Attachment 18 G6000I06 Program Review Guidellines.pdf

G6000I.06 10/26/2010 Health Services - Institutions 1

U.S. Department of Justice

Federal Bureau of Prisons

P R O G R A M R E V I E W G U I D E L I N E S

OPI: HSD/HSS

NUMBER: G6000I.06

LEVEL: Institutions

DATE: 10/26/2010

Health Services

/s/ /s/

Approved: VaNessa P. Adams Assistant Director

Program Review Division

RADM Newton E. Kendig Assistant Director

Health Services Division

1. PURPOSE AND SCOPE. To issue revised Institution Program Review Guidelines for Health Services. These guidelines were developed during May 2010 management assessment and are being disseminated for Bureau staff to use as a guide in conducting operational and program reviews.

2. VITAL FUNCTIONS

During the management assessment, vital functions were identified as follows:

(V-1) Provide open access to medically essential health care for all inmates in an environment that is safe and secure for inmates and staff.

(V-2) Provide quality health care.

(V-3) Ensure all Health Services staff are appropriately qualified and efficiently utilized.

3. REVIEW PROCEDURES

Unless otherwise indicated, review step time frames will be from the last program review.

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REFERENCES

Rescinded

G6000I.05 Health Services - Institution (3/20/09)

Program Statements

P1210.23 Management Control and Program Review Manual (8/21/02)

P4100.04 Bureau of Prisons Acquisition Policy (5/19/04)

P6010.01 Psychiatric Treatment and Medication, Administrative Safeguards for

(9/21/95)

P6010.02 Health Services Administration (1/15/05)

P6013.01 Health Services Quality Improvement (1/15/05)

P6027.01 Health Care Provider Credential Verification, Privileges, & Practice

Agreement Program (1/15/05)

P6031.01 Patient Care (1/15/05)

P6090.02 Health Information Management (10/13/08)

P6190.03 Infectious Disease Management (6/28/05)

P6270.01 Medical Designations & Referral Services for Federal Prisoners (1/15/05)

P6340.04 Psychiatric Services (1/15/05)

P6360.01 Pharmacy Services (1/15/05)

P6370.01 Laboratory Services (1/15/05)

P6400.02 Dental Services (1/15/05)

P6541.02 Over-the-Counter Medications (11/17/04)

1910.1030 OSHA Regulation

Clinical Practice Guidelines

ACA Standards

4th Edition Standards for Adult Correctional Institutions: 4-4196M, 4-4203M, 4-4258, 4-4344M, 4-4345, 4-4346, 4-4347, 4-4348, 4-4349, 4-4350, 4-4351M, 4-4352, 4-4353M, 4-4353-1, 4-4354M, 4-4354-1, 4-4355, 4-4356M, 4-4357M, 4-4358M,4-4359M, 4-4360, 4-4361, 4-4362M, 4-4363M, 4-4364, 4-4365M,4-4366, 4-4367, 4-4368M, 4-4370M, 4-4371M, 4-4372, 4-4375, 4-4376M, 4-4378M, 4-4379, 4-4380M, 4-4381M, 4-4382M, 4-4383, 4-4385, 4-4386, 4-4387, 4-4388M, 4-4389M, 4-4390, 4-4391, 4-4392, 4-4393, 4-4394, 4-4395, 4-4396M, 4-4397M, 4-4398, 4-4399, 4-4400M, 4-4401M, 4-4402M, 4-4403, 4-4403-1, 4-4405M, 4-4406, 4-4407, 4-4408, 4-4410M, 4-4411M, 4-4412, 4-4413, 4-4414, 4-4415, 4-4417, 4-4418, 4-4419, 4-4422, 4-4423, 4-4424, 4-4425, 4-4426, 4-4427

4th Edition Performance-Based Standards for Adult Local Detention Facilities:

4-ALDF-2D-03M, 4-ALDF-4C-01M, 4-ALDF-2A-53, 4-ALDF-4C-02,

4-ALDF-6A-09, 4-ALDF-4C-03, 4-ALDF-4C-04, 4-ALDF-4C-05, 4-ALDF-4C-06,

4-ALDF-4C-07, 4-ALDF-4C-08M, 4-ALDF-4C-09, 4-ALDF-4C-13M,

4-ALDF-4C-14M, 4-ALDF-4C-15, 4-ALDF-4C-16M, 4-ALDF-4C-17M,

4-ALDF-4C-18M, 4-ALDF-4C-19M, 4-ALDF-4C-20, 4-ALDF-4C-21,

4-ALDF-4C-22M, 4-ALDF-4C-23M, 4-ALDF-4C-24M, 4-ALDF-4C-25,

4-ALDF-4C-26, 4-ALDF-4C-27M, 4-ALDF-4C-29M, 4-ALDF-4C-30M,

4-ALDF-4C-31, 4-ALDF-4C-35, 4-ALDF-4C-36M, 4-ALDF-4C-38M,

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4-ALDF-4C-39, 4-ALDF-4C-41, 4-ALDF-4D-01M, 4-ALDF-4D-02M,

4-ALDF-4D-03M, 4-ALDF-4D-05M, 4-ALDF-4D-06, 4-ALDF-4D-07,

4-ALDF-1C-01M, 4-ALDF-4D-04, 4-ALDF-4D-08M, 4-ALDF-4D-09,

4-ALDF-4D-10, 4-ALDF-4D-11, 4-ALDF-4D-12, 4-ALDF-4D-13M,

4-ALDF-4D-14M, 4-ALDF-4D-15M, 4-ALDF-4D-16, 4-ALDF-4C-40,

4-ALDF-2A-45M, 4-ALDF-4D-17M, 4-ALDF-4D-18M, 4-ALDF-4D-19,

4-ALDF-4D-21M, 4-ALDF-4D-22-6M, 4-ALDF-4C-41, 4-ALDF-7D-25,

4-ALDF-7D-26, 4-ALDF-4D-24M, 4-ALDF-4D-25M, 4-ALDF-4D-26,

4-ALDF-4D-27, 4-ALDF-4D-28, 4-ALDF-4C-11, 4-ALDF-4C-10, 4-ALDF-4C-12,

4-ALDF-4D-23, 4-ALDF-7F-07

Records Retention

See the Records and Information Disposition Schedule (RIDS) on Sallyport.

