Initial Health Assessment

E-04 Initial Health Assessment (essential)

Inmates receive an initial health assessment.
—2014 Standards for Health Services for jails and prisons

In this article, we will examine a standard that is sometimes misinterpreted, leading to potential compliance issues. An initial health assessment in a correctional setting is an essential component of a health care system and the standard has many requirements that must be met to achieve compliance.

Options for Facilities

Standard E-04 is unique in that it gives a jail or prison two options for demonstrating compliance with the standard: Option One, Full Population Assessment, and Option Two, Individual Assessment When Clinically Indicated. The two choices cannot be combined, so once an option is chosen, the compliance indicators for that option must be followed. The standard for juvenile facilities does not offer different options for compliance. The differences for juveniles will be discussed throughout the article.

Option One: Full Population Assessment
This option involves performing an initial health assessment on 100% of incarcerated individuals as soon as possible, but no later than seven days (prisons and juvenile facilities) or 14 days (jails). Facilities should base their decision for scheduling the health assessment on factors such as length of stay, allocation of staff and disease prevalence in the facility or community. For example, in a jail, performing an initial health assessment within two or three days may assist in identifying patients with chronic diseases or those who may be undergoing drug or alcohol withdrawal. In a prison, performing an initial health assessment upon admission may assist in getting patients identified and enrolled in a chronic disease program earlier in their stay.

The components of an initial health assessment on the full population include a review of the receiving screening results; however, we find that this is often omitted or evidence of documenting the review is not annotated with the health assessment encounter, leading to compliance issues. The responsible health authority should ensure that the process for health assessments includes this documented review. A history, vital signs, height and weight may be collected by a qualified health care professional. The history should also include follow-up from positive findings from the receiving screening and subsequent health care encounters leading up to the health assessment.

The hands-on evaluation of the patient involves inspection, palpation, auscultation and percussion of the patient’s body to determine the presence or absence of physical signs of illness. The RHA should ensure that this part of the health assessment is truly a hands-on approach, rather than simply collecting a current health history. The physical exam can be done only by a physician, physician assistant, nurse practitioner or a registered nurse.

Another component that often poses compliance issues is the requirement for laboratory and/or diagnostic testing for communicable diseases. For jails, testing for tuberculosis is required before or during the initial health assessment. For juvenile facilities, tuberculosis testing should be done, unless there is documentation from the health department that the prevalence rate does not warrant it. Unique to the prison standards is the requirement for a pelvic exam or referral for a pelvic exam with or without a Pap smear, when clinically indicated. Immunizations, as needed, are required in all facilities.

Upon completion of the health assessment by an RN, all abnormal findings must be reviewed by the provider (physician, physician assistant or nurse practitioner). If a physician, physician assistant or nurse practitioner performs the initial health assessment, then further review may not be required. However, the treating clinician must update the problem list and develop diagnostic and therapeutic plans for each problem as clinically indicated.

Option Two: Individual Assessment When Clinically Indicated (Jails and Prisons Only)
The individual assessment when clinically indicated has many more requirements than Option One. However, it focuses staff energy and time only on those patients with chronic or acute health care needs. When using this option, it is imperative that the RHA and/or responsible physician clearly define conditions that qualify as clinically significant findings, which is defined as any deviation from the normal that significantly impact the health and safety of the patient.

To qualify for this option, the facility must have on-site health staff coverage 24 hours per day, seven days per week. This option also requires that all individuals receive a comprehensive receiving screening, which must be done only by licensed health care personnel. In addition to meeting the requirements of standard E-02 Receiving Screening, the screening must also inquire into past history and symptoms of chronic diseases, as well as medications, including dosages. A finger-stick blood glucose reading must be obtained on individuals with diabetes during the receiving screening. Finally, vital signs, including pulse, respiration, blood pressure, temperature, height, and weight, must be obtained during receiving screening and then again during the initial health assessment.

Next, within two days of admission, the initial health assessment must be performed by a physician, physician assistant or nurse practitioner. A registered nurse may not perform the physical examination in Option Two. The components of the health assessment are the same as in Option One except that laboratory and/or diagnostic tests for disease, such as a peak flow for asthma patients or blood work for diabetes patients, must be performed.

