IN performance measures.xlsx
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- Attached to
- RFP DOC Correctional Health ServicesBid Documents State and local contract opportunity
- Solicitation number
- 27-87787
- Issued by
- Hendricks County, Indiana
About this file
This is a Performance Measures document for the Indiana Department of Correction (IDOC) Medical Contract, establishing comprehensive healthcare service standards and quality assurance requirements for the vendor providing medical services to incarcerated individuals across IDOC facilities. The document outlines 37 performance measure categories encompassing 485 total measures covering access to care, administrative responsibilities, care in restrictive housing, chronic disease management (including diabetes, asthma, HIV, hypertension, cardiac conditions, dialysis, and hepatitis C), continuity of care, diagnostic testing, documentation standards, emergency services, hospital care, infection control, infirmary operations, mental health services (both adult and juvenile), medication administration and assisted treatment, pharmacy services, prescriptions, preventive services, quality assurance, reception screening, safety and security, and sick call procedures. Each performance measure requires a passing score of 90 percent or better during IDOC audits conducted through site visits, medical record reviews, and electronic medical record (EMR) inspections.
The vendor must meet all established performance standards and is subject to financial penalties for deficiencies. If a performance measure fails to meet the 90 percent threshold, the vendor receives a 30-day cure period with a single opportunity to correct the deficiency through re-audit. Failure to cure results in a minimum reimbursement requirement of $10,000 per deficiency at each facility, payable as a credit against the next invoice. Additionally, the vendor must reimburse IDOC for staffing vacancies, backlogs, contract monitoring costs, failure to meet required staffing salaries, and failure to provide telehealth services as proposed. Quarterly reporting is required, providing vendors with summaries of quality assurance activities, and failure to achieve an average pass rate of 90 percent or higher across all IDOC facilities on each performance measure constitutes a material breach of contract. The IDOC retains the right to add, revise, or delete performance measures and audit tools during the contract term.
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Text version
Measures
| Indiana Department of Correction Medical Contract Performance Measures |
| Version 7-22-2025 |
All services provided by the Vendor will be subject to inspection and evaluation by the IDOC. The Vendor must provide all files, records or other data which are necessary for the IDOC to conduct quality assurance activities. The IDOC has set Performance Measures for all healthcare services to be provided under the current contract. These Performance Measures are based on the standards for each area of care underlined in this document. The Vendor shall meet these standards and shall be required to reimburse the IDOC for additional action, oversight, and review expended by the IDOC in dealing administratively with the Vendor’s failure to meet a Performance Measure, after an opportunity to cure. The IDOC has the right to add, revise, or delete performance measures and audit tools during the course of the contract.
| REIMBURSEMENT FOR PERFORMANCE MEASURE DEFICIENCIES |
| All Performance Measures have been included into the IDOC’s audit tools. The IDOC Health Services Division will then conduct audits of health care services through ad hoc site visits, interviews, inspections, and review of health records to assess and monitor contract compliance, adherence to IDOC policy and procedure, and compliance with Performance Measures. As a part of such audit quality assurance staff will pull an adequate number of medical record packets and review the Electronic Medical Record (EMR). Each performance measure requires a passing score of 90% or better. Less than 90% is considered a fail. If a Performance Measure does not meet the passing score, the IDOC will allow the Vendor 30 days to correct or cure the failure by passing a re-audit of the services found deficient at 90% or greater. There shall be only one opportunity given to correct a deficiency. |
| On a quarterly basis, the Vendor will be provided with a summary of all quality assurance activities completed during that Quarter. Any deficiencies found at a facility and not cured will require the Vendor to reimburse the IDOC for additional action, oversight and review expended by the IDOC in responding administratively to the deficiency. The minimum cost to the IDOC of such additional action, oversight and review shall be $10,000 per deficiency at each facility. Each deficiency found during an audit shall be subject to this reimbursement. This reimbursement shall be paid as a credit on the next invoice to the IDOC after notification. |
| It is expected that the Vendor will address reported deficiencies within the next reporting period, so that each performance measure receives a passing score of 90% or higher. |
| Additionally, if the Vendor does not obtain an average pass rate of 90% or higher on each Performance Measure across all IDOC facilities for any quarter, this shall be considered as a breach of contract by the Vendor, who shall be entitled to an additional opportunity to cure under the terms for default to be set out in the contract resulting from this RFP. |
| In addition to the reimbursement of costs for failure to meet Performance Measures, the Vendor shall also be required to reimburse the IDOC for staffing vacancies, backlogs, seat charges, contract monitoring, failure to meet required staffing salaries, failure to provide telehealth to the extent proposed, as further specified in this RFP. |
Categories
| PERFORMANCE CATEGORIES | ||
| ID # | Category | # of Measures |
| 1. | Access to Care | 6 |
| 2. | Administrative Responsibilities | 3 |
| 3. | Care of Incarcerated individuals in Restricted Housing | 19 |
| 4. | Chronic Care | 8 |
| 4a. | Diabetic Management | 30 |
| 4b. | Asthma | 15 |
| 4c. | HIV | 24 |
| 4d. | HTN | 12 |
| 4e. | Cardiac | 17 |
| 4f. | Dialysis | 23 |
| 4g | HCV | 13 |
| 5. | Continuity of Care (Transitional Health Care) | 4 |
| 6. | Diagnostic tests | 6 |
| 7. | Documentation of Care | 7 |
| 8. | Emergency services | 21 |
| 9. | Hospital Care | 9 |
| 10. | Infection Control | 38 |
| 11. | Infirmary/Inpatient Unit | 27 |
| 12. | Inmate Death | 3 |
| 13. | Intoxication and Overdose Data | 10 |
| 14. | Medication Administration | 8 |
| 14.A | Medication Assisted Treatment | 10 |
| 15. | Mental Health | 52 |
| 15.A | Mental Health Documentation | 10 |
| 15.B | Adult Facilities | 17 |
| 15.C | Triage | 5 |
