Standards Q & A

Despite our best efforts to develop correctional health care standards that are easy to understand, questions may arise when facilities try to implement or comply with the standards. To aid interpretation, a Q&A column is published in NCCHC's magazine, CorrectCare.

Below is an archive of questions. These responses give general recommendations and may be revised when new editions of the Standards are published. (Last updated: November 28, 2011.)

Also be sure to check out the Spotlight on the Standards column for more in-depth discussion of common questions about the standards as well as insights for how to interpret them.

 
For questions about the Standards, call 773-880-1460, or email info@ncchc.org.

ACCESS TO CARE
In talking with health staff at the local hospital emergency room, the question arose as to whether there is a definition of “fit for confinement” that ER physicians could refer to when deciding if an inmate can be cleared for a jail. Can NCCHC help?
     I assume this is a situation in which an inmate was sent to the ER for an evaluation for a medical and/or mental health problem, and the ER is trying to decide if the inmate can be sent back to the jail.
     Your best bet is to consult NCCHC’s Standards for Health Services in Jails, specifically essential standards J-A-01 Access to Care and J-E-02 Receiving Screening and important standard J-D-05 Hospital and Specialty Care. Here is a summary of how these standards address your question.
     Inmates have a constitutional right to access to care for their significant health problems. If the level of care needed is not available at the facility, inmates are to be treated in a setting that can meet their specific health needs, such as a community hospital or ER, or perhaps a better equipped (i.e., health staff and services) correctional facility with which the original facility has transfer arrangements.
     The ER physician involved in deciding if the inmate can be appropriately treated at the jail must consider several things. Foremost is the level of health or mental health services needed for follow-up if the inmate-patient is released, and whether the available jail health resources are at that level.
     Sometimes when opinions differ between community ER physicians and jail physicians, it is because the ER physician does not really know what is available at the jail. A visit to the jail and an exchange of information about its health staffing and capabilities are essential to good planning between jail and ER health administrators and physicians.
     One way for the ER physician to think about a return to jail is to regard it as a return to home care. That is, if the inmate were a regular community patient with a home and minimally supportive situation, would the hospital send the patient home? Does the inmate-patient simply need observation that could be done by minimally trained correctional officers, or does he or she inmate-patient need nursing care that is (or is not) available on-site? If the jail has an infirmary, what scope of care is available? Is there a sheltered housing area where the inmate can receive the necessary services? For example, is there a negative-pressure room to house contagious TB patients, or does the patient need to stay at the hospital until the contagious phase has passed?
     Some ER physicians mistakenly assume that jails have 24/7 health staff and supports. While that may be true in a few jails, particularly in the mega-systems, most have limited on-site health resources. On the other hand, if you or I were treated in an ER and then sent home and not hospitalized, jails should expect that the ER will want to do the same for inmate-patients treated for the same conditions.
     Given the possibility that little attention may be given to a returning inmate, the ERs may be advised to hold the inmate-patient for a little longer observation if there is any doubt. Some jails and ERs create a “locked ward” at the hospital when such patient volume is high.
— From CorrectCare Volume 21, Issue 3, Summer 2007
 Return to List 

ACCREDITATION
We are interested in becoming accredited, but our small work camp doesn’t have 24x7 nursing staff. Does that mean we can’t be accredited?
     Not at all. NCCHC standards do not require 24x7 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 24x7 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

Our jail is accredited by NCCHC. We have been using a contract management company, but now services will be provided by our local health department. Will this affect our accreditation?
     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

Our prison recently received its accreditation survey report, which states that we need to take corrective action. When we send documentation of that action to NCCHC, who must sign off on the document? The DOC’s chief medical director? Our facility medical director? The health services administrator? Does it matter that the latter two work for a contract services company?
     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

My facility is already accredited under the NCCHC standards for health services in jails. Now I hear that NCCHC will be offering accreditation for mental health services. What does that mean for us?
     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

Our facility’s accreditation survey identified a compliance issue that was actually a systemwide problem. The central office authorities revised the policy as required by the standard in question. When we submit proof of the corrective action, do we need to send anything besides a copy of the signed, revised policy?
     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

Is there a list of accredited correctional health care companies that I can reference?
     NCCHC does not accredit companies, states, agencies, contractors or systems “in the abstract.” Rather, NCCHC accredits individual correctional facilities for compliance with the relevant Standards for Health Services. It does not matter how many players (private contractors, state employees, etc.) are in a facility’s health care system: The accreditation is awarded to the facility itself for compliance with the requirements of the standards (100% of the applicable essential standards must be met and at least 85% of the applicable important standards).
— From CorrectCare Volume 18, Issue 3, Summer 2004
 Return to List 

AIDS TO IMPAIRMENT
Under the standard regarding Aids to Impairment (G-10), are we required to provide reading glasses to inmates?
No. The standard requires that when determined by the responsible physician or dentist, an aid to impairment should be supplied in a timely manner when the health of the inmate would otherwise be adversely affected [emphasis added]. Such aids include eyeglasses when, for example, the inmate’s health and adaptation to the correctional facility could be affected. The visually impaired individual could be at a distinct disadvantage trying to assimilate into the jail or prison. This category would include elderly inmates and patients with diabetic retinopathy who are visually impaired to the extent that they require assistance in activities of daily living. (Also see G-02 Patients With Special Health Needs.)
— From CorrectCare Volume 25, Issue 1, Winter 2011
 Return to List 

BLOOD DRAW PROCEDURES
The warden at our maximum security prison does not want to allow the nurses to bring inmates out for routine blood draws. Instead, inmates are to stick their arms through the pie flap on the cell door so that nurses can obtain the venous sample. Medical staff are concerned for the safety of the inmate and our exposure to possible needlesticks. Can you give any guidance about the safety and exposure risks with this procedure?
     The NCCHC standards for health services in prisons require that health care interventions are done within community practice protocols. The warden’s proposed procedures for drawing blood are not in keeping with community standards, pose infection control and safety concerns for inmate and health provider alike, and interfere with the principle of medical autonomy in the sense that security is trying to dictate how medical procedures are to be carried out.
     Many variables go into a blood draw, which can be difficult even under the most ideal clinical settings. Doing it through a slot in the door complicates it much further. The procedure involves use of a pressure device to temporarily stop blood flow. Finding a vein may require examination of the whole arm and hand, and often the limb must be positioned in a particular way to enhance success of the draw. Infection control procedures are required to keep the field and needles sterile. We do not know how standard precautions can be maintained given the scenario you describe. And patient cooperation and communication are needed to prevent injury to either party.
     If the warden is concerned about bringing the inmate to the clinic for a routine draw, an area on the tier can be set up appropriately for such basic health interventions. A clean, private room adapted to this purpose would allow the necessary security presence if required. Not all maximum security inmates are a safety threat to the same extent. Treating inmates as the warden proposes would only serve to dehumanize them, making them more likely to act out in such circumstances.
     As to resources, we suggest you consult the CDC’s process for venipuncture, available online at www.cdc.gov/std/program/medlab/ApF-PGmedlab.htm. Also, an outline for proper phlebotomy techniques is available from the National Credentialing Agency for Laboratory Personnel: www.nca-info.org/pdfs/examoutlines/cl-lab-phlebotomy.pdf.
     Although the facility might not have a credentialed laboratory phlebotomist, it would be hard to defend its door-slot procedure in court when the community overall does not recognize the procedure.
— From CorrectCare Volume 20, Issue 2, Spring 2006
 Return to List 

CHRONIC DISEASE SERVICES
Is anything in print regarding the time lines by which chronic disease patients should be seen? If they are well controlled without any incidents, is it really necessary to see them every 90 days? In the community, people with chronic diseases that are well controlled do not see a provider every 90 days. Can you give me some guidance as to where I might be able to find such information?
     NCCHC’s G-01 Chronic Disease Services standard leaves the frequency of follow-up for medical evaluation to the provider’s clinical judgment. There isn’t a hard and fast rule in the standard that all patients with chronic disease must be seen every 90 days. The standard does expect that the responsible physician establishes and annually approves clinical protocols consistent with national clinical practice guidelines and that treatment plans are in place for patients with chronic disease. The elements of the treatment plans should indicate that the protocols are being followed and that deviations from protocols are documented with clinical justification. NCCHC has guidelines for disease management you may wish to refer to.
— From CorrectCare Volume 25, Issue 3, Summer 2011
 Return to List 

CLINIC SPACE, EQUIPMENT, & SUPPLIES
Our county juvenile detention center rarely houses pregnant juveniles, and when we do, it is always short-term. The community hospital where deliveries would take place is right across the street, and the physician treating these girls has an office nearby. We do not have a fetal heart monitor on site. Given our circumstances, must we have one in order to comply with NCCHC standard Y-D-03 Clinic Space, Equipment, and Supplies?
     The fetal heart monitor is not required, but it is recommended. To comply with a standard for accreditation purposes, you must understand and meet the requirements of the standard itself and of its compliance indicators. In standard Y-D-03, the recommendations section lists suggested equipment, including a fetal heart monitor. As its name implies, this section makes recommendations that likely will benefit a facility but that are not mandatory. If your responsible physician is comfortable with your situation and the resources available, then you may follow the physician’s protocols. You will be in compliance with the intent of the standard.
— From CorrectCare Volume 19, Issue 1, Winter 2005
 Return to List 

CLINICAL GUIDELINES
Our state prison system has implemented a chronic care clinic (CCC) program. I remember NCCHC having a list of proposed diagnoses for CCC eligibility. What diagnoses should we include in our program?
     The information you seek is found in standards P-G-01 Special Needs Treatment Plans and P-G-02 Management of Chronic Disease. From NCCHC’s standpoint, any health condition that is considered chronic or that requires multidisciplinary care also requires development of an individual treatment plan for regular, ongoing care. Examples of such conditions are listed in P-G-01.
     To sharpen the focus on chronic care, P-G-02, new to the 2003 Standards, specifies seven conditions for which the facility is expected to have identified national clinical guidelines to follow in treating these diseases. To assist facilities, NCCHC has developed correctional clinical guidelines for these conditions. Alternatively, facilities may choose any of the national clinical guidelines current in community care, such as those from the American Diabetes Association, the American Society of Internal Medicine, etc. (See the National Guideline Clearinghouse at www.guideline.gov.)
     The eventual goal is for practitioners to follow specific clinical protocols for all chronic conditions. The current seven are a first step.
— From CorrectCare Volume 19, Issue 2, Spring 2005

Why are the NCCHC clinical guidelines not included in the standards manuals?
     The standards are revised periodically, usually every three to five years. In contrast, clinical guidelines must be timely, reflecting the latest developments in the field and current treatment recommendations. NCCHC’s guidelines for disease management are revised as often as necessary to keep them current and are available online.
— From CorrectCare Volume 17, Issue 2, Spring 2003; updated February 2010
 Return to List 

CLINICAL PERFORMANCE ENHANCEMENT
I’m not very clear on the difference between a clinical performance enhancement review (C-02 Clinical Performance Enhancement) and an annual performance review. Can you please explain this?
     A clinical performance enhancement review is focused on the quality of the clinical care provided; a health professional’s work is reviewed by another professional of at least equal training in the same general discipline, such as the review of the facility’s physicians by the responsible physician. An annual performance review might address areas such as punctuality, teamwork, attitudes, goals, etc.; those types of reviews do not apply to this standard.
— From CorrectCare Volume 23, Issue 4, Fall 2009

Is our obstetrician/gynecologist required to have a clinical performance enhancement review under the Clinical Performance Enhancement standard (C-02)?
     This standard requires the clinical performance of a facility’s primary care clinicians to be reviewed at least annually. Primary care clinicians are all licensed practitioners (including medical physicians, psychiatrists, dentists, midlevel practitioners and PhD-level psychologists) who provide primary care on a regular basis. Therefore, this standard does not require an ob/gyn or any other specialist that is not considered a primary care clinician to receive a clinical performance enhancement review.
— From CorrectCare Volume 23, Issue 1, Winter 2009

This question concerns the new standard for peer review. We are a small jail, average daily population about 200, in a rural area. We understand that our consulting psychiatrist now needs an annual review of her performance at the jail, but she is the only psychiatrist who works at the jail in our area. Can our licensed psychiatric social worker do her review?
     You are referring to important standard C-02 Clinical Performance Enhancement, which is new to the 2003 jail and prison Standards and included in the 2004 juvenile Standards. To quote from the discussion section: “The intent of this standard is to enhance patient care through peer review of the clinicians’ practice. The clinical performance enhancement review process is neither an annual performance review nor a clinical case conference process. It is a professional practice review focused on the practitioner’s clinical skills; its purpose is to enhance competence and address areas in need of improvement.
     Facilities in which the practitioner (in your case, the psychiatrist) is the sole representative of a profession is actually one of the situations the standards revision committee wanted to address. The standard’s intent is to promote the professional exchange of ideas and practice that can occur only with another professional of equal or more advanced training and experience in the same discipline. So, while medical physicians can review other medical physicians and midlevel practitioners, only psychiatrists should be reviewing psychiatrists.
     So, what are you to do? Is there a community psychiatrist in private practice willing to do such a review? Will a state medical school provide such services? Ideally, the performance review is a face-to-face meeting, but telephone reviews following sample record reviews might be an option. Exchange of written materials may not be best, but it could work. Yet another possibility is the use of a university telemedicine program, if one is available.
     Failing all of the above, you should note that NCCHC has designated this standard as “important” (as opposed to “essential”) so noncompliance should not affect your accreditation status.
     For more details about compliance, see the Spotlight on the Standards that deals with this standard.
— From CorrectCare Volume 18, Issue 2, Spring 2004
 Return to List 

CONFIDENTIALITY
Where do we draw the line on what is considered “confidential” patient information? Health services conducted a urine toxicology screen of a prisoner and the results indicated the presence of an illicit drug. Is this protected medical information or should we notify custody? Do we just drop a hint, or do we name names?
     Assuming that the test was for clinical purposes (and it should have been, as per standard I-03 Forensic Information), the results should be used for clinical reasons only. You may share with the appropriate officials your concern that the substance may be present in the prison so that they can look into the possible security breach. However, the inmate’s identity must be protected. To avoid conflict or pressure from custody, health services policies and procedures should address the role of health staff in such an event and the warden and custody staff should have a clear understanding of this role. (See A-03 Medical Autonomy and H-02 Confidentiality of Health Records.)
— From CorrectCare Volume 24, Issue 3, Summer 2010

It was recently brought to my attention that inmates working in our kitchen have access to information about medical diets for other inmates; therefore, they may know about an inmate’s medical condition. Do you have any suggestions on how to address this situation?
     The most important consideration here is that an inmate who requires a medical diet actually receives the diet (see standard F-02 Medical Diets). Inmate workers perform a variety of duties in the kitchen, and it may not be possible to prevent knowledge of the fact that a particular inmate is receiving a special diet. However, the recipient’s confidentiality can be protected to some degree by limiting the information on diet cards to the type of diet ordered (e.g., low sodium, bland) and the duration without specifying the inmate’s condition or diagnosis.
— From CorrectCare Volume 23, Issue 1, Winter 2009

