E-02 Receiving Screening (essential)
Screening is performed on all inmates upon arrival at the intake facility to ensure that emergent and urgent health needs are met.
– 2018 Standards for Health Services for jails and prisons
Perhaps one of the most important processes of a correctional health system, receiving screening (standard E-02) is meant to fulfill four purposes:
- Identify and meet any urgent health needs of those being admitted
- Identify and meet any known or easily identifiable health needs that require medical intervention
- Identify and isolate inmates who may be potentially contagious
- Obtain a medical clearance when necessary
Fulfilling these purposes is a multistep process.
STEP 1: MEDICAL CLEARANCE
Medical clearance should happen as soon as the individual arrives at the facility. Reception personnel need to ensure that people who are unconscious, semiconscious, bleeding, mentally unstable, severely intoxicated, exhibiting symptoms of alcohol or drug withdrawal, or otherwise urgently in need of medical attention are referred immediately for care and a medical clearance into the facility.
This documented clinical assessment of medical, dental and/or mental status may come from on-site qualified health care professionals or may require sending the individual to the hospital emergency room. If the patient is sent to the emergency room for a medical clearance, it is imperative that reception personnel and the emergency room staff communicate about the potential health concern so that the patient is examined appropriately. Admission to the facility should be predicated on written medical clearance from the hospital for the identified condition.
STEP 2: THE ACTUAL SCREENING
The receiving screening is a process of structured inquiry and observation intended to identify potential emergency situations among new arrivals and to ensure that patients with known illnesses and those on medications are identified for further assessment and continued treatment.
In jails and juvenile facilities, the screening may be conducted by health-trained correctional personnel or qualified health care professionals. In prisons, only qualified health care professionals should conduct the screening. A qualified health care professional must also be able to respond in a timely manner.
Standard E-02 requires that the receiving screening take place “as soon as possible.” It does not define a concrete time frame but the intent is for the screening to be conducted promptly, without delay. Administrators should consider the risks of not knowing an inmate’s medical condition (e.g., suicidal ideation, prescription medications, communicable illness symptoms, drug and alcohol use and/or withdrawal symptoms) when designing the intake and receiving screening process. Generally, it is not acceptable to wait to start the screening until correctional staff complete the admission process, which may take many hours.
Ideally, the receiving screening is conducted within minutes of an inmate’s arrival. However, a good rule of thumb is that it should occur no more than two to four hours after admission. Staff need to get an idea of inmates’ urgent health needs, identify and meet any known or easily identifiable needs that require medical intervention, and identify and isolate inmates who may be contagious. For example, we do not want a person in need of insulin sitting in a holding cell for hours on end.
The standard recognizes that sometimes inmates arrive in large groups, making it impossible to conduct a receiving screening immediately. In such cases, reception personnel should quickly perform a medical clearance to determine who may be too ill to wait for a screening or be admitted.
However, another requirement is for health staff to regularly monitor the receiving screenings to determine the safety and effectiveness of the process. If the norm is to receive inmates in large groups and receiving screening times are delayed, then staffing should be adjusted to meet the intent of the standard. The timeliness of screening should be monitored regularly through the continuous quality improvement program (see standard A-06) to ensure that the screening is conducted as soon as possible but no later than the two to four hour time frame.
Another important concept is that all inmates are to be screened. This means that, as soon as possible, all inmates are to receive all elements of the screening, including every inquiry and observation noted in compliance indicators #3, #4, #5 and #6. It is not acceptable to conduct an abridged version right away with the remaining questions being asked several hours later or the next day, nor to ask only some of the questions, with a “yes” to certain questions triggering a complete screening.
For facilities that do not routinely function as intake/receiving facilities, a receiving screening must be performed on all newly arrived probation and/or parole violators.
Lastly, reception personnel should make accommodations for people who have difficulty communicating (e.g., non-English speaking, intellectually or developmentally disabled, deaf, mentally ill, under the influence) to ensure a thorough screening is conducted. People with mental disorders are often unable to give complete or accurate information in response to health status inquiries. Therefore, it is a good practice for mental health staff to be involved in training staff who do the intake screening.
Areas of Inquiry
For jails and prisons, the receiving screening inquiries are mostly the same. They include current and past illnesses, health conditions or special requirements (e.g., hearing aids, visual aids, wheelchair, walker, sleep apnea machine); past infectious disease; recent communicable illness symptoms (e.g., chronic cough, coughing up blood, lethargy, weakness, weight loss, loss of appetite, fever); current or past mental illness, including hospitalizations; current or past suicidal ideation; dental problems (e.g., decay, gum disease, abscess); allergies; dietary needs; prescription medications as well as legal and illegal drug use (type, amount, time of last use); current or prior withdrawal symptoms; possible, current or recent pregnancy; and other health problems as specified by the responsible physician.
