PRR ADC00014-00026 - Qtrly Compliance Rpt - 2Q 2013 - ASPC-Eyman, AZ DOC, 2013
Download original document:
This text is machine-read, and may contain errors. Check the original document to verify accuracy.
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