1.0 ADMINISTRATION

Objective: To determine if there is appropriate management of resources to effectively plan, implement and evaluate procedures in accordance with the health care mission.

Review Steps

1.1 Health Information Management

1.1.1 (V-2) Observe Health Services operations to determine if confidentiality, security, and integrity of health records and health-related data is maintained.

Ref: P6090.02, Sec 2; ACA: 4-4396M, 4-ALDF-4D-13M, 4-ALDF-4D-14M

1.1.2 In institutions that utilize Teleheath, interview Health Services staff to ensure a plan is in place for patient consent, confidentiality/protected health information, documentation, and integration of the report of the consultation into the primary health care record.

Note: If Telehealth is provided by a BOP employee, a consent form is not necessary.

Ref: P6340.04, Sec 5(a); ACA: 4-4403-1

1.1.3 Review 10 health records, paper or electronic (not to exceed 20 for facilities with multiple institutions or shared service operations), including the dental section, to determine if the following are present and filed in a uniform manner:

a. Patient ID on each sheet.

b. A completed receiving health screening form.

c. Health appraisal data forms.

d. Problem summary list.

e. Record of immunizations.

f. All findings, diagnoses, treatments and dispositions.

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g. A record of prescribed medications and their administration records.

h. Lab, x-ray, and diagnostic studies.

i. Place, date, and time of health encounters.

j. Health Services reports (i.e., emergency dept., dental, mental health, telemedicine, or other consultations).

k. Individualized treatment plan, when applicable.

l. Progress reports.

m. Discharge summary of hospitalization and other termination summaries.

n. Authenticated, legible signatures and title of the provider.

o. Consent and refusal forms, as indicated.

p. Release of information forms, as indicated.

Ref: P6090.02, Sec 3; ACA: 4-4413, 4-ALDF-4D-26

1.1.4 Interview medical records staff to determine if:

a. Continuity of care is maintained from admission to transfer or discharge from the facility.

b. During nonemergency transfers: summaries, originals, or copies of the health record accompany the inmate and confidentiality is maintained; suitability for travel is determined based on medical evaluation; written instructions regarding medication or health interventions required are provided to transporting officers separate from the medical record; and specific precautions are taken by transporting officers (i.e., masks or gloves).

c. Inactive health records are retained within legal requirements.

Ref: [a.] P6090.02, Secs 4, 8, & 14; ACA: 4-4347, 4-ALDF-4C-04;

[b.] P6090.01, Secs 11, 17, & 18; ACA: 4-4414, 4-ALDF-4D27; [c.] P6090.01, Secs 11, 17, & 18; ACA: 4-4415, 4-ALDF-4D-28

1.1.5 Review 10 electronic health record files (20 at complexes and MRCs) with entries in the document manager to assure:

a. The name of the file is the date the health record was originally created in yyyymmdd format.

b. When opened, the scanned document can be easily read or reviewed.

c. The first page of the document contains the inmate’s first and last name, register number, and institution.

d. When applicable, the document (results of diagnostic studies, consultations, reports from external facilities or providers) has evidence of clinical review, including provider’s name and credential and date of signature.

Ref: P6090.02, Sec 3(a)

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1.1.6 Using the sample in 1.1.5, determine if health documentation processes are being utilized consistently, are in accordance with BEMR user documentation requirements, and that paper documentation systems were only used if:

a. There is no equivalent electronic process available.

b. An emergency situation has disabled the use of BEMR.

Ref: P6090.02, Sec 2

1.2 Patient Care

1.2.1 (V-3) Interview the clinical director and chief dental officer to determine if clinical decisions are the sole province of the responsible clinicians and are not countermanded by non-clinicians.

Ref: P6031.01, Secs 8 and 8 (b); ACA: 4-4381M, 4-ALDF-4D-02M

1.2.2 Review four randomly selected Utilization Review Committee (URC) Meeting Minutes and the BEMR consultations queue from the past 12 months and interview the clinical director to determine if:

a. Outside medical, surgical, and dental procedures are reviewed by the clinical director.

b. Requests for special evaluations are reviewed and approved by the clinical director.

c. The clinical director serves as chair of the committee and is the final authority for all

URC decisions.

d. Elective medical and dental procedures are referred to the regional improving organizational planner / regional medical director / and regional chief dentists for review and disposition.

Ref: P6031.01, Secs 8 and 8 (b); AD memo regarding elective medical procedures dated

10/13/09; ACA: 4-4398, 4-ALDF-4D-16

1.2.3 Randomly select 10 inmate medical records (20 at complexes and MRCs) from the URC

Meeting Minutes to determine if inmates were notified in writing of the URC's decision.

Ref: P6031.01, Sec 8

1.2.4 Review the monthly Health Services Staffing Report (BP Med-18) and interview the HSA or CD to determine that qualified health care staff are responsible for the coordination of health services.

Ref: P6010.02, Sec 7(b); ACA: 4-4383, 4-ALDF-4D-04

1.2.5 Interview three health care personnel to ensure they are trained to respond to health-related situations within a 4-minute response time and they are trained on an annual basis.

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Ref: P6031.01, Sec 9; ACA: 4389M, 4-ALDF-4D-08M

1.2.6 (V-1) (V-2) Through observation and review of local policies, institution supplement or written plan relevant to the provision of 24-hour emergency medical, dental, and mental health services to determine if:

a. There is an established method to provide medical coverage 24 hours per day.

b. Offenders who need health care beyond the resources available in the facility are transferred to a facility where such care is on-call or available 24 hours per day.

c. There is an established transportation system that assures timely access to services that are only available outside the correctional facility if required.

d. First aid/emergency supplies are available in designated areas of the facility based on local determination of need.

e. There is an established method to provide a 4-minute response to medical emergencies, immediate medical examination and treatment, and crisis intervention for all persons injured.

f. CPR/AED certified staff are available.

g. One or more designated community hospital emergency rooms or other appropriate facilities are available for use.

h. There is an established method for the emergency evacuation of the offender.

i. There is an established method to provide emergency on-call services.

j. There are established security procedures in place for providing the immediate transfer of the offender.