| 16. | Mental Health – Juvenile | 9 |
| 16.A | Triage | 23 |
| 17. | Pharmacy Services | 10 |
| 18. | Prescriptions | 18 |
| 19. | Preventive Services and Wellness | 26 |
| 20. | Prosthetics, Orthotics & Durable Medical | 1 |
| 21. | Quality Assurance | 3 |
| 22. | Reception Screening | 5 |
| 23. | Safety and Security | 16 |
| 24. | Sick Call | 31 |
| 25. | Specialty Care | 17 |
| 25.A | Care of Pregnant Individuals | 31 |
| 26. | Staffing and Employee Competency | 9 |
| 27. | Statistics and Data Reporting | 1 |
| 28. | Substance Abuse | 11 |
| 29. | Vision Screening | 2 |
| 30. | Women’s Health Services | 5 |
| 31. | Dental Services | 20 |
| 32. | Dental – Administrative Requirements | 3 |
| 33. | Dental – Provision of Prosthesis | 5 |
| 34. | Dental – Staffing | 6 |
| 35. | Dental – Tool Control and Workplace Hazards | 10 |
| 36. | Addiction Recovery | 4 |
| 37. | Transitional Health | 17 |
1-10 PMs
| PERFORMANCE MEASURES | |
| 1. Access to Care (HCSD 2.01A) | |
| 1.1 | All incarcerated individuals will be assigned to the appropriate physical health code status and disability code during the intake process, as medically indicated and at least annually during the annual health screening process |
| 1.2 | Documentation supports that all incarcerated individuals receive information regarding access to care procedures immediately upon arrival at intake and transfer to a new facility. |
| 1.3 | Documentation supports that all incarcerated individuals shall have unimpeded access to quality care, regardless of housing assignment or lockdown status. |
| 1.4 | Clinical services must be available at least five days a week for those facilities without 24/7 nursing coverage and seven days a week for those facilities with 24/7 nursing coverage. |
| 1.5 | Documentation supports that all incarcerated individuals have unimpeded access to care, access to a professional medical opinion, and access to care and treatment that is prescribed in accordance with time frames established in the Health Care Services Directives (HCSD), American Correctional Association (ACA) and National Commission on Correctional Health Care (NCCHC) standards, and consistent with contemporary standards of practice. |
| 1.6 | All patients are transported off site for health services in a manner consistent with their clinical condition or consistent with contemporary standards of care. |
| 2. Administrative Responsibilities (HCSD 1.08) | |
| 2.1 | All statistics required for contract monitoring will be submitted monthly and as requested. |
| 2.2 | Vendor’s staff will complete and forward all responses to inquiries, reports, and other requested documents within the time frames established by IDOC - within 24 hours but not greater than three business days. |
| 2.3 | Vendor’s staff will assist or prepare all health-related plans of correction, as necessary. |
| 3. Care of Incarcerated individuals in Restrictive Housing (HCSD 2.21 and 4.03) | |
| 3.1 | All incarcerated individuals in restrictive housing are monitored in accordance with Health Care Services Directive (HCSD) 2.21. |
| 3.2 | Documentation supports that nursing staff were notified by custody or operations staff when an II transferred to restrictive status housing; a nurse immediately reviewed the II's health recoverd to determine whether restrictive status housing is contraindicated due to existing physical, dental, or behavioral health needs; and, if the health record suggests the presence of a health condition that contraindicates placement in restrictive status housing, the nurse contacted the appropriate provider for direction and orders and alerted the Warden or designee of the concern. |
| 3.3 | All incarcerated individuals admitted to Restrictive Status Housing shall be screened for suicide risk and mental health problems within twenty-four (24) hours of admission. Mental health trained nuring staff shall inquire about: Current suicidal ideation and history of suicidal ideation and behavior; Current mental health complaints; Current mental health treatment and history of mental health treatment including the use of psychotropic medications and inpatient and outpatient treatment; Substance use history including history of substance use treatment; and, Drug intoxication or withdrawal symptoms. Mental health trained nursing staff shall document observation of: Appearance; Behavior; Affect and mood; Speech; State of consciousness; Activity level; Evidence of abuse or trauma; Current symptoms suggestive of psychosis, depression, anxiety, or aggresson. Mental health trained nursing staff shall document disposition of patient: No Behavioral Health referral; Referral to Behavioral Health services; Referral to appropriate Behavioral/Mental Health care services for emergency treatment. |
| 3.4 | If a patient has a "D" Behavioral Health Code, or is within the thirty (30) day period of post-release follow-up after having been removed from suicide watch precautions, the reviewer must immediately conduct the suicide risk and mental health screening and contact the facility's lead psychologist or designee to assess the patient to determine if any immediately action is necessary. If placement and review occur after normal business hours, the lead psychologist or designee must assess the patient on the next business day. |
| 3.5 | When mental health needs are identified, the incarcerated individual shall be referred to a QMHP for a mental health evaluation. An individual who presents with serious suicidal intent, psychotic symptoms, or is a danger to self or others shall be seen immediately by the QMHP. If no mental health professional is on site, nursing shall contact the on-call QMHP for consultation and direction and nursing documents as such. |
| 3.6 | A Restrictive Housing Review, including a face-to-face interview complete with a mental health appraisal, was conducted within 72 hours of placement in restrictive housing to determine if the incarcerated individual meets criteria for classification as Seriously Mentally Ill or if there are other clinical reasons why extended restrictive status housing placement is contraindicated. The evaluation must include a review of pertinent mental health history, a thorough review of all active and provisional diagnoses, a validation of current mental health needs, and a determination of the severity of both the clinical symptoms and any resulting functional impairment. |
| 3.7 | Incarcerated individuals in restrictive status housing are completely dependent upon facility staff for all services. Incarcerated individuals shall continue to receive Physical Health and Behavioral Health Services including prescribed medication while in restrictive status housing. |
