Attachment 7 - Quality of Medical Care Inspection Worksheet.pdf

Department of Homeland Security Immigration and Customs Enforcement: Enforcement and Removal Operations

Quality of Medical Care (QMC) Inspection Worksheet

IHSC QMC for Facilities

Facility Information Facility Name:

AOR: Select Address:

City: County:

State: Select Zip:

Inspection Information Start Date: Select End Date: Select Organization: Select # Detainees at Time of Visit:

Total Facility Population at Time of Visit:

Facility Capacity:

Notes:

Reviewer Information

Lead Reviewer Name:

Date Signed:

Select

Signature:

X

HQ Use Only: 29

FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE)

IHSC QMC Inspection Worksheet - Rev: 1/17/2018

IHSC QMC Inspection Worksheet: Dashboard

Compliance Dashboard Subject Area Description Compliance

ASM Asthma CG Complaints and Grievance 0 *Total Number CM Continuity of Medications DC Dental Care DM Diabetes DSA Diagnostic Services and Specialty Care Access EED Evaluation of Care Prior to Emergency Department HA Health Assessment HIV Human Immunodeficiency Virus HTM Hypertension LT Laboratory Testing MR Medical Recordkeeping

MAR Medication Administration Records MHS Mental Health Screen MHT Mental Health Treatment Planning PG Pregnant Women SZ Seizure Disorder SS Suicide Screening TD Treatment of Disability UC Urgent Care (Sick Call)

Dashboard FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) 1 of 1

IHSC QMC Inspection Worksheet: Staffing Matrix

CDF STAFFING MATRIX

Position # FTE Filled # FTE Vacant Total FTE Per Staffing Model # Day Shift # Evening Shift # Night Shift

C.N.A.

Dental Assistant Dentist

EMT

H.S.A.

LVN/LPN

MH Counselor

MRT

NP/PA

Nurse Manager Paramedic Pharmacist Pharmacy Tech Physician Psychiatrist Psychologist

RN

Social Worker X-ray Tech Other 1 Other 2

TOTAL 0 0 0 0 0 0

IHSC QMC Inspection Worksheet: Introduction

INTRODUCTION TO THE QMC

These Quality of Medical Care (QMC) audit tools focus on the assessment of clinical performance using a set of standardized measures. The measures are based on either nationally-accepted clinical guidelines or industry best practices regarding healthcare services for chronic diseases, such as National Commission for Correctional Healthcare, National Institutes of Health, American Diabetes Association, etc.

Measurement of clinical performance is only one aspect of a facility quality assessment. It is an adjunct, not a substitute, for assessment of the effectiveness of policies and procedures, sanitation and hygiene, space and equipment, etc.

• These tools are designed to provide a snapshot of care for current or recent detainees, focused on areas of high risk.

• The data collected can be used to analyze opportunities for improvement, for tracking and trending performance over a period of time, and for cross-comparisons with other facilities.

• The measures on each audit tool are “proxy” measures which can be used to generalize about the health care for a specific situation or condition based on the answers to each question. For example, there are eight measures on the diabetes audit tool. If performance on these measures is acceptable, it is assumed that the overall care for diabetics is acceptable.

• The recommended sampling design is intended to measure recent care provided in the facility, generally on patients who have been in custody for enough time to provide expected care, follow-through and measurable outcomes. For example, the health assessment sample is taken from a list of detainees in custody ≥ 14 days.

• In most cases, the recommended sample size will provide a reliable picture of care that can be generalized.

• While the goal is 100% compliance, the performance objective for most of the audit tools is ≥ 90%. That is, a facility is meeting expectations when performance on each measure meets or exceeds 90%.

• The performance objective for the audit tool on ambulatory sensitive conditions is 100%.

• In general, the answers are either “yes,” “no,” or “not applicable due to length of stay” (N/A - LOS) or “not applicable – not due to length of stay” (N/A - NLOS). In general, a ‘yes’ response indicates that the measure has been met and a ‘no’ response indicates the measure has not been met. Two exceptions to this are noted in the section below.

AUDIT TOOL COMPLETION

Reviewers are required to complete each audit tool. If there are no detainees who meet the criteria for a particular audit tool, this should be noted on the worksheet by clicking the appropriate box. If there are no detainees who meet the criteria, but there are general questions to answer on the tool, the answers to these questions should still be filled out. If the number of detainees who meet the audit tool criteria is less than the recommended sample size, the reviewer should answer the measures for the number of detainees available and add a note in the overall remarks section about why the full sample size was not reviewed. If certain measures are not applicable to a particular detainee, the reviewer will select the ‘NA – LOS’ answer, if the reason it was not applicable is related to the shortened stay of the detainee in the facility. If the reason is not applicable due to other reasons, the reviewer will select ‘NA – Not LOS’ as the answer.

Reviewers should note that in item #2 in the Evaluation of Care Prior to Emergency Department/Hospital Visit for Conditions Sensitive to Ambulatory Care audit tool a ‘no’ response is the desired answer that would indicate that the criteria was met.