Juvenile Standard Requirements

The first noticeable difference in the juvenile standards is in the title “Health Assessments.” Whereas jails and prisons require an initial health assessment only, juveniles must receive initial and periodic assessments. The components of the health assessment for juveniles are very similar to Option One for jails and prisons. However, for juveniles, the physical exam should include breast, rectal and genitourinary exams as indicated by gender, age and risk factors. Females should also receive a gynecological assessment when clinically indicated. The responsible physician should determine which laboratory and diagnostic tests should be performed.

In juvenile facilities, the responsible physician must determine the frequency and content of periodic health assessments based on protocols promulgated by nationally recognized professional organizations. Certain elements should be repeated at an appropriate frequency as determined by the responsible physician, in consideration of age, gender and health needs, consistent with the recommendations of professional organizations.

Repeating the Health Assessment

Finally, for all facility types, when a patient is released and readmitted and a health assessment has been performed within the last 12 months, it is not necessary to repeat the health assessment under certain conditions. The new receiving screening must be reviewed to determine whether there has been any change in health status. If there are no changes, the review and the decision to not repeat the assessment must be documented in the health record. Otherwise, when appropriate, histories, physical examinations and tests should be updated on readmitted individuals.

A word of caution for facilities that include the mental health screening and oral screening in the initial health assessment: If the health assessment is deferred at readmission and there are no changes in health status, the mental health screening and oral screening still must be completed with each admission. Failure to perform those screenings may result in compliance issues in other standards.

An Integral Component of Health Care

The intent of the health assessment standard is that qualified health care professionals identify a patient’s health needs and establish a plan for meeting those needs. Having a process to effectively and efficiently complete health assessments is an integral component of a correctional health care system.

Initial Health Assessment

Over the past months, we have received many requests for information about how to handle chang­es to operations due to COVID-19. While we under­stand that there may be changes, we ask facilities to do their best to address the needs of their patients, follow the standards, document changes made, and return to normal operations as soon as possible. Many facilities are struggling with the same issue. In some, intake staff go to the cell or a private area close to the cell to complete the initial health assessment instead of bringing patients to the clinic. Other facilities complete a modified initial health assessment that assesses top comor­bid conditions along with a brief mental health screen in the time frame set forth in the standards, with a docu­mented plan to complete any omitted health screen items as soon as possible and schedule the pelvic exam as soon as the inmate can be seen in the clinic. Whatever you do, be sure your response is thoughtful and well-documented, and includes looking at the risks of postponing assessments or aspects of care. As always, come into compliance with standards as soon as possible.

— From CorrectCare Volume 34, Issue 3, Summer 2020

We are an intake facility and are quarantining all intakes for 14 days due to coronavirus concerns. Standard P-E-04 Initial Health Assessment states that initial health assessments must be completed within seven days, including a physical examination and a pelvic exam when clinically indicated. However, due to quaran­tine, our patients are not able to come to the health ser­vices unit. How does NCCHC advise that we handle this?

Because these are new patients, it’s important to get an assessment of their health status. That being said, your local medical authority should determine the details of this assessment according to the level of risk for COVID-19 or other disease transmission to and among you and your patients. Always follow recommended levels of personal protective equipment and high-quality infection control procedures, and please see Standard Y-B-01 Infection Prevention and Control Program as a reference.

— From CorrectCare Volume 34, Issue 2, Spring 2020

This was one of the changes to the 2018 edition of the jail standards. Standard E-04 Initial Health Assessment says that a physical examination is to be performed by a qualified health care professional (defined as a physician, physician assistant, nurse practitioner or nurse). There is no compliance indicator that says a physician has to sign off on the assessment. The responsible physician does, however, need to determine the components of the initial health assessment.

— From CorrectCare Volume 34, Issue 1, Winter 2020

The standard gives jails two options. (1) “Full population assessment” requires that the initial health assessment be completed as soon as possible but no later than 14 calendar days after admission. (2) The “individual assessment when clinically indicated” must be completed within two working days after admission, and other stipulations must be met in order to qualify for this option. For prisons and juvenile facilities, the full population assessment must be completed as soon as possible but no later than seven calendar days after admission; the individual assessment when clinically indicated is not an option.

In addition, periodic health assessments should be considered an important part of ongoing disease prevention. The responsible physician should determine the frequency and content of these exams for various groups based on age and risk factors. In the 2018 Standards for jails and prisons, this requirements appears in B-03 Clinical Preventive Services, compliance indicator #2. For juvenile facilities, see E-04 Health Assessment, compliance indicator #3.