| 3.8 | Documentation of restrictive housing rounds supports that the rounds were completed in accordance with HCSDs 2.21A and 4.03A (and it's associated attachment titled, "Restrictive Status Housing Mental Health Matrix/Continuum), and in accordance with American Correctional Association (ACA)/ National Commission on Correctional Health Care (NCCHC) standards. |
| 3.9 | For every incarcerated individual in restrictive housing, nursing personnel must visit each incarcerated individual in restricted housing once each shift including weekends and holidays. Nursing rounds must be documented in the incarcerated individuals' health record or on State Form #46026, “Segregation/Detention Rounds Flow Sheet”. |
| 3.1 | A mental health professional shall make weekly, documented rounds of restrictive housing units to ensure that incarcerated individuals have access to the behavioral health system. |
| 3.11 | All incarcerated individuals in restrictive housing have the same access to care as those in general population. There shall be no delay in care. |
| 3.12 | If a serious health condition is present, Health Services personnel shall ensure that proper services and support continue to be provided during restrictive status housing placement. Clinical evaluations must be done in an appropriate clinical setting and not conducted at the incarcerated individual's cell. |
| 3.13 | Documentation supports that the incarcerated individual in restricted housing had access to health care within the timeframes established for other incarcerated individuals (e.g. 24 hours for nursing triage, 7-days for a provider appointment, routine mental health evaluations within 7 days; that necessary clinical evaluations (physical exams, mental health evaluation and treatment) were conducted in an appropriate clinical setting and not conducted at the incarcerated individual’s cell; and that routine chronic care appointments and annual health screens were not delayed or stopped due to an incarcerated individual’s placement in restrictive status housing. |
| 3.14 | Incarcerated individuals who are referred for mental health treatment must receive a comprehensive evaluation by a QMHP. All staff referrals shall be seen by Mental Health within seven (7) days as outlined in HSCD 2.01A, "Access to Care. The evaluation must include: Review of mental health screening and appraisal data; Direct observations of behavior; Collection and review of additional data from individual diagnostic interviews and tests assessing personality, inellect, and coping abilities; Compilation of the individual's mental health history; Development of an overall treatment/management plan with appropriate referrals to include transfer to a mental health unit for incarcrated individuals whose treatment needs exceed what can be accommodated at the current facility. |
| 3.15 | If mental health needs are identified by the QMHP during the incarcerated individual's evaluation, the QMHP must make a determination regarding the frequency of contacts necessary for maintenance during restritive status housing placement and modify the treatment plan accordingly. Treatment plans must be reviewed and revised every six (6) months while in restrictive status housing. |
| 3.16 | For Mental Health – incarcerated individuals with an identified mental health need (Behavioral Health Code B, C, D, E) must be offered an out-of-cell evaluation which affords the incarcerated individual confidentiality no less than every 30 days and document it on the Restrictive Housing Visit template in the EMR. |
| 3.17 | For Mental Health -- incarcerated individuals with no identified mental health need (Behavioral Health Code A, F) must have a behavioral health assessment every 90 days or more frequently if clinically indicated by a QMHP in a manner that ensures confidentiality. |
| 3.18 | For SMI – an MHP must complete twice weekly rounds for incarcerated individuals classified SMI with no more than three (3) non-contact days between contacts. Contacts must be documented and filed in the paper chart or the RH round chart in the EMR. |
| 3.19 | For SMI – incarcerated individuals classified SMI must be offered an out-of-cell evaluation which affords the incarcerated individual confidentiality no less than every 14 days and document it on the Restrictive Housing Visit template in the EMR. |
| 4. Chronic Care (HCSD 3.01) | |
| 4.1 | All patients receiving chronically prescribed medications are routinely monitored at intervals consistent with the clinical condition or contemporary standards of care in accordance with all applicable HCSD and standards. |
| 4.1.1 | Documentation supports that chronically ill incarcerated individuals will be seen in chronic care clinic (CCC) at least every 90 days if criteria are met for unstable chronic care health. |
| 4.1.2 | Documentation supports that chronically ill incarcerated individuals will be seen in CCC at least every 180 days if criteria are met for stable chronic care health. |
| 4.2 | Vital signs inlcuding height and weight were obtained at every CCC visit. |
| 4.3 | Labs, or other monitoring procedures serum drug levels, liver function studies, are obtained when necessary and in accordance with applicable national and community standards. |
| 4.4 | Documentation supports that labs and other diagnostic tests have been signed off by the provider and that abnormal values have been addressed with the II. |
| 4.5 | Chronic care documentation in the health record provides adequate support for the diagnosis (e.g. reflux disease of GERD, individuals incarcerated receiving nitroglycerin, seizure disorder). |
| 4.6 | Chronic care documentation reflects that the incarcerated individual in chronic care has received disease specific education. |
| 4.A Diabetic Management | |
| A1 | All incarcerated individuals with diabetes will be managed in accordance with the guidelines of the American Diabetes Association. |
| A2 | Documentation supports that the incarcerated individual’s height, weight and Body Mass Index (BMI) were obtained at the time of the intake screen. |
| A3 | Documentation supports that the incarcerated individual’s vitals signs were obtained at the time of the intake screen. |
| A4 | Documentation supports that for diabetics receiving insulin, a fingerstick blood sugar was obtained within 8 hours of admission. |
| A5 | Documentation supports that the incarcerated individual received his/her insulin or oral hypoglycemic agent by first insulin or med pass line after admission. |
| A6 | Documentation supports that the intake physical included an examination of the foot which included one of the following: |
| A7 | Palpation of dorsalis pedis or the posterior tibial pulses |
| A8 | Monofilament sensation or a determination of proprioception or vibration |
| A9 | Documentation supports that initial labs included an Hgb AIC. |
| A10 | Documentation supports that initial labs included a test for urine albumin. |
| A11 | For finger stick blood sugars (FBS): |