Thus if all responses are ‘no’ for this item, this reflects 100% compliance with this measure. The same should be noted by reviewers for item #5 in the Suicide Screening audit tool. A ‘no’ response is the desired answer that would indicate the criteria was met.

TIPS FOR REVIEWERS

• Keep control of the medical record sample selection. Select the records to review from the primary or secondary source identified on each audit tool. Ask the medical records staff to return the list of selected records with the corresponding stack of records to know why those records were requested and what proportion of the requests were not available.

• Take note of the proportion of the requested medical records that were not available and the proportion of laboratory and diagnostic reports that were not filed and acknowledged within the medical record. These are indicators of medical record system problems.

IHSC QMC Inspection Worksheet: Introduction

• Try to maintain the sample size. If several records requested are not available, select the same number of additional records to maintain the expected sample size.

• If a question asks for clinical judgment as to timeliness or appropriateness and the reviewer is unsure of the answer, make a simple note of the circumstances and discuss with a physician before finalizing the data. This may be done “back in the office.”

• Don’t neglect to ask for any paper records in facilities that use electronic health records. Many facilities maintain a paper record for certain documents.

• Don’t hesitate to use a detainee’s record for more than one audit tool. If the name shows up on two lists, and it was selected multiple times, use that record again.

• Don’t make any assumptions about the reason for the absence of medical record documentation for any measure in the audit tools. Inquire with the facility health authority to obtain a clear understanding of the absence of information.

• Don’t let facility staff select the records for review. This introduces bias, even if not intentional.

• Don’t confuse the policy governing a certain practice with what was actually done in specific instance. Actual practice should be well-documented in the medical record.

• Don’t think about calculating a composite score for an audit tool. Composite scores are misleading. Failure to achieve ≥ 90% on any single measure is an opportunity for improvement that can reduce a potential risk to detainees.

IHSC QMC Inspection Worksheet: Key

Term Description A# Enter A# in format 123456789.

Omit all leading characters such as "A".

N/A - LOS N/A Due to Length of Stay N/A - NLOS N/A Not Due to Length of Stay ASM Asthma CG Complaints and Grievance CM Continuity of Medications DC Dental Care DM Diabetes DSA Diagnostic Services and Specialty Care Access EED Evaluation of Care Prior to Emergency Department HA Health Assessment HIV Human Immunodeficiency Virus HTM Hypertension LT Laboratory Testing MR Medical Recordkeeping MAR Medication Administration Records MHS Mental Health Screen MHT Mental Health Treatment Planning PG Pregnant Women SZ Seizure Disorder SS Suicide Screening TD Treatment of Disability UC Urgent Care (Sick Call)

ASM FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) 1 of 1

IHSC QMC Inspection Worksheet: ASM

ASTHMA (MODERATE AND SEVERE)

Number of Files Reviewed for Patients Meeting this Criteria: Select

Purpose:

To assess conformance with nationally-accepted guidelines for chronic disease and to prevent deterioration in function and cost of unnecessary care.

Source: Chronic disease registry or MARs (Medical Administrative Record).

Sample:

10 patients with moderate or severe asthma (for example, those on inhaled or oral steroids), chosen at random, if available.

Guidelines:

NCCHC Federal Clinical Guidelines https://www.ncchc.org/federal-clinical-guidelines National Heath, Lung, and Blood Institute. (Sept., 2012). Asthma Care Quick Reference: Diagnosing and https://www.nhlbi.nih.gov/files/docs/guidelines/asthma_qrg.pdf Peak Expiratory Flow Rates, (Sept, 2016) http://www.sh.lsuhsc.edu/fammed/outpatientmanual/PeakFlowTables.htm

Remarks: Type Text Here

Reviewer: Type Text Here Date Reviewed: Select Facility (f) fASM-1a: Does the facility follow a particular clinical practice guideline to manage asthma? Select fASM-1b: If yes, what is the guideline? Type Text Here

Clinical (c) cASM-1 Was patient seen in CCC by mid-level provider or physician within 14 days of illness identification? *14 days for stable patients. Unstable patients or those on multiple medications (4 or more) should be seen sooner.

cASM-2 Was a peak flow completed at the initial physical exam?

cASM-3 Was a peak flow completed at the CC visit or within the last 3 months?

cASM-4 Was a chronic disease guideline followed, which addressed disease severity, prescription of medication consistent with severity, and documented degree of control? *This criterion may require physician review. Please note in remarks if physician input was utilized.

Totals: 0 0 0 0 0 Compliance:

Patient(s) A# (numbers only) cASM-1 cASM-2 cASM-3 cASM-4 1 Select Select Select Select 2 Select Select Select Select 3 Select Select Select Select 4 Select Select Select Select 5 Select Select Select Select 6 Select Select Select Select 7 Select Select Select Select 8 Select Select Select Select 9 Select Select Select Select 10 Select Select Select Select https://www.ncchc.org/federal-clinical-guidelines https://www.nhlbi.nih.gov/files/docs/guidelines/asthma_qrg.pdf http://www.sh.lsuhsc.edu/fammed/outpatientmanual/PeakFlowTables.htm

DM FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) 1 of 1

IHSC QMC Inspection Worksheet: DM

DIABETES

Number of Files Reviewed for Patients Meeting this Criteria: Select

Purpose: To assess conformance with nationally-accepted guidelines for chronic disease and to prevent deterioration in function and cost of unnecessary care.