I am a nurse who works in a state prison. One of our inmates is getting married, and I have been designated as the health staff member to review his health record with his fiancée before the wedding. The inmate has given his written permission to do so. I am uncomfortable about this and the need to protect the confidentiality of health information. Can you provide any advice?
     NCCHC standards focus on the health services provided to incarcerated individuals and do not address such issues as procedures for inmate marriages. This is the realm of state correctional and other authorities. Your concern about confidentiality is a simpler matter: Since the inmate voluntarily gave his consent for you to share his health information, the requirement is met from NCCHC’s standpoint.
— From CorrectCare Volume 19, Issue 3, Summer 2005

When an inmate says he’s going to kill someone and the mental health care provider (in this case, a psychiatric nurse practitioner) has that information, there are issues as to whether he should pass that information to the person who’s been threatened. This is covered in California law regarding "duty to warn." How is this covered in the jail standards concerning forensic information? Also, confidentiality issues are covered in the duty to warn law. Is confidentiality also covered in the standards?
     All three sets of standards address confidentiality of health information (P-H-02, J-H-02 and Y-H-02). The situation you cite represents an exception. The right to confidentiality is not absolute and may be breached when there’s risk of serious injury or death to the patient, other inmates or staff. As you state, often state laws or regulations govern confidentiality of health information and the circumstances under which disclosure of certain information is permitted. The standard prohibiting collection of information for forensic purposes does not apply to your situation.
     Most disciplines, including those affiliated with mental health, also require that such specific information be taken to the appropriate authority. Finally, it is good practice for the mental health clinician to tell the patient in their first encounter that certain issues cannot be kept confidential: "If you tell me that you are going to harm or kill yourself or someone else, or engage in behavior that jeopardizes the safety or security of the facility, I will need to tell the appropriate authorities."
— From CorrectCare Volume 17, Issue 1, Winter 2003

My deputy warden and I would like to institute a statewide practice of identifying certain inmates with potential life-threatening conditions by using medical alerts on the back of their ID badges. I work part time in a state where this practice is in place and it works very well. As an accredited facility, is there anything that would preclude us from initiating this practice?
     That depends on how you plan to carry out this program. Because of concerns about confidentiality of medical information, you could not, for example, use yellow bracelets for epileptics, pink lettering for mental health patients, red for HIV patients, etc. Someone seeing the medical alerts on the back of an ID badge should not automatically know what the problem is. On the other hand, if you make participation voluntary, inmates could choose whether they wanted to disclose their condition on a medical alert badge or not.
— From CorrectCare Volume 16, Issue 2, Spring 2002

Our QA group would like NCCHC’s position on the sharing of confidential patient information under the following circumstances: An inmate is given a urine tox screen by clinical services and is positive for an illicit substance such as cocaine, opiates, methamphetamines, etc. What information should be shared with the warden and/or designated custody control staff? The inmate’s name and substance(s) that tested positive? The inmate’s name and a hint that he should be tested by custody staff? No inmate identification, but the fact that illicit substance(s) are in the facility? No information?
     In your scenario, I am assuming you work in a prison, and that the urine test, since it was done by clinical services, was for clinical purposes. The inmate’s results should be used for clinical reasons. The general concern that a particular substance may be in use in the facility may be shared with the warden or his designee in such a manner that the identity of the individual inmate is protected, but the issue regarding a possible serious violation of security regulations can be addressed. This type of situation should have been discussed with the warden when the health services policies and procedures were established so that there is a clear understanding of the role the health staff have and there is no pressure on health staff to reveal identifying details. The relevant prison standards are P-A-03 Medical Autonomy, P-H-02 Confidentiality of Health Records  and P-I-03 Forensic Information.
— From CorrectCare Volume 15, Issue 4, Fall 2001; updated February 2010
 Return to List 

CONTINUING EDUCATION
One of our physicians recently completed an online course for cardiopulmonary resuscitation. I am wondering if you can tell me whether this is acceptable for J-C-03?
     In the 2008 version of the NCCHC standards, J-C-03 Professional Development requires that all qualified health care professionals who have patient contact are current in cardiopulmonary resuscitation technique. The standard states that the CPR training may be provided by an approved body, such as the American Heart Association or the American Red Cross, or from an individual who possesses a current instructor’s certificate from an approved body. Therefore, your physician’s online course would be acceptable to meet the standard if it is provided by an approved body.
— From CorrectCare Volume 22, Issue 2, Spring 2008

I am a fairly new health administrator at my correctional facility. Would I be in compliance with the standard concerning health staff training if, for the portions of the training that do not deal with hands-on interventions (such as CPR or first aid), I use a PowerPoint presentation? I could send the training materials through the institutional mail to all health staff, and I have the capability of checking on my computer to see who has opened the training.
     The relevant standard is C-03 Continuing Education for Qualified Health Care Professionals. Its intent is the same for jails, prisons and juvenile settings: “the facility’s qualified health care professionals are kept current in clinical knowledge and skills.” The standard allows for a variety of approaches and methods to meet the intent.
     The use of a few computer-based offerings such as you describe may be appropriate. However (omitting discussion of the hands-on training noted above), if you used the PowerPoint method only with no face-to-face meetings, compliance may be questioned. You want to ensure that the presenter and participants have opportunities to interact, at least some of the time. The exchange of questions and answers and the sharing of experiences often are the most valuable parts of any training. NCCHC’s Accreditation Committee would make the compliance decision based on findings from the on-site survey.
     As a side note, staff can earn continuing education credit by providing documentation of external educational activities, including health classes, seminars and conferences such as those sponsored by NCCHC.
— From CorrectCare Volume 19, Issue 1, Winter 2005
 Return to List 

CONTINUITY OF CARE
In standard E-12 Continuity of Care During Incarceration, periodic health assessments are mentioned in Compliance Indicator 7. Do all inmates require a periodic health assessment on an annual basis?
     No, the standard does not require an annual health assessment. The responsible physician determines the frequency and content of periodic health assessments based on protocols promulgated by nationally recognized professional organizations. Periodic assessments are likely based on age, gender and risk factors. Certain elements of the assessment, such as mammogram or prostate exam, are repeated at appropriate frequencies.
— From CorrectCare Volume 22, Issue 3, Summer 2008
 Return to List 

CONTINUOUS QUALITY IMPROVEMENT PROGRAM
Our jail is changing to a new pharmacy and we want to make sure that changing this vendor does not affect patient outcomes or the expected standard that patients would continue to receive their medications as ordered by the physician for their treatment plan. Can we use this study for one of our outcome studies as required by J-A-06 Continuous Quality Improvement Program?
     This is a great CQI study topic, but it sounds like it is best classified as a process study (and can certainly be used as such to meet J-A-06). Remember that outcome studies examine whether patients’ conditions are improving under the care provided. From what you describe, you are assessing the pharmacy delivery system—a process. The “outcome” of the patient receiving ordered medications is part of a process and is not a clinical outcome. We have seen CQI outcome studies on topics such as the effect of valproic acid administration on the rate of violence among mentally ill inmates, monitoring to reduce hemoglobin A1c levels and degree of control in hypertensive patients. Keep up the good work on monitoring whether patients receive ordered medication as part of their continuity of care.
— From CorrectCare Volume 25, Issue 3, Summer 2011

Our question is about P-A-06 Continuous Quality Improvement Program and compliance indicator 4cii “a study is completed.” We realize that we are required to do two process and two outcome studies a year due to our ADP being over 500, but we aren’t sure of what the difference is or what evidence is required to meet this indicator.
     A “study” is a process of reviewing an identified problem to assess potential causes. A CQI study is one in which a facility problem is identified; a study is completed; a plan is developed and implemented; results are monitored and tracked; and improvement is demonstrated or the problem is restudied. Subsequent corrective action is documented and evaluated to see if the intervention was effective in addressing the problem. Process studies focus on implementation of policies and procedures (usually involving more than one category of staff) and the effectiveness of those processes. For example, examining your chronic care procedure might involve looking at how you identify chronic care patients, how you schedule them for clinics, whether security escort problems cause delays, how documentation is kept, etc. Process studies often focus on timeliness and efficiency.  An outcome study on the same subject might focus on whether the chronic care patients’ symptoms are actually decreasing or at least are not worsening as a result of the care. These studies question whether the expected outcomes of patient care were achieved (degree of control is a helpful consideration). The evidence would be documentation of the studies—either the actual study documents and summary of results, or a detailed discussion of the same in the CQI meeting minutes.
— From CorrectCare Volume 24, Issue 4, Fall 2010
 Return to List 

DENTAL EXAMS
If a juvenile is already under the care of a community dentist, has seen the dentist recently and then is admitted to a detention center, does he still need a dental exam within 60 days?
     If the facility can get a copy of the dental exam (or a current dental assessment by the treating community dentist) for its records, a new dental exam would not be required. The dental screening would still need to be done, and the facility dentist would have to review the community documentation when it comes in to ensure that any needed follow-up treatment is initiated. If you cannot obtain documentation of the community findings, then the dental exam would need to be repeated.
— From CorrectCare Volume 16, Issue 2, Spring 2002
 Return to List 

DISCHARGE PLANNING
In standard J-E-13 Discharge Planning, we interpret Compliance Indicator 1a to mean that a written prescription for medication satisfies the requirement; provision of the medication itself is not necessary. Is this in compliance?
     The intent of the standard is that “patients’ health needs are met during transition to a community health care professional.” So, if one of the needs is medication, the intent would be that the inmate have a sufficient supply to be able to continue taking the medication until seen by a community provider.
     A written prescription is sufficient only if the provider knows that the patient has the ability to have it filled immediately upon discharge. The provider must be sure that the patient has the money (not that next week he will be eligible for Medicaid or other assistance) and the means (transportation, etc.) to get to a pharmacy that will fill the prescription. For example, the facility can transport the discharged patient to a designated community pharmacy, or provide money for a cab or bus along with instructions on how to get to the pharmacy. The jail may have an account with the pharmacy so that the prescription is billed to the jail, not the patient.
     Thus, a facility giving written prescriptions would be in compliance with this important standard only if the financial and access issues are addressed. In our view, it is much easier to make a postdischarge medical appointment for the patient and to provide enough medication to last until that appointment.
— From CorrectCare Volume 20, Issue 3, Summer 2006; updated February 2010
 Return to List 

DISCIPLINARY REPORTS
At least once a year, an inmate gives one of the nurses a hard time and security staff wants nursing to write a disciplinary report. Usually we write information reports and security does the disciplinary report to avoid any conflict. We want a solid answer as to whether or not medical should be involved in disciplinary actions.
     Although no NCCHC standard explicitly addresses involvement in disciplinary matters, the principles that underlie standard I-03 Forensic Information also apply here.
     Health staff should deal with disrespectful inmates just as they would deal with unruly patients in a community outpatient setting. For example, if a patient yells in a community clinic, staff generally do not call the police, particularly if the patient is confused, upset, mentally unstable, intellectually limited, etc.
     In a correctional setting, health staff must respond professionally, stating that such behavior is unacceptable and laying out firm expectations: “I know you are upset, but if you do not calm down I must ask you to leave.” The more that health staff project the neutral yet concerned demeanor expected of a professional, the more that inmates will respond in kind.
     Obvious exceptions would be threats or physical contact by an inmate whose behavior is under his or her control and not due to a medical or mental health condition. In such cases, the procedure you describe—health staff write an information report; correctional staff do the disciplinary report—is the appropriate response. But this should be reserved for the most serious situations. In these cases, health staff retain the right to press charges.
     For “repeat offenders,” it may be best to meet with the inmate to discuss expectations and consequences. Meeting participants should include correctional staff with decision-making authority, health staff and, if applicable, an inmate corrections counselor and/or a mental health therapist. If an agreement is reached, then all health staff involved and correctional staff assigned to the area must be aware of the expectations so that the plan is followed consistently. For example, an inmate who routinely uses abusive language to health staff “contracts” that should he reply to health staff in that manner, he will immediately apologize and calm down with one reminder by staff, or else will be escorted back to his block and be rescheduled at a future date.
     If the facility has an inmate representative body, discussion with the inmate representatives about such problems can be very helpful.
— From CorrectCare Volume 20, Issue 3, Summer 2006
 Return to List 

DOCUMENTATION
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
 Return to List 

EMERGENCY RESPONSE PLAN
Recently, we had a fire in our facility and had to implement our emergency response plan and evacuate a housing unit. Can we use the critique of this incident toward meeting the A-07 Emergency Response Plan standard, even though there were no casualties?
     Yes. Actual emergencies, whether or not injuries were involved, can certainly be critiqued and shared with staff to meet the intent of this standard. (See the Discussion section in the standard.)
— From CorrectCare Volume 23, Issue 2, Spring 2009
 Return to List 

END-OF-LIFE DECISION MAKING
In our prison, terminally ill inmates are sent to a community hospital where the admission procedures enable them to execute a DNR (do not resuscitate) order that the hospital would follow. However, if the inmate improves and returns to the prison, the DNR orders are not honored. If necessary, emergency, life-saving interventions are initiated before transport back to the hospital. Are we in compliance with important standard P-I-04, End-of-life Decision Making?
     This question was taken up recently by the Accreditation Committee, which decided that in the circumstances above, the intent of the standard is not being met. Though it is possible for the inmate to be returned to a hospital setting as death approached, it also is possible that a life-threatening emergency requiring CPR and related interventions would occur in the prison and the inmate would be subjected to measures explicitly declined in the DNR order before or during transport to the hospital.
     Standard I-04 intends that inmates retain their medical-legal rights regarding end-of-life decisions. Therefore, facilities or systems considering denial of an inmate’s right to execute a DNR order should check with their appropriate legal counsel (state or county) to determine whether the directive is in compliance with the jurisdiction’s regulations on this matter.
— From CorrectCare Volume 18, Issue 4, Fall 2004
 Return to List 

ENVIRONMENTAL HEALTH AND SAFETY
Now that Environmental Health and Safety (B-02) no longer appears in the Standards [2008 jail and prison editions], are we still required to conduct inspections?
     The 2008 Infection Control standard (B-01) now requires a monthly environmental inspection to be conducted of areas where health services are provided. This is to verify that equipment is maintained, that the unit is clean and sanitary and that measures are taken to ensure the unit is occupationally and environmentally safe. Please note that the 2003 Ectoparasite Control (B-04) standard is also addressed in the 2008 Infection Control standard.
— From CorrectCare Volume 23, Issue 1, Winter 2009

What are NCCHC’s expectations for documentation of environmental/infection control to be reviewed during accreditation surveys? Are external inspections required? Do OSHA and CDC guidelines need to be followed for accreditation? 
     Whew! Let’s take your issues one at a time.