| A12 | Documentation supports that very long acting insulin accompanied by a regular insulin with each meal and that the FBS was obtained at least three times each day. |
| A13 | Documentation supports for insulin regiments, which include a short and intermediate or long acting insulin, an FSB was done twice each day. |
| A14 | Metformin is not prescribed for patients with an eGFR <30 ml/min |
| A15 | Documentation supports that for all diabetics receiving only oral medication, an FSB was obtained once each week. |
| A16 | Documentation supports that for all diabetics, the initial labs included liver function tests, serum creatinine and estimated GFR, fasting lipid profile, and test for urine albumin. |
| Diabetes Complication Management | |
| A17 | Documentation supports that high blood pressure is managed with an ACE or ARB unless the medication is contraindicated. |
| A18 | All documentation, providers orders, insulin administration records, or flow sheets support that for diabetics receiving insulin a sliding scale regimen is not used outside of an inpatient unit. |
| For every CCC visit | |
| A19 | Documentation supports that all diabetics with an HgbA1c less than 7.9 were seen by a provider once every 6 months. |
| A20 | Documentation supports that all diabetics with an HgbA1C 8.0 or above were seen by a provider once each month. |
| A21 | Patients with T2DM and established high risk of atherosclerotic disease, heart failure, and/ or CKD, the treatment regimen should include agents that reduce cardiorenal disease. |
| A22 | Incarcerated individuals living with diabetes shall have a DFE annually documented in the EMR. |
| A23 | Documentation supports that urine albumin to creatinite ratio is completed annually. |
| A24 | Documentation supports that an eGFR and LIPID panel is obtained annually. |
| A25 | Documentation supports that vital signs including height and weight were obtained at every CCC encounter. |
| A26 | Documentation supports that the physical exam included an evaluation of the incarcerated individual’s feet including a monofilament test. |
| Labs | |
| A27 | A1C should be obtained twice per year or every 6 months for patients at treatment goal of <7 and every 90 days for patients whose therapy has changed or is not meeting target treatment goals >7 (e.g. unstable ccc patients.) |
| A28 | Documentation supports that a lipid profile was obtained annually (at a minimum). |
| A29 | Documentation supports that for all diabetics with high cholesterol a lipid profile was obtained every 6 months if the incarcerated individual is receiving lipid lowering medication. |
| A30 | Documentation supports that for all diabetic patients not on dialysis an annual assessment of kidney function was done. |
| 4.B ASTHMA | |
| B1 | All incarcerated individuals with asthma will be managed in accordance with the National Heart, Lung, and Blood Institute (NHLBI) asthma guidelines. |
| For Adult Intake Units | |
| B2 | Chronic care documentation supports that an incarcerated individual was provided with an inhaler within 8 hours of admission of the incarcerated individual. |
| Arrives from the jail with an inhaler | |
| B3 | Reports a history of asthma and the incarcerated individual reports having symptoms greater than 2 times per week. |
| B4 | Baseline Peak Flow readings or Pulmonary function testing was obtained within the first 7 days of admission. |
| For All other facilities | |
| B5 | Initial chronic care clinic appointment is made within the first three months of confinement or at the time of diagnosis |
| B6 | Chronic care clinic forms or documentation in the EMR includes a notation which assigned the patient to a severity classification (mild intermittent, mild persistent, moderate persistent, and severe persistent). |
| B7 | Disease management template of flow sheet includes predicted PEAK flow results or documentation in EMR or in paper chart notes ranges which signal an exacerbation. |
| Every chronic care visit documentation supports: | |
| B8 | Pulse oximetry reading was re-obtained at each CCC visit. |
| B9 | PEAK flows were obtained at each CCC encounter. |
| B10 | Patient’s lung sounds were assessed at each visit. |
| B11 | Patient education regarding use of inhaler, disease process and triggers were provided at each CCC visit. |
| B12 | For incarcerated individuals requesting refills of inhalers “too soon”, an incarcerated individual was seen by a nurse or practitioner to rule out exacerbation or deteriorating condition (e.g. responses to the HCRFs should not be returned with written comments that the incarcerated individual is abusing the inhaler or requesting a refill too early and when an evaluation has occurred, PEAK flows and lung sounds must be documented). |
| B13 | For patients experiencing an exacerbation or receiving Nebulizer treatments documentation supports: |
| B14 | Pulmonary Assessment testing was obtained prior to the initiation of a nebulizer treatment. |
| B15 | Pulmonary Assessment testing was obtained after the nebulizer treatment. |
| 4.C HIV | |
| C1 | All incarcerated individuals with HIV will be managed in accordance with the current guidelines of the Department of Health and Human Services (DHHS), Guidelines for the Use of Anti-retroviral agents in HIV-1-Infected Adults and Adolescents. |
| For all patients who are known or report being HIV infected at intake: | |
| C2 | HIV RNA and CD4 counts were obtained |
| C3 | Completed blood count (CBC) |
| C4 | Chemistry profile (e.g. liver function tests, glucose, BUN, creatinine etc.) |
| C5 | Lipids |
| C6 | Chest X-Ray |
| C7 | Medications are continued if applicable and patient is enrolled in CCC |
| Newly Diagnosed HIV | |
| C8 | CD4 counts |
| C9 | Plasma HIV RNA |
| C10 | CBC |
| C11 | Hep B Serology (HBsAb, HBsAg, HBcAb total) |
| C12 | Chemistry panel/ BMP (e.g. liver function tests, glucose, BUN, creatinine etc.) |
| C13 | Lipid Panel |
| C14 | Genotypic resistance testing |
| C15 | Urinalysis |
| All Other facilities | |
| C16 | Chronically ill incarcerated individuals will be seen in chronic care clinic (CCC) at least every 90 days if criteria are met for unstable chronic care health |
| C17 | Chronically ill incarcerated individuals will be seen in CCC at least every 365 days if criteria are met for stable chronic care health |
| C18 | HIV RNA and CD4 counts are obtained 2-8 weeks after initiation or modification of ART therapy. |
| C19 | HIV RNA and CD4 counts are obtained every 3-4 months in patients not on medication or on medication but stable |
| C20 | HIV RNA and CD4 counts are obtained prior to the initiation of treatment. |
| C21 | When HIV RNA and CD4 counts are obtained, anti-retroviral therapy was initiated in all patients with a CD4 count below 350 (unless the incarcerated individual signed a refusal). |