Source: Chronic disease registry or MARs.

Sample: 10 patients with diabetes chosen at random, if available.

Guidelines: NCCHC Federal Clinical Guidelines https://www.ncchc.org/federal-clinical-guidelines

Remarks: Type Text Here

Reviewer: Type Text Here Date Reviewed: Select Facility (f) fDM-1: What clinical practice guideline does the facility use to manage diabetes?

Type Text Here

Clinical (c) cDM-1 Was blood sugar measured and recorded on intake?

cDM-2 Was patient seen for chronic care by mid-level provider or physician within 14* days of illness identification? (14 days for stable patients. Unstable patients or those on multiple medications (4 or more) should be seen sooner.)

cDM-3 Was a baseline HgbA1C performed within 30 days of intake or within the past 3 months?

cDM-4 Were lipids measured within one year?

cDM-5 Was patient followed at least every 90 days with appropriate vital signs?

cDM-6 Was aspirin prescribed, as clinically indicated? *Refer to User Guide for clinical indications.

cDM-7 Was degree of control (goal HgbA1C <8.0) documented?

cDM-8 Was a strategy to attain diabetes control documented if HgbA1C was above goal?

Totals: 0 0 0 0 0 0 0 0 0

Compliance:

Patient(s) A# (numbers only) cDM-1 cDM-2 cDM-3 cDM-4 cDM-5 cDM-6 cDM-7 cDM-8

1 Select Select Select Select Select Select Select Select 2 Select Select Select Select Select Select Select Select 3 Select Select Select Select Select Select Select Select 4 Select Select Select Select Select Select Select Select 5 Select Select Select Select Select Select Select Select 6 Select Select Select Select Select Select Select Select 7 Select Select Select Select Select Select Select Select 8 Select Select Select Select Select Select Select Select 9 Select Select Select Select Select Select Select Select

10 Select Select Select Select Select Select Select Select https://www.ncchc.org/federal-clinical-guidelines

IHSC QMC Inspection Worksheet: HIV

HIV FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) 1 of 2

HIV

Number of Files Reviewed for Patients Meeting this Criteria: Select

Purpose:

To assess conformance with nationally-accepted guidelines for chronic disease and to prevent deterioration in function and cost of unnecessary care.

Source: Chronic disease registry or MARs for current detainees and those detained within the last 6 months.

Sample: 10 patients with HIV chosen at random or the universe of HIV-infected detainees, if < 10.

Guidelines:

National Institutes of Health. Aids Info. https://aidsinfo.nih.gov/guidelines University of California, San Francisco. HIV Clinical Consultation Center.

http://nccc.ucsf.edu/ACA 2004 4-ALDF-4C-18

Remarks: Type Text Here

Reviewer: Type Text Here Date Reviewed: Select Facility (f) fHIV-1:

What clinical practice guideline does the facility use to manage HIV? Type Text Here

Clinical (c) cHIV-1 How was HIV status identified? By laboratory, prior medical records or patient report?

cHIV-2 Was a CD4+ and viral load completed within 14 days of arrival, or within the last 3 months?

cHIV-3 Was patient seen by an HIV or ID specialist within 30 days of HIV identification?

cHIV-4 Was antiretroviral treatment considered and documented?

cHIV-5 Was the patient seen by a mid-level provider or physician for chronic care at least every 90 days?

cHIV-6 Was a chest x-ray completed within 72 hours of problem identification, if not already done?

Totals: 0 0 0 0 0 0

Compliance:

Patient(s) A# (numbers only) cHIV-1 cHIV-2 cHIV-3 cHIV-4 cHIV-5 cHIV-6

1 Select Select Select Select Select Select 2 Select Select Select Select Select Select 3 Select Select Select Select Select Select 4 Select Select Select Select Select Select 5 Select Select Select Select Select Select 6 Select Select Select Select Select Select https://aidsinfo.nih.gov/guidelines http://nccc.ucsf.edu/ACA%202004%204-ALDF-4C-18

IHSC QMC Inspection Worksheet: HIV

HIV FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) 2 of 2

Patient(s) A# (numbers only) cHIV-1 cHIV-2 cHIV-3 cHIV-4 cHIV-5 cHIV-6 7 Select Select Select Select Select Select 8 Select Select Select Select Select Select 9 Select Select Select Select Select Select

10 Select Select Select Select Select Select

IHSC QMC Inspection Worksheet: HTM

HTM FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) 1 of 1

HYPERTENSION

Number of Files Reviewed for Patients Meeting this Criteria: Select

Purpose:

To assess conformance with nationally-accepted guidelines for chronic disease and to prevent deterioration in function and cost of unnecessary care.

Source: Chronic disease registry or MARs.

Sample: 10 patients with hypertension chosen at random, if available.