Ref: P6010.02, Sec 17 & 18; P6031.01, Sec 9; ACA: 4-4351M, 4-ALDF-4C-08M;

[b.] ACA: 4-4348, 4-ALDF-4C-05; [c.] ACA: 4-4349, 4-ALDF-4C-06; [d.] ACA:

4-4390, 4-ALDF-4D-09; [e.] ACA: 4-4203M

1.2.7 (V-1) Review the written policy and procedures for providing health care services to determine if the following are included:

a. Management of inmates with mental illnesses or disorders.

b. Patient privacy.

c. Infection control(exposure control plan), management of infectious and communicable disease, including HIV, TB, and Hepatitis A, B, and C. Procedures for prevention, education, training, identification, surveillance, immunization, treatment, follow-up, isolation, reporting requirements, appropriate safeguards, and post exposure management are included.

d. Poison control.

e. Patient triage/sick call procedures.

f. Medical duty status.

g. Treatment of patients in special housing units and detention status.

h. Intake screening.

i. Individual treatment plans, i.e., plan in SOAPE note.

j. Staff roles and responsibilities.

k. Chronic care clinics.

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l. Infirmary care, if applicable.

m. Accident reporting.

n. Physical examinations.

o. Use of restraints for medical or psychiatric purposes.

p. Eyeglasses.

q. Elective procedures for surgery.

r. Inmates are afforded the opportunity and facilities for exercise and physical therapy.

s. Annual reviews of HSU policies and procedures, and revisions as necessary.

Ref: P6031.01, Sec 12; [b.] ACA: 4-4403, 4-ALDF-4D-19; [c.] 4-4354M, 4-4355M, 4-4357M, 4-ALDF-4C-14M, 4-ALDF-4C-15, 4-ALDF4C-16M, 4-ALDF-4C 17M. [i.]

ACA: 4-4350, 4-ALDF-4C-07; [j.] ACA: 4-4380M, 4-ALDF-4D-01M; [k.] ACA:

4-4359M, 4-ALDF-4C19M; [l.] ACA: 4-4352, 4-ALDF-4C-09; [o.] ACA: 4-4405M, 4-ALDF-4D-21M; [q.] ACA: 4-4398, 4-ALDF-4D-16; [r.] ACA: 4-4407, 4-ALDF-4C-41;

[s.] ACA: 4-4424

1.2.8 Observe and interview staff responsible for performing health appraisals to determine if:

a. A uniform process has been established by the health authority.

b. Health history, vital signs, and collection of all other health appraisal data is performed only by a qualified health care professional.

c. Interpretation of the results of medical examinations or tests, and identification of problems is performed by a physician or mid-level practitioner as allowed by law.

Ref: P6031.01, Sec 12; ACA: 4-4366, 4-ALDF-4C-25

1.2.9 (V-2) Review 10 medical records (20 at complexes) of inmates who have arrived within the last 12 months and were new commitments to determine if:

a. A physical examination was completed within 14 days of their arrival.

b. An A&O dental examination within 30 days by a dentist with oral hygiene instructions was documented in the dental section of the medical record, including the oral health condition and priorities for treatment.

c. For female inmates (long-term as defined in policy):

1. Gynecological history (including sexual activity and any recent rape history) has been documented.

2. Received vaginal exam, breast, and instruction on breast self-examination.

Pregnancy testing is performed on females of child bearing age or as clinically appropriate. Pap smear is offered. Sexually communicable disease testing is conducted only as clinically indicated.

Ref: P6031.01, Sec 19 & 20; [a.] ACA: 4-4365M, 4-ALDF-4C-24M;

[b.] ACA: 4-4360, 4-ALDF-4C-20

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1.2.10 (V-1) (V-2) Observe and or interview medical staff responsible for performing medical intake screening to determine if:

a. Urgent and ongoing medical, dental, or mental health care needs are addressed.

b. Signs of acute drug or alcohol intoxication or symptoms of withdrawal are documented and referrals made as clinically indicated.

c. Observation of behavior, body deformities, skin condition, lice, evidence of abuse or trauma, drug abuse, and mental status are recorded.

d. Restrictions on temporary work assignments are determined as necessary.

e. Evaluation for contagious infectious disease is conducted.

f. Medical dispositions (e.g., general population, general population with prompt referral for health care, and emergency medical treatment) are made.

g. Inmates are informed verbally and in writing (e.g., A&O handbook) how to access medical care.

Ref: P6031.01, Sec 18; [a.] ACA: 4-4360, 4-4363M, 4-4364, 4-ALDF-4C-20, 4-ALDF-4C-23M; [b.] ACA: 4-4365M, 4-ALDF-4C-24M; [c.] ACA: 4-4362M, 4-ALDF-4C-22M; [d.] ACA: 4-4365M, 4-ALDF-4C-24M; [e.] ACA: 4-4361, 4-ALDF-4C-21; [f.] ACA: 4-4362M, 4-ALDF-4C-22M; [g.] ACA: 4-4344M, 4-ALDF-4C-01M

1.2.11 Interview the clinical director and chief dental officer to determine if:

a. Consultation is between the facility and program administrator (or designee) and the responsible clinician (or designee) prior to taking action regarding chronically ill, physically disabled, geriatric, seriously mentally ill, or developmentally disabled inmates in the following areas:

1. Housing assignments.

2. Program assignments.

3. Disciplinary measures.

4. Transfers to other facilities.

5. When immediate action is required, consultation is made as soon as possible to review the appropriateness of the action, but no later than 72 hours.

b. Exercise areas are available to meet exercise and physical therapy requirements of individual offender treatment plans.

Ref: P6031.01, Sec 8; [a.] ACA: 4-4399, 4-ALDF-4C-40, 4-4407, 4-ALDF-4C-41

1.2.12 Review 10 randomly selected medical records (20 at complexes) utilizing SENTRY or electronic medical record of sentenced female inmates 40 years of age or older who have been in custody at least 1 year to determine if a baseline mammogram has been obtained.

If the inmate refuses the mammogram, a Refusal of Medical Treatment form (BP-A0358) is on file.