| C22 | When HIV RNA and CD4 counts are obtained, a chemistry panel, CBC, and lipid profile were obtained every 6 months during the first two years of treatment and then annually after the first two years. |
| C23 | When HIV RNA and CD4 counts are obtained, a funduscopic exam was performed annually. |
| C24 | Documentation supports that all patients living with HIV have an annual dental exam performed. |
| 4.D HTN | |
| D1 | All incarcerated individuals with hypertension will be managed in accordance with the guidelines of the National Heart, Lung and Blood Institute (NHLBI). |
| For all adult facilities | |
| D2 | Documentation supports that an incarcerated individual who reported a history of high blood pressure requiring medication received urinalysis (urine dipstick or lab urinalysis). |
| D3 | Documentation supports that an incarcerated individual who reported a history of high blood pressure requiring medication received the following laboratory testing CMP, CBC inlcuding blood glucose, potassium, creatinine, and calcium. |
| D4 | Documentation supports that an incarcerated individual who reported a history of high blood pressure requiring medication received lipid profile. |
| For all other facilities | |
| D5 | Initial CCC appointment is done with the first 3 months of confinement or at the time of diagnosis and an electrocardiogram is given, urinalysis is performed, lipid panel, CMP, CBC inlcuding blood glucose, potassium, creatinine, and calcium. |
| D6 | Initial CCC appointment is done with the first 3 months of confinement or at the time of diagnosis and a urinalysis is performed. |
| D7 | For incarcerated individuals aged 18 to 59 years without major comorbidities (e.g. diabetes, chronic kidney disease), the goal blood pressure level is ≤140/90 mmHg. |
| D8 | For incarcerated individuals aged 60 years or older with diabetes, chronic kidney disease, or both conditions, the goal blood pressure level is ≤ 140/90 mmHg. |
| D9 | For incarcerated individuals aged 60 years or older who do not have diabetes or chronic kidney disease the goal blood pressure level is ≤ 150/90 mmHg. |
| D10 | Risk factors have been addressed (e.g. if the incarcerated individual is obese, there is documentation that the provider recommended weight loss; if the incarcerated individual’s LDL on the lipid panel is high, the incarcerated individual has been offered/prescribed a lipid lowering agent; the incarcerated individual has been encouraged to get at least 30 minutes of exercise a day) |
| D11 | A lipid profile, glucose, potassium and creatinine were obtained annually. |
| D12 | A funduscopic exam is performed annually. |
| 4.E CARDIAC | |
| E1 | All incarcerated individuals with cardiac disease will be managed in accordance with guidelines established by the American Heart Association and the American College of Medicine. |
| E2 | For all adult intake units there was documentation that supports that an incarcerated individual who reported a history of high blood pressure requiring medication received an intake physical exam that included a notation regarding peripheral edema or jugular venous distention. |
| E3 | For all adult intake units there was documentation that supports that an incarcerated individual who reported a history of high blood pressure requiring medication received a 12-lead EKG within the first 14 days of admission. |
| For all other facilities | |
| E4 | For all cardiac patients (CAD, stable angina, congestive heart failure, history of MI, post PTCA or CABG; for juvenile facilities, it applies to student with Marfan syndrome) there is documentation that supports: |
| E5 | Chronically ill incarcerated individuals will be seen in chronic care clinic at least every 90 days if criteria are met for unstable chronic care health |
| E6 | Chronically ill incarcerated individuals will be seen in chronic care clinic at least every 180 days if criteria are met for stable chronic care health |
| E7 | Patient was questioned about shortness of breath, fatigue, or changes in exercise tolerance at each visit (Give credit if the provider completed the “Constitutional” portion of the physical exam and charted “no apparent distress”). |
| E8 | Physical exam included an assessment of lung sounds. Give credit if the provider charted respiratory assessment was within normal limits in the physical exam section. |
| E9 | Physical exam included an assessment of heart sounds. Give credit if the provider charted cardiac assessment was within normal limits in the physical exam section. |
| E10 | Patient was examined for peripheral edema (e.g. swelling at the ankles). Give credit if the provided charted an extremity exam was within normal limits. |
| E11 | Risk factors (e.g. hypertension, obesity, elevated lipids) have been addressed (e.g. treating HTN, advised on weight reduction, treating elevated lipids). |
| E12 | Patients receiving a lipid lowering medication have had a lipid profile and liver function tests done at least every 6 months |
| E13 | For patients not receiving a lipid lowering medication, documentation supports that a lipid profile has been done at least annually. |
| E14 | Patient who are not diabetic, a serum glucose was obtained at least once each year. |
| E15 | For incarcerated individual receiving nitroglycerin there is documentation of a diagnosis of angina (Give a 0 if nitroglycerin has been prescribed and there is no diagnosis documented in the health record which requires its use. |
| E16 | Patient with angina or previous history of MI are receiving a beta blocker unless contraindicated. |
| E17 | Heart patients with diabetes are receiving an ACEI, an ARB, or a calcium channel blocker (e.g. Norvasc) unless contraindicated. |
| 4.F DIALYSIS | |
| F1 | All incarcerated individuals on dialysis will be managed in accordance with national guidelines and contemporary standards of care. |
| F2 | Documentation supports that AV Fistula/Graft sites are monitored, managed, and assesed for signs of infection. |
| F23 | Documentation supports that patients with CKD who meet one or more of the following criteria: urine albumin to creatinine ration >300 mg/g (34 mg/mmol), including nephortic syndrome, heamturia unrelated to urologic conditions, inability to identify cause of CKD, eGFR <30 or a decline of >30% in less than 4 months, anemia, Serum potassium >5.5, resistant HTN, extensive nephrolithiasis, cofirmed or presumed hereditary kidney disease |
| F4 | Documentation supports that the patients weight and blood pressure are monitored before and after each dailysis session. Documentation supports that patients receiving diaylsis are on daily weights. |
| F5 | Documentation supports that the dialysis patient has had diet orders placed (Renal Diet). |
| F6 | Documentation supports the delivered dose of hemodialysis is measured and documented using the Urea Reduction Ratio (URR) at least once each month (either the formal urea kinetic modeling (UKM) or the Daugirdas II formula for spK+/V can be used) with a 3 month average being equal to or greater than 1.2 or an average URR of at least 65%. |