Guidelines: NCCHC Federal Clinical Guidelines https://www.ncchc.org/federal-clinical-guidelines

Remarks: Type Text Here

Reviewer: Type Text Here Date Reviewed: Select Facility (f) fHTM-1a: Does the facility follow a clinical practice guideline to manage hypertension? Select fHTM-1b: If yes, what is the guideline? Type Text Here

Clinical (c) cHTM-1 Was a blood pressure reading noted at intake?

cHTM-2 Was the patient seen by an MD/PA/NP within 14 days of illness identification? *14 days for stable patients.

Unstable patients or those on multiple medications (4 or more) should be seen sooner.

cHTM-3 If blood pressure was >140 systolic or >90 diastolic, was a treatment plan initiated within 14 days of identification? *14 days for stable patients. Unstable patients or those on multiple medications (4 or more) should be seen sooner.

cHTM-4 Was a chronic disease guideline, including baseline laboratory testing, followed?

Totals: 0 0 0 0 0

Compliance:

Patient(s) A# (numbers only) cHTM-1 cHTM-2 cHTM-3 cHTM-4

1 Select Select Select Select 2 Select Select Select Select 3 Select Select Select Select 4 Select Select Select Select 5 Select Select Select Select 6 Select Select Select Select 7 Select Select Select Select 8 Select Select Select Select 9 Select Select Select Select 10 Select Select Select Select https://www.ncchc.org/federal-clinical-guidelines

IHSC QMC Inspection Worksheet: SZ

SZ FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) 1 of 1

SEIZURE DISORDER

Number of Files Reviewed for Patients Meeting this Criteria: Select

Purpose: To prevent deterioration in function and cost of unnecessary care.

Source: Chronic disease registry or MARs.

Sample: 10 patients with seizure disorder chosen at random, if available.

Guidelines:

Remarks: Type Text Here

Reviewer: Type Text Here Date Reviewed: Select Facility (f) fSZ-1: What clinical practice guideline does the facility use to manage seizures?

Type Text Here

Clinical (c) cSZ-1 Was an appropriate neurological history completed at the initial physical examination?

cSZ-2 Was the patient seen in CCC by mid-level provider or physician within 14 days of illness identification? *14 days for stable patients. Unstable patients or those on multiple medications (4 or more) should be seen sooner.

cSZ-3 Were serum drug levels performed and acknowledged in the medical record every 3 months until stable, then every 6 months, where indicated?

cSZ-4 Was a treatment plan established?

cSZ-5 Are there orders for a bottom bunk?

Totals: 0 0 0 0 0 0

Compliance:

Patient(s) A# (numbers only) cSZ-1 cSZ-2 cSZ-3 cSZ-4 cSZ-5

1 Select Select Select Select Select 2 Select Select Select Select Select 3 Select Select Select Select Select 4 Select Select Select Select Select 5 Select Select Select Select Select 6 Select Select Select Select Select 7 Select Select Select Select Select 8 Select Select Select Select Select 9 Select Select Select Select Select

10 Select Select Select Select Select

IHSC QMC Inspection Worksheet: CM

CM FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) 1 of 1

CONTINUITY OF MEDICATIONS

Meeting this Criteria: Select

Purpose: To assess timeliness of medication, as ordered.

Source:

Patients with initial intake orders for chronic medications with time urgency, such as HIV medications, Coumadin, psychotropic medication, diabetes medication, or new prescriptions for antibiotics (psychotropic medication must be part of the sample).

Sample:

Initially identify 10 patients (if available) from MARs, cross check date of first dose with order date in the medical record.

Guidelines:

Remarks: Type Text Here

Reviewer: Type Text Here Date Reviewed: Select Clinical (c) cCM-1 Period of time from completion of intake screening to the ordering of medications less than 24 hours?

cCM-2 Period of time from order to first dose less than 24 hours?

Totals: 0 0 0

Compliance:

Patient(s) A# (numbers only) cCM-1 cCM-2

1 Select Select 2 Select Select 3 Select Select 4 Select Select 5 Select Select 6 Select Select 7 Select Select 8 Select Select 9 Select Select

10 Select Select

IHSC QMC Inspection Worksheet: DC

DC FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) 1 of 1

DENTAL CARE

Meeting this Criteria: Select

Purpose: To assess compliance with detention standards and continuity of care.

Source: Dental sick call list or dental referral log.

Sample:

10 records (if available) from recent schedule of patients evaluated for a dental complaint, selected for acuity, e.g., on pain medication or antibiotics for toothache.

Guidelines: NCCHC 2014 J-A-01, J-E-02, J-E-04, J-E-06; ACA 2004 4-ALDF-4C-20.

Remarks: Type Text Here

Reviewer: Type Text Here Date Reviewed: Select Clinical (c) cDC-1 Was patient screened for symptoms during the intake process?

cDC-2 Was patient evaluated by a qualified health professional within 48 hours of request?

cDC-3 Do dental clinical notes describe findings, diagnosis, treatment, and plans?

cDC-4 Was the patient scheduled for follow-up treatment as recommended?

