Q1 2024 HS Audit Deficiences Line 11 Line 74.pdf

From: Dunigan, Andy To: Modglin, Angela; Olson, Cherie; Meggs, April; Hoard, Maureen; Bedford, Adrienne Cc: Dwenger, Deanna L; Tafoya, Nikki Subject: Q1 2024 Final Performance Measure Audits Date: Wednesday, May 22, 2024 2:39:00 PM Attachments: 01 Preventive Services and Wellness Q1 2024-Final.xlsx

02 ARS Audit Q1 2024-Final.xlsx 03 Diagnostic Tests and Specialty Care Q1 2024-Final.xlsx 04 Emergency Services & Hospital Care Q1 2024-Final.xlsx Audit Deficiencies Q1 2024-FINAL.pdf

Good afternoon. I’ve attached the final spreadsheet and narrative for finalizing Quarter 1 2024’s performance measure audits. After a review and found to be in non-compliance, audits not meeting the 90% threshold for the 1st quarter 2024 (January, February, March) after the rebuttals are:

Preventive Services and Wellness:

Heritage Trail CF Wabash Valley CF Miami CF Plainfield CF Pendleton CF New Castle CF

Diagnostic and Specialty Care:

Logansport Juvenile CF Plainfield CF Branchville CF Heritage Trail CF Wabash Valley CF

Emergency Services and Hospital Care:

Indiana State Prison

Addiction Recovery Services:

Chain O’ Lakes Miami CF Plainfield CF Wabash Valley CF

If you have any questions or concerns, please do not hesitate to contact me.

Andy Dunigan Executive Director, Healthcare Operations Indiana Department of Correction ADunigan@idoc.in.gov mailto:ADunigan@idoc.IN.gov mailto:AModglin@idoc.IN.gov mailto:COlson@idoc.IN.gov mailto:AMeggs@TeamCenturion.com mailto:mhoard@TeamCenturion.com mailto:ABedford@idoc.IN.gov mailto:DDwenger@idoc.IN.gov mailto:NTafoya@idoc.IN.gov

Summary

SUMMARY SHEET

Preventive Services and Wellness

Facility Abbrev. % Compliant % Non-Compliant

Branchville BTC 91% 8.77%

Chain O'Lakes COL 94% 5.80%

Correctional Industrial CIF 93% 6.67%

Edinburgh JCU 100% 0.00%

Heritage Trail HTCF 80% 20.34%

Indiana State ISP 90% 10.02%

Indiana Womens IWP 100% 0.00%

LaPorte Juvenile LPJ 100% 0.00%

Logansport LJCF 100% 0.00%

Madison MCU 100% 0.00%

Miami MCF 84% 16.03%

New Castle NCCF 78% 21.78%

Pendleton ISR 81% 18.89%

Pendleton Juvenile PNJ 100% 0.00%

Plainfield IYC 81% 19.35%

Putnamville ISF 98% 2.15%

Reception Diagnostic RDC ERROR:#DIV/0! ERROR:#DIV/0!

Rockville RTC 99% 1.04%

South Bend SBWR 96% 3.51%

Wabash Valley WVCF 88% 11.86%

Westville WCC 92% 7.78%

COL

Preventive Services and Wellness

Facility: COL

Date: 3/14/24

IDOC NUMBERS | 1 = YES 0 =NO Total Average Criteria Met 94%

Measure 1875817 284202 870200 229504 286450 270873 263975 264895 135763 921471

At a minimum, all services receiving an ‘A’ or ‘B’ recommendation by the US Preventive Services Task Force (USPSTF) are provided.

Documentation supports:

The annual health screen was completed during the IDPs birth month (For IDP who recently received the intake health appraisal during the previous 3 months, the annual screen may be deferred one year.) 1 1 1 1 1 1 1 1 1 1

An IDP who answered “yes” to questions regarding symptoms was referred to a practitioner for evaluation n n n n n n n n n n

Vital signs and weight were recorded in the EMR 1 1 1 1 1 1 1 1 1 1

For IDP with no chronic health problems, a lipid profile was obtained every 5 years for men over age 35 and for women over age 45 (those at increased risk of coronary heart disease (diabetes, HTN, multiple risk factors [tobacco use, HTN, etc] family history of cardiovascular disease before age 50 in male relatives and age 60 in female relatives). A serum glucose or HgbA1C was done in accordance with the time frames noted on the preventive services grid 1 1 1 n n 0 1 1 0 n

For all IDP, beginning at age 50 and continuing to age 74, a screening test for colorectal cancer was performed (fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, or double contrast barium enema) at least once every 10 years (score if the procedure was due this contract year. Mark N/A if the offender should not have been scheduled for this contract year. IDP age 55 to 80, who have a 30 pack-year smoking history and currently smoke or have quit smoking within the past 15 years, a low dose CT scan was done annually. Screening may be discontinued once an offender person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery. n n n n n n n n n n

MEN For men aged 65-75 who have ever smoked, documentation supports that an ultrasound was done to screen for abdominal aortic aneurysm (AAA) (limited to those inmates with at least 180 days or more to serve) n n n n n n n n n n

Total points: 25

93% criteria met

Measure

All vaccinations are provided in accordance with recommendations of the Advisory Committee on Immunization Practices (ACIP), CDC guidelines, FDA and USPSTF.

Tetanus-diphtheria (Tdap/Td) was administered at 10 year intervals (age 20, 30, 40, etc) 1 1 1 1 1 n 1 n 1 1

1 dose of Tdap was administered to pregnant female offender during each pregnancy (preferred during week 27 to 36 weeks gestation) regardless of the interval since prior Td or Tdap vaccination n n n n n n n n n n

All offenders over age 65 received a pneumococcal polysaccharide vaccine given n n n n n n n n n n

A single dose of zoster vaccine was administered to an adult offender age 50 or older n 0 0 n n n n 0 n n

Vaccinations are made available and offered to all IDP as recommended and guided by applicable standards. 1 1 1 1 1 1 1 1 1 1

The health record reflects the VIS Material for the current year was provided including the Publication Date 1 1 1 1 1 n 1 1 1 1

Total points: 27

90% criteria met

Measure

Influenza vaccine is made available, once each year, in accordance with the recommendations of the Centers for Disease Control and Prevention (CDC) and IDOC influenza Control Program.