| F7 | Documentation supports a patient was monitored monthly for anemia (CBC or Hgb/Hct). |
| F8 | Documentation supports a patient with Hgb below 12 was provided with epoetin alfa (Epogen, Procrit) unless contraindicated (noted on the health record). |
| F9 | Documentation supports a patient on epoetin alfa have a percent transferring saturation and serum ferritin (iron studies) concentration measured at least once every three months. |
| F10 | Documentation supports a patient with transferring saturations equal to or less than 20% and ferritin levels equal to or less than 100ng/ml receive IV iron unless contraindicated (noted on the health record). |
| F11 | Documentation supports serum albumin levels are checked at least once every three months. |
| F12 | Statistics are maintained noting the number of patients who are dialyzed for the prescribed time each week and the number and reason (e.g. patient refusal, hypotension) of patients who failed to dialyze for the prescribed number of hours. |
| F13 | Documentation supports that informed refusals are obtained and documented in the EMR for all patient that refuse a dialysis treatment or end the run time early. |
| F14 | Documentation supports that the patient is referred to the health services health care provider at time of dialysis refusal and that the attending nephrologist is informed. |
| F15 | Documentation supports that dialysis staff are updating the EMR with run records |
| F16 | Documentation supports that rounds with the Nephrologist are occuring at least monthly and records are shared with primary care provider. |
| F17 | Documentation supports that the patient receiveing dialysis was offered the Hepatitis B vaccination. |
| F18 | Statistics are maintained noting the number of patients who are dialysis through a catheter versus the number dialyzed through an arteriovenous fistula. |
| F19 | Statistics are maintained noting the number of patients with Hgb above and below 12. |
| F20 | Statistics are maintained noting the number of patients with transferring saturations above and below 20%. |
| F21 | Statistics are maintained noting the number of patients with feritin levels above and below 100 ng/ml. |
| F22 | Statistics are maintained noting the number of patients with serum albumin above and below 3.5. |
| F23 | Incarcerated individuals with chronic diseases will be provided services consistent with applicable HCSD. |
| 4.G HCV | |
| G1 | All incarcerated individuals with HCV will be managed in accordance with the guidelines of the American Association for the Study of Liver Disease (AASLD) or the Federal Bureau of Prison and HCSD 3.04A. These guidelines will help determine prioritization in the treatment queue. |
| For intake units | |
| G2 | For all patients who are known or report being HCV infected at intake, their vital signs inlcuding height and weight were obtained at each CCC visit. |
| G3 | Labs are ordered as clinically indicated and at the 30 day mark in accordance with HCSD 3.04A |
| G4 | Documentation supports that medication is continued if a patient arrives at an intake facility with a prescription. |
| For all other facilities (annual review) | |
| G5 | Chronically ill incarcerated individuals will be seen in CCC at least every 90 days if criteria are met for unstable chronic care health and in classes 2-4 in accordance with HCSD 3.04A |
| G6 | Chronically ill incarcerated individuals will be seen in CCC at least every 30 days if they are in Class 1 in accordance with HCSD 3.04A. |
| G7 | Patients living with Hepatitis C are provided treatment as clinically indicated in accordance with HCSD 3.04A |
| G8 | Documentation supports that patients diagnosed with HCV receive a referral to ARS. |
| G9 | Lipid Panel is taken |
| G10 | Comp Panel + CBC/Plt is taken every 90 days |
| G11 | LFTs are taken every 90 days |
| G12 | ALT is taken every 90 days |
| G13 | Documenation supports that once a patient clears the virus post treatment the diagnosis is resolved in the EMR. |
| 5. Continuity of Care (HCSD 2.03) (Transitional Health Care) | |
| 5.1 | All incarcerated individuals shall have care that is uninterrupted and ensures that serious medical conditions are addressed expeditiously and consistently at intake into the IDOC, during facility transfers and at time of release in accordance with HCSD 2.03A. |
| 5.2 | All incarcerated individuals who require ongoing care after release: Addiction Recovery Services, Mental Health classification codes including unstable C and all D, E, and F codes and Medical Classification codes of B and F; arrangements are made to provide incarcerated individuals with prescribed medications and follow up community services. |
| 5.3 | All care and services provided or approved at a previous facility including medication, chronic care clinics, follow up appointments, off site referrals, dental care are continued at the receiving facility. |
| 5.4 | All reception and transfer screens are completed in accordance with Health Care Service Directives 2.07A and 2.02A. |
| 6. Diagnostic Tests (HCSD 3.13) | |
| 6.1 | Documentation supports that lab tests, x-rays, and other diagnostic procedures are obtained as prescribed. |
| 6.2 | All results of diagnostics tests are available on the record within one business day after obtaining the results. |
| 6.3 | Documentation supports that for laboratory testing, the results were placed in record within one business day from receiving results if not interfaced with the EMR i.e. STAT labs orders. |
| 6.4 | Documentation supports that all diagnostic test results are initialed and dated by a provider or a progress note is available that indicates the results were noted. |
| 6.5 | All diagnostic test results will be reported to the incarcerated individual and documented in the EMR. |
| 6.6 | For all diagnostic tests which are abnormal, health record documentation reflects the practitioner's plan to address the result within five business days or routine results and within 2 business days for urgent/emergent results. |
| 7. Documentation of Care | |
| 7.1 | Health records are maintained in accordance with Health Care Services Directive (HCSD) 1.14A. |
| 7.2 | Consents and refusals are completed in accordance with HCSD 2.12A. |
| 7.3 | Documentation of care shall be completed on same business day for nursing staff, documentation of care shall be completed within 72 hours for physicians and nurse practioners. |
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Comment:
@Bedford, Adrienne @Dwenger, Deanna L ladies please look at 7.3 this PM notes that documentation shall be completed on same business day. Yes for nursing (not happening for providers and I know BH/TH have different regs... What are your recommendations here?