Totals: 0 0 0 0 0

Compliance:

Patient(s) A# (numbers only) cDC-1 cDC-2 cDC-3 cDC-4

1 Select Select Select Select 2 Select Select Select Select 3 Select Select Select Select 4 Select Select Select Select 5 Select Select Select Select 6 Select Select Select Select 7 Select Select Select Select 8 Select Select Select Select 9 Select Select Select Select

IHSC QMC Inspection Worksheet: DSA

DSA FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) 1 of 1

DIAGNOSTIC SERVICES AND SPECIALTY CARE ACCESS

Meeting this Criteria: Select

Purpose: To assess timeliness of off-site diagnostic services and specialty care.

Source: Referrals log, medical records or MedPars.

Sample:

10 specialty patients (if available) chosen by acuity or risk of harm if access is delayed, particularly in specialties where timely access has been a problem for detainees in this facility.

Guidelines: NCCHC 2014 J-D-05; ACA 2004 4-ALDF-4C-06.

Remarks: Type Text Here

Reviewer: Type Text Here Date Reviewed: Select Clinical (c) cDSA-1 Was there a documented time urgency included on the order for specialty care or diagnostic services?

cDSA-2 Was the appointment accomplished within 45 days of the order or within the ordered timeframe, e.g., “return in 90 days”?

cDSA-3 Was the patient re-evaluated for deterioration every 30 days until off-site service completed?

cDSA-4 Did the facility clinician acknowledge the specialist's report in the medical record within 7 days of the date the service was performed?

Totals: 0 0 0 0 0 Compliance:

Patient(s) A# (numbers only) Clinic cDSA-1 cDSA-2 cDSA-3 cDSA-4 1 Select Select Select Select Select 2 Select Select Select Select Select 3 Select Select Select Select Select 4 Select Select Select Select Select 5 Select Select Select Select Select 6 Select Select Select Select Select 7 Select Select Select Select Select 8 Select Select Select Select Select

IHSC QMC Inspection Worksheet: EED

EVALUATION OF CARE PRIOR TO EMERGENCY DEPARTMENT/HOSPITAL VISIT FOR CONDITIONS SENSITIVE TO AMBULATORY CARE

Number of Files Reviewed for Patients Meeting this Criteria: Select

Purpose:

To determine whether earlier intervention might have prevented morbidity and cost of outside care. To measure continuity and coordination of care for inbound patients.

Source: Emergency Department (ED) logs.

Sample:

Within the past 6 months, 10 patients (if available) sent to ED with ambulatory sensitive conditions, such as seizure, alcohol and/or substance withdrawal, skin or deep tissue infections, DKA, abdominal pain, or chest pain.

Guidelines: NCCHC 2014 J-E-12.

Remarks: Type Text Here

Reviewer: Type Text Here Date Reviewed: Select Clinical (c) cEED-1 Is there an outbound progress note?

cEED-2 Is there evidence that earlier intervention might have prevented deterioration to the point of need for ED/hospital care? If yes, please describe in the remarks portion of the report.*This will require physician review in some cases. If a physician assists with completion of this review, please include his or her name in the report comments.

cEED-3 Is there discharge documentation from the hospital or ED in the chart?

cEED-4 Is there an inbound assessment?

cEED-5 Does the assessment reflect hospital findings and concurrence or deviation from hospital recommendations?

Totals: 0 0 0 0 0 0

Compliance:

Patient(s) A# (numbers only) Chief Complaint cEED-1 cEED-2 cEED-3 cEED-4 cEED-5

1 Select Select Select Select Select

2 Select Select Select Select Select

3 Select Select Select Select Select

4 Select Select Select Select Select

5 Select Select Select Select Select

6 Select Select Select Select Select

7 Select Select Select Select Select

8 Select Select Select Select Select

9 Select Select Select Select Select

EED FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) 1 of 1

IHSC QMC Inspection Worksheet: CG

CG FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) 1 of 2

COMPLAINTS AND GRIEVANCES

Meeting this Criteria:

Purpose: To assess use of medical grievance data as part of the quality management program.

Source: Facility grievance logs.

Sample:

Facility’s periodic grievance analyses, with underlying data (grievances and responses). Include no greater than 30 A#’s per grievance category.

Guidelines: NCCHC 2014 J-A-06, J-A-11.

Remarks:

Type Text Here

Reviewer: Type Text Here Date Reviewed: Select Facility (f) fCG-1:

Does your review of the facility’s grievances reveal any possible barriers to care or repetitive concerns that could affect clinical care?

If yes, please address in the remarks section whether and how the facility uses this information to implement change.

fCG-2: How many medical grievances were submitted over the past 3 months? Select fCG-3:

Of medical grievances submitted over the past three months, how many were appropriately addressed within 5 working days of receipt? Select

Clinical (c) cCG-1 What is the A# for each of the grievances submitted over the past 3 months for each category in the table below?

cCG-2 What was the number of grievances submitted, by A#, over the past 3 months for each category in the table below?

Totals: 0 0 0 0 0 0 0

Patient(s)

A# (numbers only)

Availability of care

(sick call hours, etc.)