Documentation in the health record or sign up logs supports that all offenders have been offered the influenza vaccine each year during the flu season. 1 1 1 1 1 n 1 1 1 1

Total points: 9

100% criteria met

NOTES / COMMENTS:

ISP

Preventive Services and Wellness

Facility: ISP

Date: 3/27/24

IDOC NUMBERS | 1 = YES 0 =NO Total Average Criteria Met 90%

Measure 872828 196070 940294 883740 109321 931588 273873 221230 220116 196998

At a minimum, all services receiving an ‘A’ or ‘B’ recommendation by the US Preventive Services Task Force (USPSTF) are provided.

Documentation supports:

The annual health screen was completed during the IDPs birth month (For IDP who recently received the intake health appraisal during the previous 3 months, the annual screen may be deferred one year.) 1 1 1 1 1 1 1 1 1 1

An IDP who answered “yes” to questions regarding symptoms was referred to a practitioner for evaluation n n n n n n n n n n

Vital signs and weight were recorded in the EMR 1 1 1 1 1 1 1 1 1 1

For IDP with no chronic health problems, a lipid profile was obtained every 5 years for men over age 35 and for women over age 45 (those at increased risk of coronary heart disease (diabetes, HTN, multiple risk factors [tobacco use, HTN, etc] family history of cardiovascular disease before age 50 in male relatives and age 60 in female relatives). A serum glucose or HgbA1C was done in accordance with the time frames noted on the preventive services grid 1 1 1 1 1 1 1 n 1 n

For all IDP, beginning at age 50 and continuing to age 74, a screening test for colorectal cancer was performed (fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, or double contrast barium enema) at least once every 10 years (score if the procedure was due this contract year. Mark N/A if the offender should not have been scheduled for this contract year. IDP age 55 to 80, who have a 30 pack-year smoking history and currently smoke or have quit smoking within the past 15 years, a low dose CT scan was done annually. Screening may be discontinued once an offender person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery. 0 n 0 0 n n n n n n

MEN For men aged 65-75 who have ever smoked, documentation supports that an ultrasound was done to screen for abdominal aortic aneurysm (AAA) (limited to those inmates with at least 180 days or more to serve) n n 0 n n n n n n n

Total points: 28

88% criteria met

Measure

All vaccinations are provided in accordance with recommendations of the Advisory Committee on Immunization Practices (ACIP), CDC guidelines, FDA and USPSTF.

Tetanus-diphtheria (Tdap/Td) was administered at 10 year intervals (age 20, 30, 40, etc) 1 1 1 n n 1 1 1 1 1

1 dose of Tdap was administered to pregnant female offender during each pregnancy (preferred during week 27 to 36 weeks gestation) regardless of the interval since prior Td or Tdap vaccination n n n n n n n n n

All offenders over age 65 received a pneumococcal polysaccharide vaccine given n n 0 n n n n n n n

A single dose of zoster vaccine was administered to an adult offender age 50 or older 0 n 1 n n n n n n n

Vaccinations are made available and offered to all IDP as recommended and guided by applicable standards. 1 1 1 1 1 1 1 1 1 1

The health record reflects the VIS Material for the current year was provided including the Publication Date 1 1 1 1 1 1 1 1 1 1

Total points: 29

94% criteria met

Measure

Influenza vaccine is made available, once each year, in accordance with the recommendations of the Centers for Disease Control and Prevention (CDC) and IDOC influenza Control Program.

Documentation in the health record or sign up logs supports that all offenders have been offered the influenza vaccine each year during the flu season. 1 n 1 1 1 0 1 1 1 1

Total points: 8

89% criteria met

NOTES / COMMENTS:

LPJ

Preventive Services and Wellness

Facility: Laporte

Date: 1/12/24

IDOC NUMBERS | 1 = YES 0 =NO Total Average Criteria Met 100%

Measure 237772 296339 294255 295566 237741 295398

At a minimum, all services receiving an ‘A’ or ‘B’ recommendation by the US Preventive Services Task Force (USPSTF) are provided.

Documentation supports:

The annual health screen was completed during the IDPs birth month (For IDP who recently received the intake health appraisal during the previous 3 months, the annual screen may be deferred one year.) 1 1 1 1 1 1 n n n n

An IDP who answered “yes” to questions regarding symptoms was referred to a practitioner for evaluation n n n n n n n n n n

Vital signs and weight were recorded in the EMR 1 1 1 1 1 1 n n n n

Total points: 12

100% criteria met

Measure

All vaccinations are provided in accordance with recommendations of the Advisory Committee on Immunization Practices (ACIP), CDC guidelines, FDA and USPSTF.

Tetanus-diphtheria (Tdap/Td) was administered at 10 year intervals (age 20, 30, 40, etc)

1 dose of Tdap was administered to pregnant female offender during each pregnancy (preferred during week 27 to 36 weeks gestation) regardless of the interval since prior Td or Tdap vaccination n n n n n n n n n n

A single dose of zoster vaccine was administered to an adult offender age 50 or older n n n n n n n n n n

Vaccinations are made available and offered to all IDP as recommended and guided by applicable standards. 1 1 1 1 1 1 n n n n

The health record reflects the VIS Material for the current year was provided including the Publication Date 1 1 1 1 1 1 n n n n

Childhood vaccines were administered in accordance with the schedule established by the Vaccines for Children Program 1 1 1 1 1 1 n n n n

Total points: 18

100% criteria met

Measure

Influenza vaccine is made available, once each year, in accordance with the recommendations of the Centers for Disease Control and Prevention (CDC) and IDOC influenza Control Program.

