2 Is Mental Health Disposition Form 1103-44 being completed by Mental Health staff or Nursing
Staff with verbal orders from Mental Health Staff?
4 Is Mental Health Disposition Form 1103-44 being review and updated daily as needed?
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?
PRR ADC00121

2 Are treating staff informed of the clinical mortality review and administrative review findings?
[NCCHC Standard P-A-10]
3 Are deaths being reviewed by the complex CQI committee? [NCCHC Standards P-A-06; P-A-10]
4 Is the FHA (Site Manager) completing the CIU chart review memo in a timely manner? [DO 1105]
Procedure on the Event of Sexual Assault
1 Is a physical exam of the victums(s)being conducted by health staff?
2 After the physical exam, is there an evaluation by a qualified, mental health professional for crisis
intervention counseling?
Professional Development
1 Do the qualified health care professionals obtain 12 hours of continuing education per year that
are appropriate for their position? [NCCHC Standard P-C-03]
2 Do Part-time qualified health care professionals pro-rate their continuing education hours based
on full-time equivalency? [NCCHC Standard P-C-03]
3 Do health staff demonstrate compliance with C.E. Licensure requirements? [HSTM Chapter 3,
Section 4.0 and NCCHC Standard P-C-03]
4 Are all qualified healthcare professionals who have patient contact current in cardiopulmonary
resuscitation technique?
[HSTM Chapter 3. Section 4.0, NCCHC Standard P-C-03]
Patient Safety
1 Does the FHA proactively implement patient safety systems to prevent adverse and near miss
clinical events? [NCCHC Standard P-B-02]
2 Has the FHA implemented an error reporting system for health staff to voluntarily report
environmental factors that affect patient safety? [NCCHC Standard P-B-02]
Infection Control
1 Does the facility have a written exposure control plan?
2 Is the health unit in compliance with NCCHC Standard P-B-01 compliance indicators?
3 Are standard precautions used by health care practitioners?
4 Are precautionary instructions given to security when necessary (to include transportation staff)?
5 Are Sanitation workers trained in appropriate methods for handling and disposing of biohazard
spills and materials?
6 Are active TB patients transported to hospitals with negative pressure rooms?
7 Does the facility assure that inmates released with infectious or communicable diseases are
provided with community referrals and for transfer inmates, notify the receiving facility of the
medical condition?
8 Are facilities using effective ectoparasite control procedures to treat infected inmates and to
disinfect clothing and bedding?
9 Does the prescribed treatment given to inmates consider conditions such as pregnancy, open
sores, or rashes and is ordered only by a clinician?
10 Does the facility complete and file all reports as required by local, state, and federal laws and
regulations and reports to local health departments?
11 Does the facility follow a TB plan consistent with CDC guidelines and conduct PPD tests and
chest x-rays per policy with annual PPD check-up?
12 Has the facility developed a needle-stick prevention program?
13 Is there a designated Infection Control liaison ?
14 Are red bags being handled and stored appropriately?
PRR ADC00123

5 Does a review of appointment logs and medical encounters reflect appropriate charges?
Diagnostic Services
1 Does the responsible health authority maintain documentation that on-site diagnostics services
are certified or licensed (and posted)? [NCCHC Standard P-D-04]
2 Is there a procedure manual if a facility provides on-site diagnostic services including protocols for
calibration of testing devices (available to staff)? [NCCHC Standard P-D-04]
3 Do facilities with full-time health staff have multiple-test dip-stick urinalysis, finger-stick glucose
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?
PRR ADC00125

1 Do policy and procedures specify types of restraint or conditions of seclusion that may be used?
2 Are health staff notified when restraints are used for custody purposes so the health record can
be reviewed for contraindications or accommodations (and communicate such issues with custody
staff) to initiate health monitoring which continues at designated intervals as long as the inmate is
restrained?
3 Does health monitoring include checks for circulation, nerve damage, airway construction, and
psychological trauma: (Exercising the limb 10 minutes every 2 hours is recommended to prevent
clots).
4 Are restraints used only for medically necessary purposes?
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?
PRR ADC00128