Standards Q & A

Despite our best efforts to develop correctional health care standards that are easy to understand, questions sometimes arise when facilities try to implement or comply with the standards. To aid interpretation, a Q&A column is published in NCCHC's magazine, CorrectCare.

Below are questions from recent issues. Please note that these responses give general recommendations and may be revised over time when new editions of the Standards are published. (Last updated: July 11, 2008.)

If you have a question about the Standards, call us at
773-880-1460, or e-mail info@ncchc.org.

ACCESS TO CARE
In talking with health staff at the local hospital emergency room, the question arose as to whether there is a definition of “fit for confinement” that ER physicians could refer to when deciding if an inmate can be cleared for a jail. Can NCCHC help?
     I assume this is a situation in which an inmate was sent to the ER for an evaluation for a medical and/or mental health problem, and the ER is trying to decide if the inmate can be sent back to the jail.
     Your best bet is to consult NCCHC’s Standards for Health Services in Jails, specifically essential standards J-A-01 Access to Care and J-E-02 Receiving Screening and important standard J-D-05 Hospital and Specialty Care. Here is a summary of how these standards address your question.
     Inmates have a constitutional right to access to care for their significant health problems. If the level of care needed is not available at the facility, inmates are to be treated in a setting that can meet their specific health needs, such as a community hospital or ER, or perhaps a better equipped (i.e., health staff and services) correctional facility with which the original facility has transfer arrangements.
     The ER physician involved in deciding if the inmate can be appropriately treated at the jail must consider several things. Foremost is the level of health or mental health services needed for follow-up if the inmate-patient is released, and whether the available jail health resources are at that level.
     Sometimes when opinions differ between community ER physicians and jail physicians, it is because the ER physician does not really know what is available at the jail. A visit to the jail and an exchange of information about its health staffing and capabilities are essential to good planning between jail and ER health administrators and physicians.
     One way for the ER physician to think about a return to jail is to regard it as a return to home care. That is, if the inmate were a regular community patient with a home and minimally supportive situation, would the hospital send the patient home? Does the inmate-patient simply need observation that could be done by minimally trained correctional officers, or does he or she inmate-patient need nursing care that is (or is not) available on-site? If the jail has an infirmary, what scope of care is available? Is there a sheltered housing area where the inmate can receive the necessary services? For example, is there a negative-pressure room to house contagious TB patients, or does the patient need to stay at the hospital until the contagious phase has passed?
     Some ER physicians mistakenly assume that jails have 24/7 health staff and supports. While that may be true in a few jails, particularly in the mega-systems, most have limited on-site health resources. On the other hand, if you or I were treated in an ER and then sent home and not hospitalized, jails should expect that the ER will want to do the same for inmate-patients treated for the same conditions.
     Given the possibility that little attention may be given to a returning inmate, the ERs may be advised to hold the inmate-patient for a little longer observation if there is any doubt. Some jails and ERs create a “locked ward” at the hospital when such patient volume is high.
— Originally published in CorrectCare Volume 21, Issue 3, Summer 2007.
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ACCREDITATION
Our facility’s accreditation survey identified a compliance issue that was actually a systemwide problem. The central office authorities revised the policy as required by the standard in question. When we submit proof of the corrective action, do we need to send anything besides a copy of the signed, revised policy?
     NCCHC’s accreditation is facility-specific. When corrective action is forwarded, we need to be as sure as we can that the action was implemented at the facility. The accreditation committee also wants to know whether the corrective action described has solved the concerns.
     Suppose the compliance issue has to do with missing information on the co-pay system for inmate-initiated health services. Written, systemwide information on co-pay policies that is given to incoming inmates does not state that no one will be denied care because of inability to pay. After the survey at Facility X, the central office issues a directive that the information sheet is to be revised and reprinted. Sending NCCHC a copy of that directive is part of the answer. However, we want to know what is happening now at Facility X. Did you print a temporary sheet with the needed information? (Please send a copy.) When were staff in-serviced about the change? (Send date and sign-in for the in-service.) As of when are the new sheets being used? (What confirmation can you send?) What about the inmates already at the facility; what is being done to inform them of the change? (New signs outside the clinic? Please send a picture.)
     In short, we need documentation that describes the actions taken at the facility surveyed, but we also need proof that those actions actually occurred and had the intended effect.
— Originally published in CorrectCare Volume 21, Issue 2, Spring 2007.

Our accredited jail changed health service contractors last year. We have almost no records from the previous provider. Will we be held accountable for what happened before the switch?
     Changes in health services providers—facility to contractor, contractor to contractor and variations thereof—are now fairly common. What’s important to remember is that accreditation is granted to the facility for its health services, regardless of who provides the services, so NCCHC needs to know about any significant changes and how they will affect care.
     The correctional authority is expected to notify NCCHC of changes in a timely fashion. Depending on the circumstances, the date of the last survey and whether problems are anticipated, the accreditation committee may ask the facility to send a report on the transition, may provide consultation on the change of health services or may require a new survey. It also may postpone the next scheduled survey six months to a year to give the new provider time to make the transition.
     The current health service provider is held accountable for what is happening under its authority. If noncompliance with the standards under a previous provider has required corrective action, the surveyors will look for confirmation that the action taken subsequently has resolved the issues for an appropriate period of time.
     In your case, records of the quarterly administrative meetings and monthly staff meetings may not available for the previous two years under the former health authority. But if you have the records for the last year under the current health authority, you would be in compliance. However, if you just began holding the meetings, you would be deemed to be in partial compliance until you can demonstrate compliance over a longer period of time.
     Since you have been on-site for a year now, the surveyors will focus primarily on the events of the past year. When it comes to the random pull of records to assess initial assessment time frames, you will do well to have a list of those admitted to the facility since you assumed responsibility so the physician-surveyor can choose records randomly from that group.
— Originally published in CorrectCare Volume 21, Issue 1, Winter 2007.