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Ref: P6031.01, Sec 20; ACA: 4-4397M, 4-ALDF-4D-15M

1.2.13 Review health records of all pregnant inmates over the past 12 months to determine if:

a. Inmates are referred to a physician within 14 days for an initial exam and testing.

b. Prenatal care and counseling is offered (both routine and high risk).

c. Chemical addiction is addressed and treated.

d. Appropriate nutrition is provided.

e. Inmates are offered the HIV antibody test.

f. Post-partum follow-up is completed.

g. Provisions are made for a nursery and qualified staff when nursing infants are allowed to remain with their mothers.

Ref: P6031.01, Sec 20; ACA: 4-4353M, 4-4353-1, 4-ALDF-4C-13M, 4-4354M, 4-ALDF-4C-14M

1.2.14 Review the records of up to five inmates who have been identified as victims of sexual assault (since the last Program Review) to determine if inmates are referred under appropriate security procedures to a community facility for treatment and gathering of evidence or if procedures are performed in house by specifically trained examiners and the following are addressed:

a. A history is taken by health care professionals who conduct an examination to document the extent of physical injury and to determine if referral to another medical facility is indicated.

b. Provision is made for testing of sexually transmitted diseases and counseling.

c. Prophylactic treatment and follow-up for sexually transmitted diseases are offered.

d. Evaluation by a mental health professional is made.

e. A report is made to assure separation of the victim from his or her assailant.

Ref: P6031.01, Sec 42; ACA: 4-4406, 4-ALDF-4D-22-6M

1.2.15 (V-2) Review 10 (not to exceed 20 for facilities with multiple institutions or shared services operations) electronic Exit Summary of inmates who have transferred to determine if:

a. Medication instructions are written in lay terms and include dosage, frequency, route of administration, and expiration date or non-expiration statement.

b. TB clearance information is documented.

Ref: P6270.01, Sec 13; P6190.03, Sec 7; ACA: 4-4414, 4-ALDF-4D-27

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1.2.16 Review the A&O handbook at each location for basic Health Services information and criteria of inmate eligibility for periodic examinations and a system for resolving offender grievances relating to health care concerns. Determine that the handbook includes the inmate's health rights and responsibilities and is put into a language that is clearly understood by the inmate.

Ref: P6013.01, Sec 6, Attch B; P6031.01 Sec 19c; ACA: 4-4344M, 4-4361, 4-4394, 4-ALDF-4C-01M, 4-ALDF-4C-21

1.2.17 Observe triage (two at complexes) to determine if:

a. Inmates are afforded privacy and daily access.

b. There is a referral procedure for over-the-counter medication (OTC) as indicated.

c. There is a procedure in place for a physician referral as indicated.

Ref: P6031.01 Sec 17; [a.] ACA: 4-4403, 4-4346, 4-ALDF-4C-03, 4-ALDF-4D-19;

[b.] ACA: 4-4379, 4-ALDF-4C-39; [c.] ACA: 4-4348, 4-ALDF-4C-05

1.2.18 If medical co-payment fees are imposed, determine if the program contains the following:

a. All inmates are advised in writing at the time of admission to the facility of the guidelines of the co-payment program and that a clear definition of indigence exists.

b. Needed offender health care is not denied due to lack of available funds.

c. Co-payment fees are waived when appointments or services, including follow-up appointments are initiated by medical staff.

d. Review 10 clinical encounters (20 at a complex, i.e., sick call and after-hours encounters) to determine if co-pay status was accurately entered into the Trust Fund system.

Ref: P6031.02; ACA: 4-4345, 4-ALDF-4C-02, 4-ALDF-6A-09

1.2.19 Review local policy and procedures to determine if medical or dental adaptive devices

(eyeglasses, hearing aids, dentures, wheelchairs, or other prosthetic devices) are provided when the health of the offender would otherwise be adversely affected, as determined by the attending physician or dentist.

Ref: P6031.01, Secs 27, 29, & 47; P6010.02, Sec 9; ACA: 4-4375, 4-ALDF-4C-35

1.2.20 (V-1) (V-2) Randomly select 10 health records (20 in complexes) of inmates enrolled in chronic care clinic for each category (cardiac, hypertensive, insulin dependent diabetic, and asthmatic) to determine if:

a. There is a plan for treatment that addresses the monitoring of medications, laboratory testing, the use of chronic care clinics, health record forms, and the frequency of specialist consultation and review.

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b. All inmates are evaluated by a physician within established time frame, or more often as clinically indicated as determined by the health authority.

c. Entries documented on the clinical encounter notes are completed utilizing the

SOAP(E) format.

d. Administrative notes are not used to document chronic care clinic encounters.

Ref: P6031.01, Sec 15 and 16; [a.] ACA: 4-4359M, 4-ALDF-4C-19M;

[b.] ACA: 4-4367, 4-ALDF-4C-26; Clinical Practice Guidelines

1.2.21 Determine if there is long-term care or inpatient beds. If so, review 10 inmate health records to determine if:

a. All inmates are within sight or sound of a staff member.

b. Health care personnel are on-call or on duty 24 hours per day.

c. There are sufficient bathing, hand-washing, and toilet facilities.

Ref: [a.] ACA: 4-4352, 4-ALDF-4C-09; [b.] ACA: 4-4352, 4-ALDF-4C-09;

[c.] ACA: 4-4417, 4-4418, 4-4419, 4-ALDF-4C-10, 4-ALDF-4C-11, 4-ALDF-4C-12

1.2.22 (V-1) (V-2) Observe, review documentation, and interview clinical staff who conduct SHU rounds to determine if:

a. A health care provider makes daily rounds during the lights-on period, except in extenuating circumstances.

b. A mechanism exists for SHU inmates to notify medical staff of their need for health care.

c. Daily rounds to triage urgent requests for care are accomplished.

d. Follow-up care by an MLP, physician, or dentist is provided if warranted.

e. Health Services staff are notified immediately when an inmate is transferred to SHU.

Ref: P6031.01, Sec 13; ACA: 4-4346, 4-ALDF-4C-03; [a.] ACA: 4-4258, 4-ALDF-2A-53; [e.] ACA: 4-4400M, 4-ALDF-2A-45M

1.2.23 Randomly select 10 (20 at complexes) Special Housing Unit Records (BP-A0292) for inmates currently housed in SHU(s) to determine if rounds are announced and recorded.