1. Documentation of environmental and infection control practices can include inspection reports, meeting minutes, quality improvement studies, policies and procedures specifying such practices, logs or other evidence of appropriate sterilization of instruments and equipment, sharps disposal containers, evidence that biohazardous materials are handled and disposed of appropriately, etc.
2. Inspections by outside agencies are useful, but they are not required for accreditation.
3. Similarly, while NCCHC recommends that agencies follow OSHA and CDC guidelines, the commission’s surveyors are not inspectors for those government agencies.

— From CorrectCare Volume 15, Issue 3, Summer 2001
 Return to List 

FAMILY SUPPORT RESOURCES
Our daughter has spent a good deal of her life in correctional facilities, and she is serving time again. Her crime is what she is doing to herself: She has mental health and drug addiction problems. We cannot find advocacy groups of family members in support of those who find themselves incarcerated in a system that does not appear able to help them deal with their problems and get treatment so they can stay out of prison. Do you know of any resources?
     Unfortunately, many families and friends are in the situation you find yourself regarding your daughter. While your inquiry does not relate to NCCHC standards, we want to address it in this column to provide information for correctional health staff who may be asked the same question.
     Your best initial contacts are the National Mental Health Association (703-684-7722) and the National Alliance on the Mentally Ill (703-524-7600). Both organizations have national, state and local chapters, as well as subgroups that focus on issues related to mentally ill people who are incarcerated. The specialized groups are involved with initiatives such as diversion from correctional settings, quality care while incarcerated, and discharge and follow-up issues. They also may be able to direct you to other resources in your area.
— From CorrectCare Volume 20, Issue 1, Winter 2006
 Return to List 

FORENSIC INFORMATION
Our health services team is clashing with security about collecting forensic information. Our facility is accredited, and we argue that we cannot be involved according to NCCHC standards. We also feel it is a conflict of interest and would interfere with patient relationships. Security claims that certain activities are “medical” and they want the nurses to take blood samples, DNA swabs, etc.
     You are correct; standard J-I-03 intends that health staff serve the health needs of their patients, and this means that they should not gather forensic information because of the professional and ethical conflicts in taking actions that (a) are typically done without inmate consent, (b) could lead to adversarial action against the patient and (c) undermine professional credibility.
     Some states require that certain forensics-related acts be conducted by health professionals; in those cases, the services should be provided by a staff member who is not involved in that patient’s care or by an outside party. That said, the standard does make an exception in Compliance Indicator 1. To summarize, health services staff may participate in the following circumstances:
     • State law requires a blood sample, so long as the inmate consents and health staff are not involved in punitive action if the inmate refuses to consent
     • A physician orders a body cavity search or blood/urine testing for medical purposes (e.g., to test for alcohol or drugs in the blood)
     • With inmate consent, conducting court-ordered lab tests, exams or radiology procedures
     • With inmate consent, gathering evidence from a victim of sexual assault
     Finally, you should educate security officials that many techniques for collecting forensic information do not require health expertise. These include urine testing and oral and buccal swabs for DNA testing.
— From CorrectCare Volume 24, Issue 4, Winter 2010

Where do we draw the line on what is considered “confidential” patient information? Health services conducted a urine toxicology screen of a prisoner and the results indicated the presence of an illicit drug. Is this protected medical information or should we notify custody? Do we just drop a hint, or do we name names?
     Assuming that the test was for clinical purposes (and it should have been, as per standard I-03 Forensic Information), the results should be used for clinical reasons only. You may share with the appropriate officials your concern that the substance may be present in the prison so that they can look into the possible security breach. However, the inmate’s identity must be protected. To avoid conflict or pressure from custody, health services policies and procedures should address the role of health staff in such an event and the warden and custody staff should have a clear understanding of this role. (See A-03 Medical Autonomy and H-02 Confidentiality of Health Records.)
— From CorrectCare Volume 24, Issue 3, Summer 2010

I work at a detention facility whose function and purpose are defined under state laws. There is some controversy about blood draws here. Only one RN is on site at any given time, and when someone is arrested for driving under the influence, that nurse is asked to draw the inmate’s blood for analysis. We only draw it and give it to the arresting officer; we do not analyze it. One of the RNs thinks that under state standards we are not supposed to draw the blood and is reluctant to do so.
     NCCHC is not expert in state regulations or standards. We base our reply on the 2003 NCCHC Standards for Health Services in Jails. Standard J-I-03 Forensic Information prohibits health services staff from participating in the collection of forensic information based on the bioethical principle of protecting the patient-provider relationship. When health staff are involved in collecting information for punitive matters (and which is usually done without an inmate’s consent), the therapeutic relationship with the inmate is jeopardized. The health services staff should protect their ethical boundaries to serve the health needs of their patients first. The credibility of health staff with their patients should never be compromised.
     If the state requires that such acts be performed by health professionals, the facility should use the services of outside providers or someone on staff who is not involved in the therapeutic relationship. If neither of those options is possible, health services staff may comply with state laws and take forensic blood samples so long as the inmate gives consent and, if the inmate refuses to participate, health services staff are not involved in any punitive action taken as a result of the refusal.
— From CorrectCare Volume 22, Issue 1, Winter 2008

Custody staff often seek medical clearance before using pepper spray on an inmate. Does this act of clearance, giving the “yea or nay,” qualify as partaking in a disciplinary proceeding? Does such an act undermine the intent of the forensic information standard? One can argue that if health staff did not participate, it would cause more harm than good (because those with contraindications would be sprayed). However, reasonable people could conclude that any participation undermines the credibility of health professionals.
     The answer relates to standards A-08 Communication on Special Needs Patients and I-03 Forensic Information. The responsible physician decides how health services will respond. Usually the physician is the staff member to determine what would prohibit an inmate from being sprayed because of possible negative consequences. The determination may be done at the time of the incident, or it may be done routinely as part of the initial health assessment, with a notation in the same place in each health chart. The wording of the “clearance” should be simply that there is or is not any health contraindication to the use of pepper spray for the inmate. The physician is not giving an order for the spray nor saying that it is OK to use it.
     All health and custody staff should be able to reference a written protocol as to any health intervention required after the spray is used. Any inmates who do receive pepper spray are taken to medical staff for appropriate interventions.
     You imply that health staff may not participate in disciplinary proceedings. Actually, health staff may consult in disciplinary hearings or decisions provided that they do not make the decision. In such cases, health staff, including mental health staff, should indicate whether any health or mental health condition may have contributed to the behavior in question. Health staff also may alert custody to the potential negative effects on the inmate of the proposed disciplinary action, and to help find appropriate alternate measures if the disciplinary action is contraindicated.
— From CorrectCare Volume 21, Issue 4, Fall 2007

Standard J-I-03 Forensic Information addresses DNA testing for inmates. But how would NCCHC review situations in which jail staff collect DNA samples for non-inmates as requested by court order? For instance, the court may require that an individual at trial must have his DNA taken, although he is not currently in jail.
     The NCCHC standards do not address services for or interactions with non-inmates. We suggest that if you do draw the samples, you do so only with the individual’s consent, just as you would for an inmate. Your system may want to consider buccal DNA sampling, which is easily done by trained nonhealth staff.
— From CorrectCare Volume 20, Issue 3, Summer 2006

Does NCCHC have a policy or guideline about doing drug screens on intake for inmates suspected of substance abuse problems? Assessment is difficult without testing since drug intoxication and withdrawal often present with mental illness symptoms.
     NCCHC standards require that you conduct your clinical practice as you would in any other setting, modifying nonclinical issues as required by the correctional setting but not compromising your clinical guidelines.
     Health staff in facilities accredited by NCCHC are often cautious about substance abuse testing, being mindful of standard I-03 Forensic Information and the need to avoid getting into potential adversarial situations with inmates they are trying to treat.
     However, your intent is a clinical one: to assess a substance-abusing inmate for diagnostic and treatment planning purposes. An important caution is that the results of such testing are not to be shared with corrections; results should be treated with the same confidentiality as any other blood or urine testing and recorded in the medical record.
— From CorrectCare Volume 20, Issue 2, Spring 2006

I am the health services administrator at a county jail. We have been asked to draw the blood alcohol test specimens used to determine DUI charges. Can a trained medical technician or phlebotomist draw this, when requested, as part of the intake bloods? This staff member would be permanently assigned to the intake area and would not float to other areas in the medical unit. Two samples would be drawn: The blood alcohol test sample would be given to the officer; the intake sample would be in a separate tube. The inmate would be told the specimen was for DUI and a consent form would have to be signed. I do not think there would be a problem with compliance with standard J-I-03 Forensic Information.
     You are correct. Phlebotomists or trained med-techs who only draw blood are not considered to have a therapeutic relationship with the inmates as defined by NCCHC and standard J-I-03. The safeguards you mention need to be reflected in your policies and procedures.
— From CorrectCare Volume 19, Issue 3, Summer 2005

 Return to List 

HEALTH ASSESSMENT
I work in a jail and would like to know if we are required to complete a screening test for tuberculosis as part of the receiving screening.
     No, the E-02 Receiving Screening standard for jails does not require inmates to receive a tuberculosis test at the time of the receiving screening. Mainly this is because detainees often do not remain in the facility long enough to have the tuberculin skin test read. However, TB testing is required under the E-04 Initial Health Assessment standard (see Compliance Indicators 2e and 5e). We also recommend that a tuberculosis control plan be followed that is consistent with published guidelines from the Centers for Disease Control and Prevention. Please note that for prisons, a screening test for tuberculosis is required under the Receiving Screening standard (Compliance Indicator 10).
— From CorrectCare Volume 23, Issue 2, Spring 2009

I was wondering if a history and physical is required as part of the infirmary admitting order, under the G-03 Infirmary Care standard?
     No. A patient may have just had a health assessment prior to being placed in the infirmary, so an additional history and physical would not be required. An infirmary order should include the admitting diagnosis, medication, diet, activity restrictions, diagnostic testing required, frequency of vital sign monitoring and other follow-up (Compliance Indicator 8a). Admission to and discharge from the infirmary should occur only on the order of a physician (or other clinician where permitted by virtue of his or her credentials and scope of practice).
— From CorrectCare Volume 23, Issue 2, Spring 2009
 Return to List 

HEALTH CARE LIAISON
Our facility has health staff on site 19 hours a day, seven days a week. Does the Health Care Liaison standard (C-08) apply to us?
     Yes. According to the standard, a designated, trained health care liaison coordinates the health care delivery services in the facility when qualified health care professionals are not on site. The intent is to ensure that inmates continue to have access to health services. On shifts where qualified health care professionals are not on duty, the liaison may communicate the health needs of inmates to the responsible health authority. Health care liaisons are guided by protocols, developed by the responsible physician, that give direction about the triaging of nonemergency sick-call requests.
— From CorrectCare Volume 22, Issue 4, Fall 2008
 Return to List 

HEALTH RECORDS
We have an electronic health records system. Will NCCHC be updating accreditation requirements concerning electronic signatures and forms?
     The Standards for Health Services already address electronic health records (EHR). In essential standard H-01 Health Record Format and Contents, Compliance Indicator 3 states, “If electronic records are used, procedures address integration of electronic and paper health information.” The Recommendations section adds that such systems “should protect access and provide security... by the use of passwords. Procedures for ‘down time’ and regular backups should be in place.”
     Basically, everything that is required of a hard record is also required of the electronic record. Using standard H-04 Availability and Use of Health Records as an example, if sick calls are entered directly into the EHR, health staff must be able to access the record in the sick-call room. As with the hard records, forms may be facility-specific as long as they provide the required documentation. If it is legal in your state, NCCHC does accept electronic signatures of health staff.
— From CorrectCare Volume 20, Issue 4, Fall 2006

Do the NCCHC standards require that a jail start a health record for everyone who is admitted?
     No. Each inmate admitted must have a receiving screening completed and documented (standard J-E-02 Receiving Screening). Most jails keep the receiving screening documents in a general file for easy access or future reference should the inmate be readmitted. However, a health record must be created if any health intervention is provided after the receiving screening (J-H-01 Health Record Format and Contents). A copy of the receiving screening forms should be included in this record.
— From CorrectCare Volume 19, Issue 4, Fall 2005

My state’s department of corrections uses prison beds in another state. What is NCCHC’s stance on integrating medical records from one state into another state system? We had been placing all medical information (summaries of patient care received from the other state) in the medical file’s miscellaneous section and all mental health information in the mental health section. The DOC says we should sort all information from the other state—e.g., progress notes, physician orders, labs—into the current chart. We have no problem doing this, but feel it might be confusing as to what took place where.
     This issue is not addressed in NCCHC’s standards. Thus, you can make an internal decision about the most useful way to organize the chart for your health staff and have the state medical director issue the directive. NCCHC accreditation surveyors would be concerned that documentation from another system was clearly labeled as such and readily available for reference by the health staff of your system. How you choose to do that, though, is up to your system.
— From CorrectCare Volume 17, Issue 2, Spring 2003
 Return to List 

HOSPITAL AND SPECIALTY CARE
When an inmate returns after a hospital visit, certain paperwork is supposed to accompany him back to the jail. According to standard J-D-05 Hospital and Specialty Care, Compliance Indicator 2, the written agreement with the hospital requires the hospital “...to give the inmate a summary of the treatment given and any follow-up instructions....” Is it wise to let the inmate have these papers?
     The phrasing is not meant to imply that the inmate should literally take possession of the documents. Rather, such documents should be given to health staff. Our intent with this standard is to convey the importance of having the outside provider send this information at the same time that an inmate is returned to the facility so that it can be reviewed immediately by facility health staff (see also J-E-12 Continuity of Care, Compliance Indicator 3).
— From CorrectCare Volume 24, Issue 1, Winter 2010

Are we required to have a contract between our facility and the local hospital?
     No. According to the Hospital and Specialty Care standard (D-05), for each community hospital or off-site specialty service used regularly for medical and mental health care, there should be a written agreement that outlines the terms of the care to be provided. Such a written agreement could be a contract, but it could also be a memorandum of understanding (MOU) or letter of agreement. The intention is that the responsible health authority anticipates and resolves problems in advance of the delivery of specialty care or hospitalization by having written agreements in place.
— From CorrectCare Volume 23, Issue 3, Summer 2009

What is NCCHC’s position on providing casting services on site for closed fractured extremities in a correctional setting?
     Two standards apply to this question. C-01 Credentialing, Compliance Indicator #3: “Health providers do not perform tasks beyond those permitted by their credentials”; and D-05 Hospital and Specialty Care, Compliance Indicator #4: “For on-site specialty services used regularly for medical and mental health care, there are appropriate licenses and certifications.” So if the staff doing the procedure on-site would be able to do it in a community setting, and the facility’s setting/tools/supplies/etc. would meet credentialing requirements if credentialing were needed to perform the service, then NCCHC’s Standards for Health Services would allow the practice. The responsible health authority and responsible physician (when the RHA is not a physician) must determine that there are appropriately credentialed and trained health staff, and appropriate direct and auxiliary services and supplies on-site (x-ray, casting materials, etc.). If you are not sure what is needed, an orthopedic specialist could assist.
— From CorrectCare Volume 22, Issue 1, Winter 2008