When we forward documentation of corrective action to NCCHC after a survey, under whose signature does the documentation need to come?
     Accreditation is specific to each facility, so official responses to NCCHC must be sent by the health care authority’s designee at the facility (see standard A-02 Responsible Health Authority). Therefore, when corrective action is taken, the documentation sent to NCCHC must be verified by the facility designee. When materials are submitted by contracted, statewide, systemwide, or regional health service providers, involvement by the health authority’s facility designee must be evident, usually by a cosignature. Additional signatures required by corporate or systemwide guidelines are fine as long as the on-site designee is involved.
— Originally published in CorrectCare Volume 21, Issue 1, Winter 2007.

Our jail is preparing for its first NCCHC accreditation survey. What percentage of compliance is required to “pass” a standard?
     We encourage facilities to aim for full compliance with each standard, so we expect compliance to be as close to 100% as possible. For accreditation purposes, however, as standard is generally assessed as being met if the facility is at least 90% compliant with each of the compliance indicators listed as required and applicable to the facility. The 10% noncompliance must not represent a negative pattern or developing trend, but rather random events. The accreditation committee also may find that standard’s intent is being met in ways other than the usual compliance with the indicators; such determinations are specific to each facility and survey.
— Originally published in CorrectCare Volume 20, Issue 4, Fall 2006.

Is there a list of accredited correctional health care companies that I can reference?
     NCCHC does not accredit companies, states, agencies, contractors or systems “in the abstract.” Rather, NCCHC accredits individual correctional facilities for compliance with the relevant Standards for Health Services. It does not matter how many players (private contractors, state employees, etc.) are in a facility’s health care system: The accreditation is awarded to the facility itself for compliance with the requirements of the standards (100% of the applicable essential standards must be met and at least 85% of the applicable important standards).
— Originally published in CorrectCare Volume 18, Issue 3, Summer 2004.
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BLOOD DRAW PROCEDURES
The warden at our maximum security prison does not want to allow the nurses to bring inmates out for routine blood draws. Instead, inmates are to stick their arms through the pie flap on the cell door so that nurses can obtain the venous sample. Medical staff are concerned for the safety of the inmate and our exposure to possible needlesticks. Can you give any guidance about the safety and exposure risks with this procedure?
     The NCCHC standards for health services in prisons require that health care interventions are done within community practice protocols. The warden’s proposed procedures for drawing blood are not in keeping with community standards, pose infection control and safety concerns for inmate and health provider alike, and interfere with the principle of medical autonomy in the sense that security is trying to dictate how medical procedures are to be carried out.
     Many variables go into a blood draw, which can be difficult even under the most ideal clinical settings. Doing it through a slot in the door complicates it much further. The procedure involves use of a pressure device to temporarily stop blood flow. Finding a vein may require examination of the whole arm and hand, and often the limb must be positioned in a particular way to enhance success of the draw. Infection control procedures are required to keep the field and needles sterile. We do not know how standard precautions can be maintained given the scenario you describe. And patient cooperation and communication are needed to prevent injury to either party.
     If the warden is concerned about bringing the inmate to the clinic for a routine draw, an area on the tier can be set up appropriately for such basic health interventions. A clean, private room adapted to this purpose would allow the necessary security presence if required. Not all maximum security inmates are a safety threat to the same extent. Treating inmates as the warden proposes would only serve to dehumanize them, making them more likely to act out in such circumstances.
     As to resources, we suggest you consult the CDC’s process for venipuncture, available online at www.cdc.gov/std/program/medlab/ApF-PGmedlab.htm. Also, an outline for proper phlebotomy techniques is available from the National Credentialing Agency for Laboratory Personnel: www.nca-info.org/pdfs/examoutlines/cl-lab-phlebotomy.pdf.
     Although the facility might not have a credentialed laboratory phlebotomist, it would be hard to defend its door-slot procedure in court when the community overall does not recognize the procedure.
— Originally published in CorrectCare Volume 20, Issue 2, Spring 2006.
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CLINIC SPACE, EQUIPMENT, & SUPPLIES
Our county juvenile detention center rarely houses pregnant juveniles, and when we do, it is always short-term. The community hospital where deliveries would take place is right across the street, and the physician treating these girls has an office nearby. We do not have a fetal heart monitor on site. Given our circumstances, must we have one in order to comply with NCCHC standard Y-D-03 Clinic Space, Equipment, and Supplies?
     The fetal heart monitor is not required, but it is recommended. To comply with a standard for accreditation purposes, you must understand and meet the requirements of the standard itself and of its compliance indicators. In standard Y-D-03, the recommendations section lists suggested equipment, including a fetal heart monitor. As its name implies, this section makes recommendations that likely will benefit a facility but that are not mandatory. If your responsible physician is comfortable with your situation and the resources available, then you may follow the physician’s protocols. You will be in compliance with the intent of the standard.
— Originally published in CorrectCare Volume 19, Issue 1, Winter 2005.
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CLINICAL GUIDELINES
Our state prison system has implemented a chronic care clinic (CCC) program. I remember NCCHC having a list of proposed diagnoses for CCC eligibility. What diagnoses should we include in our program?
     The information you seek is found in standards P-G-01 Special Needs Treatment Plans and P-G-02 Management of Chronic Disease. From NCCHC’s standpoint, any health condition that is considered chronic or that requires multidisciplinary care also requires development of an individual treatment plan for regular, ongoing care. Examples of such conditions are listed in P-G-01.
     To sharpen the focus on chronic care, P-G-02, new to the 2003 Standards, specifies seven conditions for which the facility is expected to have identified national clinical guidelines to follow in treating these diseases. To assist facilities, NCCHC has developed correctional clinical guidelines for these conditions. Alternatively, facilities may choose any of the national clinical guidelines current in community care, such as those from the American Diabetes Association, the American Society of Internal Medicine, etc. (See the National Guideline Clearinghouse at www.guideline.gov.)
     The eventual goal is for practitioners to follow specific clinical protocols for all chronic conditions. The current seven are a first step.
— Originally published in CorrectCare Volume 19, Issue 2, Spring 2005.