Ref: P6031.01 Sec 13; ACA: 4-4400M, 4-ALDF-2A-45M

1.2.24 Interview the clinical director to determine that non-therapeutic medical experimentation and pharmaceutical testing is not conducted on inmates.

Ref: P6031.01, Sec 45; ACA: 4-4402M, 4-ALDF-4D-18M

1.2.25 Review the Serious Illness and Death Institution Supplement to determine if it addresses the following:

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a. Notification procedures (individuals designated by the offender, medical examiner/coroner).

b. Advance directives.

c. Autopsies.

Ref: P6080.01, Sec 4; P6031.01, Sec 24; [a.] ACA: 4-4395, 4-4425, 4-ALDF-4D-12, 4-ALDF-4D-23

1.2.26 (V-2) Review local detoxification policy to determine if it is current and in accordance with local, state, and federal laws. Interview the HSA and clinical director to determine if procedures are in place for gradual detoxification from drugs or alcohol. (Note: The detoxification can be completed either at the institution or an outside facility).

Ref: P6031.01, Sec 35; ACA: 4-4376M, 4-ALDF-4C-36M

1.3 Pharmacy

1.3.1 Tour the Health Services unit and observe all areas where needles, syringes, and sharps are utilized to determine if:

a. All unused sub-stock needles, syringes, and sharps are stored in a separate locked cabinet, drawer, or computer-driven medication station (SureMed, Pyxis) and are secured in a locked room at all times when staff are not present.

b. All unused sub-stock needles and syringes are inventoried on each medically staffed shift.

c. All medical mainstock needles and syringes (including prefilled items) are controlled and inventoried.

d. All substock and mainstock counts for needles and syringes (to include prefilled items) are accurate.

Ref: P6360.01, Sec 14; ACA: 4-4196M, 4-ALDF-2D-03M

1.3.2 Select five medications from the National Formulary to determine if generic equivalents are used when available. Consult with the regional chief pharmacist for recommended list.

Ref: P6360.01, Sec b

1.3.3 Randomly select four Pharmacy and Therapeutic Committee Meeting Minutes since the last program review to determine if the following are addressed:

a. Drugs on the National Formulary (locally).

b. Available strengths and dosage.

c. Restricted drugs on the National Formulary.

d. Prescribing, dispensing, and administration errors.

e. Adverse drug reactions.

f. Drug Use Evaluations (DUE) data and track problems.

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g. Changes in the National Formulary.

h. New drug information.

i. Requests for additions to formulary.

j. Quality improvement measures.

k. Investigational drugs.

l. Floor stock medications.

m. Overall and specific pharmaceutical cost trends.

Ref: P6360.01, Sec 7; ACA: 4-4378M, 4-ALDF-4C-38M

1.3.4 (V-2) (V-3) Review 10 health records, (not to exceed 20 for facilities with multiple institutions or shared service operations), including the dental section, to determine if proper management of pharmaceuticals is administered in accordance with state and federal law, to include:

a. Medications are prescribed only when clinically indicated as one facet of the program of therapy.

b. A provider with prescribing authority reevaluates a prescription prior to its renewal.

c. Medications are administered by persons properly credentialed / trained and under the level of supervision required by their position and consistent with their documented competence.

d. Accountability for administering or distributing medications is in a timely manner and in accordance with physician orders.

e. Ensure an institution formulary is available and it meets the requirements of the

National Formulary.

g. There is a formalized process for obtaining nonformulary medications.

Ref: P6360.01, Secs 7, 9(g), 10 (c)(2); ACA: 4-4378M, 4-ALDF-4C-38M; [e.] ACA: 4-

4378M, 4-ALDF-4C-38M; [f.] ACA: 4-4378M, 4-ALD-4C-38M

1.3.5 Through interviews and review of documentation, determine if there are procedures in place for procurement, receipt, distribution, storage, dispensing, administration, and disposal of controlled substances in a manner prescribed by the DEA. If the institution self-destructs controlled substances, obtain a copy of the written agreement with the DEA.

Ref: P6360.01, Sec 8.h.; 21 CFR 1307.21; ACA: 4-4378M, 4-ALDF-4C-38M

1.3.6 Review the most recent biennial inventory of controlled substance stock to determine if it was performed as required by the DEA.

Ref: P6360.01, Sec 8; ACA: 4-4378M, 4-ALDF-4C-38M

1.3.7 Randomly select three medications from the inventory of DEA controlled substances sub-stock inventory. Utilize tracer methodology to determine if inventory procedures were followed. Also ensure the inventory is stored in a secure location.

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Ref: P6360.01, Sec 8; ACA: 4-4378M, 4-ALDF-4C-38M, 4-4427

1.3.8 Review a random sample of 10 (20 at complexes) medication orders for controlled substances using BEMR to determine if:

a. A physician/dentist countersigns health record entry by his/her next working day, or the order is countersigned by a physician/dentist providing remote oversight.

b. DEA number (if R&D prescription) is included.

c. Strength is indicated.

d. Directions are provided.

e. Duration of therapy is indicated.

f. They are limited to the period specified in the program statement on pharmacy services.

Ref: P6360.01, Sec 9; ACA: 4-4378M, 4-ALDF-4C-38M

1.3.9 Review a random sample of 10 (20 at complexes) medication orders for non-controlled substances using BEMR to determine the prescriber included the following in the medication order:

a. Drug name.

b. Route and site of administration.

c. Dosage form.

d. Dose.

e. Strength.

f. Frequency of administration.

g. Duration of therapy.

h. Prescriber's name.

Ref: P6360.01, Sec 10; ACA: 4-4378M, 4-ALDF-4C-38M

1.3.10 (V-2) Review and observe procedures for the administration of medication to determine if:

a. Medication administration record is prepared for each patient.

b. Patient is identified utilizing two forms of identification prior to administration of medication.

c. Medication is immediately drawn from sub-stock and recorded on the Medication

Administration Record (MAR).

Ref: P6360.01, Sec 9d; ACA: 4-4378M, 4-ALDF-4C-38M

1.3.11 Review the meeting minutes from the Pharmacy and Therapeutics Committee to determine if over-the-counter items are carried in the commissary and local procedures for referring inmates to the commissary for these items are approved by a representative of Health

Services and the warden.

