Standards Q & A: Policy vs. Practice, Pharmacy Inspections, and More

Staggered Suicide Monitoring

Q: During our survey, the surveyors cited Standard B-05 Suicide Prevention and Intervention compliance indicator 2 as noncompliant. We provide nonacute suicide monitoring at precise 15-minute intervals. Is that not the correct practice?

A: The compliance indicator specifically states that “nonacutely suicidal inmates are monitored by facility staff at unpredictable intervals with no more than 15 minutes between checks.” Surveyors review monitoring logs to ensure monitoring times are staggered and unpredictable and that the monitoring does not go beyond 15 minutes. Your facility is out of compliance because you are monitoring nonacutely suicidal inmates precisely every 15 minutes. Monitoring at precise intervals allows the inmate to understand the pattern of checks, which is why the standard supports unpredictable and staggered times not to exceed 15 minutes. For additional information regarding suicide prevention and intervention, please see the discussion section for B-05 in the jail standards book.

Pharmacy Inspections

Q: How do we handle interruptions to our quarterly pharmacy inspections as required in Standard D-01 Pharmaceutical Operations? In 2020 the pharmacy inspections were missed due to the COVID-19 pandemic.

A: Over the past few months, NCCHC has received many questions on how to handle changes to operations due to COVID-19. While we understand that there may be changes to daily operations, we are asking facilities to do their best to address the needs of their patients, follow the standards, document the changes made, and return to normal operations as soon as possible.

Throughout 2020, many facilities operated under their emergency management plan with surges in COVID-19 cases. As facilities return to normal operating procedures, NCCHC requires accredited facilities to work with their consulting pharmacists to conduct quarterly on-site inspections. If COVID-19 cases are surging at a facility, the pharmacist can conduct a virtual consultation. The responsible health authority and the health services administrator can work with the consulting pharmacist to ensure that the facility’s pharmaceutical services are operating safely, properly, and according to the law. Given that medication dispensing, administering, and procuring are high-risk endeavors, it is imperative that quarterly pharmacy inspections resume whether on-site or via a virtual consultation.

Policy vs. Reality

Q: During our recent on-site survey, the surveyors cited noncompliance with standard B-03 Clinical Preventive Services. This is confusing to us since our policy and procedures for B-03 state that we follow nationally recognized standards. Can you provide clarity on how we need to address this?

A: Often the compliance issue with this standard has to do with an inconsistency between written policy and practice. Most facilities have policies and procedures in place, but the actual practice does not always reflect the policy or the national guidelines the policy is based on.

For this standard, these inconsistencies are usually discovered during chart reviews. Upon review of the medical records, the physician surveyors may note that actual practice is not in compliance with the written policies. For instance, they may find that screenings being ordered do not follow the facility’s policy and/or national guidelines.

While it is important to have clear policies and procedures, it is equally important to conduct periodic chart audits to ensure you are doing what you say you will do for your patients. Trust what you are doing, but periodically verify with a chart audit. 

Author: Amy Panagopoulos, MBA, BSN, NCCHC’s vice president of accreditation.

Send your standards-related questions to [email protected].