Why are the NCCHC clinical guidelines not included in the 2003 jail and prison standards manuals?
     The standards are revised periodically, usually every three to five years. In contrast, clinical guidelines must be timely, reflecting the latest developments in the field as well as current treatment recommendations. NCCHC’s clinical guidelines will be revised as often as necessary to keep them current, and will continue to be available online.
— Originally published in CorrectCare Volume 17, Issue 2, Spring 2003.
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CLINICAL PERFORMANCE ENHANCEMENT
This question concerns the new standard for peer review. We are a small jail, average daily population about 200, in a rural area. We understand that our consulting psychiatrist now needs an annual review of her performance at the jail, but she is the only psychiatrist who works at the jail in our area. Can our licensed psychiatric social worker do her review?
     You are referring to important standard C-02 Clinical Performance Enhancement, which is new to the 2003 jail and prison Standards and included in the 2004 juvenile Standards. To quote from the discussion section: “The intent of this standard is to enhance patient care through peer review of the clinicians’ practice. The clinical performance enhancement review process is neither an annual performance review nor a clinical case conference process. It is a professional practice review focused on the practitioner’s clinical skills; its purpose is to enhance competence and address areas in need of improvement.
     Facilities in which the practitioner (in your case, the psychiatrist) is the sole representative of a profession is actually one of the situations the standards revision committee wanted to address. The standard’s intent is to promote the professional exchange of ideas and practice that can occur only with another professional of equal or more advanced training and experience in the same discipline. So, while medical physicians can review other medical physicians and midlevel practitioners, only psychiatrists should be reviewing psychiatrists.
     So, what are you to do? Is there a community psychiatrist in private practice willing to do such a review? Will a state medical school provide such services? Ideally, the performance review is a face-to-face meeting, but telephone reviews following sample record reviews might be an option. Exchange of written materials may not be best, but it could work. Yet another possibility is the use of a university telemedicine program, if one is available.
     Failing all of the above, you should note that NCCHC has designated this standard as “important” (as opposed to “essential”) so noncompliance should not affect your accreditation status.
     For more details about compliance, see the Spotlight on the Standards that deals with this standard.
— Originally published in CorrectCare Volume 18, Issue 2, Spring 2004.
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CONFIDENTIALITY
I am a nurse who works in a state prison. One of our inmates is getting married, and I have been designated as the health staff member to review his health record with his fiancée before the wedding. The inmate has given his written permission to do so. I am uncomfortable about this and the need to protect the confidentiality of health information. Can you provide any advice?
     NCCHC standards focus on the health services provided to incarcerated individuals and do not address such issues as procedures for inmate marriages. This is the realm of state correctional and other authorities. Your concern about confidentiality is a simpler matter: Since the inmate voluntarily gave his consent for you to share his health information, the requirement is met from NCCHC’s standpoint.
— Originally published in CorrectCare Volume 19, Issue 3, Summer 2005.

When an inmate says he’s going to kill someone and the mental health care provider (in this case, a psychiatric nurse practitioner) has that information, there are issues as to whether he should pass that information to the person who’s been threatened. This is covered in California law regarding "duty to warn." How is this covered in the jail standards concerning forensic information? Also, confidentiality issues are covered in the duty to warn law. Is confidentiality also covered in the standards?
     All three sets of standards address confidentiality of health information (P-H-02, J-H-02 and Y-61). The situation you cite represents an exception. The right to confidentiality is not absolute and may be breached when there’s risk of serious injury or death to the patient, other inmates or staff. As you state, often state laws or regulations govern confidentiality of health information and the circumstances under which disclosure of certain information is permitted. The standard prohibiting collection of information for forensic purposes does not apply to your situation.
     Most disciplines, including those affiliated with mental health, also require that such specific information be taken to the appropriate authority. Finally, it is good practice for the mental health clinician to tell the patient in their first encounter that certain issues cannot be kept confidential: "If you tell me that you are going to harm or kill yourself or someone else, or engage in behavior that jeopardizes the safety or security of the facility, I will need to tell the appropriate authorities."
— Originally published in CorrectCare Volume 17, Issue 1, Winter 2003.

My deputy warden and I would like to institute a statewide practice of identifying certain inmates with potential life-threatening conditions by using medical alerts on the back of their ID badges. I work part time in a state where this practice is in place and it works very well. As an accredited facility, is there anything that would preclude us from initiating this practice?
     That depends on how you plan to carry out this program. Because of concerns about confidentiality of medical information, you could not, for example, use yellow bracelets for epileptics, pink lettering for mental health patients, red for HIV patients, etc. Someone seeing the medical alerts on the back of an ID badge should not automatically know what the problem is. On the other hand, if you make participation voluntary, inmates could choose whether they wanted to disclose their condition on a medical alert badge or not.
— Originally published in CorrectCare Volume 16, Issue 2, Spring 2002.

Our QA group would like NCCHC’s position on the sharing of confidential patient information under the following circumstances: An inmate is given a urine tox screen by clinical services and is positive for an illicit substance such as cocaine, opiates, methamphetamines, etc. What information should be shared with the warden and/or designated custody control staff? The inmate’s name and substance(s) that tested positive? The inmate’s name and a hint that he should be tested by custody staff? No inmate identification, but the fact that illicit substance(s) are in the facility? No information?
     In your scenario, I am assuming you work in a prison, and that the urine test, since it was done by clinical services, was for clinical purposes. The inmate’s results should be used for clinical reasons. The general concern that a particular substance may be in use in the facility may be shared with the warden or his designee in such a manner that the identity of the individual inmate is protected, but the issue regarding a possible serious violation of security regulations can be addressed. This type of situation should have been discussed with the warden when the health services policies and procedures were established so that there is a clear understanding of the role the health staff have and there is no pressure on health staff to reveal identifying details. This interpretation is based on the 1997 NCCHC Standards for Health Services in Prisons; specifically P-03 Medical Autonomy; P-61 Confidentiality of Health Records and Health Information; and P-68 Forensic Information.
— Originally published in CorrectCare Volume 15, Issue 4, Fall 2001.
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CONTINUING EDUCATION
One of our physicians recently completed an online course for cardiopulmonary resuscitation. I am wondering if you can tell me whether this is acceptable for J-C-03?
     In the 2008 version of the NCCHC standards, J-C-03 Professional Development requires that all qualified health care professionals who have patient contact are current in cardiopulmonary resuscitation technique. The standard states that the CPR training may be provided by an approved body, such as the American Heart Association or the American Red Cross, or from an individual who possesses a current instructor’s certificate from an approved body. Therefore, your physician’s online course would be acceptable to meet the standard if it is provided by an approved body.
— Originally published in CorrectCare Volume 22, Issue 2, Spring 2008.