Documentation in the health record or sign up logs supports that all offenders have been offered the influenza vaccine each year during the flu season. 1 1 1 1 1 1 n n n n

Total points: 6

100% criteria met

NOTES / COMMENTS:

SBWR

Preventive Services and Wellness

Facility: SBWR

Date: 2/8/24

IDOC NUMBERS | 1 = YES 0 =NO Total Average Criteria Met 96%

Measure 943742 956917 280845 293276 272623 108015 289441 903494 268879 129885

At a minimum, all services receiving an ‘A’ or ‘B’ recommendation by the US Preventive Services Task Force (USPSTF) are provided.

Documentation supports:

The annual health screen was completed during the IDPs birth month (For IDP who recently received the intake health appraisal during the previous 3 months, the annual screen may be deferred one year.) 1 1 1 1 1 1 1 1 1 1

An IDP who answered “yes” to questions regarding symptoms was referred to a practitioner for evaluation n n n n n n n n n n

Vital signs and weight were recorded in the EMR 1 1 1 1 1 1 1 1 1 1

For IDP with no chronic health problems, a lipid profile was obtained every 5 years for men over age 35 and for women over age 45 (those at increased risk of coronary heart disease (diabetes, HTN, multiple risk factors [tobacco use, HTN, etc] family history of cardiovascular disease before age 50 in male relatives and age 60 in female relatives). A serum glucose or HgbA1C was done in accordance with the time frames noted on the preventive services grid 1 n n 1 n 1 1 1

For all IDP, beginning at age 50 and continuing to age 74, a screening test for colorectal cancer was performed (fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, or double contrast barium enema) at least once every 10 years (score if the procedure was due this contract year. Mark N/A if the offender should not have been scheduled for this contract year. IDP age 55 to 80, who have a 30 pack-year smoking history and currently smoke or have quit smoking within the past 15 years, a low dose CT scan was done annually. Screening may be discontinued once an offender person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery. 0 n n n 0 n n n n n

MEN For men aged 65-75 who have ever smoked, documentation supports that an ultrasound was done to screen for abdominal aortic aneurysm (AAA) (limited to those inmates with at least 180 days or more to serve) n n n n n n n n n n

WOMEN For female IDP age 21-65 with a cervix, documentation supports that a PAP smear was done in accordance with the timeframes recommended by applicable HCSD and preventive services grid. Score only if the pap smear was due during this contract year. Mark N/A if not due this contract year. n n n n n n n n n n

A mammogram was done every two years for women age 50 to 74 (score if the audit was during the years due, mark N/A if offender is not due this year) n n n n n n n n n n

Woman aged 65 and older were screened for osteoporosis (repeat screening interval is a minimum of 2 years after age 65; to be determined case by case by the facility’s provider n n n n n n n n n n

Total points: 25

93% criteria met

Measure

All vaccinations are provided in accordance with recommendations of the Advisory Committee on Immunization Practices (ACIP), CDC guidelines, FDA and USPSTF.

Tetanus-diphtheria (Tdap/Td) was administered at 10 year intervals (age 20, 30, 40, etc) 1 1 1 1 1 1 1 1 1 1

1 dose of Tdap was administered to pregnant female offender during each pregnancy (preferred during week 27 to 36 weeks gestation) regardless of the interval since prior Td or Tdap vaccination n n n n n n n n n n

All offenders over age 65 received a pneumococcal polysaccharide vaccine given n n n n n n n n n n

A single dose of zoster vaccine was administered to an adult offender age 50 or older 1 n n 0 n n n n n n

Vaccinations are made available and offered to all IDP as recommended and guided by applicable standards. 1 1 1 1 1 1 1 1 1 1

The health record reflects the VIS Material for the current year was provided including the Publication Date 1 1 1 1 1 1 1 1 1 1

Childhood vaccines were administered in accordance with the schedule established by the Vaccines for Children Program n n n n n n n n n n

Total points: 31

97% criteria met

Measure

Influenza vaccine is made available, once each year, in accordance with the recommendations of the Centers for Disease Control and Prevention (CDC) and IDOC influenza Control Program.

Documentation in the health record or sign up logs supports that all offenders have been offered the influenza vaccine each year during the flu season. 1 1 1 1 1 1 1 1 1 1

Total points: 10

100% criteria met

NOTES / COMMENTS:

WCC

Preventive Services and Wellness

Facility: WCC

Date: 3/20/24

IDOC NUMBERS | 1 = YES 0 =NO Total Average Criteria Met 92%

Measure 222499 294578 106204 911250 982407 251865 120309 257263 135073 264424

At a minimum, all services receiving an ‘A’ or ‘B’ recommendation by the US Preventive Services Task Force (USPSTF) are provided.

Documentation supports:

The annual health screen was completed during the IDPs birth month (For IDP who recently received the intake health appraisal during the previous 3 months, the annual screen may be deferred one year.) 0 0 0 0 0 1 1 1 0 0

An IDP who answered “yes” to questions regarding symptoms was referred to a practitioner for evaluation n n n n n n n n n n

Vital signs and weight were recorded in the EMR 1 1 1 1 1 1 1 1 1 1

For IDP with no chronic health problems, a lipid profile was obtained every 5 years for men over age 35 and for women over age 45 (those at increased risk of coronary heart disease (diabetes, HTN, multiple risk factors [tobacco use, HTN, etc] family history of cardiovascular disease before age 50 in male relatives and age 60 in female relatives). A serum glucose or HgbA1C was done in accordance with the time frames noted on the preventive services grid n 1 1 1 1 n 1 1 1 1

For all IDP, beginning at age 50 and continuing to age 74, a screening test for colorectal cancer was performed (fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, or double contrast barium enema) at least once every 10 years (score if the procedure was due this contract year. Mark N/A if the offender should not have been scheduled for this contract year. IDP age 55 to 80, who have a 30 pack-year smoking history and currently smoke or have quit smoking within the past 15 years, a low dose CT scan was done annually. Screening may be discontinued once an offender person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery. n n n 1 n n n n n 1