Reply:
Behavioral Health notes are due within 7 days unless crises or suicide/safety precautions related, in which case documentation shall be completed same day. @Tafoya, Nikki Reply:
@Tafoya, Nikki we need to review with the team.
| 7.4 | Documentation supports that Late entries are completed in the EMR and notated as such. |
| 7.5 | Documentation supports that in the event of a patient death the EMR is locked after 24 hours. |
| 7.6 | Documentation of care shall fully describe the actions of care taken and the plan of care. |
| 7.7 | Documentation via use of the EZMAR is completed daily and there are no missing administration or absentee markups. |
| 8. Emergency Services (HCSD 3.13) | |
| 8.1 | For all treatment provided in a local emergency room (ER), all documentation of the care provided (discharge instructions) is obtained and scanned into the health record within 2 business days of receipt of dictated notes. |
| 8.2 | The health record contains all documentation from the local emergency room (TBNA, ER encounter form) of the care and treatment provided. |
| 8.3 | Documentation in the health record identifies the nature of the emergency, the clinical condition or the collection of symptoms that required emergency services or referral to an emergency room (e.g. vomiting blood, low blood pressure, chest pain, and rule out MI etc.). |
| 8.4 | Documentation in the health record identifies the clinical services or treatment provided (e.g. CPR, oxygen, IV therapy, etc.). |
| 8.5 | Documentation supports that when an ambulance was called, a progress note reflects the time EMS was notified, the time they arrived, and the time they departed. |
| 8.6 | Documentation must support that the discharge instructions were reviewed immediately upon the patients return from the ER by nursing and the provider called for orders if recommended by the ER provider. |
| 8.7 | For all incarcerated individuals sent to the ER, documentation in the medical record identifies the provider who gave the order to send the incarcerated individual out. |
| 8.8 | All scanned documents show signature and date of provider who reviewed the ER orders. This may be notated by a chart update from the reviewing provider attached to the scanned documents. |
| 8.9 | There is a nursing note included in patients’ health records when an incarcerated individual is returned to site and that a provider was notified. |
| 8.1 | Upon return from the ER the patient must be placed on the providers schedule on next business day |
| 8.11 | For all instances of sexual assault, care is provided in accordance with Health Care Services Directive (HCSD) 2.22, guidelines in the Sexual Assault Manual, and IDOC policy. |
| 8.12 | Documentation supports that immediate assessments are made of sexual assault victim. |
| 8.13 | Documentation supports that emergency room services are provided if they are required via a SANE nurse. |
| 8.14 | Documentation supports that sexual assault victims were provided with counseling from mental health. |
| 8.15 | All equipment and supplies, such as an AED, naloxone nasal misters, ambu bag oxygen tanks etc., are in proper working order (and not expired) and immediately available to treat emergencies in all facilities. |
| 8.16 | Inspection, logs, equipment check lists, observation support that the AED is proper working order (battery is charged and in place, pads, wires etc.). |
| 8.17 | Inspection, logs, equipment check lists, observation support that the EKG machine, oxygen tanks, IV supplies or other equipment needed in an emergency is proper working order and immediately available for use. |
| 8.18 | Logs, procedures, equipment check lists or other documentation supports that equipment needed for emergency care is periodically checked or tested in accordance with the manufacturer’s recommendation (e.g. blood pressure cuffs, glucometers - hi, low testing, expiration dates for IV bags). |
| 8.19 | Rescue Bags used in "man down," signal 3000's or other onsite emergencies contain appropriate equipment and supplies and are checked and maintained in accordance the IDOC policy or contemporary standards of practice. |
| 8.2 | Inspection of equipment checklist on man down bags is consistent with what is in the bag. |
| 8.21 | Inspection confirms there are no outdated or expired items in the bag. |
| 9. Hospital Care (HCSD 3.13) | |
| 9.1 | For all incarcerated individuals released from the hospital, the orders of the discharging provider are implemented, or if not implemented, documentation in the medical record explains the rationale for not following the recommendations within 2 hours of the patients return or by the next business day. |
| 9.2 | For all hospital admissions, facility administrative personnel are advised and updated regarding the patient's condition and expected date of release. |
| 9.3 | For all incarcerated individuals released from the hospital, the hospital discharge summary is scanned into the electronic medical record. |
| 9.4 | Documentation supports that patients released from the hospital are seen on the next business day by the provider. |
| 9.5 | Documentation supports that the provider is notified upon a patients return and that discharge orders were reviewed and addressed. |
| 9.6 | For all patients admitted to the hospital, the health record contains a progress note or all other documentation which notes the reason for the admission (difficulty breathing, rule out MI, etc.). |
| 9.7 | There shall be a uniform process in place to track daily inpatient days and to provide daily report of condition to IDOC Division of Health Services. |
| 10. Infection Control | |
| 10.1 | All patients receiving medication for latent TB including INH are monitored for adverse effects as indicated by the current CDC recommendations or contemporary standards of practice. |
| 10.2 | Specific disease documentation supports that the incarcerated individual on INH (or Rifampin) are seen monthly. |
| 10.3 | Specific disease documentation supports that the incarcerated individual was assessed for clinical symptoms suggestive of hepatitis B or C. |
| 10.3a | Nausea |
| 10.3b | Vomiting |
| 10.3c | Abdominal pain |
| 10.3d | Jaundice |
| 10.3e | Yellow or brown urine |
| 10.4 | All outbreaks of infectious or communicable diseases are managed in accordance with CDC/IDOH recommendations. |
| 10.5 | There is an Infection Control Committee that meets at least quarterly which monitors the presence, transmission and control of infections in the facility. |