I am a fairly new health administrator at my correctional facility. Would I be in compliance with the standard concerning health staff training if, for the portions of the training that do not deal with hands-on interventions (such as CPR or first aid), I use a PowerPoint presentation? I could send the training materials through the institutional mail to all health staff, and I have the capability of checking on my computer to see who has opened the training.
     The relevant standard is C-03 Continuing Education for Qualified Health Care Professionals. Its intent is the same for jails, prisons and juvenile settings: “the facility’s qualified health care professionals are kept current in clinical knowledge and skills.” The standard allows for a variety of approaches and methods to meet the intent.
     The use of a few computer-based offerings such as you describe may be appropriate. However (omitting discussion of the hands-on training noted above), if you used the PowerPoint method only with no face-to-face meetings, compliance may be questioned. You want to ensure that the presenter and participants have opportunities to interact, at least some of the time. The exchange of questions and answers and the sharing of experiences often are the most valuable parts of any training. NCCHC’s Accreditation Committee would make the compliance decision based on findings from the on-site survey.
     As a side note, staff can earn continuing education credit by providing documentation of external educational activities, including health classes, seminars and conferences such as those sponsored by NCCHC.
— Originally published in CorrectCare Volume 19, Issue 1, Winter 2005.
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DENTAL EXAMS
If a juvenile is already under the care of a community dentist, has seen the dentist recently and then is admitted to a detention center, does he still need a dental exam within 60 days?
     If the facility can get a copy of the dental exam (or a current dental assessment by the treating community dentist) for its records, a new dental exam would not be required. The dental screening would still need to be done, and the facility dentist would have to review the community documentation when it comes in to ensure that any needed follow-up treatment is initiated. If you cannot obtain documentation of the community findings, then the dental exam would need to be repeated.
— Originally published in CorrectCare Volume 16, Issue 2, Spring 2002.
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DISCHARGE PLANNING
In standard J-E-13 Discharge Planning, we interpret Compliance Indicator 2a to mean that a written prescription for medication satisfies the requirement; provision of the medication itself is not necessary. Is this in compliance?
     The intent of the standard is that “patients’ health needs are met during transition to a community provider.” So, if one of the needs is medication, the intent would be that the inmate have a sufficient supply to be able to continue taking the medication until seen by a community provider.
     A written prescription is sufficient only if the provider knows that the patient has the ability to have it filled immediately upon discharge. The provider must be sure that the patient has the money (not that next week he will be eligible for Medicaid or other assistance) and the means (transportation, etc.) to get to a pharmacy that will fill the prescription. For example, corrections can transport the discharged patient to a designated community pharmacy. Or the facility can provide money for a cab or bus along with instructions on how to get to the pharmacy. The jail may have an account with the pharmacy so that the prescription is billed to the jail, not the patient.
     Thus, a facility giving written prescriptions would be in compliance with this important standard only if the financial and access issues are addressed. In our view, it is much easier to make a postdischarge medical appointment for the patient and to provide enough medication to last until that appointment.
— Originally published in CorrectCare Volume 20, Issue 3, Summer 2006.
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DISCIPLINARY REPORTS
At least once a year, an inmate gives one of the nurses a hard time and security staff wants nursing to write a disciplinary report. Usually we write information reports and security does the disciplinary report to avoid any conflict. We want a solid answer as to whether or not medical should be involved in disciplinary actions.
     Although no NCCHC standard explicitly addresses involvement in disciplinary matters, the principles that underlie standard I-03 Forensic Information also apply here.
     Health staff should deal with disrespectful inmates just as they would deal with unruly patients in a community outpatient setting. For example, if a patient yells in a community clinic, staff generally do not call the police, particularly if the patient is confused, upset, mentally unstable, intellectually limited, etc.
     In a correctional setting, health staff must respond professionally, stating that such behavior is unacceptable and laying out firm expectations: “I know you are upset, but if you do not calm down I must ask you to leave.” The more that health staff project the neutral yet concerned demeanor expected of a professional, the more that inmates will respond in kind.
     Obvious exceptions would be threats or physical contact by an inmate whose behavior is under his or her control and not due to a medical or mental health condition. In such cases, the procedure you describe—health staff write an information report; correctional staff do the disciplinary report—is the appropriate response. But this should be reserved for the most serious situations. In these cases, health staff retain the right to press charges.
     For “repeat offenders,” it may be best to meet with the inmate to discuss expectations and consequences. Meeting participants should include correctional staff with decision-making authority, health staff and, if applicable, an inmate corrections counselor and/or a mental health therapist. If an agreement is reached, then all health staff involved and correctional staff assigned to the area must be aware of the expectations so that the plan is followed consistently. For example, an inmate who routinely uses abusive language to health staff “contracts” that should he reply to health staff in that manner, he will immediately apologize and calm down with one reminder by staff, or else will be escorted back to his block and be rescheduled at a future date.
     If the facility has an inmate representative body, discussion with the inmate representatives about such problems can be very helpful.
— Originally published in CorrectCare Volume 20, Issue 3, Summer 2006.
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DOCUMENTATION
The mental health staff in our prison would like to know how long they have to keep inmate requests (kites). Currently, once they have addressed them, they place them in an envelope for storage.
     The answer is twofold—from the perspective of good clinical practice, and from the perspective of confirming compliance for accreditation purposes.
     Essential standard P-E-07 Nonemergency Health Care Requests and Services requires that inmates’ routine health care needs are met and specifies that inmates are to have the ability to request services directly from health staff daily; that sick-call slips are picked up at least every 24 hours; that inmates are seen within 24 hours of triage if the request does not provide enough information to make an informed assessment; and that clinical need dictates the timing of a midlevel, physician or specialist provider appointment. Without documentation of these steps, it is not possible to evaluate the responsiveness of your sick-call system, and if you are seeking accreditation, to determine if you are in compliance.
     Request slips are usually filed in the health records and begin the documentation trail. If you do not file the slips in the record, a log may be kept to monitor the stages of the response. The log needs to include the request date, date and result of triage, date of the sick-call visit if required, etc.
     For accreditation purposes, you should have documentation of compliance, either through the health records or through logs spanning three years (the time between surveys). Surveyors will look for information on the timeliness of response to sick-call slips, and if it is not in the record the facility may need to show source documents. Beyond that, it is up to the health and/or mental health authority how to ensure and verify that the standard’s requirements are being met and that inmates are receiving needed care in a timely and professional manner.
— Originally published in CorrectCare Volume 22, Issue 1, Winter 2008.