MEN For men aged 65-75 who have ever smoked, documentation supports that an ultrasound was done to screen for abdominal aortic aneurysm (AAA) (limited to those inmates with at least 180 days or more to serve) n n n n n n n n n n

WOMEN For female IDP age 21-65 with a cervix, documentation supports that a PAP smear was done in accordance with the timeframes recommended by applicable HCSD and preventive services grid. Score only if the pap smear was due during this contract year. Mark N/A if not due this contract year. n n n n n n n n n n

A mammogram was done every two years for women age 50 to 74 (score if the audit was during the years due, mark N/A if offender is not due this year) n n n n n n n n n n

Woman aged 65 and older were screened for osteoporosis (repeat screening interval is a minimum of 2 years after age 65; to be determined case by case by the facility’s provider n n n n n n n n n n

Total points: 23

77% criteria met

Measure

All vaccinations are provided in accordance with recommendations of the Advisory Committee on Immunization Practices (ACIP), CDC guidelines, FDA and USPSTF.

Tetanus-diphtheria (Tdap/Td) was administered at 10 year intervals (age 20, 30, 40, etc) 1 1 1 1 1 1 1 1 1 1

1 dose of Tdap was administered to pregnant female offender during each pregnancy (preferred during week 27 to 36 weeks gestation) regardless of the interval since prior Td or Tdap vaccination n n n n n n n n n n

All offenders over age 65 received a pneumococcal polysaccharide vaccine given n n n n n n n n n n

A single dose of zoster vaccine was administered to an adult offender age 50 or older n 1 n 1 n n n n n 1

Vaccinations are made available and offered to all IDP as recommended and guided by applicable standards. 1 1 1 1 1 1 1 1 1 1

The health record reflects the VIS Material for the current year was provided including the Publication Date 1 1 1 1 1 1 1 1 1 1

Childhood vaccines were administered in accordance with the schedule established by the Vaccines for Children Program n n n n n n n n n n

Total points: 33

100% criteria met

Measure

Influenza vaccine is made available, once each year, in accordance with the recommendations of the Centers for Disease Control and Prevention (CDC) and IDOC influenza Control Program.

Documentation in the health record or sign up logs supports that all offenders have been offered the influenza vaccine each year during the flu season. 1 1 1 1 1 1 1 1 1 1

Total points: 10

100% criteria met

NOTES / COMMENTS:

Break

MCF

Preventive Services and Wellness

Facility: MCF

Date:

IDOC NUMBERS | 1 = YES 0 =NO Total Average Criteria Met 84%

Measure 120077 201157 854085 281539 186638 260694 212107 188885 178947 905774

At a minimum, all services receiving an ‘A’ or ‘B’ recommendation by the US Preventive Services Task Force (USPSTF) are provided.

Documentation supports:

The annual health screen was completed during the IDPs birth month (For IDP who recently received the intake health appraisal during the previous 3 months, the annual screen may be deferred one year.) 0 1 1 1 0 1 1 0 1 1

An IDP who answered “yes” to questions regarding symptoms was referred to a practitioner for evaluation N N N N N N N N N N

Vital signs and weight were recorded in the EMR 0 1 0 1 0 1 1 0 1 1

For IDP with no chronic health problems, a lipid profile was obtained every 5 years for men over age 35 and for women over age 45 (those at increased risk of coronary heart disease (diabetes, HTN, multiple risk factors [tobacco use, HTN, etc] family history of cardiovascular disease before age 50 in male relatives and age 60 in female relatives). A serum glucose or HgbA1C was done in accordance with the time frames noted on the preventive services grid 1 N 1 1 1 1 N 1 1 1

For all IDP, beginning at age 50 and continuing to age 74, a screening test for colorectal cancer was performed (fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, or double contrast barium enema) at least once every 10 years (score if the procedure was due this contract year. Mark N/A if the offender should not have been scheduled for this contract year. IDP age 55 to 80, who have a 30 pack-year smoking history and currently smoke or have quit smoking within the past 15 years, a low dose CT scan was done annually. Screening may be discontinued once an offender person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery. N N 1 N N 0 N N N N

MEN For men aged 65-75 who have ever smoked, documentation supports that an ultrasound was done to screen for abdominal aortic aneurysm (AAA) (limited to those inmates with at least 180 days or more to serve) N N N N N N N N N N

Total points: 22

73% criteria met

Measure 120077 201157 854085 281539 186638 260694 212107 188885 178947 905774

All vaccinations are provided in accordance with recommendations of the Advisory Committee on Immunization Practices (ACIP), CDC guidelines, FDA and USPSTF.

Tetanus-diphtheria (Tdap/Td) was administered at 10 year intervals (age 20, 30, 40, etc) 1 1 1 N 1 1 1 1 0 N

1 dose of Tdap was administered to pregnant female offender during each pregnancy (preferred during week 27 to 36 weeks gestation) regardless of the interval since prior Td or Tdap vaccination N N N N N N N N N N

All offenders over age 65 received a pneumococcal polysaccharide vaccine given N N 0 N N N N N N N

A single dose of zoster vaccine was administered to an adult offender age 50 or older N N 0 0 N 0 N N N 0

Vaccinations are made available and offered to all IDP as recommended and guided by applicable standards. 1 1 1 1 1 1 1 1 1 1

The health record reflects the VIS Material for the current year was provided including the Publication Date 1 N N N 1 1 1 N N 1

Childhood vaccines were administered in accordance with the schedule established by the Vaccines for Children Program N N N N N N N N N N

Total points: 22

79% criteria met

Measure 120077 201157 854085 281539 186638 260694 212107 188885 178947 905774

Influenza vaccine is made available, once each year, in accordance with the recommendations of the Centers for Disease Control and Prevention (CDC) and IDOC influenza Control Program.