In talking with health staff at the local hospital emergency room, the question arose as to whether there is a definition of “fit for confinement” that ER physicians could refer to when deciding if an inmate can be cleared for a jail. Can NCCHC help?
     I assume this is a situation in which an inmate was sent to the ER for an evaluation for a medical and/or mental health problem, and the ER is trying to decide if the inmate can be sent back to the jail.
     Your best bet is to consult NCCHC’s Standards for Health Services in Jails, specifically essential standards J-A-01 Access to Care and J-E-02 Receiving Screening and important standard J-D-05 Hospital and Specialty Care. Here is a summary of how these standards address your question.
     Inmates have a constitutional right to access to care for their significant health problems. If the level of care needed is not available at the facility, inmates are to be treated in a setting that can meet their specific health needs, such as a community hospital or ER, or perhaps a better equipped (i.e., health staff and services) correctional facility with which the original facility has transfer arrangements.
     The ER physician involved in deciding if the inmate can be appropriately treated at the jail must consider several things. Foremost is the level of health or mental health services needed for follow-up if the inmate-patient is released, and whether the available jail health resources are at that level.
     Sometimes when opinions differ between community ER physicians and jail physicians, it is because the ER physician does not really know what is available at the jail. A visit to the jail and an exchange of information about its health staffing and capabilities are essential to good planning between jail and ER health administrators and physicians.
     One way for the ER physician to think about a return to jail is to regard it as a return to home care. That is, if the inmate were a regular community patient with a home and minimally supportive situation, would the hospital send the patient home? Does the inmate-patient simply need observation that could be done by minimally trained correctional officers, or does he or she inmate-patient need nursing care that is (or is not) available on-site? If the jail has an infirmary, what scope of care is available? Is there a sheltered housing area where the inmate can receive the necessary services? For example, is there a negative-pressure room to house contagious TB patients, or does the patient need to stay at the hospital until the contagious phase has passed?
     Some ER physicians mistakenly assume that jails have 24/7 health staff and supports. While that may be true in a few jails, particularly in the mega-systems, most have limited on-site health resources. On the other hand, if you or I were treated in an ER and then sent home and not hospitalized, jails should expect that the ER will want to do the same for inmate-patients treated for the same conditions.
     Given the possibility that little attention may be given to a returning inmate, the ERs may be advised to hold the inmate-patient for a little longer observation if there is any doubt. Some jails and ERs create a “locked ward” at the hospital when such patient volume is high.
— From CorrectCare Volume 21, Issue 3, Summer 2007
 Return to List 

INFANTS IN CORRECTIONAL FACILITIES
New York State law allows women who give birth while in jail to have their newborn in the jail with them if they wish until the child reaches one year of age. In at least one New York State jail accredited by NCCHC, a woman is keeping her baby in the jail environment. What do the standards say about this? Are health staff responsible for the child’s health?
     The Commission’s standards do not address the provision of health care for anyone other than inmates. Whether health staff at a particular facility are responsible for providing health services to a child of an inmate who resides at the facility depends on the rules that were established to govern this program.
— From CorrectCare Volume 16, Issue 3, Summer 2002

We are an accredited women’s prison and our commissioners have asked us to develop a “newborn” program on-site so that pregnant inmates wanting to keep their child would be able to have the baby in the facility for the first year. Would such a program be in compliance with NCCHC standards? Do you have any advice for us?
     NCCHC’s standards do not address this issue since infants are not inmates in the traditional sense of the word. My advice is to research this issue carefully before launching such a program, because there are a number of legal, ethical and financial concerns that must be addressed. You also may want to visit a correctional facility that permits “babies behind bars” (such as Bedford Hills in New York State) to see how their program operates. [Note: For further discussion, see “Babies Behind Bars: The Rights and Liabilities of Babies and Mothers,” in the Winter 2001 CorrectCare.]
— From CorrectCare Volume 15, Issue 4, Fall 2001
 Return to List 

INFECTION CONTROL PROGRAM
What are NCCHC’s expectations for documentation of environmental/infection control to be reviewed during accreditation surveys? Are external inspections required? Do OSHA and CDC guidelines need to be followed for accreditation?
     Whew! Let’s take your issues one at a time.

1. Documentation of environmental and infection control practices can include inspection reports, meeting minutes, quality improvement studies, policies and procedures specifying such practices, logs or other evidence of appropriate sterilization of instruments and equipment, sharps disposal containers, evidence that biohazardous materials are handled and disposed of appropriately, etc.
2. Inspections by outside agencies are useful, but they are not required for accreditation.

3. Similarly, while NCCHC recommends that agencies follow OSHA and CDC guidelines, the commission’s surveyors are not inspectors for those government agencies.

— From CorrectCare Volume 15, Issue 3, Summer 2001

How do we prove that our isolation rooms are working? Do we actually need isolation rooms on-site to be in compliance?
     There should be some evidence that the isolation rooms are checked periodically to ensure that negative air pressure is maintained and that the contaminated air is not circulated throughout the system. Often, equipment manufacturers provide guidelines on what should be checked and at what frequency. You do not need to have an isolation room if you never keep inmates with contagious conditions in your facility. In this case, however, your policies and procedures or infection control plan should specify where such individuals are transferred and what precautions are to be taken until the transfer can be effected.
— From CorrectCare Volume 15, Issue 3, Summer 2001
 Return to List 

INFIRMARY CARE
I would like some interpretation and clarification for the standard on infirmary care, and specifically how often the physician must actually see the patients in the jail infirmary. The standard states that the frequency of physician rounds is based on the categories of care provided, but are there some guidelines we could draw from? For instance, should each patient be seen by the physician daily, a minimum of three times per week, etc.?
     We do leave it to the responsible physician to determine the frequency of rounding. It depends on the acuity of the cases that are admitted. It doesn’t make sense to require daily rounding by the physician when the patient with a postsurgical gunshot wound is in the infirmary for dressing changes. Nor would it make sense to require daily rounds when the physician provides only 20 hours a week in the jail. So the answer is that the “frequency of physician rounds is specified based on the categories of care provided.” Some facilities use midlevel providers, such as a nurse practitioner or physician assistant, to conduct daily rounds, with the physician rounding three times a week or even once a week. This approach would be fine.
— From CorrectCare Volume 24, Issue 2, Spring 2010

I was wondering if a history and physical is required as part of the infirmary admitting order, under the G-03 Infirmary Care standard?
     No. A patient may have just had a health assessment prior to being placed in the infirmary, so an additional history and physical would not be required. An infirmary order should include the admitting diagnosis, medication, diet, activity restrictions, diagnostic testing required, frequency of vital sign monitoring and other follow-up (Compliance Indicator 8a). Admission to and discharge from the infirmary should occur only on the order of a physician (or other clinician where permitted by virtue of his or her credentials and scope of practice).
— From CorrectCare Volume 23, Issue 2, Spring 2009

We operate an infirmary and have a supervising registered nurse on every shift. Is this what is intended by the standard?
     In standard G-03 Infirmary Care, Compliance Indicator 4 requires that “a supervising registered nurse is on site at least once every 24 hours” (emphasis added). A supervising RN need not be present on every shift.
— From CorrectCare Volume 22, Issue 3, Summer 2008

Please clarify your standards concerning inmate workers. In C-06, Compliance Indicator 3 states, “Inmates do not provide direct patient care,” but the Discussion says they may assist other inmates in activities of daily living, such as ambulation, bathing, dressing, feeding and toileting. In the community, ADLs are direct patient care for certified nursing assistants. How do you define direct patient care?
     In general, NCCHC defines direct patient care as health interventions or services that in the free world usually are provided only by appropriate health professionals who have the necessary clinical skills. Inmate workers are not to take the place of health staff. However, ADLs can be provided on different levels and, depending on the patient’s status, may or may not require clinical skills.
     In the free world, when assistance in ADLs is part of services provided by family members, volunteers, paraprofessionals, etc., in what are considered non-inpatient settings (home, assisted living situations, hospice care, etc.), it generally falls under the category of nonskilled nursing care. But when a patient is hospitalized, those same ADLs become part of the skilled nursing care provided by nurses of various levels according to the tasks needed.
     Similarly, different levels of ADL assistance may exist in correctional settings. Here’s how NCCHC distinguishes between these levels to assess compliance with the intent of the relevant standards (C-06 Inmate Workers and G-03 Infirmary Care). When the patient is housed in general population (defined as any noninfirmary setting, such as medical housing, sheltered housing, segregation, hospice, etc.), trained inmate workers (known by various names in different facilities) may provide the ADL assistance. However, if the patient is admitted to an infirmary on infirmary status, the ADLs become part of the skilled nursing care required and inmate workers may not provide the assistance.
     Some infirmaries may house patients who are not classified as on “infirmary status.” In such cases, it is possible for an inmate worker to assist one patient living in the infirmary who is there on sheltered care status, but not assist another patient who is there to receive infirmary care.
— From CorrectCare Volume 19, Issue 1, Winter 2005

In the infirmary, may inmate-orderlies assist patients with activities of daily living such as bathing, brushing teeth, transferring and feeding? Do the NCCHC standards allow this as long as the orderlies are directly supervised by nursing? If so, does it have to be an RN or can it be an LPN? I could not find anything about this in our state regulations.
     The standards governing this matter are C-06 Inmate Workers and G-03 Infirmary Care, both of which are essential. (They are the same for prisons, jails and juvenile facilities.)
     Infirmary care is skilled nursing care within the facility’s defined scope of practice. In the correctional environment it is considered inpatient care. It differs from outpatient care for those who may need sheltered housing or observation.
     When a patient is on infirmary status, the usual activities of daily living (e.g., bathing, feeding, dressing) are within the nursing discipline’s scope of practice. Inmate orderlies, assistants or whatever they are called may not provide such assistance to patients, whether or not the inmate workers are under the direct observation of nursing staff. It does not matter how well they are trained. If an inmate needs skilled nursing care, assistance with these tasks requires the attention and assistance of nursing staff.
     However, trained inmate workers can assist other inmates in general population or other outpatient housing areas with these tasks. In settings other than an infirmary they are providing assistance that parallels home care in the community. They also may assist inmates who happen to be housed in the infirmary, but who are not on inpatient status.
     That said, it may be confusing to staff, patients and inmate-workers as to who’s who in the infirmary, so most clinicians prefer that such assistance by inmate-workers not take place in the infirmary.
— From CorrectCare Volume 18, Issue 3, Summer 2004; updated February 2010.
 Return to List 

Given the national nursing shortage, could a paramedic take the place of an RN in an infirmary for the night shift? Paramedics can do assessments, which LPNs cannot.
     In all three sets of standards (jail, prison and juvenile), the basic requirement for infirmary staffing is that the patients are within sight or sound of a health staff member at all times. This staff member does not have to be an RN, but must be someone authorized by the responsible physician who can meet the needs of the patients on a particular shift. The patients’ acuity levels and the types of services they need will determine the level of staff required. For example, if IVs are being given and only RNs may give this level of care in your state, then an RN would be needed. If the patients’ acuity level is lower and the services they require are within the scope of practice of a paramedic, a paramedic could work on that shift. In all cases, however, an RN must be on site in the infirmary at least once every 24 hours to review care, the functioning of the infirmary, etc. Whether the paramedic is a member of the health staff also matters. Officers who happen to be paramedics but are on duty functioning as officers could not do "double duty" under this standard.
— From CorrectCare Volume 16, Issue 3, Summer 2002
 Return to List 

INFORMATION ON HEALTH SERVICES
I am helping a jail get ready for its accreditation survey. I am told that there is not really a Spanish-speaking population in this community. In that case, do they still need to have the inmate orientation information in Spanish as well as English?
     Standard J-E-01 Information on Health Services does not state that inmate orientation information must be written in Spanish. The third compliance indicator says,  “Special procedures ensure that inmates who have difficulty communicating (e.g., foreign speaking, developmentally disabled, illiterate, mentally ill, deaf) understand how to access health services.” Therefore, if there isn’t a community need to pre-print information in Spanish (or other foreign language), at least there should be a procedure in place so that appropriate efforts are made to ensure that inmates understand how they can access health services. For example, a language line or local translator might be available in the event a Spanish-speaking inmate arrives. Keep in mind that if the bulk of your population speaks only Swahili, then you should accommodate these inmates.
— From CorrectCare Volume 25, Issue 4, Fall 2011
 Return to List 

INFORMED CONSENT
Does a general informed consent form signed by an inmate upon arrival cover us?
     No. Written consents are still required for invasive procedures including surgeries, invasive diagnostic tests, dental extractions and use of psychotropic medications. In fact, a blanket refusal for treatment would not be in compliance with the I-05 standard either.
— From CorrectCare Volume 23, Issue 3, Summer 2009

Our jail’s previous intake screening form had a line that gave “blanket” consent for medical treatment. Separately, consent would be obtained by the dentist for extractions and by the mental health department for medications. Now, medical has no signed consent, “blanket” or otherwise, since the new screening form has no place for this consent. Don’t we need signed consent for evaluation and treatment, and specific consent for invasive procedures? PPD placement, blood draws (RPR, CBC, etc.), I&D, and even Pap tests could all be considered invasive. I was told that only a refusal needs to be signed, which is like putting the cart before the horse.
     Any procedure requiring written consent in the community also requires a signed consent from an inmate in a correctional setting. Generally, written consent is required for any treatment or procedure that is invasive and carries some risk of an adverse outcome. Note, though, that not all health encounters require written consent. If the treatment/procedure is neither risky nor invasive, consent may be implied when the patient shows up for the health encounter. That said, if your facility wants to obtain written consent for every health encounter, it may do so. Standard J-I-05 Informed Consent and Right to Refuse Treatment addresses these issues in more detail.
— From CorrectCare Volume 17, Issue 2, Spring 2003; updated February 2010
 Return to List 

INMATE DEATH
Typically, we wait for the results of the autopsy in order to complete a clinical mortality review. This often takes 60 days or more. Is it acceptable to wait for the autopsy results before completing the clinical mortality review?
     Death reviews should be completed in a timely manner even if the autopsy results are not yet returned. According to standard A-10 Procedure in the Event of an Inmate Death, all deaths should be reviewed within 30 days (see Compliance Indicators). Reviews consist of an administrative review, a clinical mortality review and, if the death is by suicide, a psychological autopsy. The intention of this standard is to avoid preventable deaths; therefore, any corrective actions identified through this process should be implemented and monitored sooner rather than later and treating staff should be informed of the administrative review and clinical mortality review findings. Clinical mortality reviews can be appended with information from the medical autopsy report.
— From CorrectCare Volume 23, Issue 2, Spring 2009
 Return to List 