Our jail is seeking accreditation for the first time. How must we document the meetings we are required to have? Is there a form you require or recommend?
     NCCHC does not specify the format for meeting minutes required by the standards. We try to give facilities as much flexibility as possible in such matters, as long as the format used provides an appropriate vehicle for documenting the necessary information or processes and the intent of the particular standard is met.
     Information that needs to be recorded in the minutes depends on the type of meeting and the requirements of the individual standard(s). In the standards that require written documentation, the Compliance Indicator section provides guidance as to what is required.
     For example, in J-A-04 Administrative Meetings and Reports, administrative meeting minutes need to be kept to document discussion of all the topics listed in the standard, while the documentation of monthly health staff meetings need include only attendees and topics or agenda. However, for CQI meetings (J-A-06 Continuous Quality Improvement Program), the minutes need to record topics or problems discussed, assigned responsibilities, action plans, findings, evaluation, subsequent actions, etc.
— Originally published in CorrectCare Volume 18, Issue 2, Spring 2004.

What is the time frame for which documentation should be prepared for an accreditation survey? For example, for how many months should a facility have copies of minutes, documentation on training and other statistics before a survey?
     The answer is a bit complex. Time frames for required documentation are linked both to the type of survey and the requirements of the individual standards. For an initial accreditation survey, the surveyors will go back about 12 months to assess compliance. During surveys for continuing accreditation, the time frame will be "since NCCHC was last on site" (usually every three years). If a standard requires quarterly meetings, documentation of four meetings per year would be expected. If the standard does not specify frequency, surveyors usually will look at the most recent year’s worth of data. For a re-survey where the last year’s data look problematic, the surveyor may check the previous two years as well.
     Note that NCCHC does not require extra copies of documentation to be kept for survey purposes. It is acceptable that access to the appropriate book or filing drawer be given; documents for the last three years for a re-survey need not be copied and filed separately in a folder labeled to coincide with the standard number.
— Originally published in CorrectCare Volume 16, Issue 3, Summer 2002.
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EMERGENCY RESPONSE PLAN
In the standard concerning a jail’s emergency response plan, compliance indicator #4 states that a man-down drill is practiced once a year on each shift. However, the discussion says that an actual emergency can be used as proof if it is critiqued. If so, what would be the purpose of a man-down drill since any facility would have actual emergencies throughout the year?
     You are correct. What facility goes a whole year without several man-down situations! This is one reason the standard (J-A-07) was revised. However, facilities may not always take advantage of such occurrences to fine-tune their emergency responses, so the standard makes this option explicit.
     When an actual event is critiqued, the requirement for a drill is met. Facilities that have only seizures or heart attacks to deal with may wish to drill other situations, but they are not required to do so provided at least one event is critiqued per year per shift where health staff are on site (per satellite where applicable).
     One difference between the real situation and the drill is that in an actual event (even a mass disaster situation), injuries need not be sustained for the experience to count. Thus, being hit by a hurricane and working under emergency conditions for two days would count toward meeting the standard even if no one was injured. In a drill (mass disaster or man-down), however, simulated injury with opportunity for health staff to triage injuries is required.
— Originally published in CorrectCare Volume 17, Issue 4, Fall 2003.
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END-OF-LIFE DECISION MAKING
In our prison, terminally ill inmates are sent to a community hospital where the admission procedures enable them to execute a DNR (do not resuscitate) order that the hospital would follow. However, if the inmate improves and returns to the prison, the DNR orders are not honored. If necessary, emergency, life-saving interventions are initiated before transport back to the hospital. Are we in compliance with important standard P-I-04, End-of-life Decision Making?
     This question was taken up recently by the Accreditation Committee, which decided that in the circumstances above, the intent of the standard is not being met. Though it is possible for the inmate to be returned to a hospital setting as death approached, it also is possible that a life-threatening emergency requiring CPR and related interventions would occur in the prison and the inmate would be subjected to measures explicitly declined in the DNR order before or during transport to the hospital.
     Standard I-04 intends that inmates retain their medical-legal rights regarding end-of-life decisions. Therefore, facilities or systems considering denial of an inmate’s right to execute a DNR order should check with their appropriate legal counsel (state or county) to determine whether the directive is in compliance with the jurisdiction’s regulations on this matter.
— Originally published in CorrectCare Volume 18, Issue 4, Fall 2

In standard P-I-04, End-of-Life Decision Making, compliance indicator #4 regarding health care proxies and living wills requires an independent review by a physician not directly involved in the patient’s treatment, while compliance indicator #5 states that “DNR orders are reviewed by a medical professional.” What types of providers does the term “medical professional” include?
     In this case, the use of the term “medical professional” was intended to mean only physicians.
— Originally published in CorrectCare Volume 18, Issue 1, Winter 2004.
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ENVIRONMENTAL HEALTH AND SAFETY
What are NCCHC’s expectations for documentation of environmental/infection control to be reviewed during accreditation surveys? Are external inspections required? Do OSHA and CDC guidelines need to be followed for accreditation? 
     Whew! Let’s take your issues one at a time.

