St. Anthony Work Camp, ID Update Report NCCHC 2010
Download original document:
Document text
Document text
This text is machine-read, and may contain errors. Check the original document to verify accuracy.
St. Anthony Work Camp, ID November 12, 2010 UPDATE REPORT The National Commission on Correctional Health Care is dedicated to improving the quality of correctional health services and helping correctional facilities provide effective and efficient care. NCCHC grew out of a program begun at the American Medical Association in the 1970s. The standards are NCCHC’s recommended requirements for the proper management of a correctional health services delivery system. These standards have helped correctional facilities improve the health of their inmates and the communities to which they return, increase the efficiency of their health services delivery, strengthen their organizational effectiveness, and reduce their risk of adverse patient outcomes and legal judgments. The St. Anthony Work Camp was surveyed under the NCCHC 2008 Standards for Health Services in Prisons on May 27-28, 2010. On June 25, 2010, NCCHC granted continuing accreditation with verification. Subsequently, the RHA has submitted corrective action, which brought the facility into compliance with an additional essential standard. This report focuses primarily on issues that required corrective action for compliance with the standards and is most effective when read in conjunction with NCCHC's June 25, 2010 report. There are 37 essential standards; 33 are applicable to this facility and 33 (100%) were found to be in compliance. One hundred percent of the applicable essential standards must be met. The St. Anthony Work Camp has now met this condition. Essential Standards Not in Compliance None Essential Standards Not Applicable P-E-02 Receiving Screening P-E-09 Segregated Inmates P-G-03 Infirmary Care P-G-07 Care of the Pregnant Inmate There are 31 important standards; 30 are applicable to this facility and 29 (97%) were found to be in compliance. Eighty-five percent or more of the applicable important standards must be met. The St. Anthony Work Camp has met this condition. Important Standard Not in Compliance P-F-02 Medical Diets Important Standard Not Applicable P-G-10 Pregnancy Counseling We commend the facility staff for their professional conduct in coming into compliance with NCCHC's Standards for Health Services in Prisons. The St. Anthony Work Camp is awarded accreditation. St. Anthony Work Camp, ID Update Report November 12, 2010 2 P-A-06 Continuous Quality Improvement Program (E). The basic CQI program monitors major aspects of health care through a multidisciplinary committee that meets monthly. The membership includes the RN, responsible physician, HSA, nurse practitioner, and others. A process CQI study was completed on charting weight, height, and vital signs during sick call. An annual review of the program’s effectiveness was performed in 2009. However, a CQI study examining compliance with a new DOC policy requiring that all the inmates had to be cleared for kitchen duty was categorized as an outcome study. The facility implemented a process by which to comply, made a video, and developed handouts informing inmates of the process. This is not an outcome study. The standard is not met. Corrective action is required for Compliance Indicator #3b At least one process and one outcome study should be performed each year. Outcome studies examine whether expected outcomes of patient care were achieved. D ocumentation is required to demonstrate thata plan is in place to implementthe remaining outcome study. Acceptable documentation includes a copy of CQI meeting minutes demonstrating that problem identification has taken place and there is a planned date of implementation. In order to receive accreditation, verification that this standard has been met is required. On July 26, 2010, the RHA submitted documentation of an outcome study on diabetic patients. The questions to be answered included verifying that diabetic patients are being tracked in chronic care clinics at least every 90 days, that the results of tests have been reviewed and initialed by the provider, that HgbAIC levels fall below the acceptable range of 7.0, and that the patient had been informed of the test results and educated or counseled appropriately, with the development of a treatment plan. Compliance was indicated to have increased to 100%. The study’s results were also discussed during the medical audit committee meeting of January, 2010. The standard is now met. P-F-02 Medical Diets (I). Inmates may self select the diet that they wish to be on and stay on it for a month. Their options include vegetarian, lactose intolerant, no pork, healthy heart, and moderate consistency. However, a registered dietitian last reviewed the menus in April 2009. The standard is not met. Corrective action is required for Compliance Indicator #2 A registered or licensed dietitian should review medical diets for nutritional adequacy at least every six months, and whenever a substantial change in the menu is made, through a documented on-site visit or by written consultation. The following is acceptable documentation for compliance: (a) a copy of written documentation/consultation that includes the date, signature, and title of the consulting dietitian; or (b) a copy of the most recently dietitian approved and signed medical diet menu. Corrective action is required in order to meet this standard. This standard was not addressed. The standard is not met.