INMATE WORKERS
We are considering offering basic first aid and CPR classes to our inmates. It is not our intention to use inmates in any capacity to provide routine care for other inmates, but rather, to provide those inmates who are interested with skills that may be of value in the event of an extreme emergency situation. What is NCCHC’s position on training inmates in basic health care issues? Would you consider this a violation of standard C-06?
     C-06 Inmate Workers prohibits the use of inmates as health care workers. Since you have stated that you would not be using inmates in this capacity, there is no violation of the standard. NCCHC supports health education programs for inmates. As long as you do not intend to use inmates to provide ongoing care, there is no reason that they should not have an opportunity to learn CPR and basic first aid.
     Examples of violations of this standard include inmate workers taking pulse and oximetry readings on patients waiting for sick call, checking abnormal blood pressure readings and changing bandages, or even taking supplies from the cabinet. Inmates translating sick call slips from English is a violation of patient confidentiality. These situations may place inmate workers in a position of power over their peers. It may be tempting to use inmate workers in health care delivery when staffing is an issue, but besides violating the NCCHC standard, doing so frequently violates state laws, invites litigation and brings discredit to the correctional health care field.
— From CorrectCare Volume 22, Issue 3, Summer 2008

In our facility, we have hospice inmate volunteers and some inmates are permitted to help others with activities of daily living (ADL), such as toilet assistance. Where is the line between nursing care and ADL assistance?
     In the 2008 standard C-06 Inmate Workers, Compliance Indicator 1 states that inmates do not make treatment decisions or provide patient care. Compliance Indicator 4 indicates that while inmates are not substitutes for regular program staff, they may be involved in appropriate peer health-related programs such as hospice or buddy systems for potentially suicidal inmates. Our answer assumes that the inmate-worker has been properly vetted and trained to work in the hospice program. As in most hospice settings, family members may assist in feeding, bathing and dressing their loved ones. In a correctional hospice setting, it is understood that some inmate-worker volunteers may perform these functions.
— From CorrectCare Volume 22, Issue 2, Spring 2008

Would use of a “lifeline” suicide prevention program affect our prison’s accreditation with NCCHC? In this program, staff from a community suicide prevention agency train inmates to provide peer support to suicidal inmates. When inmates are identified as suicidal, a mental health clinician or nurse assesses their mental status. Those admitted to the infirmary on mental health watch are assigned a trained “lifeliner,” who comes to the infirmary to sit and talk with the suicidal inmate. Afterwards, the lifeliner debriefs with a mental health worker. These services are not in lieu of formal mental health treatment but are a complement to it.
     As long as the inmates in the lifeline program are not used to substitute for staff but only provide supplemental services for the suicidal inmates, you would be in compliance with the relevant standards, P-C-06 Inmate Workers and P-G-05 Suicide Prevention Program (2003 Prison Standards). As you implied, training and supervision of the lifeliners is essential to the success of such a program.
— From CorrectCare Volume 21, Issue 2, Spring 2007

Please clarify your standards concerning inmate workers. In C-06, Compliance Indicator 3 states, “Inmates do not provide direct patient care,” but the Discussion says they may assist other inmates in activities of daily living, such as ambulation, bathing, dressing, feeding and toileting. In the community, ADLs are direct patient care for certified nursing assistants. How do you define direct patient care?
     In general, NCCHC defines direct patient care as health interventions or services that in the free world usually are provided only by appropriate health professionals who have the necessary clinical skills. Inmate workers are not to take the place of health staff. However, ADLs can be provided on different levels and, depending on the patient’s status, may or may not require clinical skills.
     In the free world, when assistance in ADLs is part of services provided by family members, volunteers, paraprofessionals, etc., in what are considered non-inpatient settings (home, assisted living situations, hospice care, etc.), it generally falls under the category of nonskilled nursing care. But when a patient is hospitalized, those same ADLs become part of the skilled nursing care provided by nurses of various levels according to the tasks needed.
     Similarly, different levels of ADL assistance may exist in correctional settings. Here’s how NCCHC distinguishes between these levels to assess compliance with the intent of the relevant standards (C-06 Inmate Workers and G-03 Infirmary Care). When the patient is housed in general population (defined as any noninfirmary setting, such as medical housing, sheltered housing, segregation, hospice, etc.), trained inmate workers (known by various names in different facilities) may provide the ADL assistance. However, if the patient is admitted to an infirmary on infirmary status, the ADLs become part of the skilled nursing care required and inmate workers may not provide the assistance.
     Some infirmaries may house patients who are not classified as on “infirmary status.” In such cases, it is possible for an inmate worker to assist one patient living in the infirmary who is there on sheltered care status, but not assist another patient who is there to receive infirmary care.
— From CorrectCare Volume 19, Issue 1, Winter 2005

In the infirmary, may inmate-orderlies assist patients with activities of daily living such as bathing, brushing teeth, transferring and feeding? Do the NCCHC standards allow this as long as the orderlies are directly supervised by nursing? If so, does it have to be an RN or can it be an LPN? I could not find anything about this in our state regulations.
     The standards governing this matter are C-06 Inmate Workers and G-03 Infirmary Care, both of which are essential. (They are the same for prisons, jails and juvenile facilities.)
     Infirmary care is skilled nursing care within the facility’s defined scope of practice. In the correctional environment it is considered inpatient care. It differs from outpatient care for those who may need sheltered housing or observation.
     When a patient is on infirmary status, the usual activities of daily living (e.g., bathing, feeding, dressing) are within the nursing discipline’s scope of practice. Inmate orderlies, assistants or whatever they are called may not provide such assistance to patients, whether or not the inmate workers are under the direct observation of nursing staff. It does not matter how well they are trained. If an inmate needs skilled nursing care, assistance with these tasks requires the attention and assistance of nursing staff.
     However, trained inmate workers can assist other inmates in general population or other outpatient housing areas with these tasks. In settings other than an infirmary they are providing assistance that parallels home care in the community. They also may assist inmates who happen to be housed in the infirmary, but who are not on inpatient status.
     That said, it may be confusing to staff, patients and inmate-workers as to who’s who in the infirmary, so most clinicians prefer that such assistance by inmate-workers not take place in the infirmary.
— From CorrectCare Volume 18, Issue 3, Summer 2004; updated February 2010.
 Return to List 

INTOXICATION AND WITHDRAWAL
Please resolve a dispute we are having at our large jail. Who should be responsible for providing detoxification services, the physician or the psychiatrist? The responsibility was not explicitly addressed in either of their staff contracts.
     Essential standard J-G-06 Intoxication and Withdrawal requires that these services be provided to inmates who need them. Such services may be provided on-or off-site, depending on the severity of the clinical condition of a patient.
     Compliance Indicator 4 says, “Detoxification is done only under physician supervision in accordance with local, state, and federal laws.” However, it does not specify who is to provide the service. This must be determined by the responsible health authority at each level as part of that authority’s responsibility to establish practitioner qualifications and to enter into contracts and agreements.
     The health authority must see that the service is provided one way or another. Further, the facility must provide the full continuum of care as needed, whether in a community hospital or in a specialized jail setting with staff and procedures that meet the inmates’ medical and psychological needs.
— From CorrectCare Volume 20, Issue 1, Winter 2006
 Return to List 

JUVENILE STANDARDS
We are ready to jump into the new standards for juvenile facilities, but where do we begin? What’s new? Are there any major changes?
     NCCHC is proud of the 2011 Standards for Health Services in Juvenile Detention and Confinement Facilities, the result of the hard work and collaboration of national experts in juvenile justice and health care. Some of the most significant changes are discussed in the Spotlight column, but here’s a quick rundown. We also we will discuss the changes, both significant and subtle, in greater detail in upcoming columns.
     Standards Y-B-03 Patient Safety and Y-B-04 Staff Safety are new; both are classified as important. Y-G-01 Chronic Disease Services was classified as important in the previous edition but it is now an essential standard, which means that it must be met in order to achieve accreditation. Please note that Y-G-01 was also updated for 2011.
     Be sure to carefully review standards where major changes were made. These include (but are not limited to) Y-A-04 Administrative Meetings and Reports; Y-A-06 Continuous Quality Improvement Program; Y-A-10 Procedure in the Event of a Juvenile Death; Y-C-01 Credentialing; Y-D-01 Pharmaceutical Operations; Y-D-03 Clinic Space, Equipment, and Supplies; Y-E-12 Continuity of Care During Incarceration; Y-G-01 Chronic Disease Services; and Y-G-05 Suicide Prevention Program.
     Update: Please note the revised time line for compliance:
• June 1: All juvenile facilities seeking initial accreditation will be surveyed under the 2011 edition of the Standards.
• June 1 through September 30: All currently accredited juvenile facilities will be surveyed under the 2004 edition.
• October 1: All juvenile facilities will be surveyed under the 2011 edition.
— From CorrectCare Volume 25, Issue 2, Spring 2011
 Return to List 

JUVENILES IN ADULT FACILITIES
Our prison houses juveniles adjudicated as adults. What is NCCHC’s age designation for adolescents? Those who work in adolescent medicine consider all youth to be adolescents up to age 21; I’m not sure that is NCCHC’s intent. In the 2008 prison Standards, P-G-02 includes adolescents in the list of patients with special health needs, and the dietary standard (P-F-02) discusses extra calories for adolescents.
     NCCHC’s intent is that, from a health standpoint, adolescents should be treated as they would be in the community. All references to adolescents in the Standards, adult or juvenile, are based on the definition used by the medical/mental health field, not the legal definitions that vary from state to state. More a developmental stage of life than a chronological age, adolescence usually is considered to span the ages of 12-13 through 18-21. The Standards glossary defines it as “the period of life that begins with puberty and ends with completed growth and physical maturity, and requires special attention to exercise, nutrition, and appropriate social interaction.”
     The concern is that adequate attention be given to the interventions that promote healthy physical development, with emphasis on immunizations, exercise as a necessity, adequate nutrition, preventive dental care, and early identification of and intervention for health care needs, including mental health and substance issues. In general, when surveyors review records of inmates under age 21, they are looking for documentation of those considerations. The treatment plans for adolescents certainly can be used as a template focusing on these developmental issues, with, of course, areas that can be individualized. 
     For more guidance, see NCCHC’s position statement on Health Services to Adolescents in Adult Correctional Facilities.
— From CorrectCare Volume 17, Issue 4, Fall 2003; updated February 2010
 Return to List 

MEDICAL AUTONOMY
We have been holding sick call in the afternoons. Now the warden wants sick call held at 5 a.m. so that inmates can be screened before the workday starts. Isn’t it a violation of the standard on medical autonomy for the warden to tell us to change our sick call time?
     The standard on medical autonomy (A-03) covers clinical decisions. If a practitioner determines that a specific treatment is necessary, a nonmedical person may not countermand that order regardless of the security risk of the patient or the cost of the proposed treatment. However, a decision as to the time that sick call is held is not a clinical issue. These types of decisions should be made jointly by the administrative and the health staff.
— From CorrectCare Volume 23, Issue 1, Winter 2009
 Return to List 

MEDICAL NECESSITY
How does the National Commission on Correctional Health Care define "medical necessity"?
     NCCHC’s definition is based on the same assumptions the standards themselves are founded on; namely, a clinical decision by a qualified health practitioner based on clinical judgment in keeping with current community standards of practice to meet a serious health need of the individual in question. This does not mean that every medical request must be answered in the manner the patient desires, but that each request must be evaluated by the appropriate clinician. Procedures considered elective or experimental and those for cosmetic rather than functional reasons generally are not considered medical necessities. The qualified clinician making this clinical determination should document the decision and steps taken to arrive at it in the medical record of the individual involved.
— From CorrectCare Volume 16, Issue 4, Fall 2002
 Return to List 

MEDICATION SERVICES
I have been given the task of developing a statewide policy for our prison system on providing prescribed medications to inmates who are not available to take them due to court trips, appointments outside the facility, transfers to other institutions, administrative leaves such as funerals, etc. Can you help?
     The guidance you need is based on one principle: If the medication is clinically necessary, provisions must be made to supply that medication.
     When it is the judgment of the treating physician, psychiatrist or other primary care provider that the medication needs to be continued when the inmate is temporarily out of the facility, provision must be made either for the inmate to self-medicate or for transporting agents or health staff at the “temporary” facility to provide the medications.
     On the other hand, the physician may determine that a one-day “drug holiday” or other length of time without the medication will not interfere with treatment. Skipping a dose may not make a difference in the case of some medications. However, some medications need to be taken daily and on time so that the therapeutic levels remain within the proper range. This is especially true of psychotropic medications, including those for depression, antiseizure medications, HIV medications, and others as determined by the physician.
     Your policy should include consulting with the designated health services staff in the situation at hand and then making appropriate arrangements. Policy should include such issues as whether the medication is to be sent with the inmate to cover him or her for the duration of the absence, or whether a prescription is sufficient. This is important when the medication may not be readily available at the receiving institution.
     As well, there should be provision for steps to take when an inmate on medication is moved out without notification of the medical staff. Training for transporting staff who may need to give the medication must be addressed. When the physician determines that the medication is not needed during the temporary absence, be sure the policy includes informing the inmate of this so the inmate does not worry when the medication is not available.
— From CorrectCare Volume 18, Issue 2, Spring 2004

I am a psychologist practicing in New Mexico and have qualified for prescribing medication privileges under the new state law. Can I prescribe in the prison setting and be in compliance with NCCHC standards?
     Yes. In the 2008 prison Standards, P-D-02 Medication Services states the following: "Prescription medications are administered or delivered to the patient only on the order of a physician, dentist, or other legally authorized individual" (Compliance Indicator 1).
— From CorrectCare Volume 16, Issue 4, Fall 2002; updated February 2010
 Return to List 

MENTAL HEALTH SCREENING AND EVALUATION
Our facility is trying to make better use of staff time by reassigning job duties. One idea was to have correctional officers perform the mental health screening for new inmates. Is this OK under the standards?
     No. To be clear, let’s distinguish between receiving screening and mental health screening. Standard E-02 Receiving Screening states that the screening done at intake includes questions related to mental health and these may be asked by a health-trained correctional officer. However, these questions alone do not constitute the mental health screening. Within 14 days of admission, an initial mental health screening needs to be conducted by qualified mental health professionals or mental health staff (see E-05 Mental Health Screening and Evaluation). “Mental health staff” includes qualified health care professionals who have been trained and are supervised in identifying and interacting with people in need of mental health services.
— From CorrectCare Volume 25, Issue 1, Winter 2011