| 10.6 | Specific disease documentation supports that statistics are maintained showing the number of incarcerated individuals treated for all infectious diseases including LTBI and Active TB |
| 10.7 | Upon notification of suspected TB is reported to the Executive Director of Health Services and IDOC CMO immediately. |
| 10.8 | Screening for tuberculosis is completed in accordance with the IDOC's TB Control Plan. A symptom screen is done in conjunction with the TB skin test for all incarcerated individuals annually and at reception. |
| 10.9 | Specific disease documentation supports that a symptom screen was done upon arrival. |
| 10.1 | Specific disease documentation supports that newly admitted incarcerated individuals who report symptoms suggestive of active TB were masked and evaluated immediately by a practitioner. |
| 10.11 | Specific disease documentation supports that a TB skin test was planted within the first 24 hours of incarceration. |
| 10.12 | Specific disease documentation supports that the TB skin test was read between 48 and 72 hours of administration. |
| 10.13 | For adults only, at the time of the initial TB skin test, all documentation supports that two-step skin testing was completed at least 7 days but no more than 30 days after the first test (does not apply to juveniles and does not apply to parole violators who have already had 2-step testing). |
| 10.14 | Specific disease documentation supports that the incarcerated individuals had a symptoms screen done annually (e.g. annual health screen) – this applies to every incarcerated individual regardless of previous results of TB skin test. |
| 10.15 | For those incarcerated individuals who are skin test negative, all documentation supports that the incarcerated individual received a TB skin test annually. |
| 10.16 | Incarcerated individuals with history of a positive TB skin test and symptoms suggestive of TB were immediately referred to a practitioner for evaluation. |
| 10.17 | All chest x-rays are completed in accordance with the IDOC’s TB Control Plan. |
| 10.18 | Documentation supports that a chest x-ray (CXR) was done within 7 days on an incarcerated individual with a history of a negative TB skin test who is now positive (mm of induction >10 for most incarcerated individuals) who has no symptoms. |
| 10.19 | Documentation supports that new incarcerated individuals (intake facilities) known to have HIV infection or other severe immunosuppression had a CXR done as part of the initial screening, completed within 7 days, regardless of the results of the incarcerated individual’s TB skin test. |
| 10.2 | Documentation supports that a chest x-ray was done within 24 hours for any incarcerated individual who complained of symptoms suggestive of TB (e.g. at intake or during the annual screen). |
| 10.21 | Documentation supports CXR was interpreted by a radiologist or radiology service within 48 hours of exposure. |
| 10.22 | Documentation supports that a written report of a CXR reading by the radiologist or radiology service was forwarded to the facility within 24 hours of interpretation |
| 10.23 | Documentation (e.g. initials on the report, a provider’s encounter notes in the EMR etc.) supports that a provider reviewed the CXR report by the first business day following the receipt of the radiologist’s written report. |
| 10.24 | Documentation supports that the radiologist or designee telephoned to report abnormal results suggestive of TB. |
| 10.25 | Documentation (e.g. initials, progress note, etc.) support that an abnormal chest x-ray was immediately brought to the attention of the practitioner |
| 10.26 | All patients with latent TB are managed in accordance with the TB control plan and the current CDC recommendations. |
| 10.27 | Documentation supports that the incarcerated individual who convert from negative to positive (>10 mm induration unless in a high-risk group) was evaluated for treatment against LTBI (e.g. INH). For intake facilities a note indicating the incarcerated individual should be evaluated for INH at the parent facility is sufficient to meet criteria. |
| 10.28 | If the incarcerated individual was not placed on INH, all documentation must explain the reason why not. |
| 10.29 | Documentation supports that the results of the chest x-ray were known before INH or Rifampin therapy was initiated. |
| 10.3 | Documentation supports that the liver function tests were obtained prior to the initiation of treatment against LTBI for any patient with a history of liver disease, patients who used alcohol regularly, and persons at risk for chronic liver disease (e.g. hepatitis C). |
| 10.31 | Documentation supports that a standard treatment regimen is/was used to treat LTBI (INH 300 mg daily for 9 months, INH 900 twice weekly for 9 months, Rifampin 600 mg daily for 4 months). |
| 10.32 | All incarcerated individuals who are symptomatic or have chest x-rays suggestive or suspicious of TB are moved to a negative pressure room. |
| 10.33 | Documentation supports that an incarcerated individual with a chest x-ray suggestive of active TB was moved to a negative pressure room. |
| 10.34 | For all patients with active TB care and treatment is provided in accordance with the TB control plan or the CDC's recommendations. All contact tracing in conducted in accordance with generally accepted principles of infection control or at the direction of the local or state TB office. |
| 10.35 | Isolation status is mandatory. Arrangements for transfer to a negative air-flow room are made |
| 10.36 | Dcoumenation supports that the Executive Director of Physical Heath or designee must be fully informed regarding contact investigation activities and outcome.IDOH and correctional epidemiologist must also be notified. |
| 10.37 | Sharps and hazardous waste are disposed of in accordance with IDOC procedures, the Health Care Services Directives (HCSD) and OSHA regulations. |
| 10.38 | Documentation supports that nationally reported infectious diseases are reported to IDOH and ED of PH within 24 hours of identification |
@Bedford, Adrienne @Dwenger, Deanna L ladies please look at 7.3 this PM notes that documentation shall be completed on same business day. Yes for nursing (not happening for providers and I know BH/TH have different regs... What are your recommendations here?
Behavioral Health notes are due within 7 days unless crises or suicide/safety precautions related, in which case documentation shall be completed same day. @Tafoya, Nikki
@Tafoya, Nikki we need to review with the team.
11-20 PMs
| PERFORMANCE MEASURES | |
| 11. Infirmary/Inpatient Unit |
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