Documentation in the health record or sign up logs supports that all offenders have been offered the influenza vaccine each year during the flu season. 1 1 1 1 1 1 1 1 1 1

Total points: 10

100% criteria met

NOTES / COMMENTS:

LJCF

Preventive Services and Wellness

Facility: LJCF

Date:

IDOC NUMBERS | 1 = YES 0 =NO Total Average Criteria Met 100%

Measure 284637 284935 284989 284969 284727

At a minimum, all services receiving an ‘A’ or ‘B’ recommendation by the US Preventive Services Task Force (USPSTF) are provided.

Documentation supports:

An IDP who answered “yes” to questions regarding symptoms was referred to a practitioner for evaluation N N N N N N N N N N

Vital signs and weight were recorded in the EMR 1 1 1 1 1 N N N N N

Total points: 5

100% criteria met

Measure 284637 284935 284989 284969 284727

All vaccinations are provided in accordance with recommendations of the Advisory Committee on Immunization Practices (ACIP), CDC guidelines, FDA and USPSTF.

Tetanus-diphtheria (Tdap/Td) was administered at 10 year intervals (age 20, 30, 40, etc) N N N 1 1 N N N N N

Vaccinations are made available and offered to all IDP as recommended and guided by applicable standards. 1 1 1 1 1 N N N N N

The health record reflects the VIS Material for the current year was provided including the Publication Date 1 1 1 1 1 N N N N N

Childhood vaccines were administered in accordance with the schedule established by the Vaccines for Children Program 1 1 1 1 1 N N N N N

Total points: 17

100% criteria met

Measure 284637 284935 284989 284969 284727

Influenza vaccine is made available, once each year, in accordance with the recommendations of the Centers for Disease Control and Prevention (CDC) and IDOC influenza Control Program.

Documentation in the health record or sign up logs supports that all offenders have been offered the influenza vaccine each year during the flu season. 1 1 1 1 1 N N N N N

Total points: 5

100% criteria met

NOTES / COMMENTS:

IYC

Preventive Services and Wellness

Facility: IYC

Date:

IDOC NUMBERS | 1 = YES 0 =NO Total Average Criteria Met 81%

Measure 120180 296166 936629 199499 985968 172381 129759 153866 273752 294169

At a minimum, all services receiving an ‘A’ or ‘B’ recommendation by the US Preventive Services Task Force (USPSTF) are provided.

Documentation supports:

The annual health screen was completed during the IDPs birth month (For IDP who recently received the intake health appraisal during the previous 3 months, the annual screen may be deferred one year.) 0 0 0 N 0 0 0 0 0 0

An IDP who answered “yes” to questions regarding symptoms was referred to a practitioner for evaluation N N N N N N N N N N

Vital signs and weight were recorded in the EMR 1 1 1 1 1 1 1 0 1 1

For IDP with no chronic health problems, a lipid profile was obtained every 5 years for men over age 35 and for women over age 45 (those at increased risk of coronary heart disease (diabetes, HTN, multiple risk factors [tobacco use, HTN, etc] family history of cardiovascular disease before age 50 in male relatives and age 60 in female relatives). A serum glucose or HgbA1C was done in accordance with the time frames noted on the preventive services grid 1 1 1 1 1 N 1 1 N 1

For all IDP, beginning at age 50 and continuing to age 74, a screening test for colorectal cancer was performed (fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, or double contrast barium enema) at least once every 10 years (score if the procedure was due this contract year. Mark N/A if the offender should not have been scheduled for this contract year. IDP age 55 to 80, who have a 30 pack-year smoking history and currently smoke or have quit smoking within the past 15 years, a low dose CT scan was done annually. Screening may be discontinued once an offender person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery. N N 0 N 0 N N N N N

MEN For men aged 65-75 who have ever smoked, documentation supports that an ultrasound was done to screen for abdominal aortic aneurysm (AAA) (limited to those inmates with at least 180 days or more to serve) N N N N N N N N N N

WOMEN For female IDP age 21-65 with a cervix, documentation supports that a PAP smear was done in accordance with the timeframes recommended by applicable HCSD and preventive services grid. Score only if the pap smear was due during this contract year. Mark N/A if not due this contract year.

A mammogram was done every two years for women age 50 to 74 (score if the audit was during the years due, mark N/A if offender is not due this year)

Woman aged 65 and older were screened for osteoporosis (repeat screening interval is a minimum of 2 years after age 65; to be determined case by case by the facility’s provider

Total points: 17

59% criteria met

Measure 120180 296166 936629 199499 985968 172381 129759 153866 273752 294169

All vaccinations are provided in accordance with recommendations of the Advisory Committee on Immunization Practices (ACIP), CDC guidelines, FDA and USPSTF.

Tetanus-diphtheria (Tdap/Td) was administered at 10 year intervals (age 20, 30, 40, etc) N N 1 N 1 N N N 0 N

1 dose of Tdap was administered to pregnant female offender during each pregnancy (preferred during week 27 to 36 weeks gestation) regardless of the interval since prior Td or Tdap vaccination N N N N N N N N N N

All offenders over age 65 received a pneumococcal polysaccharide vaccine given N N N N N N N N N N

A single dose of zoster vaccine was administered to an adult offender age 50 or older N N N N N N N N N N

IYC 1 1 0 1 1 1 1 1 N 1

The health record reflects the VIS Material for the current year was provided including the Publication Date N N 0 N 1 1 1 1 N 1

Childhood vaccines were administered in accordance with the schedule established by the Vaccines for Children Program

Total points: 15

83% criteria met

Measure 120180 296166 936629 199499 985968 172381 129759 153866 273752 294169

Influenza vaccine is made available, once each year, in accordance with the recommendations of the Centers for Disease Control and Prevention (CDC) and IDOC influenza Control Program.