1. Documentation of environmental and infection control practices can include inspection reports, meeting minutes, quality improvement studies, policies and procedures specifying such practices, logs or other evidence of appropriate sterilization of instruments and equipment, sharps disposal containers, evidence that biohazardous materials are handled and disposed of appropriately, etc.
2. Inspections by outside agencies are useful, but they are not required for accreditation.
3. Similarly, while NCCHC recommends that agencies follow OSHA and CDC guidelines, the commission’s surveyors are not inspectors for those government agencies.

— Originally published in CorrectCare Volume 15, Issue 3, Summer 2001.
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FAMILY SUPPORT RESOURCES
Our daughter has spent a good deal of her life in correctional facilities, and she is serving time again. Her crime is what she is doing to herself: She has mental health and drug addiction problems. We cannot find advocacy groups of family members in support of those who find themselves incarcerated in a system that does not appear able to help them deal with their problems and get treatment so they can stay out of prison. Do you know of any resources?
     Unfortunately, many families and friends are in the situation you find yourself regarding your daughter. While your inquiry does not relate to NCCHC standards, we want to address it in this column to provide information for correctional health staff who may be asked the same question.
     Your best initial contacts are the National Mental Health Association (703-684-7722) and the National Alliance on the Mentally Ill (703-524-7600). Both organizations have national, state and local chapters, as well as subgroups that focus on issues related to mentally ill people who are incarcerated. The specialized groups are involved with initiatives such as diversion from correctional settings, quality care while incarcerated, and discharge and follow-up issues. They also may be able to direct you to other resources in your area.
— Originally published in CorrectCare Volume 20, Issue 1, Winter 2006.
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FORENSIC INFORMATION
I work at a detention facility whose function and purpose are defined under state laws. There is some controversy about blood draws here. Only one RN is on site at any given time, and when someone is arrested for driving under the influence, that nurse is asked to draw the inmate’s blood for analysis. We only draw it and give it to the arresting officer; we do not analyze it. One of the RNs thinks that under state standards we are not supposed to draw the blood and is reluctant to do so.
     NCCHC is not expert in state regulations or standards. We base our reply on the 2003 NCCHC Standards for Health Services in Jails. Standard J-I-03 Forensic Information prohibits health services staff from participating in the collection of forensic information based on the bioethical principle of protecting the patient-provider relationship. When health staff are involved in collecting information for punitive matters (and which is usually done without an inmate’s consent), the therapeutic relationship with the inmate is jeopardized. The health services staff should protect their ethical boundaries to serve the health needs of their patients first. The credibility of health staff with their patients should never be compromised.
     If the state requires that such acts be performed by health professionals, the facility should use the services of outside providers or someone on staff who is not involved in the therapeutic relationship. If neither of those options is possible, health services staff may comply with state laws and take forensic blood samples so long as the inmate gives consent and, if the inmate refuses to participate, health services staff are not involved in any punitive action taken as a result of the refusal.
— Originally published in CorrectCare Volume 22, Issue 1, Winter 2008.

Custody staff often seek medical clearance before using pepper spray on an inmate. Does this act of clearance, giving the “yea or nay,” qualify as partaking in a disciplinary proceeding? Does such an act undermine the intent of the forensic information standard? One can argue that if health staff did not participate, it would cause more harm than good (because those with contraindications would be sprayed). However, reasonable people could conclude that any participation undermines the credibility of health professionals.
     The answer relates to standards A-08 Communication on Special Needs Patients and I-03 Forensic Information. The responsible physician decides how health services will respond. Usually the physician is the staff member to determine what would prohibit an inmate from being sprayed because of possible negative consequences. The determination may be done at the time of the incident, or it may be done routinely as part of the initial health assessment, with a notation in the same place in each health chart. The wording of the “clearance” should be simply that there is or is not any health contraindication to the use of pepper spray for the inmate. The physician is not giving an order for the spray nor saying that it is OK to use it.
     All health and custody staff should be able to reference a written protocol as to any health intervention required after the spray is used. Any inmates who do receive pepper spray are taken to medical staff for appropriate interventions.
     You imply that health staff may not participate in disciplinary proceedings. Actually, health staff may consult in disciplinary hearings or decisions provided that they do not make the decision. In such cases, health staff, including mental health staff, should indicate whether any health or mental health condition may have contributed to the behavior in question. Health staff also may alert custody to the potential negative effects on the inmate of the proposed disciplinary action, and to help find appropriate alternate measures if the disciplinary action is contraindicated.
— Originally published in CorrectCare Volume 21, Issue 4, Fall 2007.

Standard J-I-03 Forensic Information addresses DNA testing for inmates. But how would NCCHC review situations in which jail staff collect DNA samples for non-inmates as requested by court order? For instance, the court may require that an individual at trial must have his DNA taken, although he is not currently in jail.
     The NCCHC standards do not address services for or interactions with non-inmates. We suggest that if you do draw the samples, you do so only with the individual’s consent, just as you would for an inmate. Your system may want to consider buccal DNA sampling, which is easily done by trained nonhealth staff.
— Originally published in CorrectCare Volume 20, Issue 3, Summer 2006.