Denial or refusal of specific request(s) for care

Delay(s) in care

Competency/pr ofessional skillset of medical staff

Attitude, demeanor or conduct of staff

Other

1 Select Select Select Select Select Select 2 Select Select Select Select Select Select 3 Select Select Select Select Select Select 4 Select Select Select Select Select Select 5 Select Select Select Select Select Select

IHSC QMC Inspection Worksheet: CG

CG FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) 2 of 2

Availability of care

(sick call hours, etc.)

Denial or refusal of specific request(s) for

Delay(s) in care

Competency/pr ofessional skillset of medical staff

Attitude, demeanor or conduct of staff

Other

6 Select Select Select Select Select Select 7 Select Select Select Select Select Select 8 Select Select Select Select Select Select 9 Select Select Select Select Select Select

10 Select Select Select Select Select Select

IHSC QMC Inspection Worksheet: HA

HA FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) 1 of 1

HEALTH ASSESSMENT

Purpose:

To determine compliance with detention standards to assure continuity and coordination of care for serious medical needs.

Source: Detainees arriving during recent period, at least 2 weeks prior to review, to allow for evaluation of timely follow-up.

Sample: 20 medical records chosen at random.

Guidelines: NCCHC 2014 J-E-04; ACA 2004 4-ALDF-4C-24, 4-ALDF-4C-25

Clinical (c) cHA-1 Initial screen complete within 12 hours of booking?

cHA-2 PPD placed during medical screening and read within 48-72 hours, or chest x-ray is taken, or if PPD is positive by history, chest x-ray is ordered and read?

cHA-3 Are detainees who screen positive for mental illness or suicide risk referred for evaluation?

cHA-4 Is there timely follow-up for significant findings of acute and chronic conditions? *A significant finding is a condition that, without timely intervention, could lead to deterioration in function, pain, death, or risk to the public health.

cHA-5

Is there a complete health evaluation? Vital signs, adequate medical and behavioral health history, physical examination by licensed MD/PA/NP/RN within 14 days of booking? Patients with HIV, diabetes, dialysis, asthma (on daily meds), and other chronic illness will be seen within 2 business days or addressed by phone and seen on the next business day.

Totals: 0 0 0 0 0 0 Compliance:

Patient(s) A# (numbers only) cHA-1 cHA-2 cHA-3 cHA-4 cHA-5 1 Select Select Select Select Select 2 Select Select Select Select Select 3 Select Select Select Select Select 4 Select Select Select Select Select 5 Select Select Select Select Select 6 Select Select Select Select Select 7 Select Select Select Select Select 8 Select Select Select Select Select

IHSC QMC Inspection Worksheet: LT

LT FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) 1 of 1

LABORATORY TESTING

Purpose: To assess timeliness, continuity, and coordination of care.

Source: Medical records, laboratory logs, sick call logs, and/or chronic care logs.

Sample: 10 orders for labs within the last 6 months (refer to User Guide for additional guidance) , if available.

Guidelines:

Clinical (c) cLT-1 Was blood drawn or test done within 1 business day of ordered date?

cLT-2 Was there a report back within 24 hours, as appropriate, for acute labs or within 7 days for routine labs?

cLT-3 Was there clinical acknowledgment?

cLT-4 Was there an appropriate clinical response?

cLT-5 Was patient advised of laboratory results?

Totals: 0 0 0 0 0 0

Compliance:

Patient(s) A# (numbers only) cLT-1 cLT-2 cLT-3 cLT-4 cLT-5

1 Select Select Select Select Select 2 Select Select Select Select Select 3 Select Select Select Select Select 4 Select Select Select Select Select 5 Select Select Select Select Select 6 Select Select Select Select Select 7 Select Select Select Select Select 8 Select Select Select Select Select

IHSC QMC Inspection Worksheet: MAR

MAR FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) 1 of 1

MEDICATION ADMINISTRATION RECORDS

Purpose: To assess continuity of ordered care and notification to clinician of poor adherence to medication orders.

Source: MARS.

Sample:

MAR and medical record for 10 patients, if available. Medication refusals and/or no shows are defined as those instances in which a patient refuses medications on 3 consecutive days or for 3 consecutive doses and /or 4 or more doses in a week.

Facility (f) fMAR-1: Does facility have a policy in place stating which medications, if missed a certain number of consecutive doses, require provider notification and/or follow-up?

fMAR-2:

Based on review of current month MARs or previous month’s MARs, if available, what percentage of MARs that have either blanks, consecutive refusals, or no shows on the MARs?

fMAR-3: In the medical record filing area, how many months of MARs are unfiled, not counting unfiled MARs within 14 days of the end of the previous month?

Select fMAR-4: Estimate the percentage of patients on self-administered medication ordered by a provider.

Select fMAR-5: OTCs provided by medical, commissary or both? Select Clinical (c) cMAR-1 What is the number of refusals and no shows during the previous month for each patient?

cMAR-2 Is there documentation in the medical record that the prescribing clinician was notified of consecutive refusals?

cMAR-3 Was there an appropriate response from the clinician (i.e., was the patient interviewed or was the prescription changed or discontinued?)