Who is allowed to do mental health screenings of inmates admitted to our jail? We already use nurses to do the health assessments. Can we train them to do the mental health screenings, as well?
     This issue is addressed in the “screening” element of important standard E-05 Mental Health Screening and Evaluation (the standard for prisons is exactly the same except it is designated as essential). This standard’s intent is to “ensure that the inmate’s serious mental health needs, including those related to developmental disability and/or addictions, are identified.”
     All inmates are to receive an initial mental health screening that covers the issues listed in Compliance Indicator 2. This screening may be done by mental health staff, which NCCHC defines as qualified health care professionals who have received instruction and supervision in identifying and interacting with individuals in need of mental health services. If so trained, your nurses would qualify as mental health staff for the purposes of this standard.
     Those nurses may not, however, conduct the subsequent evaluation of inmates who screen positive for mental health problems. Rather, the evaluation must be done by a qualified mental health professional, such as a psychiatrist, psychologist, psychiatric nurse or psychiatric social worker (Compliance Indicator 4).
— From CorrectCare Volume 24, Issue 3, Summer 2010

Regarding standard J-E-05 Mental Health Screening and Evaluation: Do we need to screen every admission? For example, if an inmate was seen just 30 days ago and is booked into our county jail again, would the inmate need another screen?
     The intent of J-E-05 is to identify people with mental health problems, to determine whether there’s a clinical need for further evaluation or treatment, and, if so, to provide it in a timely manner.
     To deal with frequently readmitted inmates, the responsible health/mental health authority can establish a protocol that permits modification of the mental health screening interview, but the protocol should not eliminate inquiry into mental health status. Patients well-known to staff and for whom previous incarceration health records are available may simply need a brief interview to ascertain whether anything has changed since the last discharge that would impact mental health treatment. This interview can be combined with the physical review and assessment, provided the staff are trained and the results are documented.
     Since mental health problems can and often do change with time or circumstances, this must remain an area of inquiry for all readmissions.
— From CorrectCare Volume 19, Issue 2, Spring 2005
 Return to List 

MENTAL HEALTH STANDARDS
My facility is already accredited under the NCCHC standards for health services in jails. Now I hear that NCCHC will be offering accreditation for mental health services. What does that mean for us?
     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
 Return to List 

NCCHC AWARDS
I am writing an article on a jail that received NCCHC’s Facility of the Year Award. Can you explain the criteria for this award?
     The award is given annually to one of the hundreds of jails, prisons and juvenile facilities accredited by NCCHC. Nominations often come from accreditation survey team members but we also accept nominations from the field. The accreditation committee chooses recipients. However, the award may not be given if no strong candidates are nominated.
     Besides being in good standing in the accreditation program and in compliance with the standards for health services, we also look for a facility that presents exceptional professionalism in health services delivery and whose health services can serve as a model for others.
     Each facility so honored is unique in the reason for the award. In the jail category, past winners include a jail that evidenced significant positive change over a three-year period; a small jail with an exemplary program of collaboration with community health providers; and a jail that developed a health care system based on a community service provision model.
— From CorrectCare Volume 20, Issue 2, Spring 2006; updated February 2010
 Return to List 

NONEMERGENCY HEALTH CARE REQUESTS AND SERVICES
We have an inmate who frequently complains about the same chronic problem (a bad back) and asks to be seen by the physician. Can we schedule a monthly check up with the physician and deny the inmate’s other requests to see a physician about this condition?
     The standards do not address how frequently an individual must be seen for a particular condition. That decision rests with the treating clinician. If the clinician wishes to schedule monthly check ups for this patient, he/she should write the order accordingly. The standards do state that inmates must have an opportunity daily to request medical assistance and that their requests must be triaged and acted upon as appropriate (E-07 Nonemergency Health Care Requests and Services). This does not mean, however, that an inmate must be seen each time he/she makes a request. In your case, I would suggest that each time this inmate makes a request, you bring it to the attention of the treating clinician and let him/her decide whether the patient needs to be seen and, if so, when. If the clinician determines the patient does not need to be seen until the next scheduled visit, that information should be communicated to the patient exactly that way (e.g., “Dr. Jones says she will see you at your next scheduled visit on Jan. 15”).
— From CorrectCare Volume 22, Issue 4, Fall 2008
 Return to List 

OPIOID TREATMENT
We are thinking about starting a methadone program in our jail, but we don’t know where to begin. What advice can you give us?
     If you are considering an opioid treatment program using methadone, by federal law, OTPs based in correctional facilities must obtain certification from the Substance Abuse and Mental Health Services Administration. To become certified, the OTP first must be accredited by a federally approved body—which NCCHC is, and we offer OTP accreditation. The NCCHC Standards for Opioid Treatment Programs in Correctional Facilities are based on federal regulations but address the special nature of care provided in correctional facilities as well as the necessarily limited focus of such treatment in this setting. For more information, including how to obtain the Standards, click here.
— From CorrectCare Volume 25, Issue 4, Fall 2011

Is there any resource about the use of methadone to treat drug addiction in jails? Whenever I raise the subject, our facility physician says it’s just substituting one drug for another. Our sheriff says such a program is more trouble than it is useful.
     Addiction to heroin, morphine and some prescription opioids is a major problem in many communities. Our country has a long history with the use of opioids; they were even used during the Civil War to reduce pain. Perhaps because of this long-term experience with opioids, there are many misconceptions about the treatment of opioid addiction.
     There are two schools of thought about treatment. The first is that this addiction originates because the person is weak-willed and lacks the individual strength to resist drugs. Other environmental or psychological factors may also contribute to addiction. In this model, abstinence is the only way to treat. The second approach is that opioid addiction is an incurable disease that requires long-term maintenance with medication—just as for hypertension or diabetes. Known as medication-assisted treatment (MAT), this approach is advocated by the American Society of Addiction Medicine, a supporting organization of NCCHC. Working with SAMHSA and CSAT, NCCHC has developed an educational CD-ROM on MAT and the use of methadone in correctional facilities and will send it to jails and prisons this summer. You may find it helpful in answering the objections that your medical director and sheriff have raised.
— From CorrectCare Volume 21, Issue 2, Spring 2007

This question concerns use of methadone in jails. From a session at the 2004 National Conference, I understood that methadone should not be used in jails except for pregnant inmates, for whom it is imperative that she not miss any doses. Now I read an article in CorrectCare (Vol. 19, Issue 1) that encourages continuation of methadone if the person is in a maintenance program. Which is it? Should we continue it or not?
     What if the person comes in on methadone prescribed by his primary care physician for chronic pain? I have an inmate now in that situation, with a medical history that precludes the use of NSAIDs or Tylenol, and we generally do not use narcotics for chronic pain. We want to be doing the correct thing.
     Your questions are timely. The use of methadone to treat opioid dependence—not to mention its use in correctional settings—remains controversial, and experts sometimes differ in their recommendations.
     Based on new research findings, however, the leading view in the field of addiction treatment now is that some opioid-dependent persons need methadone analogous to the need of some diabetics for insulin. Methadone has become part of the community standard of care as a method of detoxification, and methadone maintenance is one of several legitimate treatments for opioid addiction. As such, its use is to be expected in correctional settings, especially jails.
     Naturally, use of this controlled substance is highly regulated by federal authorities. So if your jail (or any other correctional facility) decides to operate an on-site opioid treatment program that uses methadone, your OTP must obtain certification and accreditation as required by the federal Substance Abuse and Mental Health Services Administration’s Center for Substance Abuse Treatment, which regulates OTPs.
     Such requirements may not apply in some circumstances, such as the medical use of methadone solely for pain control and/or to protect the fetus in an opioid-dependent pregnant woman, or the use of buprenorphine by a trained physician. The only way to be sure you are operating within the law, though, is to contact SAMHSA/CSAT.
     Required federal certification is contingent upon accreditation by a CSAT-approved accrediting body (AB). The only AB that focuses on corrections, NCCHC based its OTP accreditation standards on federal regulations but with attention to the special nature of correctional facilities. (See the 2004 Standards for Opioid Treatment Programs in Correctional Facilities.)
     Federal grant money is available for technical assistance and, at least for the next two years, subsidies of OTP accreditation fees. Please contact NCCHC for assistance on these issues.
— From CorrectCare Volume 19, Issue 3, Summer 2005
 Return to List 

ORAL HEALTH CARE
Our jail houses both state and county inmates. During a recent state inspection a question arose as to why we were not supplying dental floss to the state prisoners. The jail regulations say nothing about us having to provide dental floss. Someone said it was a potential weapon and could not be used. Someone else remembered that we once had samples of a special floss that was apparently OK to use in secure environments, but we cannot find the samples or the vendor. Does NCCHC require that inmates be given dental floss? What about the “potential weapon” aspect? Do you know of any vendors?
     The NCCHC jail standards do not require that dental floss be provided to all inmates. The relevant standard is J-E-06 Oral Care. However, a facility’s responsible dentist may recommend use of dental floss as a good oral health practice. Also, as with any other prescribed health intervention, dental floss would be required under the standards if the responsible dentist or physician indicated a need for an inmate to use the floss for a specific health reason.
     As to whether dental floss could or should be considered a potential weapon or contraband, this determination is to be made by the local correctional authorities. If this is the case and a dentist prescribes dental floss for an inmate, appropriate accommodations or alternatives would need to be made (J-A-03 Medical Autonomy).
     Since you indicate that this issue came up during a state inspection, it is possible that your state regulations require correctional authorities to provide dental floss. Your state contact to the jail should be able to advise you.
     If the state does require dental floss, the state prison system’s medical or dental director should be able to identify a vendor that sells a product appropriate for a correctional environment.
— From CorrectCare Volume 18, Issue 4, Fall 2004; updated February 2010
 Return to List 

PHARMACEUTICAL OPERATIONS
Since we do not have a staff pharmacist, standard D-01 Pharmaceutical Operations says that a consulting pharmacist should be used for documented inspections and consultation on a regular basis, not less than quarterly. Does a pharmacist have to be the one to physically conduct the inspections, or can a pharmacy tech do the inspection as long as it is reviewed and signed off by a pharmacist?
     No. The intention of this standard is that a consulting pharmacist actually conducts the inspections. A situation where another type of staff member conducts the inspection and then has a pharmacist sign off would not be in compliance with the standard.
— From CorrectCare Volume 23, Issue 4, Fall 2009
 Return to List 

POLICIES AND PROCEDURES
Our facility is about to contract with a company that provides health services. The contractor has its own policies and procedures that we would be using. Can we follow the contractor’s policies and procedures, or must we develop our own?
     You certainly may use a contractor’s policies and procedures as long as they have been tailored to meet the needs of your particular facility with regard to construction, services and staffing. The Policies and Procedures standard (A-05) requires that a manual or compilation of written policies and defined procedures regarding health care services at the facility addresses each applicable standard, and that the policies and procedures are site specific. For example, if your facility houses females, then care of the pregnant inmate should be addressed. If you operate an infirmary, then there should be policy and procedure on infirmary care. As long as the policies and procedures are site specific to provide guidance to the staff, then they would be in compliance.
— From CorrectCare Volume 23, Issue 3, Summer 2009
 Return to List 

PROFESSIONAL CREDENTIALS
What is NCCHC’s position on providing casting services on site for closed fractured extremities in a correctional setting?
     Two standards apply to this question. C-01 Credentialing, Compliance Indicator #3: “Health providers do not perform tasks beyond those permitted by their credentials”; and D-05 Hospital and Specialty Care, Compliance Indicator #4: “For on-site specialty services used regularly for medical and mental health care, there are appropriate licenses and certifications.” So if the staff doing the procedure on-site would be able to do it in a community setting, and the facility’s setting/tools/supplies/etc. would meet credentialing requirements if credentialing were needed to perform the service, then NCCHC’s Standards for Health Services would allow the practice. The responsible health authority and responsible physician (when the RHA is not a physician) must determine that there are appropriately credentialed and trained health staff, and appropriate direct and auxiliary services and supplies on-site (x-ray, casting materials, etc.). If you are not sure what is needed, an orthopedic specialist could assist.
— From CorrectCare Volume 22, Issue 1, Winter 2008

I am looking for specific training requirements for RNs who want to work in prisons and jails. Do the NCCHC Standards have any information about this?
     NCCHC does not specify preemployment training requirements, nor do correctional facilities generally. However, RNs interested in working in this challenging field should be current in their state licensure, keep up with renewal requirements and be sure their assigned duties are in keeping with their qualifications. CPR and first aid certifications are a must.
     Important standard C-09 Orientation for Health Staff stipulates that new health staff employees must receive basic orientation on the first day of on-site duty and in-depth orientation within the first 90 days. Some facilities, often state prisons and large jail systems, send new employees to a central academy for orientation and training on issues such as security. Some national correctional health care contractors have extensive initial orientation for new RNs.
     Unfortunately, some new nurses don’t receive orientation and find themselves alone and unprepared for a paramilitary setting in which security and safety—not health care—is the main focus. They can be prey to many problems, not only from inmate behavior but also from unfamiliarity with their environment and dependence on correctional staff cooperation to do their jobs effectively.
     Knowledge about correctional health care is highly valuable for a nurse seeking to navigate these waters. NCCHC receives many calls from experienced RNs who are new to corrections and astute enough to realize they need help. If the facility is accredited by NCCHC, the nurse is at great advantage in working under a mentor who is knowledgeable about the Commission and its standards. The Academy of Correctional Health Professionals, a supporting organization of NCCHC, has as members correctional nurses who will mentor or share advice. Nurses new to corrections also would benefit from attending NCCHC conferences and participating in its certification program to better understand this complex field, develop professional networks and build confidence. Finally, the American Nursing Association, another NCCHC supporting organization, has a booklet with guidelines for correctional nursing.
— From CorrectCare Volume 20, Issue 4, Fall 2006

What is NCCHC’s position on the use of residents or physicians-in-training in correctional settings?
     This is covered in standard C-01 Credentialing in all three sets of Standards (jails, prisons and juvenile facilities). Compliance Indicator 3 states, “Health providers do not perform tasks beyond those permitted by their credentials.” The Discussion section elaborates: “Students in the various health professions may receive training in correctional environments, so they may supplement services under the supervision of appropriate qualified health care professionals just as they would in a community setting.” Orientation to the correctional setting and to their tasks is required so that the trainees “do not perform tasks beyond those permitted by their student status” and are able to practice safely and professionally.
     Student involvement, whether at beginning or advanced levels of training, benefits the inmates and facility health staff, and gives the students an excellent introduction to the correctional health care field, whether or not they choose to work in this end of the public health continuum.
— From CorrectCare Volume 19, Issue 2, Spring 2005
 Return to List 