Does NCCHC have a policy or guideline about doing drug screens on intake for inmates suspected of substance abuse problems? Assessment is difficult without testing since drug intoxication and withdrawal often present with mental illness symptoms.
     NCCHC standards require that you conduct your clinical practice as you would in any other setting, modifying nonclinical issues as required by the correctional setting but not compromising your clinical guidelines.
     Health staff in facilities accredited by NCCHC are often cautious about substance abuse testing, being mindful of standard I-03 Forensic Information and the need to avoid getting into potential adversarial situations with inmates they are trying to treat.
     However, your intent is a clinical one: to assess a substance-abusing inmate for diagnostic and treatment planning purposes. An important caution is that the results of such testing are not to be shared with corrections; results should be treated with the same confidentiality as any other blood or urine testing and recorded in the medical record.
— Originally published in CorrectCare Volume 20, Issue 2, Spring 2006.

I am the health services administrator at a county jail. We have been asked to draw the blood alcohol test specimens used to determine DUI charges. Can a trained medical technician or phlebotomist draw this, when requested, as part of the intake bloods? This staff member would be permanently assigned to the intake area and would not float to other areas in the medical unit. Two samples would be drawn: The blood alcohol test sample would be given to the officer; the intake sample would be in a separate tube. The inmate would be told the specimen was for DUI and a consent form would have to be signed. I do not think there would be a problem with compliance with standard J-I-03 Forensic Information.
     You are correct. Phlebotomists or trained med-techs who only draw blood are not considered to have a therapeutic relationship with the inmates as defined by NCCHC and standard J-I-03. The safeguards you mention need to be reflected in your policies and procedures.
— Originally published in CorrectCare Volume 19, Issue 3, Summer 2005.

What is the recommendation for medical staff ordered to gather buccal swabs for DNAs? It seems to conflict with the role of the health care giver.
     Nurses do not need to be involved in collecting DNA samples when the method used is the buccal swab. With training, this testing can be done by nonhealth staff such as correctional officers. This is one of the advantages of using buccal swabs as opposed to blood draws.
     To answer your question more directly, in general, NCCHC agrees that health staff need to remain neutral and not be involved in gathering forensic information. However, in the 2003 revision of the jail and prison Standards for Health Services, an exception was made for DNA testing (providing certain conditions are met) because the DNA results are unlikely to pose a conflict of interest for treating staff during the inmates’ current incarceration.
     Specifically, the revised standard on Forensic Information (P-I-03, J-I-03) states that the facility’s health care staff may be involved in DNA testing given the following parameters: DNA sampling is required by law (as it now is in almost all states), the inmate consents and, if the inmate refuses, health staff are not involved in any negative consequences for the inmate.
— Originally published in CorrectCare Volume 17, Issue 3, Summer 2003.
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GENDER REASSIGNMENT
Do the NCCHC standards for prisons and jails address the medical management of inmates who were candidates for gender reassignment (presurgical) prior to incarceration? The client is concerned primarily with the use of hormones to maintain secondary sexual characteristics.
     Such situations would be covered implicitly in the standards on medical autonomy (P-A-03, J-A-03), special needs treatment plans (P-G-01, J-G-01) and continuity of care (P-E-12, J-E-12). The basic question that should direct the facility is whether the procedure is considered a medical necessity by a qualified physician. If the physician determines that the hormones are necessary for the inmate’s overall health, or that to continue treatment is necessary because if stopped it would have serious negative health consequences, then treatment should be provided. Medical opinions on the subject may differ, however, and you may want to consult facility or system attorneys along with an expert in this field.
— Originally published in CorrectCare Volume 17, Issue 1, Winter 2003.
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HEALTH ASSESSMENT
At our prison, the trained registered nurses do the initial physical assessments and the full-time physician assistant reviews all of the findings and signs off on them. Are we in compliance with P-E-04 Health Assessment?
     You need one more step to be in full compliance with this essential standard, which intends that clinicians be able to assess and plan for meeting the inmates’ health needs. The PA may review the physicals taken by the RN when the findings are normal.
     However, when the RN finds significant results, the assessment must be reviewed by a physician and so documented, as required by Compliance Indicators 6 and 7. Your options are to have the PA review the assessment with the physician, or to send the assessment directly to the physician for review. In either case, the RN should receive feedback on the review of findings.
— Originally published in CorrectCare Volume 18, Issue 4, Fall 2004.
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HEALTH RECORDS
Our accredited jail changed health service contractors last year. We have almost no records from the previous provider. Will we be held accountable for what happened before the switch?
     Changes in health services providers—facility to contractor, contractor to contractor and variations thereof—are now fairly common. What’s important to remember is that accreditation is granted to the facility for its health services, regardless of who provides the services, so NCCHC needs to know about any significant changes and how they will affect care.
     The correctional authority is expected to notify NCCHC of changes in a timely fashion. Depending on the circumstances, the date of the last survey and whether problems are anticipated, the accreditation committee may ask the facility to send a report on the transition, may provide consultation on the change of health services or may require a new survey. It also may postpone the next scheduled survey six months to a year to give the new provider time to make the transition.
     The current health service provider is held accountable for what is happening under its authority. If noncompliance with the standards under a previous provider has required corrective action, the surveyors will look for confirmation that the action taken subsequently has resolved the issues for an appropriate period of time.
     In your case, records of the quarterly administrative meetings and monthly staff meetings may not available for the previous two years under the former health authority. But if you have the records for the last year under the current health authority, you would be in compliance. However, if you just began holding the meetings, you would be deemed to be in partial compliance until you can demonstrate compliance over a longer period of time.
     Since you have been on-site for a year now, the surveyors will focus primarily on the events of the past year. When it comes to the random pull of records to assess initial assessment time frames, you will do well to have a list of those admitted to the facility since you assumed responsibility so the physician-surveyor can choose records randomly from that group.
— Originally published in CorrectCare Volume 21, Issue 1, Winter 2007.