Documentation in the health record or sign up logs supports that all offenders have been offered the influenza vaccine each year during the flu season. 1 1 1 N 1 1 1 1 N 1

Total points: 8

100% criteria met

NOTES / COMMENTS:

RDC

Preventive Services and Wellness

Facility: RDC

Date:

IDOC NUMBERS | 1 = YES 0 =NO Total Average Criteria Met ERROR:#DIV/0!

Measure

At a minimum, all services receiving an ‘A’ or ‘B’ recommendation by the US Preventive Services Task Force (USPSTF) are provided.

Documentation supports: N N N N N N N N N N

The annual health screen was completed during the IDPs birth month (For IDP who recently received the intake health appraisal during the previous 3 months, the annual screen may be deferred one year.) N N N N N N N N N N

An IDP who answered “yes” to questions regarding symptoms was referred to a practitioner for evaluation N N N N N N N N N N

Vital signs and weight were recorded in the EMR N N N N N N N N N N

For IDP with no chronic health problems, a lipid profile was obtained every 5 years for men over age 35 and for women over age 45 (those at increased risk of coronary heart disease (diabetes, HTN, multiple risk factors [tobacco use, HTN, etc] family history of cardiovascular disease before age 50 in male relatives and age 60 in female relatives). A serum glucose or HgbA1C was done in accordance with the time frames noted on the preventive services grid N N N N N N N N N N

For all IDP, beginning at age 50 and continuing to age 74, a screening test for colorectal cancer was performed (fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, or double contrast barium enema) at least once every 10 years (score if the procedure was due this contract year. Mark N/A if the offender should not have been scheduled for this contract year. IDP age 55 to 80, who have a 30 pack-year smoking history and currently smoke or have quit smoking within the past 15 years, a low dose CT scan was done annually. Screening may be discontinued once an offender person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery. N N N N N N N N N N

MEN For men aged 65-75 who have ever smoked, documentation supports that an ultrasound was done to screen for abdominal aortic aneurysm (AAA) (limited to those inmates with at least 180 days or more to serve) N N N N N N N N N N

Total points: 0

Not Applicable criteria met

Measure

All vaccinations are provided in accordance with recommendations of the Advisory Committee on Immunization Practices (ACIP), CDC guidelines, FDA and USPSTF.

Tetanus-diphtheria (Tdap/Td) was administered at 10 year intervals (age 20, 30, 40, etc) N N N N N N N N N N

1 dose of Tdap was administered to pregnant female offender during each pregnancy (preferred during week 27 to 36 weeks gestation) regardless of the interval since prior Td or Tdap vaccination N N N N N N N N N N

All offenders over age 65 received a pneumococcal polysaccharide vaccine given N N N N N N N N N N

A single dose of zoster vaccine was administered to an adult offender age 50 or older N N N N N N N N N N

Vaccinations are made available and offered to all IDP as recommended and guided by applicable standards. N N N N N N N N N N

The health record reflects the VIS Material for the current year was provided including the Publication Date N N N N N N N N N N

Childhood vaccines were administered in accordance with the schedule established by the Vaccines for Children Program N N N N N N N N N N

Total points: 0

Not Applicable criteria met

Measure

Influenza vaccine is made available, once each year, in accordance with the recommendations of the Centers for Disease Control and Prevention (CDC) and IDOC influenza Control Program.

Documentation in the health record or sign up logs supports that all offenders have been offered the influenza vaccine each year during the flu season. N N N N N N N N N N

Total points: 0

Not Applicable criteria met

NOTES / COMMENTS:

Break1

BTC

Preventive Services and Wellness

Facility: BTC

Date:

IDOC NUMBERS | 1 = YES 0 =NO Total Average Criteria Met 91%

Measure 870201 222175 995993 163001 244177 141169 984816 148938 290854 261493

At a minimum, all services receiving an ‘A’ or ‘B’ recommendation by the US Preventive Services Task Force (USPSTF) are provided.

Documentation supports: N N N N N N N N N N

The annual health screen was completed during the IDPs birth month (For IDP who recently received the intake health appraisal during the previous 3 months, the annual screen may be deferred one year.) 1 1 1 1 1 1 1 1 1 1

An IDP who answered “yes” to questions regarding symptoms was referred to a practitioner for evaluation N N N N N N N N N 1

Vital signs and weight were recorded in the EMR 1 1 1 1 1 1 1 1 1 1

For IDP with no chronic health problems, a lipid profile was obtained every 5 years for men over age 35 and for women over age 45 (those at increased risk of coronary heart disease (diabetes, HTN, multiple risk factors [tobacco use, HTN, etc] family history of cardiovascular disease before age 50 in male relatives and age 60 in female relatives). A serum glucose or HgbA1C was done in accordance with the time frames noted on the preventive services grid 1 1 1 1 1 N N 1 1 N

For all IDP, beginning at age 50 and continuing to age 74, a screening test for colorectal cancer was performed (fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, or double contrast barium enema) at least once every 10 years (score if the procedure was due this contract year. Mark N/A if the offender should not have been scheduled for this contract year. IDP age 55 to 80, who have a 30 pack-year smoking history and currently smoke or have quit smoking within the past 15 years, a low dose CT scan was done annually. Screening may be discontinued once an offender person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery. N N N N N N N N N N

MEN For men aged 65-75 who have ever smoked, documentation supports that an ultrasound was done to screen for abdominal aortic aneurysm (AAA) (limited to those inmates with at least 180 days or more to serve) N N N N N N N N N N

WOMEN For female IDP age 21-65 with a cervix, documentation supports that a PAP smear was done in accordance with the timeframes recommended by applicable HCSD and preventive services grid. Score only if the pap smear was due during this contract year. Mark N/A if not due this contract year. N N N N N N N N N N

A mammogram was done every two years for women age 50 to 74 (score if the audit was during the years due, mark N/A if offender is not due this year) N N N N N N N N N N

Woman aged 65 and older were screened for osteoporosis (repeat screening interval is a minimum of 2 years after age 65; to be determined case by case by the facility’s provider N N N N N N N N N N

Total points: 28

100% criteria met

Measure 870201 222175 995993 163001 244177 141169 984816 148938 290854 261493

All vaccinations are provided in accordance with recommendations of the Advisory Committee on Immunization Practices (ACIP), CDC guidelines, FDA and USPSTF.