Totals: 0 0 0 0 Compliance:

Patient(s) A# (numbers only) cMAR-1 cMAR-2 cMAR-3 1 Select Select Select 2 Select Select Select 3 Select Select Select 4 Select Select Select 5 Select Select Select 6 Select Select Select 7 Select Select Select 8 Select Select Select 9 Select Select Select

10 Select Select Select

IHSC QMC Inspection Worksheet: MR

MEDICAL RECORD-KEEPING PRACTICES Number of Files Reviewed for Patients

Purpose: To assess completeness of the medical record and appropriateness of medical record practices. Source: Medical Records, Chronic Care Log, and MARs.

Sample: 10 records of detainees with chronic disease, if available.

Instructions:

For all answers that are “partial compliance” or “non-compliant”, the reviewer should insert a comment in the remarks section of the report. For example, if most of the progress notes are legible, but one or two practitioner’s notes are barely legible, the appropriate comment would be “Dr. XX’s notes are not legible.”

Guidelines: NCCHC 2014 J-H-01, J-H-03.

Facility (f) fMR-1: Type of Medical Records? Select fMR-2: Name of Electronic Health Record? Type Text Here

Totals: 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Compliance:

Identifying information:

Detainee name, ID number, date of birth, gender.

Current problem list: Medical and mental health diagnoses and treatments; known allergies.

Receiving screen and health assessment forms

Progress notes:

For all encounters, with documentation of significant findings, diagnoses, treatments, and dispositions, preferably SOAP format.

Clinician orders for medication are signed

MARs: Placed in record within 2 weeks of previous month

Lab and diagnostic reports:

Acknowledged and dated.

Flowsheets

Consents for medical care and treatment

Signed refusals of

Results of specialty consultations and referrals:

Acknowledged and dated.

Discharge summaries from

ED and hospitalizations

Special needs treatment plan, where applicable

Immunization records, where applicable

Date and time of each encounter

Integrated medical, dental and mental health record

Timely filing, within 72 hours

Consolidated medical record:

Records from prior stays incorporated.

Content organized for easy retrieval of outside records, pertinent diagnostics, and consultations

EHR password protected

Integrated health information with

EHR, where applicable:

Incorporation of information that arrives on paper into the EHR.

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MR FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) 1 of 1

IHSC QMC Inspection Worksheet: MHS

MHS FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) 1 of 1

MENTAL HEALTH SCREEN

Purpose: To assess conformance with nationally-accepted guidelines for mental health evaluation.

Source: Intake screens of detainees, mental health referral logs, mental health caseload.

Sample: 10 randomly selected intake screens with positive mental health screens, if available.

Clinical (c) cMHS-1

Are detainees with positive screens for mental illness evaluated by mental health professionals in a timely manner (emergent = immediately; urgent = within 24 hours; routine = within 7 days)? *14 days for stable patients. Unstable patients or those on multiple medications (4 or more) should be seen sooner.

Totals: 0 0 Compliance:

Patient(s) A# (numbers only) cMHS-1 1 Select 2 Select 3 Select 4 Select 5 Select 6 Select 7 Select 8 Select 9 Select

10 Select

IHSC QMC Inspection Worksheet: MHT

MHT FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) 1 of 1

MENTAL HEALTH TREATMENT PLANNING

Meeting this Criteria: Select

Purpose:

To conform with detention standards for mental health intervention, consistent with nationally-accepted clinical guidelines (NCCHC).

Source: Patients on mental health caseload, including all patients on psychotropic medication.

Sample: 10 patients selected from mental health caseload log or MARs, currently or recently in custody, if available.

Guidelines: NCCHC 2014 J-G-04 (Item 2)

Remarks: Type Text Here

Reviewer: Type Text Here Date Reviewed: Select Clinical (c) cMHT-1 Is a clinical assessment, treatment, and follow-up plan documented?

cMHT-2 Are treatment plans updated at a minimum of every 90 days?

Totals: 0 0 0

Compliance:

Patient(s) A# (numbers only) cMHT-1 cMHT-2

1 Select Select 2 Select Select 3 Select Select 4 Select Select 5 Select Select 6 Select Select 7 Select Select 8 Select Select 9 Select Select

10 Select Select

IHSC QMC Inspection Worksheet: PG

PG FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) 1 of 1

PREGNANT WOMEN

Meeting this Criteria: Select

Purpose: To determine compliance with detention standards and continuity and coordination of care.

Source: Current census of pregnant detainees or pregnant detainees in custody in the last 6 months.

Sample: 10 pregnant detainees, if available.

Guidelines: NCCHC 2014 J-G-09; ACA 2004 4-ALDF-4C-13.

Remarks: Type Text Here

Reviewer: Type Text Here Date Reviewed: Select Facility (f) fPG-1: Does the facility perform a pregnancy test on females aged 10 to 56 during intake screening?

Select

Clinical (c) cPG-1 Was a pregnancy test performed prior to x-ray or before initiation of any medications?

cPG-2 Was an OB/GYN consult ordered for each pregnant patient with 7 days of pregnancy confirmation?

cPG-3 Was the pregnant patient seen by OB/GYN within 30 days of pregnancy confirmation?

cPG-4 Was the pregnant patient screened for HIV, STI and viral hepatitis?

cPG-5 Were prenatal vitamins prescribed?