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Ref: P6542.02, Sec 5; ACA: 4-4379, 4-ALDF-4C-39

1.3.12 Review plan for pharmacy coverage in the absence of the pharmacist to determine if the plan is consistent with policy. Review the absences of the pharmacist for the past year to determine if the coverage was compliant with policy.

Ref: P6360.01, Sec 9

1.4 Dental

1.4.1 Review 10 (20 for facilities with multiple institutions or shared service operations) dental records of dental surgical (exodontia) inmates to determine if the approved consent form is used and signed by the patient and witnessed as required with all entries accurate.

Ref: P6400.02, Sec 8(c); ACA: 4-4397M, 4-ALDF-4D-15M

1.4.2 Review inventory records in the dental clinic to assure:

a. Accountability of dental needles and syringes (including prefilled items), sharps, and etching tips is accurately maintained.

b. A system of accountability for dental instruments is accurately maintained.

Ref: P6400.02, Sec 17

1.5 Radiology Services

1.5.1 Review the last biennial FDA radiation survey of radiographic equipment to determine if it was completed and corrective action implemented.

Ref: P6031.01, Sec 46

1.5.2 Review logs of radiographs to determine that all radiographs, whether for clinical or security purposes, are taken by appropriately trained staff consistent with P6031.01, Sec

46 a. All radiographs taken are documented, interpreted and retained consistent with the policy statement.

Ref: P6031.01, Sec 46.a.

1.6 Psychiatric Services

1.6.1 (V-1) (V-2) Review 10 (MRCs only) medical records over the past 90 days to determine if staff performing intake screening assessed and made appropriate referrals to a mental health professional when the inmate:

a. Has a mental health designation.

b. Exhibits signs or symptoms consistent with a possible mental health disorder.

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c. Is on medication for treatment of a mental illness or disorder.

Ref: P6340.04, Sec 9; ACA: 4-4362M, 4-ALDF-4C-22M, 4-4365M, 4-ALDF-4C-24M

1.6.2 (V-2) Review 5 (MRCs only) medical records for offenders referred for mental health treatment received a comprehensive evaluation by a qualified mental health practitioner within 14 days of the referral request date and the evaluation included:

a. A review of the mental health screening and appraisal data.

b. Direct observations of behavior.

c. Collection and review of additional data from individual diagnostic interviews and tests.

d. Compilation of individual’s mental health history.

e. Development of an overall treatment/management plan with appropriate referral.

Ref: ACA: 4-4372, 4-ALDF-4C-31

1.6.3 Review 10 (20 at complexes) health records of inmates assigned to mental health clinics to determine that psychiatric treatment began after the psychiatric evaluation and plans were completed, except in an emergency.

Ref: P6340.04, Sec 10

1.6.4 Review 10 (20 at complexes) medical records for inmates assigned to a mental health chronic care clinic to determine if the following services are provided:

a. When an initial psychiatric evaluation is required and completed by a psychiatrist, the psychiatric diagnosis is documented using DSM-IV format and all five axes are documented.

b. Current mental health concerns are addressed by the primary care provider during the mental health chronic care appointment.

Ref: P6010.01, Sec 5 & 6; P6340.04, Sec 12, ACA: 44368M, 4-ACDF-4C-27M

1.6.5 Review 10 (20 at complexes) medical records for inmates assigned to a mental health chronic care clinic to determine if:

a. Informed Consent forms for newly prescribed psychiatric medication are completed prior to administration of medication.

b. Patient's competency to give informed consent is assessed and documented.

c. The involuntary administration of psychotropic medication(s) to an offender is governed by applicable laws and regulations of the jurisdiction.

Ref: P6010.01, Sec 5 & 6; P6340.04, Secs 9 & 10; [a.] ACA: 4-4397M, 4-ALDF-4D-15M; [b.] ACA: 4-4397M, 4-ALDF-4D-15M; [c.] ACA: 4-4401M, 4-ALDF-4D-17M

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1.6.6 Interview the clinical director or chief psychiatrist to determine if any inmates are currently in psychiatric seclusion or psychiatric restraints, or if any inmates are involuntarily receiving psychotropic medication(s) and, if so, review current case(s) to determine if management is in compliance with local policy (i.e., Use of Psychiatric Seclusion and

Restraints or Involuntary Administration of Psychotropic Medications) .

Ref: P6340.04, Sec 11; ACA: 4-4401M, 4-4405M, 4-ALDF-4D-21M, 4-ALDF-4D-17M

1.7 Resources

1.7.1 Interview the HSA to determine if any students, interns, or residents delivering health care in the facility as part of a formal training program work under staff supervision commensurate with their level of training and:

a. There is a written agreement between the facility and training or educational facility that covers the scope of work, length of agreement, and any legal or liability issues.

b. Students or interns agree in writing to abide by all facility policies, including those relating to the security and confidentiality of information.

Ref: P6010.02, Sec 22; ACA: 4-4392, 4-ALDF-4D-10

1.7.2 Observe and interview five (not to exceed 10 at complexes/shared service facilities) inmate workers to determine that inmate workers are:

a. Excluded from pharmacy and medical storeroom (except for janitorial duties under direct supervision).

b. Not assigned to jobs involving handling, processing, or having access to pharmaceuticals, medical supplies, syringes, needles, or surgical instruments. Under the direct supervision (by specially trained staff) in a vocational training program inmates may have access to dental instruments.

c. Not assigned where they will have access to health records, including copies of records and documents that will become part of the health record or blank medical forms.

d. Not assigned jobs located in health records, as clerks to physicians, jobs having access to budget or medical invoices, the laboratory, or x-ray.

e. Not assigned functions involving scheduling of appointments or other tasks with potential for determining access to medical care.

f. Not assigned jobs involving responsibility for direct patient care services or treatment procedures.

g. Not assigned duties that involve physical presence in the operating room during surgery.

h. Not assigned duties involving responsibility for clinical tests, measurements, or assisting consultants.

i. Not assigned duties that involve operating diagnostic or therapeutic equipment, except under direct supervision (by specially trained staff) in a vocational training program.

