3 Are inmates on suicide watch being issued only items authorized in the Suicide Watch Order?
6 Are inmate placed on a 10 minute suicide watch checked at random times not to exceed 10
minutes between each check?
3 Are inmates on suicide watch medications change to unit dose?
8 Are checks on inmates placed on 30 minute mental health watch conducted at random times not
to exceed 30 minutes between each check?
4 Are inmate placed on a suicide or mental health mental only removed from watch by a licensed
mental health professional?
Oral Care (Dental)
1 Is an oral examination performed by a dentist within 30 days of admission to ADC?
2 Is instruction on oral hygiene and preventive oral education given within one month of admission
to ADC?
3 Are there inmates waiting over 90 days for routine dental care?
4 Are 911's seen within 24 hours of HNR submission?
5 Are treatment plans developed and documented in the medical record?
6 Are daily inventories for all dental instruments being conducted before the first patient and after
the last?
7 Are all supplies that have an expiration date checked monthly?
8 If items are within 30 days of expiration, are they flagged and disposed of when they expire?
9 Are X-Rays taken of the tooth/teeth that are addressed during an emergency (911) visit?
10 Is the dental wait time log/report being maintained?
11 Is the MSDS binder being maintained?
12 Are patients provided with the medications that are prescribed by the dentist?
13 Are equipment repairs being addressed in a timely manner?
14 Are all orders for materials/supplies being fulfilled in a timely manner?
15 Are dental entries complete with military time and signature over name stamp?
16 Is treatment plan section C and priority section D of the dental chart completed?
17 Is the X-Ray certification/registration certificate posted in the dental clinic?
18 Are weekly SPORE testing logs available for the Autoclaves?
19 Is there a mechanism in place for immediate notification of a positive SPORE count?
Segregated Inmates
1 Are medical records being review for contraindications by nursing when notified an inmate has
been placed in administrative segregation and documented in the chart?
2 Are inmates in segregation being monitored by medical staff or Mental Health staff in accordance
with NCCHC standard for the level of segregation the inmate has been placed?
3 Is there a POST Order identifying the level of segregation for each administrative segregation unit
and monitoring requirement for each unit?
3 Are inmates in segregation provided an opportunity to submit HNR daily?
4 Is security staff immediately notifying health staff when an inmate is placed in detention /
segregation?
5 Are SMIs placed in segregation seen within 24 hours by mental health staff?
6 Are vital signs done on all segregated inmates every month?
PRR ADC00017

tests, peak flow meters, stool blood-testing material, and if applicable, pregnancy tests? (Post
orders for these tests?) [NCCHC Standard P-D-04]
4 Are laboratory tubes checked monthly for expiration?
5 Does radiology regularly monitor levels of exposure through dosimeters? [NCCHC Standard P-D04]
Hospital Specialty Care
1 Does each community hospital or off-site specialty service used have a written agreement that
outlines terms of care to be provided?
[NCCHC Standard P-D-05]
2 Do agreements with outside providers or off-site facilities require that a summary of treatment
provided and any follow-up instructions (this follow up information is to accompany the inmate upon
return to the facility)? [NCCHC Standard P-D-05]
Emergency Services
1 Is an emergency/after hours on-call physician, mental health, dental roster available to nursing
staff? [P-E-08]
2 Are emergency drugs, supplies, and medical equipment regularly maintained (is there proof of
routine monthly inventory of Man-down Bag and no expired supplies)? [P-E-08]
3 Is (are) an AED(s) available, checked for fully functioning batteries and new pads? Is the location
clearly marked or known? [P-E-08]
4 Are nurses familiar with off site emergency transport procedures? [P-E-08]
5 Are there "Emergency Nursing Proctocols" in place and utilized?
6 Is the facility using a Medical Appointment List Form marked "ER" for inmates brought to health
unit to be seen as an emergency? [P-E-08]
Continuity of Care During Incarceration
1 Are ordered tests or specialty consultations completed in a timely manner and there is evidence
in the record of ordering clinicians review of the results?
2 When an inmate returns from hospitalization, does the physician see the patient, review the
discharge orders, and issue follow-up orders as clinically indicated?
3 Do clinicians use diagnostic and treatment results to modify treatment plans as appropriate?
4 Are individual treatment plans used to guide treatment for episodes of illness? Does the format
include, at a minimum, the frequency follow-up for medical and diagnostic testing and therapeutic
regimens and when appropriate, instructions about diet, exercise, adaptation tot he correctional
environment and medication?
5 Does the responsible physician determine the frequency and content of periodic health
assessments on the basis of protocols promulgated by nationally recognized professional
organizations?
6 Are physician's chart reviews sufficient in number and frequency to assure that appropriate care
is ordered and implemented by attending health staff
7 Are chronic conditions listed on Problem List?
8 Are inmates with chronic conditions seen regularly or every six months (three for diabetics)?
9 Are labs and x-rays ordered in accordance with policy?
10 If the physician is not on-site when inmate is returned from the hospital, does designated staff
immediately review discharge instructions and contact the facility physician for orders as needed?
Nursing Assessment Protocols
1 Are protocols developed and reviewed annually by the health administrator and responsible
physician? [NCCHC Standard P-E-11]
2 Is there documentation that nurses have been trained in the use of nursing protocols,
PRR ADC00021

5 Is PBC attempted prior to MBC unless authorized by a physician?
6 Are restraints authorized by physicians or other professionals documented in SOAP notes?
7 Is it documented that the inmate was a danger to self other others?
8 Do orders for restraints exceed 12 hours?
9 Do the FHA and Warden receive daily reports on frequency and use of restraints?
Emergency Psychotropic Medication
1 Do the policies regarding use of psychotropic medications: -Require physician authorization
before use? -Specify when, where, and how psychotropic medication may be forced?
2 Does written evidence exist in the health record that terminally ill patients executing such
documents have been provided sufficient and appropriate information to make voluntary and
informed decisions?
3 Does documentation adhere to review board's policy?
4 Does the inmate have a mental disorder?
5 Is the inmate severely impaired or conduct present likelihood of serious harm?
6 Does documentation exist that proposed medications are in the inmate's best interest?
End of life Decision Making
1 Do written advance directives protocols that specify end of life decisions:
-Ensure patient decisions are voluntary, un-coerced, and based on medical information that is
complete and comprehensible to the patient?
-Specify how competency to make the decision is evaluated?
-Include a process to follow when inmate is judged incompetent to make end-of-life decisions?
2 Does written evidence exist in the health record that terminally ill patients executing such
documents have been provided sufficient and appropriate information to make voluntary and
informed decisions?
3 Prior to health care proxy or living will use, is an independent review by a physician not directly
involved in the patient's treatment conducted?
4 Are DNR orders reviewed by a medical professional who is not directly involved in the patient's
treatment?
5 Do Correctional and Health Services staff receive in-service training on end-of-life decisions so
they can be knowledgeable and comfortable presenting options to inmates and explaining
implementation?
6 Is the inmate advised of the process and allowed to request limitations?
Informed Consent and Right to Refuse
1 Are they addressed by written policy and procedures?
2 Do policies and procedures specify circumstances when written documentation of informed
consent is required?
3 Does a health services staff witness note on the form when an inmate does not sign the refusal
form?
4 Is informed consent documented when any invasive procedure or treatment where there is some
risk containing both the inmate's signature and a health services staff witness? (Consent is
necessary even for "blanket consents forms upon admission.)
Return to Custody
1 Is a physical examination completed by a medical provider as part of the RTC intake process??
2 Is a mental health assessment completed by a mental health practitioner as part of the RTC
intake process?
3 Have Base Line labs been drawn?
PRR ADC00024