PROFESSIONAL DEVELOPMENT
We don’t think that cardiopulmonary resuscitation certification should be required for mental health liaisons because we don’t view them as qualified health care professionals like our medical staff are. Are we correct?
No. NCCHC defines qualified health care professionals as physicians, physician assistants, nurses, nurse practitioners, dentists, mental health professionals and others who by virtue of their education, credentials and experience are permitted by law to evaluate and care for patients.  Therefore, if the mental health liaisons are evaluating and caring for patients, then these mental health professionals fit into the definition of qualified health care professional and are required to be current in CPR technique under essential standard C-03 Professional Development.
— From CorrectCare Volume 24, Issue 3, Summer 2010
 Return to List 

PSYCHOTROPIC MEDICATION
When the physician writes an order for forced psychotropic medication, often the inmate is already in or being placed in restraints, or, at a minimum, being held by correctional staff. Just as the shot is about to be given, the inmate appears calm. Can we force the medication? Also, the psychiatrist usually orders a kind of “cocktail,” which may be a mixture of short- and long-term medications. Should our nurses not administer the shot because the inmate is “calm” and the longer-acting medicine is a therapeutic intervention?
     Anyone know Solomon’s phone number? Let’s start with the intent of standard I-02 Emergency Psychotropic Medication: “...to have a protocol for emergency situations when an inmate is dangerous to self or others due to a medical or mental illness and when forced psychotropic medication may be used to prevent harm, based on a physician’s order.”
     This emergency intervention by physician’s order is a therapeutic intervention that is used when all else fails. The longer effect of some portion of the medication is a positive outcome for such interventions, and medications are often chosen precisely for this effect. If the inmate can clinically tolerate it, such a 2/1 intervention can be the door that opens the inmate to healing. The nurses need to discuss the issues with the ordering physician so they understand such orders. For example, at staff meetings ask the psychiatrist to explain the therapeutic effects. That is why you consulted the psychiatrist in the first place—for expertise in safely calming an inmate.
     The restraint is merely a temporary calm in the storm; without the medications, you soon will be back where you started. If the inmate appears calm when you are ready to give the injection, you certainly should ask if he or she will take the medications voluntarily. If the inmate says yes, administer them with permission. If not, then force it as the physician ordered.
     The whole intervention should be done quickly and at the time the inmate is upset; in fact, that is the only time a physician can order such an intervention. Usually, once the medications take effect, the restraints can be removed. The physician usually writes the restraint order as “up to X hours until in control.”
     You can ask the physician to write the injection order such that it’s up to the judgment of the staff that’s about to give the med, but that would lead me to wonder if you are using the forced medication intervention too easily. Many inmates requiring such intervention will fight the restraints and the shot.
— From CorrectCare Volume 21, Issue 3, Summer 2007
 Return to List 

RECEIVING SCREENING
I work in a jail and would like to know if we are required to complete a screening test for tuberculosis as part of the receiving screening.
     No, the E-02 Receiving Screening standard for jails does not require inmates to receive a tuberculosis test at the time of the receiving screening. Mainly this is because detainees often do not remain in the facility long enough to have the tuberculin skin test read. However, TB testing is required under the E-04 Initial Health Assessment standard (see Compliance Indicators 2e and 5e). We also recommend that a tuberculosis control plan be followed that is consistent with published guidelines from the Centers for Disease Control and Prevention. Please note that for prisons, a screening test for tuberculosis is required under the Receiving Screening standard (Compliance Indicator 10).
— From CorrectCare Volume 23, Issue 2, Spring 2009

I noticed a change in the E-02 Receiving Screening standard: “as soon as possible” from the 2008 standards versus “immediately upon arrival” in the 2003 version. What is the difference in the wording?
     In the 2008 Standards, the definition of “as soon as possible” means that a receiving screening should be promptly conducted without delay. It is reasonable to expect that this could take time when there is a large group of detainees; however, it is not acceptable to wait to start the screenings until correctional staff complete the admission process. Individuals should not be released from the intake area until the receiving screening is completed. It can become nearly impossible to screen each inmate “immediately” when newly arriving inmates are received in large groups.
— From CorrectCare Volume 22, Issue 2, Spring 2008

Does NCCHC have a policy or guideline about doing drug screens on intake for inmates suspected of substance abuse problems? Assessment is difficult without testing since drug intoxication and withdrawal often present with mental illness symptoms.
     NCCHC standards require that you conduct your clinical practice as you would in any other setting, modifying nonclinical issues as required by the correctional setting but not compromising your clinical guidelines.
     Health staff in facilities accredited by NCCHC are often cautious about substance abuse testing, being mindful of standard I-03 Forensic Information and the need to avoid getting into potential adversarial situations with inmates they are trying to treat.
     However, your intent is a clinical one: to assess a substance-abusing inmate for diagnostic and treatment planning purposes. An important caution is that the results of such testing are not to be shared with corrections; results should be treated with the same confidentiality as any other blood or urine testing and recorded in the medical record.
— From CorrectCare Volume 20, Issue 2, Spring 2006
 Return to List 

Our prison recently received its accreditation survey report, which states that we need to take corrective action. When we send documentation of that action to NCCHC, who must sign off on the document? The DOC’s chief medical director? Our facility medical director? The health services administrator? Does it matter that the latter two work for a contract services company?
     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

Is it OK for our sergeant to be the health services administrator?
     Standard A-02 Responsible Health Authority states that a health administrator is a person who by virtue of education, experience or certification (e.g., MSN, MPH, MHA, FACHE, CCHP) is capable of assuming responsibility for arranging all levels of health care and ensuring quality and accessible health services for inmates. If the sergeant is a Certified Correctional Health Professional (CCHP) or has other relevant educational credentials, then by virtue of his or her education, experience or certification this position would be appropriate.
— From CorrectCare Volume 23, Issue 4, Fall 2009
 Return to List 

Restraint and Seclusion
We are revising our policy and procedures manual and would like your opinion on revising J-I-01 Restraint and Seclusion. We are considering changing our policy to limit nursing staff calls to the physician when an inmate is placed in custody-ordered restraints. The idea is that nursing staff would call the physician only in cases of chronic medical conditions. Would this revision be acceptable in terms of meeting the standards?
     In the 2008 version of the standards, Compliance Indicator 2b of J-I-01 Restraint and Seclusion reads as follows: “If the restrained inmate has a medical or mental health condition, the physician is notified immediately so that appropriate orders can be given.” Therefore, to call the physician only in cases of chronic medical conditions would not meet the standard. Under your proposal, consider a situation where an inmate with a recent acute medical injury, such as a chest contusion, would be placed in custody ordered restraints and the physician would not be notified. NCCHC’s expectation is that the physician be notified so that he or she can work with custody staff in restraining an inmate with an acute injury—not just chronic medical conditions. Therefore, we do not advise a revision of your policy to exclude other medical or mental health conditions.
— From CorrectCare Volume 22, Issue 2, Spring 2008
 Return to List 

RIGHT TO REFUSE TREATMENT
We understand that patients have the right to refuse treatment (standard I-05) and we always have them sign a refusal form when they do. Are we also required to have them sign a refusal form for refusing a single dose of medication?
     No. A form does not need to be signed for every no-show at pill line or for every time a patient refuses a medication. However, if the patient is repeatedly refusing, the responsible health authority would do well to have a policy to address follow-up such as provider notification and patient counseling.
— From CorrectCare Volume 25, Issue 2, Spring 2011

I know that inmates have a right to refuse treatment (standard I-05), but what if they refuse a laboratory test for a communicable disease? Can we force them to take a PPD test [for tuberculosis] or an RPR blood test [for syphilis] against their will?
     No, you cannot force an individual to have a test against his or her will (at least not without a court order). However, when an inmate’s refusal has possible public health consequences, you have to treat the situation differently. What staff in most facilities do is to tell inmates that if they refuse a screening test for a communicable disease, they will be segregated from the rest of the population. Until it can be determined whether the inmate is contagious or infectious, they cannot be allowed to mix with others. In our experience, when you provide this type of explanation, virtually everybody decides to comply.
— From CorrectCare Volume 23, Issue 3, Summer 2009

Our jail’s previous intake screening form had a line that gave “blanket” consent for medical treatment. Separately, consent would be obtained by the dentist for extractions and by the mental health department for medications. Now, medical has no signed consent, “blanket” or otherwise, since the new screening form has no place for this consent. Don’t we need signed consent for evaluation and treatment, and specific consent for invasive procedures? PPD placement, blood draws (RPR, CBC, etc.), I&D, and even Pap tests could all be considered invasive. I was told that only a refusal needs to be signed, which is like putting the cart before the horse.
     Any procedure requiring written consent in the community also requires a signed consent from an inmate in a correctional setting. Generally, written consent is required for any treatment or procedure that is invasive and carries some risk of an adverse outcome. Note, though, that not all health encounters require written consent. If the treatment/procedure is neither risky nor invasive, consent may be implied when the patient shows up for the health encounter. That said, if your facility wants to obtain written consent for every health encounter, it may do so. Standard J-I-05 Informed Consent and Right to Refuse Treatment addresses these issues in more detail.
— From CorrectCare Volume 17, Issue 2, Spring 2003; updated February 2010

What is the Commission’s position on history and physicals when an inmate initially refuses? Do you have a time for when it should be offered again (e.g., every 90 days or at the time of the one-year annual)?
     Inmates have a right to refuse health evaluations and diagnostic testing as well as health treatment. Thus, NCCHC does not require that health staff continue to offer an inmate a routine history and physical on an ongoing basis. Barring other health problems for the inmate who refuses the intake history and physical, it is OK to wait until the next routine health evaluation is scheduled. That said, the frequency of such refusals should be very low. It would be prudent to document that the individual who refused the intake history and physical was counseled against doing so.
— From CorrectCare Volume 15, Issue 3, Summer 2001
 Return to List 

SEGREGATED INMATES
What is NCCHC’s position on the punitive segregation of pregnant inmates? Is this addressed in the Standards?
     Health considerations for segregated inmates are discussed in standard E-09 of the 2003 Standards for Health Services for adult settings. When corrections officials place any inmate in segregation, they are to notify health services. Designated health staff are to review the inmate’s health record and alert corrections if any health-related contraindications to the segregation exist or if special accommodations are required.
     From best practice, general health, and emotional health standpoints, segregation is generally not the best setting for a pregnant inmate. However, the facility’s responsible physician must decide whether policy will prohibit segregation for all pregnant inmates or whether to make the determination on a case-by-case basis.
     In assessing whether pregnancy is a contraindication or requires accommodation, the physician would consider such factors as the physical conditions of the segregation area and cells and whether they present any potential harm to the inmate or the fetus; the pregnancy status and anticipated delivery date; presence of complications; and presence of other medical or mental health conditions.
     Health staff should consult with corrections when the behavior that would result in disciplinary action may relate to the physiological or emotional consequences of pregnancy. Given the many pressures an incarcerated pregnant patient may be experiencing, discipline may not be the best intervention to address her unacceptable behavior.
     So that pregnancy is not seen as a free ticket to negative behavior, the health and correctional staff may find alternative consequences for negative behavior that is not related to health or mental health conditions, such as delaying the segregation time until after delivery or curtailing other privilege as a substitute for segregation.
— From CorrectCare Volume 21, Issue 2, Spring 2007

Please clarify standard Y-E-09 Segregated Juveniles. At our small juvenile center (average daily population usually under 50), the nurse is on duty on days, five days a week. It is rare that a youth is placed in segregation, but when it does happen, it is usually on the weekend. Compliance Indicator 3.d. states, “On days when health staff are not on site, health-trained child care workers or program staff alert health staff on call if a health problem is noted during the staff checks.” What does this mean? Does the nurse on call have to come in if there is a problem?
     The answer—the on-call nurse uses clinical judgment based on the facility’s protocols—is one that you would expect when you consider the intent of this standard: “to ensure that juveniles placed in segregation maintain their medical and mental health while physically and socially isolated” from the rest of the population.
     Staff training should include what to look for that would require notifying the on-call nurse, and what information the nurse requires in order to provide appropriate direction to staff. The on-call nurse will decide whether to come in based on the physical and mental health status and history of the youth involved, the resources available on site and the nurse’s distance from the facility.
— From CorrectCare Volume 20, Issue 1, Winter 2006

In our maximum security prison, the segregation area is a very controlled environment since the inmates here are considered dangerous individuals, known to attack staff and other inmates. The superintendent has asked health services to limit these inmates’ trips to the facility clinic whenever possible. We want to cooperate with security concerns, but do not wish to violate standards or give less than appropriate care. How far can we go in providing “cell-side” interventions?
     The standards most directly relevant are P-A-09 Privacy of Care and P-E-07 Nonemergency Health Care Requests and Services, although several other standards come into play: P-A-01 Access to Care; P-D-03 Clinic Space, Equipment, and Supplies; P-E-09 Segregated Inmates; and P-H-02 Confidentiality of Health Records and Information. It may be helpful to share copies of these standards with the correctional authorities so that they have the “big picture” from the health services perspective.
     NCCHC (P-E-07) distinguishes between triaging health care requests (“sorting and classifying ... to determine priority of need and the proper place for health care to be rendered”) and sick call (“evaluation and treatment of an ambulatory patient in a clinical setting”). Clinical setting is defined as “an examination room or treatment room appropriately supplied and equipped” to address health care needs (P-E 07). Clinical encounters are “interactions between inmates and health care providers that involve a treatment and/or exchange of confidential information” (P-A 09).
Privacy is to be respected at all times, and when security personnel must be present due to risk to the safety of the health care provider or others, efforts are made to afford partial visual and verbal privacy (P-A-09).
     Cell-side triage of health care requests is fine. However, when triage indicates a need to examine, treat or delve into confidential information, the inmate must be taken to a clinical setting. So while routine blood pressure checks could be done in the cell with the door open (not by the inmate pushing his arm through a slot), an extensive examination of heart and lungs requires a clinical setting. Likewise, mental health staff may ask about the inmate’s well-being at the cell door, but if the reply to “Do you need to talk?” is positive, a clinical area is needed where confidential exchanges can take place.
     A clinical area can be set up in the segregation area provided that it has the necessary equipment and supplies (see P-D-03) for evaluation and treatment. For example, if a sink is lacking, then “appropriate alternate means of hand sanitization” must be available. Otherwise, the inmate must be taken to the central clinic for assessment and/or treatment.
     Officers assigned to segregation must receive training on their role in protecting the confidentiality of any health information they are exposed to because of their duties (P-H-02). In such a setting, any joking, teasing or reference to confidential health information by staff would only exacerbate tension.
     As health staff aware of the potential risks these inmates present, you will want to work as a team with correctional staff without compromising the ethics of your professions. Often it is the quality of respect and nonverbal interaction between health and correctional staff that the inmates pick up on and respond to, either positively or negatively.
— From CorrectCare Volume 19, Issue 4, Fall 2005
 Return to List 

