake Process: Dr. Anna reviewed the intake logs for OctoberDecember. A total of 245 individuals were admitted that quarter. Timeliness of
admission screenings was problematic during the prior quarter. We are pleased to
report significant improvement in all areas of intake screening. In October, 25
(36.2/o) were not screened within 24 hours. By November, this figure was down to
13.7%, and by December, only 5.8% were not screened within the required 24 hours.
The intake logs were also reviewed to determine the timeliness of the
medical, mental health, and dental assessments. Again, significant improvements
had occurred. In October, there were still 12 inmates (27.3%) who were not given
their physicals within the required seven days. By November, this figure was at
3.9%, and by December, only 1.6% of the new admissions had not had their physical
assessment completed within seven days. The majority of these inmates (n =223 or
92%) had their mental health assessments completed within the required 14 days.
As for dental exams, all of the new admissions had an exam within the required
seven days from admission.

Mit aim,

Dr, Bischoff also selected six medical records (~,
from the Chronic Care Clinic Log dated January 5,
2006. They were reviewed for the appropriateness and timeliness of the Medical
History and Screening and the Physical Assessment. All of the charts reviewed
contained the Medical History and Screening and the Physical Assessment Forms.
In all the cases, the Medical History and Screenings were appropriately completed
and dated on the day of arrival. The Physical Assessments were completed on the
day of arrival or the following day. In these six cases, the physical assessments were
performed by the physician assistant and reviewed and signed by the physician.
41111114 OMNI and VMS)

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Sick Call Process; Dr. Anna reviewed the sick call logs for the quarter. Of
the 863 sick call requests, 759 patients (88%) were seen on the date scheduled,
which was usually only a day or two after receipt of the request. In only 29 cases
(18 owing to a nursing shortage and 11 owing to a CO shortage), the facility was
short-staffed, so a nurse triaged the requests and determined these patients could
safely be earlied over to the next day. This, too, is an improvement over the prior
quarter. The remaining patients were not seen as scheduled for a variety of reasons
including resolution of their problems, refusal to go to sick call, being a "no show"
for sick call, transferring to another institution, at work, etc.

(mat, mow #arar,
sem
and
igaim to
111111, l

Dr. Bischoff reviewed twelve medical records

NUM *am.

determine the timeliness of the sick call process and the adequacy of the treatment
provided. He noted the date of the submission of an Inmate Medical Request Foam;
the date triaged by the registered nurse, the licensed practical nurse, or the dental
assistant; the assessment and treatment by the registered nurse; and if referred to a
provider, the date seen by the provider. In all instances, the registered nurse,
licensed practical nurse, or dental assistant evaluated the patient's request within.one
to three days, most often the same day or the next day.
Five of these patients (001, amp, ORM Wei and *Oft were
evaluated, appropriately handled and/or treated by the nurse according to nursing
protocols_ Six patients WM, ISM Armalilt ilsowand MIL
were seen by the registered nurse or licensed practical nurse and referred to the
physician or physician assistant. Five of these patients were seen and treated by the
health care provider within ten days. One patient IOW submitted a request on
December 21, 2005, stating "still having problem with my right hand, it is still
numb...." He was triaged on 12/22/05, seen by the LYN on 12/24/05 and referred to
the provider. There was no documentation in the progress notes whether the
provider had yet seen the patient for this request. This patient had been previously
seen by the provider on October 26, 2005.
One patient (MOM submitted a requested for dental care on September 28,
2005. On 10/3/05 he was notified that he was "already on dental list for middle part
of October." He was seen in the dental clinic on 10/19/05.
Chronic Care Clinics
Dr. Bischoff reviewed the chronic care provided at WSE for the quarter,
The Chronic Clinic Log dated January 5, 2006 contained 258 active patients with
chronic conditions. Ninety patients were listed as having hypertension; thirty-seven
patients as having asthma/chronic obstructive lung disease; thirty-seven patients as
having diabetes mellitus; and eight patients as having seizure disorders. Twentyseven of these patients had two or more of these chronic conditions. Although not
reviewed on this audit; there were fifty-five patients listed with hepatitis C, and

