Accreditation Q and A

Over the past months, NCCHC has received many similar questions about compliance with standards during the pandemic. Many accredited facilities share your concerns.

While we understand the challenges of providing health care during this time and know that care may have been interrupted during the pandemic, there are a few keys to success when thinking about the future and getting beyond the coronavirus crisis.

Here’s how correctional leaders can begin navigating what’s next as you think about accreditation or reaccreditation.

  1. Decisions about resource allocation should be made at the system level in alignment with your emergency response plan.
  2. Standards are the backbone of a health services delivery system; therefore, no standards are “waived.” The key to success is to document the reasons for all deviations to health care plans and resume normal operations as soon as safely feasible.
  3. Document your response to the crisis in a thorough and thoughtful manner. Be clear when services deviated from the plan and when they are anticipated to get back on track. Document your triage plan when providing care: who can wait, and why? Document, document, document.
  4. Document your contingency plans when needing to provide emergency medical or dental care.
  5. Follow national guidelines like those of the CDC for guidance on care protocols during a pandemic. Keep these guidelines as part of your documentation to support your rationale.
  6. Think beyond coronavirus and what the path to normal looks like. Document when services resumed and how you went about assessing patients and addressing the backlog of health service needs. NCCHC surveyors are experienced correctional health care professionals who know what you are going through; many have been through similar crises themselves. They will consider the unusual circumstances you are facing and the adjustments you are having to make.

    We understand the changes made to your health care delivery system were in order to respond to vulnerable populations while also actively working to reduce potential exposure to the virus.

    Thank you for the amazing patient care you are delivering during these challenging times.

— From CorrectCare Volume 34, Issue 4, Fall/Winter 2020

First, thank you for participating in NCCHC’s accreditation program for health services and soon-to-be for OTP. Yes, we do offer mental health accreditation for facilities that have a more robust mental health program in place. It is based on the 2015 Standards for Mental Health Services in Correctional Facilities. The survey for this program can take place at the same time as the surveys for health services and/or the OTP, or it can be conducted at a separate date or time. Facilities that attain all three types of accreditation will be awarded NCCHC’s Pinnacle Recognition.

— From CorrectCare Volume 33, Issue 3, Summer 2019

The answer depends on when the facility is due for a survey. The anticipated release date for the 2018 Standards for Health Services is April 21. Facilities have approximately six months to transition to the new set of standards. While exceptions may be granted, a general guide is this: If your survey is scheduled for between January 1 to July 31, it will be surveyed under the 2014 Standards. Facilities scheduled for a survey in August, September or October will have the choice of being surveyed under the 2014 or 2018 Standards. Beginning November 1, all surveys for jails and prisons will be conducted under the 2018 Standards. Depending on the date of application, facilities that are applying for initial accreditation in 2018 will likely be surveyed under the new set of standards.
— From CorrectCare Volume 31, Issue 4, Fall 2017

NCCHC does not accredit any kind of company (such as health care contractors, electronic health records vendors or pharmacies), states or agencies. Rather, NCCHC accredits individual correctional facilities for compliance with the relevant Standards for Health Services. The accreditation is awarded to the facility itself for its established system of health care delivery and demonstrated compliance with the requirements of the standards.
— From CorrectCare Volume 31, Issue 4, Fall 2017

We are pleased that you are preparing for initial NCCHC accreditation and our staff is ready to assist with your questions. Each standard is classified as either essential or important. For accreditation purposes, 100% of applicable essential standards must be met, and at least 85% of applicable important standards.

Accreditation is not based on partial compliance; each compliance indicator must be met in order to meet the standard. Some standards have only one compliance indicator, while others have more than 10. However, not every standard may apply to your facility. For example, if your facility houses only men, the standard regarding pregnancy would not apply.

Now that you’ve applied for initial accreditation, you should contact us to schedule a free webinar on how to prepare for accreditation. This webinar shares preparation tips and discusses what to expect during a survey. It also allows health staff the opportunity to ask questions.

— From CorrectCare Volume 31, Issue 3, Summer 2017

Not at all. NCCHC standards do not require 24×7 nursing coverage for accreditation. When health staff are not on site, a health care liaison can coordinate a number of health services activities, such as triaging nonemergency sick-call requests every 24 hours, facilitating sick call by having inmates and records available for the health care professional, and helping to carry out clinicians’ orders regarding such matters as diet, housing and work assignments. The health care liaison may be a correctional officer or other person without a health care license who is trained by the responsible physician in limited aspects of health care coordination. Note that if infirmary care is provided on site, then 24×7 coverage would be required as infirmary patients should always be within sight or hearing of a qualified health care professional.
— From CorrectCare Volume 25, Issue 2, Spring 2011

Remember that health services accreditation is granted to the facility, not to the provider, regardless of the delivery model. However, such changes can have an impact on care, so NCCHC requires that the correctional authority notify us in writing of any substantive change in management of the health care program within 30 days.

The next steps depend on the particulars of your situation (such as date of the last survey, any anticipated problems). The accreditation committee may request a written report on the transition, provide consultation or require a new survey. It also may postpone the next scheduled survey by up to six months to give the new provider time to make the transition.

The current health services provider is accountable for what is happening under its authority. When the survey does occur, we will focus primarily on information dating from the time of the transition. However, if corrective action to comply with the standards was required under the previous provider, we will look for confirmation that action has been taken and has rectified the problem. As to other issues that might arise, we deal with them on a case-by-case basis.
— From CorrectCare Volume 24, Issue 2, Spring 2010

NCCHC accredits individual facilities, not systems, so the correspondence must come from the responsible health authority’s designee at the facility (standard A-02 Responsible Health Authority, Compliance Indicator 4). Usually this is the facility health services administrator. When materials are sent by contracted, system-level or regional providers, the facility-based designee must verify the documentation, usually by a cosignature. It doesn’t matter that the designee’s employer is a contractor.
— From CorrectCare Volume 24, Issue 1, Winter 2010

With the 2008 release of the Standards for Mental Health Services in Correctional Facilities, health professionals and administrators in the mental health arena can now access more specific guidance on quality mental health care services organization and delivery. These standards are the foundation of a new accreditation program originally intended for correctional facilities in which the legal authority for mental health services is separate from their other health services. While it is always a benefit to pursue accreditation as a unified health care delivery system, this option enables mental health services to seek accreditation even if the health services counterpart does not. However, because of great interest in the program from a wide variety of facilities seeking to achieve excellence in mental health care, NCCHC is looking to revise the criteria in the future.
— From CorrectCare Volume 22, Issue 4, Fall 2008

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.
— From CorrectCare Volume 21, Issue 2, Spring 2007