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j. Not present during formal clinical contact between staff and patients except for emergency treatment, testing, or serving as an interpreter. Inmates in the dental training program are not subject to this restriction when working in the dental clinic.

k. Inmates who perform the following duties are properly supervised and trained:

1. Peer support and education.

2. Hospice activities.

3. Assisting impaired inmates on a one-on-one basis with activities of daily living.

4. Serving as a suicide companion or buddy if qualified and trained through a formal program that is part of a suicide prevention plan.

Ref: P6010.02, Sec 8; ACA: 4-4393, 4-ALDF-4D-11

1.7.3 Interview the HSA to determine if volunteers are used in the delivery of health care. If so, review the documentation for selecting, training, staff supervision, facility orientation, and a definition of tasks, responsibilities, and authority that is approved by the health authority.

Ref: ACA: 4-4391, 4-ALDF-7F-07

1.7.4 Review documentation (CPR certification cards or training records) to verify the following:

a. All non-clerical health care practitioners, HSA/AHSA, and lieutenants are CPR/AED certified, not to exceed a total sample size of 20.

b. All staff are trained annually on emergency response (4-minute response time), signs and symptoms of emergencies, basic first aid, methods of obtaining assistance, signs and symptoms of mental illness, procedures for patient transfers, and suicide intervention.

Ref: P6031.01, Sec 9; ACA: 4-4389M, 4-ALDF-4D-08M

1.7.5 Interview the HSA to determine if the facility uses a staffing analysis to determine the essential positions needed to perform the Health Services mission and provide the defined scope of services. A staffing plan is developed and implemented from this analysis and the staffing plan is reviewed by the health authority yearly.

Ref: ACA: 4-4412

1.8 Safety

1.8.1 Review the biannual preventive maintenance reports since the last program review to determine that the maintenance was completed on equipment, supplies, and materials for

Health Services and any corrective action identified has been addressed.

Ref: P6010.02, Sec 10; ACA: 4-4427

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1.8.2 (V-1) Observe all areas of the HSU and any other areas where health care is provided to

a. Adequate space is provided for administrative, direct care, professional, and clerical staff. This space includes conference areas, a storage room for records, and toilet facilities.

b. Biohazardous waste is properly contained, collected, and disposed.

c. There is a plan for decontamination of medical and dental equipment.

d. There is a plan for validation of the physical integrity of radiologic shields as required by state or federal requirements. The plan will include the reference used to develop the plan.

Ref: P6109.03, Sec 12; P6031.01, Sec 46; ACA: 4-4426; [b.] ACA: 4-4358M, 4-

ADLF-4C-18M; [c.] ACA: 4-4358M, 4-ALDF-4C-18M; [d.] P 6031.01, Sec 46, j

1.8.3 Review all Health Services emergency disaster drills since the last program review to

a. All health care personnel in the facility are trained in the implementation of the facility’s emergency plans.

b. Two emergency disaster drills were conducted per year.

c. Emergency disaster drills were critiqued to identify deficiencies and corrective actions were addressed.

Ref: P6010.02, Sec 18; ACA: 4388M, 4-ALDF-1C-01M

1.9 Oversight

1.9.1 Review a random sample of 10 percent (but not less than two) credit card statements and supporting documentation over the past 12 months to determine if purchases are appropriate and if the approving official signs the monthly statement.

Ref: P4100.04, Part 13

1.9.2 Examine all operational reviews since the last program review (including working papers and reports) to determine if reviews were timely and complete.

Ref: P1210.23, CH 3; ACA: 4-4423

2.0 INFECTIOUS DISEASES

Objective: To ensure there is a system of procedures to identify, monitor, treat, and prevent the spread of communicable diseases.

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2.1 Identification and Treatment

2.1.1 (V-2) Identify 10 inmates (20 at complexes) with infectious diseases (HIV and TB) since the last program review. Utilize tracer methodology to determine if:

a. HIV testing and management is provided to high-risk inmates.

b. TB testing and management is provided.

c. Inmates with HIV and/or TB are evaluated and treated in accordance with approved practice guidelines.

d. Follow-up care is provided, including arrangements with appropriate health care authorities for continuity of care when offenders are relocated prior to completion of therapy (TB).

Ref: P6190.03, Secs 6-11; Clinical Practice Guidelines for the Management of HIV

Infection (most current); Clinical Practice Guideline for Management of Tuberculosis

(most current); ACA: 4-4355M, 4-ALDF-4C-15, 4-4357M, 4-ALDF-4C-17M

2.1.2 Review medical documentation of 5 inmates (10 at complexes) in work assignments that staff determine to present a potential for occupational exposure to blood or infectious body fluids to determine if annual training was provided and Hepatitis B vaccinations were offered within 10 working days of initial assignment.

Ref: P6190.03 Sec 12; ACA: 4-4361, 4-4356M, 4-ALDF-4C-21, 4-ALDF-4C-16M

2.1.3 (V-2) Review medical documentation of 5 inmates (10 at complexes) with Methicillin

Resistant Staphylococcus Aureus (MRSA) to determine if:

a. The inmates are evaluated and treated in accordance with approved practice guidelines.

b. The inmates are placed in medical isolation, when indicated.

c. Follow-up care is provided, including arrangements with appropriate health care authorities for continuity of care when offenders are relocated prior to completion of therapy.

Ref: Clinical Practice Guideline for MRSA (most current); ACA: 4-4354-1

2.1.4 Review exposure control documentation and select five inmate and five staff exposure incidents (10 inmates and 10 staff at complexes) [i.e., bloodborne pathogens, post-exposure evaluation, and follow-up] which have occurred since the last program review to determine if:

a. Immediate emergency care was offered.

b. Counseling was provided.

c. Mandatory testing was conducted.

d. Anti-retroviral medications were offered if clinically indicated.

e. Post-exposure counseling was provided by a physician.

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f. The infection control officer has a tracking mechanism for sharp injuries to identify high-risk areas and assist in the selection and review of safety devices.

Ref: P6031.01, Sec 12; P6190.03, Sec 11; ACA: 4-4203M, 4-4356M, 4-ALDF-4C-16M

2.1.5 Review health records of five Health Services staff hired since the last program review to determine the following:

a. If a screening for tuberculosis (TST or chest x-ray) was provided prior to job assignment and offered on an ongoing basis.

b. All direct care staff are offered hepatitis B vaccine series (does not include contractors).