Tetanus-diphtheria (Tdap/Td) was administered at 10 year intervals (age 20, 30, 40, etc) N 1 N 1 N N N 1 1 N

1 dose of Tdap was administered to pregnant female offender during each pregnancy (preferred during week 27 to 36 weeks gestation) regardless of the interval since prior Td or Tdap vaccination N N N N N N N N N N

All offenders over age 65 received a pneumococcal polysaccharide vaccine given N N N N N N N N N N

A single dose of zoster vaccine was administered to an adult offender age 50 or older N N N 0 N N N N N N

Vaccinations are made available and offered to all IDP as recommended and guided by applicable standards. 1 1 1 1 1 1 1 1 1 1

The health record reflects the VIS Material for the current year was provided including the Publication Date N 0 N 0 N N N 0 0 N

Childhood vaccines were administered in accordance with the schedule established by the Vaccines for Children Program N N N N N N N N N N

Total points: 14

74% criteria met

Measure 870201 222175 995993 163001 244177 141169 984816 148938 290854 261493

Influenza vaccine is made available, once each year, in accordance with the recommendations of the Centers for Disease Control and Prevention (CDC) and IDOC influenza Control Program.

Documentation in the health record or sign up logs supports that all offenders have been offered the influenza vaccine each year during the flu season. 1 1 1 1 1 1 1 1 1 1

Total points: 10

100% criteria met

NOTES / COMMENTS:

Other sites have printed VIS for TDAP - no change to score

HTCF

Preventive Services and Wellness

Facility: HTCF

Date:

IDOC NUMBERS | 1 = YES 0 =NO Total Average Criteria Met 80%

Measure 286420 294665 945396 105299 974824 160862 252269 146579 211337 224233

At a minimum, all services receiving an ‘A’ or ‘B’ recommendation by the US Preventive Services Task Force (USPSTF) are provided.

Documentation supports: N N N N N N N N N N

The annual health screen was completed during the IDPs birth month (For IDP who recently received the intake health appraisal during the previous 3 months, the annual screen may be deferred one year.) 0 0 0 0 1 0 0 1 0 1

An IDP who answered “yes” to questions regarding symptoms was referred to a practitioner for evaluation N N N N N N 0 N N N

Vital signs and weight were recorded in the EMR 0 1 1 1 1 1 0 1 1 1

For IDP with no chronic health problems, a lipid profile was obtained every 5 years for men over age 35 and for women over age 45 (those at increased risk of coronary heart disease (diabetes, HTN, multiple risk factors [tobacco use, HTN, etc] family history of cardiovascular disease before age 50 in male relatives and age 60 in female relatives). A serum glucose or HgbA1C was done in accordance with the time frames noted on the preventive services grid 1 1 1 1 1 1 0 N 1 N

For all IDP, beginning at age 50 and continuing to age 74, a screening test for colorectal cancer was performed (fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, or double contrast barium enema) at least once every 10 years (score if the procedure was due this contract year. Mark N/A if the offender should not have been scheduled for this contract year. IDP age 55 to 80, who have a 30 pack-year smoking history and currently smoke or have quit smoking within the past 15 years, a low dose CT scan was done annually. Screening may be discontinued once an offender person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery. N N N N N N N N N N

MEN For men aged 65-75 who have ever smoked, documentation supports that an ultrasound was done to screen for abdominal aortic aneurysm (AAA) (limited to those inmates with at least 180 days or more to serve) N N N N N N N N N N

WOMEN For female IDP age 21-65 with a cervix, documentation supports that a PAP smear was done in accordance with the timeframes recommended by applicable HCSD and preventive services grid. Score only if the pap smear was due during this contract year. Mark N/A if not due this contract year. N N N N N N N N N N

A mammogram was done every two years for women age 50 to 74 (score if the audit was during the years due, mark N/A if offender is not due this year) N N N N N N N N N N

Woman aged 65 and older were screened for osteoporosis (repeat screening interval is a minimum of 2 years after age 65; to be determined case by case by the facility’s provider N N N N N N N N N N

Total points: 18

62% criteria met

Measure 286420 294665 945396 105299 974824 160862 252269 146579 211337 224233

All vaccinations are provided in accordance with recommendations of the Advisory Committee on Immunization Practices (ACIP), CDC guidelines, FDA and USPSTF.

Tetanus-diphtheria (Tdap/Td) was administered at 10 year intervals (age 20, 30, 40, etc) N N N N N N N N N N

1 dose of Tdap was administered to pregnant female offender during each pregnancy (preferred during week 27 to 36 weeks gestation) regardless of the interval since prior Td or Tdap vaccination N N N N N N N N N N

All offenders over age 65 received a pneumococcal polysaccharide vaccine given N N N N N N N N N N

A single dose of zoster vaccine was administered to an adult offender age 50 or older N N N N N N N 0 0 N

Vaccinations are made available and offered to all IDP as recommended and guided by applicable standards. 1 1 1 1 1 1 N 1 1 1

The health record reflects the VIS Material for the current year was provided including the Publication Date N N N N N N N 0 N 1

Childhood vaccines were administered in accordance with the schedule established by the Vaccines for Children Program N N N N N N N N N N

Total points: 10

77% criteria met

Measure 286420 294665 945396 105299 974824 160862 252269 146579 211337 224233

Influenza vaccine is made available, once each year, in accordance with the recommendations of the Centers for Disease Control and Prevention (CDC) and IDOC influenza Control Program.