Totals: 0 0 0 0 0 0

Compliance:

Patient(s) A# (numbers only) cPG-1 cPG-2 cPG-3 cPG-4 cPG-5

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IHSC QMC Inspection Worksheet: SS

SS FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) 1 of 1

SUICIDE SCREENING

Meeting this Criteria: Select

Purpose: To assess conformance with nationally-accepted guidelines for suicide risk assessment and prevention.

Source: Patients on suicide watch or hospitalized for suicidality within the last 3 months or since the most recent review.

Sample:

Medical records for 10 patients (if available) placed on suicide watch or hospitalized for suicidality within the last 3 months or since the most recent review.

Guidelines: NCCHC 2014 J-G-05; ACA 2004 4-ALDF-4C-32

Remarks: Type Text Here

Reviewer: Type Text Here Date Reviewed: Select Facility (f) fSS-1:

What is the total number of patients placed on suicide watch or hospitalized for suicidality within the last 3 months or since the most recent review? Select fSS-2:

Does the facility use an acceptable suicide risk management screening instrument, including at a minimum, asking for a history of suicide attempts and for current suicidal ideation?

Select fSS-3:

Are all screeners and all staff in direct contact with detainees trained to assess suicide risk (see training logs)? Select

Clinical (c) cSS-1 What type of monitoring was practiced while the patient was on suicide watch?

cSS-2 Were checks documented consistently?

cSS-3 Was the suicidal patient evaluated by a mental health professional within 24 hours of identification?

cSS-4 Was the patient evaluated by a qualified mental health professional daily while on suicide watch?

cSS-5 Is there evidence that earlier intervention might have prevented deterioration to the point of need for a suicide watch? If yes, please describe in the remarks section.

Totals: 0 0 0 0 0 Compliance:

Patient(s) A# (numbers only) cSS-1 cSS-2 cSS-3 cSS-4 cSS-5 1 Select Select Select Select Select 2 Select Select Select Select Select 3 Select Select Select Select Select 4 Select Select Select Select Select 5 Select Select Select Select Select 6 Select Select Select Select Select 7 Select Select Select Select Select 8 Select Select Select Select Select

IHSC QMC Inspection Worksheet: TD

TD FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) 1 of 1

TREATMENT OF DISABILITY

Purpose:

To assess the care of patients with disabilities who need accommodations to access the facility’s programs or activities as a result of their disabilities.

Source:

Facility logs, tour of facility, list of patients who require DME (to include walkers, canes, wheel chairs, hearing aids, or other items to assist the patients to access the facility’s programs and activities), and interviews with patients with disabilities who need accommodations to access the facility’s programs and

Sample:

10 patients (if available) within the population who have a disability that requires medical involvement.

Determine if the patients with disabilities received appropriate treatment and disability accommodations through medical record examination.

Guidelines: NCCHC J-G-02.

Facility (f) fTD-1: Does the facility maintain a current list of all patients with disabilities on site? Select Clinical (c) cTD-1 Is the disability prominently noted in the file, along with any needed accommodations?

cTD-2 Was the patient assessed for assistance with activities of daily living (ADL) upon identification of disability?

cTD-3 Were appropriate accommodation orders entered (e.g., lower bunk, mobility device (wheelchair, walker, canes, crutches), hearing aid, assistive listening device, sign language interpreter, meal, etc.)?

cTD-4 Was ADL assistance provided, if applicable?

Totals: 0 0 0 0 0

Compliance:

Patient(s) A# (numbers only) cTD-1 cTD-2 cTD-3 cTD-4

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IHSC QMC Inspection Worksheet: UC

URGENT CARE (SICK CALL)

Meeting this Criteria: Select

Purpose: To assess for timely and appropriate nursing care for acute conditions.

Source: Urgent care log, sick call request list, or sick call visit list, preferably with reason for visit noted on log.

Sample:

10 urgent care visits for detainees with potentially serious complaints that occurred 1 to 3 weeks prior to review, if available. Common potentially serious complaints include chest pain, abdominal pain, seizure, vomiting, skin infection, diabetic complications, etc.

Guidelines: NCCHC 2014 J-A-01, J-E-07; ACA 2004 4-ALDF-4C-03, 4-ALDF-4D-03.

Remarks: Type Text Here

Reviewer: Type Text Here Date Reviewed: Select Clinical (c) cUC-1 Was there timely and appropriate evaluation by nursing staff, depending on the nature of the complaint?

cUC-2 Was care delivered within the scope of the nurse’s license?

cUC-3 Were vital signs documented during the nurse's assessment?

cUC-4 If necessary, was a nursing referral to an MD/PA/NP/DMD submitted within 24 hours where appropriate?

cUC-5 If referred, was an MD/PA/NP/DMD assessment and plan documented?

Totals: 0 0 0 0 0 0

Compliance:

Patient(s) A# (numbers only) Chief Complaint cUC-1 cUC-2 cUC-3 cUC-4 cUC-5

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8 Select Select Select Select Select

9 Select Select Select Select Select

UC FOR OFFICIAL USE ONLY (LAW ENFORCEMENT SENSITIVE) 1 of 1