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seventy-nine patients with gastra-esophageal reflux disease (GERD) or dyspepsia.
The remaining patients had a variety of other conditions including hypothyroid
disease, gastritis, hyperlipidema, emphysema, Crohn's disease, }JIV+, and herpes.
Twenty-four medical records were selected from. he Chronic Clinic Log for
review. These were patients whose last chronic care clinic appointment was in the
months of October, November or December 2005. Six of these patients have
hypertension (, #411.1141.111111
AMMO and 111111111111); six have
41111113111); six have diabetes
asthma MOM 1111111111*	
1111111111t
Wet jiallt, OEMS and WIIMIIII); and six have seizure
disorders (4110/41, Mink MOW
and
Hypertension: In the six charts reviewed, the Problem List included the
diagnosis of hypertension and the Hypertension Flow Sheets were updated to include
the last chronic care clinic visit. Only one patient 4111111•11) did not have his
chronic care clinic visit within thirty days of arrival. He arrived on 5/23/05 and his
initial visit was on 7/18/05. This occurred during the time of transition from CMS to
PHS. One patient (IOW did not have an ECG in the year 2005. Ths last EKG in
the chart was on 2/4/04. Similarly, one patient (fai/a) did not have a baseline
chest x-ray in the present volume of his chart. One patient (111111111t) did not have his
annual urinalysis performed in 2005. The last one was dated 10/27/04, Two
patients 4,411101111111 ands) did not have their blood pressures within acceptable
control. Both had blood pressures above the range of 140/90 during the past three
months.
Diabetes: In the six charts reviewed, all of the patients had their diabetic
condition listed on the Problem List and the Diabetes Flow Sheets were updated to
include the last chronic care clinic visit. One patient (111110116) did not have his
initial chronic care clinic visit with thirty days of arrival. He arrived on 7/18/05 and
was not seen until 12/2/05_ One patient (111/1/A) did not a documentation of his
annual funduscopic examination in 2005. His last examination was on 11/11/04.
Two patients OM and NM did not have an annual EKG in, 2005. The last
examinations in the charts were 9/24/04 and 1218/04 respectively. Similarly, patient
aillillardid not have his annual chemistry profile, urinalysis or microalburninuria in
2005. His last chemistry was on 12/3/04 and last rinalysis on 12/7/04. Patient
4111111111 did not have a HbAlc during the past six months. The last one in his chart
was dated 3/3/05. Four patients (011M, 41111.111t
and 1111111111) did not have
documentation of having received the Pneurriovax in the present volume of their
charts. Similarly, at the time of our audit, these same patients did not have
documentation of having received the influenza vaccine for 2005/2006 in their
charts.

NM

Asthma: In the six charts reviewed, all of the patients had their chronic
condition of Asthxna/COPD listed on the Problem List and their Flow Sheets were
updated to include their last chronic care clinic visit. Three patients (411111111k
Ml= and 01011110) did not have the required annual complete blood count (CBC).
The last CBC values on the charts were in 2003 or 2004. Three patients ($11111M1,
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amit

did not have documentation that they had received the
NNW, and
Pneumovax and two patients (OM and /M) did not yet have documentation
that they had received the annual flu vaccine for 2005/2006. Another patient
(L1) had his Pneumovax and Influenza vaccine ordered on 12/19/05, but there
was no documentation that they were administered.
Seizures; In the six charts reviewed, only one patient (MU) did not have
a liver function test (LFT) within the past six months. One patient (111111111) did not
have his seizure disorder under control.
Infirmary (Inpatient Services): The PSIS Medical Housing Log for the
dates 12/6105 through 1/6/06 contained the names of nine inmates. Only one
OM was identified by the staff as an inpatient and had an inpatient chart.
This 60 year old diabetic and hypertensive patient had his left 4 th toe amputated in
May of 2005, secondary to gangrene, which later became infected. On 12/31/05, he
was referred to the hospital in Casper for surgical debridement of the wound and
possible partial amputation. He returned to the infirmary on 1/6/06 fiom the Casper
hospital.
A second inmate (011110) was not identified as an inpatient by the staff and
had no inpatient chart, but was listed on the Medical Housing Log as returning from
the hospital on 12/27/05. This inmate apparently became weak, lost his balance and
fell. He complained of chest pain and weakness in his left ann. He was sent to the
Carbon County Memorial Hospital ER on 12/26/05 with a diagnosis of rule-out
cardiac myocardial infraction. This inmate, as noted above, returned from the
hospital on 12/27/05. On 12/29/05, an IV with normal saline was ordered and
started. According to Dr. Bischoff, this inmate should have been desi gnated as an
inpatient.
Mortality Review: There were two deaths reported during the quarter. Dr.
Bischoff reviewed both charts. The first death (MRS occurred on October 18,
2005. This 50 year old male patient had end-stage liver disease secondary to
hepatitis C. He returned from out-of-state housing in Texas on October 10, 2005.
On 10/12/05, he fell in this cell, bit his head and was sent to the ER for evaluation.
The patient continued to decline and expired on 10/18/05. The autopsy report
indicated the cause of death as bilateral acute pneumonia complicating end-stage
cirrhosis. His manner of death was natural.

The second inmate death (illa occurred on November 26, 2005. This 57
year old Hispanic male had a history of diabetes, neuropathy, hepatitis C and
dementia. He was housed in the infirmary due to his low level of function (primarily
due to his dementia). On 11/25/05, he vomited in his cell; this was dark red with
dark chunks of material. He was transported to the local hospital with the diagnosis
of GI bleed. He was admitted to the ICU, but continued to decline and expired on
11/26/05. No autopsy report was available.