We have an electronic health records system. Will NCCHC be updating accreditation requirements concerning electronic signatures and forms?
     The Standards for Health Services already address electronic health records (EHR). In essential standard H-01 Health Record Format and Contents, Compliance Indicator 3 states, “If electronic records are used, procedures address integration of electronic and paper health information.” The Recommendations section adds that such systems “should protect access and provide security... by the use of passwords. Procedures for ‘down time’ and regular backups should be in place.”
     Basically, everything that is required of a hard record is also required of the electronic record. Using standard H-04 Availability and Use of Health Records as an example, if sick calls are entered directly into the EHR, health staff must be able to access the record in the sick-call room. As with the hard records, forms may be facility-specific as long as they provide the required documentation. If it is legal in your state, NCCHC does accept electronic signatures of health staff.
— Originally published in CorrectCare Volume 20, Issue 4, Fall 2006.

Do the NCCHC standards require that a jail start a health record for everyone who is admitted?
     No. Each inmate admitted must have a receiving screening completed and documented (standard J-E-02 Receiving Screening). Most jails keep the receiving screening documents in a general file for easy access or future reference should the inmate be readmitted. However, a health record must be created if any health intervention is provided after the receiving screening (J-H-01 Health Record Format and Contents). A copy of the receiving screening forms should be included in this record.
— Originally published in CorrectCare Volume 19, Issue 4, Fall 2005.

As a medical records technician for a county jail, I have received many requests for copies of in-custody health records of released inmates who are suing the county. The requests have no authorization or consent-to-release information. Is a release required?
     The general community confidentiality regulations for release of medical records apply to health records of inmates. This is true not only when the request is related to legal proceedings but also in continuity of care matters. Without a subpoena, you need a release of information from the inmate. You can develop a facility-specific release form or accept the inmate’s written request.
     You also need to check the correctional law in your jurisdiction since additional permissions may be required in some cases (e.g., for psychiatric records, the treating staff may need to advise whether the entire record can be shared given the clinical status of the inmate).
     Lawyers representing the inmate should forward the release with their request. In some jurisdictions, laws require that the attorney general, district attorney or other county official representing the facility in an investigation have access to the records without the inmate’s specific consent, the interpretation being that once the inmate raises the question of adequate care, ordinary rights to confidentiality are not in effect. Please consult the county attorney assigned to your facility about this.
— Originally published in CorrectCare Volume 18, Issue 1, Winter 2004.

My state’s department of corrections uses prison beds in another state. What is NCCHC’s stance on integrating medical records from one state into another state system? We had been placing all medical information (summaries of patient care received from the other state) in the medical file’s miscellaneous section and all mental health information in the mental health section. The DOC says we should sort all information from the other state—e.g., progress notes, physician orders, labs—into the current chart. We have no problem doing this, but feel it might be confusing as to what took place where.
     This issue is not addressed in NCCHC’s standards. Thus, you can make an internal decision about the most useful way to organize the chart for your health staff and have the state medical director issue the directive. NCCHC accreditation surveyors would be concerned that documentation from another system was clearly labeled as such and readily available for reference by the health staff of your system. How you choose to do that, though, is up to your system.
— Originally published in CorrectCare Volume 17, Issue 2, Spring 2003.
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HEARING EXAMS
I am preparing my facility for accreditation. We have been performing hearing exams on juveniles on admission and yearly. Now I am being told that isn’t required. Do the standards specify that we test the hearing of newly committed juveniles on admission and yearly (as we do with eye exams)?
     No. The need for a hearing test, whether on admission or yearly, is a clinical decision to be made by your responsible physician. The admission physical should include some assessment of hearing function, but the decision to perform a specific test is a clinical one. Usually, a physician will follow clinical guidelines or protocols promoted by those medical groups that are expert in treating adolescents.
— Originally published in CorrectCare Volume 16, Issue 4, Fall 2002.
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HOSPITAL AND SPECIALTY CARE
What is NCCHC’s position on providing casting services on site for closed fractured extremities in a correctional setting?
     Two standards apply to this question. C-01 Credentialing, Compliance Indicator #3: “Health providers do not perform tasks beyond those permitted by their credentials”; and D-05 Hospital and Specialty Care, Compliance Indicator #4: “For on-site specialty services used regularly for medical and mental health care, there are appropriate licenses and certifications.” So if the staff doing the procedure on-site would be able to do it in a community setting, and the facility’s setting/tools/supplies/etc. would meet credentialing requirements if credentialing were needed to perform the service, then NCCHC’s Standards for Health Services would allow the practice. The responsible health authority and responsible physician (when the RHA is not a physician) must determine that there are appropriately credentialed and trained health staff, and appropriate direct and auxiliary services and supplies on-site (x-ray, casting materials, etc.). If you are not sure what is needed, an orthopedic specialist could assist.
— Originally published in CorrectCare Volume 22, Issue 1, Winter 2008.

In talking with health staff at the local hospital emergency room, the question arose as to whether there is a definition of “fit for confinement” that ER physicians could refer to when deciding if an inmate can be cleared for a jail. Can NCCHC help?
     I assume this is a situation in which an inmate was sent to the ER for an evaluation for a medical and/or mental health problem, and the ER is trying to decide if the inmate can be sent back to the jail.
     Your best bet is to consult NCCHC’s Standards for Health Services in Jails, specifically essential standards J-A-01 Access to Care and J-E-02 Receiving Screening and important standard J-D-05 Hospital and Specialty Care. Here is a summary of how these standards address your question.
     Inmates have a constitutional right to access to care for their significant health problems. If the level of care needed is not available at the facility, inmates are to be treated in a setting that can meet their specific health needs, such as a community hospital or ER, or perhaps a better equipped (i.e., health staff and services) correctional facility with which the original facility has transfer arrangements.
     The ER physician involved in deciding if the inmate can be appropriately treated at the jail must consider several things. Foremost is the level of health or mental health services needed for follow-up if the inmate-patient is released, and whether the available jail health resources are at that level.
     Sometimes when opinions differ between community ER physicians and jail physicians, it is because the ER physician does not really know what is available at the jail. A visit to the jail and an exchange of information about it