Documentation

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In the past, we have put together files for each standard for the NCCHC site survey. For example, files for standard J-A-01 Access to Care has sick call records, J-A-02 Responsible Health Authority has job descriptions and invoices and J-A-03 Medical Autonomy has grievance letters with documentation to back up the response. Are we required to assemble a file for each of the standards?

While it is not a requirement to have a file for each standard, it is helpful for the survey teams if the material for surveys is compiled in one place. For example, you need not create a separate file for J-C-01 Credentialing if you keep all of your staff credentials in a book. Having all materials readily available, whether it is in separate files or in several books or binders, will enhance the survey process.
— From CorrectCare Volume 27, Issue 2, Spring 2013

 
 

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.
— From CorrectCare Volume 22, Issue 1, Winter 2008

 
 

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.
— From CorrectCare Volume 16, Issue 3, Summer 2002