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Continuous Quality Improvement (CO: Dr. Anno reviewed the CQI
studies for the quarter. The recently hired CQI nurse has been very active. CQI
meetings were held on 10/27/05, 11/7/05, and 1/5/06. A number of studies were
conducted each month including 11 in October, four in November, and eight in
December. We were pleased to note that CQI studies were conducted on mental
health care and dental care as well as medical care Corrective action is planned for
areas with deficiencies,
Referrals: Dr. Anno reviewed the outside referral logs for the quarter.
There were 97 requests for outside care, all of which were approved. For the vast
majority of these cases (rr .90 or 92%), approval was received within one week of
the request. The time interval from the date of approval &the request to the date the
patient was seen was also calculated. In October, 66.6% were seen within one
month and 93.3% were seen within two months. In November, 70.6% were seen
within one month and 85.3% were seen within two months, For December, these
'figures were 70% and 100% respectively. Again, this is a significant improvement
over the prior quarter.
Grievances: Dr MAO reviewed the inmate grievance logs for health services
for the quarter. There were 156 informal grievances and 41 formal grievances filed
for a total of 197. The tone of the responses was respectful and staff is doing a better
job of keeping the grievance logs up-to-date. It is evident that the staff take
grievances seriously, because over a quarter of them (26.4%) were deemed to have
merit The total number of formal grievances filed for the quarter was 237, of
which 20.2% were complaints about health services.
Conclusions and Recommendations;
Health care services at WSP have been under contract to Prison Health
Services (PHS) since July 1, 2005. This audit reviewed the delivery of health care
for the last quarter of 2005. The MS clinic staff is obviously very committed to
providing quality health care services. The medical intake process performed very
well during the months audited. Staff continued to get better and better at
performing the required receiving screenings, intake physicals, and dental and
mental health exams within the required time frames. In the medical records
reviewed, all of the patients had a Medical History and Screening performed on the
day of arrival and their Physical Assessments within 1-2 days of arrival at the
institution. The physician assistant performed the physical examinations. In all the
cases audited, examinations performed by the physician assistant were reviewed by
the physician.
The sick call process also appears to be functioning very well. The vast
majority (88%) of patients were seen on the date scheduled, usually only a day or
two after their requests. In the twelve charts audited, the PHS Inmate Medical
Request Forms were reviewed by a nurse or dental clerk in a timely fashion. When

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appropriate, the registered nurse assessed and treated the patient, generally on the
same day, When a referral was made to a health care provider, the patient was seen
within ten days from the submission of the request.
The chronic care program at WSP is also functioning quite well. In all of the
charts audited, the patient's chronic condition was listed on their problem list and
flow sheets were routinely updated. Nevertheless, there were a few patients that
lacked the required baseline and/or periodic laboratory and diagnostic tests (e. g.,
chest x-ray, electrocardiogram, finaloscopic examination, complete blood count,
liver function test, chemistry panel, and urnialysis). These requirements are based
on national guidelines to assist the provider in monitoring the patient's chronic
condition and the resultafrom these tests indicate the quality of medical care
provided. In several Instances, there was a lack of documentation for the required
vaccines (Pneumovax and annual influenza) in the audited volume of the patients'
medical records. Many of these patients have more than one volume to their medical
record. It is prudent to place baseline diagnostic and laboratory reports along with
the last chronic care clinic visit in the latest volume of the patient's medical record.
The use of the PHS standardized chronic care forms, specific to the chronic
condition, (i.e. diabetes, hypertension, asthma, and seizure disorder) have proven
extremely useful in evaluating and monitoring these patients. The completion of the
flow sheets is critical in determining when the periodic diagnostic and laboratory
tests need to be ordered. There definitely has been an improvement in the in the
Chronic Care Program overall. Only a few deficiencies were noted.
The infirmary at WSP continues to house a mix of "medical patients" and
"residents." There appears to be some confusion among the staff as to whether the
inmate Is a resident or an inpatient. An inpatient chart is required for each identified
patient. The chart must contain a physician's admit order, an admission history and
physical, and periodic provider progress notes. Generally, this process functions very
well; however, during this audit, only one patient was identified as an inpatient.
Nonetheless, there was another inmate who recently returned from the hospital and
was receiving II/therapy, but was not identified as an inpatient. There needs to be a
better process for identifying and monitoring infirmary inpatients.
The mortality reviews of inmate deaths were acceptable.
A number of other improvements were noted this quarter as well. Staff vacancies
were down, all professional staff had proof of licensure, and only three staff members

were in need of proof of current certification in CPR Staff meetings were held monthly
and the CQI program has become very active. Approval for outside referrals was timely,
and there was an increasing trend in getting the patients to outside providers in a timely
manner. All in all, a job well done.