— From CorrectCare Volume 33, Issue 2, Spring 2019

Standard E-04 Initial Health Assessment requires that inmates receive an initial health assessment as soon as possible and provides two options for completing this task: the full population assessment and individual assessment when clinically indicated.

The initial health assessment requires many components, some of which involve having a qualified health care professional collect additional data to complete the medical, dental and mental health histories including any follow-up from positive findings obtained during receiving screening and subsequent encounters as well as recording vital signs. A qualified health care professional is defined as anyone who by virtue of education, credentials and experience is permitted by law to evaluate and care for patients.

Your question relates to the physical examination component of the initial health assessment. The standard specifies who is permitted to complete this portion on both options. For the full population assessment, the physical exam may be completed by a physician, a midlevel provider or an RN who has completed the appropriate training. For the individual assessment when clinically indicated, the exam may be performed only by a physician or midlevel provider. The standard does not permit a physical exam to be conducted by a paramedic in either option.

— From CorrectCare Volume 31, Issue 2, Spring 2017

The answer varies depending on whether you are referring to a jail or a prison.

For jails, this is addressed in standard E-04 Initial Health Assessment. Whether you are using the full population assessment or individual assessment when clinically indicated, it is expected that TB testing is done at the time of the health assessment unless there is documentation from the health department that the prevalence rate does not warrant it (see compliance indicators #2e and #6e). The health assessments must be conducted within 14 calendar days after admission for facilities that conduct full population assessments, and within two days for facilities that choose the individual health assessment option.

For prisons, the Receiving Screening standard (E-02) states that a tuberculosis test must be completed during the screening (see compliance indicator #11).

— From CorrectCare Volume 31, Issue 1, Winter 2017

Standard A-02 Responsible Health Authority defines a health administrator as a person who by virtue of education, experience or certification is capable of assuming responsibility for arranging all levels of health care and ensuring quality and accessible health services for inmates. While an LPN may serve as the health services administrator, final clinical judgments must rest with a single, designated, licensed responsible physician.

Your second question refers to Standard E-04 Initial Health Assessment. While states vary in the scope of practice for LPNs, NCCHC standards are clear. An LPN may collect additional data to complete the medical, dental and mental health histories, and may take and record vital signs, but the hands-on physical must be performed by a physician, physician assistant, nurse practitioner or trained RN.

— From CorrectCare Volume 30, Issue 3, Summer 2016

There are a couple of standards to consider. First, E-04 Initial Health Assessment has requirements for what the health assessment should include and who may perform each component of the assessment (history vs. physical examination). You would need to determine if the health assessments being done at the surrounding jails meet this standard. The second standard to consider is E-03 Transfer Screening. Health staff at the regional jail would need to confirm that the initial health assessment was completed at the intake jail when transfer screening is completed. If not, it would need to be completed at the regional jail as soon as possible. If the health assessments that are done at the surrounding jails meet the standard, then it would not need to be repeated at the regional jail.

— From CorrectCare Volume 28, Issue 4, Fall 2014

J-E-04 does not require an annual physical. This standard pertains to the initial health assessment and not ongoing care. Health care for chronic diseases may require periodic assessments, and relevant clinical practice guidelines should be consulted. Standard J-E-12 Continuity of Care During Incarceration requires that the responsible physician determine the frequency and content of periodic health assessments based on protocols promulgated by nationally recognized professional organizations.

— From CorrectCare Volume 27, Issue 2, Spring 2013

First, you did not indicate who conducts the intake screening. To qualify for option two (Individual Assessment When Clinically Indicated), standard E-04 requires that a licensed health care professional conduct a comprehensive receiving screening.

In your process, individuals who have significant health problems are sent to the infirmary (it is assumed that the initial health assessment is done within two days). However, you have created a classification of “stable clinically significant finding.” NCCHC does not recognize this classification. By definition, if one has been found to have a clinically significant finding—whether acute or chronic, stable or unstable—they are treated the same and hence are to have the initial health assessment within two working days.

Option two is meant to focus resources on patients with the greatest health needs. If the enhanced receiving screening process identifies individuals with any deviation from the normal that significantly affects their health, safety and welfare, then it is expected that the initial health assessment be done within two working days. “Working day” is defined as any day of the week except Sunday, public holidays and, in some cases, Saturday. Thus, a Friday admission would need the initial health assessment to be done on Monday.

— From CorrectCare Volume 26, Issue 4, Fall 2012