Documentation in the health record or sign up logs supports that all offenders have been offered the influenza vaccine each year during the flu season. 1 1 1 1 1 1 1 1 1 1

Total points: 10

100% criteria met

NOTES / COMMENTS:

ISF

Preventive Services and Wellness

Facility: ISF

Date:

IDOC NUMBERS | 1 = YES 0 =NO Total Average Criteria Met 98%

Measure 293159 954897 290821 189130 289015 159117 104110 198933 179357 998237

At a minimum, all services receiving an ‘A’ or ‘B’ recommendation by the US Preventive Services Task Force (USPSTF) are provided.

Documentation supports: N N N N N N N N N N

The annual health screen was completed during the IDPs birth month (For IDP who recently received the intake health appraisal during the previous 3 months, the annual screen may be deferred one year.) 1 1 1 1 1 1 1 1 1 1

An IDP who answered “yes” to questions regarding symptoms was referred to a practitioner for evaluation N N N N N N N N N N

Vital signs and weight were recorded in the EMR 1 1 1 1 1 1 1 1 1 1

For IDP with no chronic health problems, a lipid profile was obtained every 5 years for men over age 35 and for women over age 45 (those at increased risk of coronary heart disease (diabetes, HTN, multiple risk factors [tobacco use, HTN, etc] family history of cardiovascular disease before age 50 in male relatives and age 60 in female relatives). A serum glucose or HgbA1C was done in accordance with the time frames noted on the preventive services grid 1 1 1 0 1 1 1 1 N 1

For all IDP, beginning at age 50 and continuing to age 74, a screening test for colorectal cancer was performed (fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, or double contrast barium enema) at least once every 10 years (score if the procedure was due this contract year. Mark N/A if the offender should not have been scheduled for this contract year. IDP age 55 to 80, who have a 30 pack-year smoking history and currently smoke or have quit smoking within the past 15 years, a low dose CT scan was done annually. Screening may be discontinued once an offender person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery. N N N N N N N 1 N N

MEN For men aged 65-75 who have ever smoked, documentation supports that an ultrasound was done to screen for abdominal aortic aneurysm (AAA) (limited to those inmates with at least 180 days or more to serve) N N N N N N N 0 N N

WOMEN For female IDP age 21-65 with a cervix, documentation supports that a PAP smear was done in accordance with the timeframes recommended by applicable HCSD and preventive services grid. Score only if the pap smear was due during this contract year. Mark N/A if not due this contract year. N N N N N N N N N N

A mammogram was done every two years for women age 50 to 74 (score if the audit was during the years due, mark N/A if offender is not due this year) N N N N N N N N N N

Woman aged 65 and older were screened for osteoporosis (repeat screening interval is a minimum of 2 years after age 65; to be determined case by case by the facility’s provider N N N N N N N N N N

Total points: 29

94% criteria met

Measure 293159 954897 290821 189130 289015 159117 104110 198933 179357 998237

All vaccinations are provided in accordance with recommendations of the Advisory Committee on Immunization Practices (ACIP), CDC guidelines, FDA and USPSTF.

Tetanus-diphtheria (Tdap/Td) was administered at 10 year intervals (age 20, 30, 40, etc) N N N N N N 1 N N N

1 dose of Tdap was administered to pregnant female offender during each pregnancy (preferred during week 27 to 36 weeks gestation) regardless of the interval since prior Td or Tdap vaccination N N N N N N N N N N

All offenders over age 65 received a pneumococcal polysaccharide vaccine given N N N N N N N N N N

A single dose of zoster vaccine was administered to an adult offender age 50 or older N N N N N N 1 N N N

Vaccinations are made available and offered to all IDP as recommended and guided by applicable standards. 1 1 1 1 1 1 1 1 1 1

The health record reflects the VIS Material for the current year was provided including the Publication Date 1 1 1 1 1 1 1 1 1 N

Childhood vaccines were administered in accordance with the schedule established by the Vaccines for Children Program N N N N N N N N N N

Total points: 21

100% criteria met

Measure 293159 954897 290821 189130 289015 159117 104110 198933 179357 998237

Influenza vaccine is made available, once each year, in accordance with the recommendations of the Centers for Disease Control and Prevention (CDC) and IDOC influenza Control Program.

Documentation in the health record or sign up logs supports that all offenders have been offered the influenza vaccine each year during the flu season. 1 1 1 1 1 1 1 1 1 1

Total points: 10

100% criteria met

NOTES / COMMENTS:

Excellent job on this audit- documentation is amazing!

WVCF

Preventive Services and Wellness

Facility: WVCF

Date:

IDOC NUMBERS | 1 = YES 0 =NO Total Average Criteria Met 88%

Measure 286734 268921 210674 885175 983974 196052 106121 885722 289711 243730

At a minimum, all services receiving an ‘A’ or ‘B’ recommendation by the US Preventive Services Task Force (USPSTF) are provided.

Documentation supports: N N N N N N N N N N

The annual health screen was completed during the IDPs birth month (For IDP who recently received the intake health appraisal during the previous 3 months, the annual screen may be deferred one year.) 1 0 1 1 1 1 1 1 1 1

An IDP who answered “yes” to questions regarding symptoms was referred to a practitioner for evaluation N N N N N N N N N N

Vital signs and weight were recorded in the EMR 1 1 1 1 1 1 1 1 1 1

For IDP with no chronic health problems, a lipid profile was obtained every 5 years for men over age 35 and for women over age 45 (those at increased risk of coronary heart disease (diabetes, HTN, multiple risk factors [tobacco use, HTN, etc] family history of cardiovascular disease before age 50 in male relatives and age 60 in female relatives). A serum glucose or HgbA1C was done in accordance with the time frames noted on the preventive services grid N N 1 N 1 N N N 1 1

For all IDP, beginning at age 50 and continuing to age 74, a screening test for colorectal cancer was performed (fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, or double contrast barium enema) at least once every 10 years (score if the procedure was due this contract year. Mark N/A if the offender should not have been scheduled for this contract year.