Ref: OSHA 1910.1030; [a.] ACA: 4-4386, 4-ALDF-4D-06; [b.] ACA: 4-4387, 4-ALDF-4D-07

3.0 Quality Improvement (Assurance)

Objective: Ensure a system of control is in place to measure and improve the performance of the

Health Services Unit.

3.1 Improving Organizational Performance (IOP)

3.1.1 Review the last four Health Services IOP Committee Meeting Minutes to determine if:

a. Committee participants are multi-disciplinary.

b. Data is being collected based on governing body approved monitoring activities.

c. Collected data is evaluated, trended and analyzed to develop conclusions, recommend improvement actions, and assist in planning and intervention.

d. Recommended actions are presented for consideration to the governing body.

e. All deaths in custody, suicides or suicide attempts, and illness outbreaks are reviewed.

f. Measures are implemented to address and resolve important problems and concerns identified (corrective action plans) and problems/concerns are reevaluated to determine whether the corrective measures have been achieved.

g. Findings of internal review activities are incorporated into the organization’s educational and training activities.

h. Appropriate records (meeting minutes) of internal review activities are maintained.

i. A quarterly report of the findings of internal review activities is issued to the facility or program administrator and all records of internal review activities comply with legal requirements on confidentiality of records.

j. There are established medical goals, which are reviewed at least annually, updated as needed, and program changes are implemented as necessary in response to findings.

k. Quarterly data is collected regarding:

1. Health care services by category.

2. URC.

3. Prescriptions written.

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4. Laboratory X-rays completed.

5. Referrals to specialists.

6. On-site or off-site hospital admissions and transports.

7. Serious injuries, illness, or deaths.

Ref: P6013.01, Sec. 5; [a.] ACA: 4-4410M, 4-ALDF-4D-24M; [j.] ACA: 4-4422, 4-4423; [k.] (P6010.02, Sec 7; ACA: 4-ALDF-7D-26

3.1.2 (V-3) Review the last four Health Services Governing Body Meeting Minutes to determine if:

a. Meetings are conducted at least quarterly.

b. Reviews of requests for appointments/privileging/ practice agreements of staff are conducted.

c. Biomedical ethics are addressed.

d. Quality improvement activities, including an assessment of the plan are addressed.

e. Risk management issues are addressed.

f. Potential or actual sentinel events are discussed.

g. Other pertinent Health Services issues are discussed.

Ref: P6013.01, Sec. 8; ACA: 4-ALDF-7D-26; [a.] ACA: 4-4408, 4-ALDF-7D-25; [b.]

ACA: 4-ALDF-4D-05M

3.1.3 Review five inmate deaths (10 at MRCs and complexes) since the last program review to

a. The medical director is notified within 24 hours of the inmate death or on the next duty day.

b. The multi-level mortality review report is submitted to OQM within the required time frame.

Ref: P6013.01, Sec. 11; ACA: 4-4425, 4-ALDF-4D-23

4.0 Credential Verification/Clinical Privileges/Practice Agreements/Peer Review

Objective: Ensure health care providers are qualified and credentialed and the care they provide is pursuant to written privileges, practice agreements, and protocols.

4.1 Credentialing

4.1.1 (V-3) Review all staff and contract credential files, not to exceed 10 for Licensed

Independent Practitioners to determine if:

a. The license is verified in writing as current, valid, and unrestricted.

b. Documentation of professional education has been verified in writing.

c. Post-graduate training has been verified in writing.

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d. All past and pending actions taken against a practitioner's license or registration, and any malpractice history has been documented.

e. NPDB query is initiated, current, and renewed every 2 years.

f. Written job descriptions, statement of work for contractors, or written agreements are on file in the facility and approved by the health care authority.

Ref: P6027.01, Sec 6; ACA: 4-4382M, 4-ALDF-4D-05M, 4-ALDF-4D-03

4.1.2 (V-3) Using the same files from 4.1.1, review 10 staff, including BOP Telehealth providers, and on-site contractor credential files for Licensed Independent Practitioners (20 at complexes) to determine if peer reviews have been completed and clinical privileges have been granted and approved every 2 years.

Ref: P6027.01, Secs 6(b) and 7; ACA: 4-4411M, 4-ALDF-4D-25M

4.1.3 (V-3) Review the credential files of ancillary staff and/or contractors (nurses, EMT-P, physical therapist, radiology technician, pharmacists, etc.,) who are required by applicable law to maintain licensure and/or certification to determine it is verified in writing as current, valid and unrestricted.

Ref: ACA: 4-4382M, 4-ALDF-4D-05M

4.1.4 (V-3) Review 10 staff and contract mid-level practitioners, dental hygienists, and dental assistants to determine they have Practice Agreements which are complete, accurate, and renewed every 2 years.

Ref: P6027.01, Sec 7; ACA: 4-4411M, 4-ALDF-4D-25M

4.1.5 (V-2) (V-3) Review 10 medical records (20 at complexes) of after-hours encounters performed by registered nurses or EMT-paramedics to determine if performance is within the scope of individual licensure/certification and that emergencies are covered by protocols approved by a LIP.

Ref: P6027.01, Sec 7; ACA: 4-4382 M, 4-ALDF-4D-05M

5.0 CLIMATE

(The climate component is only utilized during the program review process. It is not to be included in the operational review process.)

Objective: Assess perceptions, behaviors, and attitudes within the work environment to determine the impact on staff performance and the discipline and the institution's ability to accomplish its mission.

5.1.1 Interview the department head to determine if there are relief posts for the department. If yes, randomly select five of these posts and observe to determine if staff assigned to these

G6000I.06 10/26/2010 Health Services - Institutions 24 posts enter and depart the facility within the 8-hour shift or no more than a total of 10 minutes beyond the shift (i.e., 3 minutes in a.m./6 minutes in p.m.). The random sample should include some posts that are farthest from the control center.

Determine from those staff observed if the roster and attendance files reflect actual practice, and if it is representative of what occurs during the review week.

5.1.2 Interview up to five staff within the department to determine if they perform work duties during lunch breaks; work extra hours to complete tasks by prescribed deadlines; or report to work prior to, or remain after, the regular shift for any reason.