In prisons, a screening test for latent tuberculosis should be done (e.g., skin test, chest X-ray, laboratory test).
Observations to document include appearance (e.g., sweating, tremors, anxious, disheveled), behavior (e.g., disorderly, inappropriate, insensible), state of consciousness (e.g., alert, responsive, lethargic), ease of movement (e.g., body deformities, gait), breathing (e.g., persistent cough, hyperventilation) and skin (including lesions, jaundice, infestations, bruises, scars, tattoo, needle marks or other indications of drug abuse). It is good practice to not only observe but also ask additional questions. For example, when an individual has a rash that’s not visible to the screener, asking questions will yield the best possible screening.
Staff who work in juvenile detention and confinement facilities should also inquire whether there are children under the juvenile’s care; the type and time of the most recent sexual encounter and use of contraception and condoms in order to screen for emergency contraception eligibility; and victimization by recent sexual assault in order to screen for emergency contraception eligibility.
All pregnant females should be asked about opioid history. In all types of facilities, females who report opioid use should immediately be offered a pregnancy test to avoid withdrawal risks to the fetus. In juvenile facilities, all females should be offered a pregnancy test upon arrival and referred to health staff within 48 hours for testing. In addition, sexually transmitted disease testing should be offered to all juveniles upon arrival or at least within the first 24 to 48 hours.
STEP THREE: DOCUMENTATION AND FOLLOW-UP
Based on the findings from the screening, the disposition of the inmate should be documented (e.g., referred to the appropriate health care service, placed in general population). The forms should be dated and timed immediately upon completion and include the name, signature and title of the person completing the form.
If the screening revealed recent communicable illness symptoms, the potentially infectious patient should be isolated from the general inmate population.
All immediate health needs identified through the screening process should be properly addressed by qualified health care professionals. When inmates indicate they are under treatment for a medical, dental, mental health or substance use problem, health staff should initiate a request for a health summary from the community prescribers after obtaining a signed release from the patient.
However, health staff should be cautious with this practice: Community providers may take days or weeks to provide records (or sometimes not at all), and waiting for them before proceeding with treatment plans may be detrimental to patient care. Depending on the nature of the problem, patients may need to be monitored and/or referred to the facility’s providers to initiate a treatment plan prior to receiving records.
ADDITIONAL SCREENING TIPS
Screeners should fully explore the potential for suicide for incoming inmates. This includes reviewing any history of suicidal behavior and visually observing their behavior (delusions, hallucinations, difficulty communicating, speech, posture, impaired level of consciousness, disorganization, memory defects, depression or evidence of self-mutilation).
Screeners should also investigate the potential for individuals to exhibit symptoms of withdrawal from alcohol and other drugs. These approaches, coupled with training in aspects of mental health and chemical dependency, enable staff to intervene early to treat withdrawal and to help prevent suicides (see B-05 Suicide Prevention and Intervention and F-04 Medically Supervised Withdrawal and Treatment).
Inmates arriving with signs of recent trauma should be referred immediately for medical observation and treatment. A history of trauma may also warrant follow-up care by mental health professionals.
Patients enrolled in a community substance abuse program should be considered for ongoing medication-assisted treatment.
CO'S PERFORMING RECEIVING SCREENING
The training given to correctional officers who conduct the receiving screening in jails and juvenile facilities depends on the role they are expected to play in the process. The responsible physician or designee needs to provide documented training in early recognition of medical, dental and mental health conditions that require clinical attention. At a minimum, this includes how to take a medical history; how to make the medical, dental and mental health observations; how to determine the appropriate disposition based on responses to questions and observations; and how to document their findings on the receiving screening form.
Facilities that use correctional officers to perform receiving screening should not depend on this screening alone to meet the mental health and oral screening requirements (see standards E-05 Mental Health Screening and Evaluation and E-06 Oral Care). The screenings required by those two standards must be done, at a minimum, by trained qualified health care professionals.
Regardless of the term used in your facility—receiving screening, intake screening or booking questions—standard E-02 Receiving Screening is the first step in establishing a quality correctional health care system. Identifying medical, dental and mental health needs as soon as possible upon arrival and referral to appropriate health services promotes the continuity that is required for quality patient care.
[This article first appeared in the Spring 2019 issue of CorrectCare.]