SELF-DEFENSE
I am a nurse working in a county jail. During a routine examination to rule out lice infestation, a female inmate had a defensive attitude and while I was visually inspecting her head, she raised her right hand as though she was going to grab my arm to stop my actions. My first reaction was to step backwards and in a very firm but polite manner ask (for the second time) her permission to continue with my job.
     Later, one of the new officers asked me why I did not apply a physical restraint technique or “grab her wrist” and let the officers handle the situation. I am not sure that in such a case there is enough time for the officers to react. Am I legally allowed to stop a possible physical assault or establish any physical contact to prevent harm? Would I be charged with battery? Assault?
     Among the assumptions upon which the standards are built is the one that professional health staff will function as they have been trained when it comes to health-related interactions. Professional health staff should respond as they would in the community, even when the patient is an inmate and the setting is a correctional facility. Your response was not only professional but was likely to de-escalate the situation since you were backing off and allowing the patient space.
     Of course, if an inmate is about to strike you, you are always justified in defending yourself. This is your right in the community or in a correctional facility.
— From CorrectCare Volume 17, Issue 3, Summer 2003
 Return to List 

SICK CALL
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

At our medium-security prison, about 10% of the sick calls are no-shows. At what percentage of no-show should we become concerned?
     There is no typical rate of no-shows that I am aware of. From NCCHC’s standpoint, any failure to show for sick call is a red flag that should be looked into. Of particular concern would be rising percentages or numbers of no-shows, or development of patterns with individual inmates, specific practitioners, specific clinics, inmate housing units, etc.
     Several NCCHC standards address various aspects of a no-show problem. Please see A-01 Access to Care, A-06 Continuous Quality Improvement Program, E-07 Nonemergency Health Care Requests and Services, E-10 Patient Escort and I-06 Right to Refuse Treatment. (They are the same in both the jail and prison versions of the 2003 Standards for Health Services.)
     The bottom line is to view no-shows as an indicator of a potential problem with access to care in which systemic issues or staff behavior may contribute to no-shows. Rather than blaming individual inmates, an exploration of the root causes of their failure to show up for sick call can lead to resolution of the underlying problems, not just the symptoms.
— From CorrectCare Volume 21, Issue 1, Winter 2007

In our jail, which houses 500+ males and females, the inmates are relentless in their requests for sick-call services. Sometimes it seems they are seeking a change in scenery or a reason to get out of their housing units. This is really straining our limited resources. Does NCCHC address this problem?
     How to promote appropriate sick-call requests is a complex issue and one not addressed by NCCHC standards. You might want to consult B. Jaye Anno’s book Correctional Health Care: Guidelines for the Management of an Adequate Delivery System (2001), which is available from NCCHC. The book offers several suggestions for ensuring that the sick-call process is both efficient and effective.
     One suggestion is a “face-to-face triage” of sick-call requests. With this approach, a nurse goes to the housing areas and in a private area (often a small office) sees inmates who are requesting services. Those who require further assessment can be scheduled for evaluation in the clinic, those who require nonemergency mental health or dental care can be scheduled based on their needs, and those with minor problems (such as colds) can be taken care of then and there according to your protocols.
     Here are some other suggestions:
     • Some facilities use health staff to deal with issues unrelated to health care, such as approval of extra blankets, so if your facility uses health staff in this manner, you may wish to discontinue that.
     • For common complaints, permit inmates to purchase from the commissary OTC medications such as pain relievers, laxatives, antidiarrheic agents and cold medications.
     • Consider offering health classes that address self-care issues or that explain health topics of interest or concern to the population (HIV, hepatitis C, alcohol use, sprained ankles, etc.).
     Some facilities have instituted fee-for-service programs in the belief that they help to control the volume of sick-call use. Such co-pay systems may not be the best solution, however. For more advice on this topic, see NCCHC’s position statement.
— From CorrectCare Volume 17, Issue 3, Summer 2003
 Return to List 

SPECIAL NEEDS PATIENTS
Custody staff often seek medical clearance before using pepper spray on an inmate. Does this act of clearance, giving the “yea or nay,” qualify as partaking in a disciplinary proceeding? Does such an act undermine the intent of the forensic information standard? One can argue that if health staff did not participate, it would cause more harm than good (because those with contraindications would be sprayed). However, reasonable people could conclude that any participation undermines the credibility of health professionals.
     The answer relates to standards A-08 Communication on Special Needs Patients and I-03 Forensic Information. The responsible physician decides how health services will respond. Usually the physician is the staff member to determine what would prohibit an inmate from being sprayed because of possible negative consequences. The determination may be done at the time of the incident, or it may be done routinely as part of the initial health assessment, with a notation in the same place in each health chart. The wording of the “clearance” should be simply that there is or is not any health contraindication to the use of pepper spray for the inmate. The physician is not giving an order for the spray nor saying that it is OK to use it.
     All health and custody staff should be able to reference a written protocol as to any health intervention required after the spray is used. Any inmates who do receive pepper spray are taken to medical staff for appropriate interventions.
     You imply that health staff may not participate in disciplinary proceedings. Actually, health staff may consult in disciplinary hearings or decisions provided that they do not make the decision. In such cases, health staff, including mental health staff, should indicate whether any health or mental health condition may have contributed to the behavior in question. Health staff also may alert custody to the potential negative effects on the inmate of the proposed disciplinary action, and to help find appropriate alternate measures if the disciplinary action is contraindicated.
— From CorrectCare Volume 21, Issue 4, Fall 2007
 Return to List 

STAFFING
We are interested in becoming accredited, but our small work camp doesn’t have 24x7 nursing staff. Does that mean we can’t be accredited?
     Not at all. NCCHC standards do not require 24x7 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 24x7 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

We want to revise our health services staffing plan to improve efficiency. Our ADP is roughly 4,000. The jail standards give general guidance on how many hours our physicians must be on site, but how do we factor in time spent by physician assistants and by specialists?
     The Staffing standard (J-C-07) intends that prescribing clinician time must be sufficient to prevent unreasonable delay in patients receiving necessary care. Because of variability among inmate populations NCCHC does not mandate an exact clinician-to-patient ratio, but the general guideline is that the staffing plan includes at least one physician on site 3.5 hours per week for each 100 inmates, regardless of facility size. However, this number is not among the compliance indicators for accreditation.
     Where permitted by state law, midlevel providers (e.g., nurse practitioners and physician assistants) under the supervision of a physician can substitute for a portion of the physician’s time seeing patients. It is up to each facility to determine staffing based on its unique inmate needs and to provide justification if physician hours are less than we suggest, or if midlevel hours are used to cover part of the physician’s time. Finally, on-site time of specialists, including psychiatrists, does not count toward the basic primary provider time.
— From CorrectCare Volume 24, Issue 1, Winter 2010

What is NCCHC’s position on the use of residents or physicians-in-training in correctional settings?
     This is covered in standard C-01 Credentialing in all three sets of Standards (jails, prisons and juvenile facilities). Compliance Indicator 3 states, “Health providers do not perform tasks beyond those permitted by their credentials.” The Discussion section elaborates: “Students in the various health professions may receive training in correctional environments, so they may supplement services under the supervision of appropriate qualified health care professionals just as they would in a community setting.” Orientation to the correctional setting and to their tasks is required so that the trainees “do not perform tasks beyond those permitted by their student status” and are able to practice safely and professionally.
     Student involvement, whether at beginning or advanced levels of training, benefits the inmates and facility health staff, and gives the students an excellent introduction to the correctional health care field, whether or not they choose to work in this end of the public health continuum.
— From CorrectCare Volume 19, Issue 2, Spring 2005

What is a correct or suggested staffing level for RNs? For example, how should we determine the ratio of nurses to inmates?
     There are no published guidelines that address the ratio of RNs to inmates. Developing an appropriate staffing plan is a complicated process that must take into account the characteristics of the institution (e.g., custody level, total annual intake, average daily population), the health care mission (e.g., intake facility, ambulatory care only, infirmary care, specialty services), and the health status and needs of the inmate population. Other factors such as the location of the health unit and the number and types of services, such as medication distribution, that must be done cell-side also affect the number of nursing personnel needed. Because of such factors, the Commission has chosen not to publish staffing ratios.
— From CorrectCare Volume 16, Issue 2, Spring 2002
 Return to List 

STATE REGULATIONS
Do NCCHC standards supercede state regulations? (For example, if my state requires that LPNs must be supervised by an RN.)
     No. NCCHC standards require that the facility and its health staff comply with relevant state regulations. Although NCCHC standards are not practice standards per se, they require that health staff practice within the scope of their licensure, certification or registration. They also require that health staff meet credentialing standards in corrections as they would in community settings. At times, NCCHC standards may go beyond state regulations. If your state requires that an LPN be supervised by an RN, we would expect the staff at your facility to comply with that requirement.
— From CorrectCare Volume 17, Issue 2, Spring 2003
 Return to List 

SUICIDE PREVENTION
There has been some debate as to the interpretation of the Suicide Prevention Program standard (Y-G-05) in the new 2011 Standards for Health Services in Juvenile Detention and Confinement Facilities. Compliance indicator #1d states: “Potentially suicidal juveniles are monitored on an irregular schedule with no more than 15 minutes between two checks. If, however, the potentially suicidal juvenile is placed in isolation, constant observation is required.”
     Our debate comes in understanding what is meant by “isolation.” Is it used to refer to those youth on suicide precautions in a room by himself/herself or does it refer to more of a punitive status, as in the youth was placed in isolation for behavioral issues in addition to suicide precautions? I contend that it is the former and the latter is generally referred to as “segregation” rather than “isolation.” Another option is that both interpretations are incorrect. Either way, we want to ensure that we have the correct interpretation.
     This is a great question. You are correct that the standard is referring to the first interpretation of isolation. When a youth is placed on suicide precautions in a room alone, then constant observation should be conducted.
— From CorrectCare Volume 25, Issue 4, Fall 2011

We perform 15-minute checks on our potentially suicidal inmates. Is this practice in compliance with the G-05 Suicide Prevention Program standard?
     Potentially suicidal inmates are those who are not actively suicidal but express suicidal ideation and/or have a recent history of self-destructive behavior. These inmates should be observed at staggered intervals not to exceed every 15 minutes (e.g., 5, 10, 7 minutes). It depends on what you mean by 15-minute checks: If the observation is occurring regularly every 15 minutes, this is not in compliance with the standard. The idea is to check on the potentially suicidal inmate at irregular intervals, with no more than 15 minutes in between each check (see Compliance Indicator 1d). Lastly, if the potentially suicidal inmate is placed in isolation, then constant observation is required.
— From CorrectCare Volume 23, Issue 2, Spring 2009

Would use of a “lifeline” suicide prevention program affect our prison’s accreditation with NCCHC? In this program, staff from a community suicide prevention agency train inmates to provide peer support to suicidal inmates. When inmates are identified as suicidal, a mental health clinician or nurse assesses their mental status. Those admitted to the infirmary on mental health watch are assigned a trained “lifeliner,” who comes to the infirmary to sit and talk with the suicidal inmate. Afterwards, the lifeliner debriefs with a mental health worker. These services are not in lieu of formal mental health treatment but are a complement to it.
     As long as the inmates in the lifeline program are not used to substitute for staff but only provide supplemental services for the suicidal inmates, you would be in compliance with the relevant standards, P-C-06 Inmate Workers and P-G-05 Suicide Prevention Program (2003 Prison Standards). As you implied, training and supervision of the lifeliners is essential to the success of such a program.
— From CorrectCare Volume 21, Issue 2, Spring 2007
 Return to List 

TRANSFER SCREENING
Standard E-03 Transfer Screening says that “qualified health care professionals review each transferred inmate’s health record or summary within 12 hours of arrival.” Does it mean within 12 hours after the inmate arrives at the new jail and is in housing? Or does it mean within 12 hours of the chart’s arrival at the new jail?
     The standard intends that within 12 hours of the inmate’s arrival at the facility (emphasis added), a qualified health care professional should be reviewing the health record or summary to ensure continuity of care.
— From CorrectCare Volume 25, Issue 4, Fall 2011
 Return to List 

TRANSGENDER HEALTH CARE
Our facility occasionally receives an inmate who is at some stage of gender reassignment. We would like to develop policies and procedures for managing their medical needs related to this process. Do the NCCHC standards offer any guidance?
     Implicit guidance is found in three standards: Medical Autonomy (J-A-03, P-A-03), Patients With Special Health Needs (J-G-02, P-G-02) and Continuity of Care During Incarceration (J-E-12, P-E-12). However, you may find it helpful to consult NCCHC’s recent position statement on Transgender Health Care in Correctional Settings. Below are relevant excerpts from two recommendations in the Health Management section.
     • The management of medical (e.g., medically necessary hormone treatment) and surgical (e.g., genital reconstruction) transgender issues should follow accepted standards¹ developed by professionals with expertise in transgender health. Determination of treatment necessary for transgender patients should be on a case-by-case basis. Ideally, correctional health staff should be trained in transgender health care issues. Alternatively, they should have access to other professionals with expertise in transgender health care to help determine appropriate management and provide training in transgender issues.
     • Diagnosed transgender patients who received hormone therapy prior to incarceration should have that therapy continued without interruption pending evaluation by a specialist, absent urgent medical reasons to the contrary. Transgender inmates who have not received hormone therapy prior to incarceration should be evaluated by a health care provider qualified in the area of transgender health to determine their treatment needs. When determined to be medically necessary…hormone therapy should be initiated and sex reassignment surgery considered on a case-by-case basis. Regular laboratory monitoring should be conducted according to community medical standards.
— From CorrectCare Volume 24, Issue 2, Spring 2010
 Return to List 

USE OF TOBACCO
Our state passed a law that prohibits smoking in all public spaces. Our facility is now smoke-free. Do we still need to have a policy?
     Yes. Standard F-03 Use of Tobacco requires that smoking is prohibited in all inside areas, and if the facility allows smoking outside, specific areas are designated. In addition, the standard requires that, at a minimum, the prevention and abatement program includes nicotine replacement products and written materials on prevention and abatement of tobacco use. The written materials should be available in areas accessible to all inmates (such as the clinic, library and housing). Since all applicable NCCHC standards should be addressed in policy, even if your facility is officially smoke-free, your policy still should address the standard’s compliance indicators.
— From CorrectCare Volume 23, Issue 4, Fall 2009

In standard J-F-05 Use of Tobacco, compliance indicator 3 states, “At a minimum, the prevention and abatement program includes nicotine replacement products...” Do we need to offer every inmate who quits smoking a nicotine replacement product? That may be a costly proposition for our accredited jails.
     This indicator requires the availability of nicotine replacement products when the physician determines that it is medically necessary for an individual. While all inmates should have access to the written materials on prevention and abatement of tobacco use, nicotine replacement products supplied by health services are required only when ordered by a physician. The concern is that since nicotine use may be a significant addiction problem for some inmates, a physician should be able to prescribe aids to smoking abatement efforts when medically indicated.
— From CorrectCare Volume 17, Issue 2, Spring 2003
 Return to List