Auditor Training Program

January 2012

Phoenix, Arizona

The most recent information, interpretations, ideas, and answers from the ACA Standards Specialists

Kathy Black-Dennis, Director

Bridget Bayliss-Curren

Terry Carter

Ben Shelor

Updates

• 2012 Supplement- due out soon

• Standards and Accreditation Department Staff Changes

▫ Ben Shelor

▫ Darya Seraj

• January 2012 Standards Revisions

▫ Physical Plant Standards

▫ All revisions available on www.aca.org

Interpretations- Overview • ACI 4-4003-1: Clean and Green (August 2010) • ACI 4-4129: Rated Capacity

▫ Subcommittee update ▫ Counting beds vs. bodies

• ACI 4-4410: Medical peer reviews • Who can serve as a peer reviewer? Appeal Authority?

• ACI 4-4411: Medical peer reviews (continued) • ACI 4-4414: What is the definition of “Transfer”? • ACI 4-4502: Community furloughs

▫ If an agency does not allow furloughs, is the facility non-compliant? Or is the standard non-applicable?

Standard ACI 4-4003-1 (2012 Sup.)

Added August 2010

The facility/agency shall demonstrate they have examined, and where appropriate and feasible, implemented strategies that promote recycling, energy and water conservation, pollution reduction and utilization of renewable energy alternatives.

Standard ACI 4-4129

Revised January 2008

The number of inmates does not exceed the maximum allowable inmate population as based on the standards compliant bed capacity (SCBC) formula.

Standard ACI 4-4129 (Continued) SCBC FORMULA FOR ADULT CORRECTIONAL INSTITUTIONS Step No. 1: Calculation to be used for all cells (multiple occupancy and single) in general population (Ref. #4-4132). Sq.ft. total of unencumbered space in housing = Answer #1 25 sq.ft

Step No. 2: Calculation to be used for single cells in general population for special management purposes (Ref. #4-4133) and segregation (Ref. #4-4141). Sq.ft. total of unencumbered space in all single cells = Answer #2 35 sq.ft.

Sq.ft. total of all single cells = Answer #3 80 sq.ft.

Place lowest number of Answer #2 & Answer #3 = Answer #4 Step No. 3: Determination of SCBC for the entire facility.

Answer #1 + Answer #4 = ___________

Standard ACI 4-4410 (Mandatory) A system of documented internal review will be developed and implemented by the health authority. The necessary elements of the system will include: • Participating in a multidisciplinary quality improvement committee • Collecting, trending, and analyzing of data combined with planning,

intervening, and reassessing • Evaluating defined data, which will result in more effective access,

improved quality of care, and better utilization of resources • Onsite monitoring of health service outcomes on a regular basis

through: Chart reviews by the responsible physician or his or her designee,

including investigation of complaints and quality of health records

Review of prescribing practices and administration of medication practices

Systematic investigation of complaints and grievances Monitoring of corrective action plans

ACI 4-4410 (Man.) (Continued)

• Reviewing all deaths in custody, suicides or suicide attempts, and illness outbreaks

• Implementing measures to address and resolve important problems and concerns identified (corrective action plans)

• Reevaluating problems or concerns to determine objectively whether the corrective measures have achieved and sustained the desired results

• Incorporating findings of internal review activities into the organization s educational and training activities

• Maintaining appropriate records (in other words, meeting minutes) of internal review activities

• Issuing a quarterly report to be provided to the health services administrator and facility or program administrator of the findings of internal review activities

• Requiring a provision that records of internal review activities comply with legal requirements on confidentiality of records

ACI 4-4410: Questions

• Who is qualified to serve as a peer reviewer?

• Who is qualified to serve as an appeal authority?

Standard ACI 4-4411 (Mandatory)

• A documented peer review program for all health care practitioners and a documented external peer review program will be utilized for all physicians, psychologists, and dentists every two years.

Standard ACI 4-4414 ACI 4-4414: Non-emergency offender transfers require the following:

▫ Health record confidentiality to be maintained. ▫ Summaries, originals, or copies of the health record accompany the offender to

the receiving facility. Health conditions, treatments and allergies should be included in the record.

▫ Determination of suitability for travel based on medical evaluation, with particular attention given to communicable disease clearance

▫ Written instructions regarding medication or health interventions required en route should be provided to transporting officers separate from the medical record.

▫ Specific precautions (including standard) are to be taken by transportation officers (for example, masks or gloves).

A medical summary sheet is required for all inter- and intra-system transfers to maintain the provision of continuity of care. Information included does not require a release of information form.

Inmates confined within a correctional complex with consolidated medical services do not require health screening for intra-system transfers.

ACI 4-4414 (Continued)

• How does ACA define “transfer”?

• If an inmate is simply being moved to the hospital for an appointment, does that qualify as a “transfer”?

• What about over-night trips to the hospital?

• Other instances?

Standard ACI 4-4502

Written policy, procedure, and practice provide that inmates with appropriate security classifications are allowed furloughs to the community to maintain community and family ties, seek employment opportunities, and for other purposes consistent with the public interest.

ACI 4-4502 (Continued)

• If an agency has a policy against community furloughs, is a facility operating under that agency’s authority non-compliant? Or is the standard non-applicable?

Frequently Asked Questions (FAQ)

• How do we update our facility information with ACA?

▫ www.aca.org

Standards and Accreditation

Facility Update

• Who initiates reaccreditation?

▫ The Agency/Facility initiates reaccreditation, not ACA!

Frequently Asked Questions (FAQ)

(Continued) • If I am an auditor, how can I update my contact

information?

▫ Contact ACA and we will coordinate the change to keep you in the loop

• Even if I am not available for a certain week, should I read the ACA Audits email?

▫ Yes! We use ACA Audits emails as a means of communications with our auditors. Please read them- they may contain important information!

Report Writing

• Write clearly and concisely

• Use appropriate grammar

• Avoid technical jargon and overly complicated wording

• Please proof-read your work

• Use paragraphs and spacing to make everyone’s life easier

Advice and Tips

• My ACA Auditor ID is expired- how do I renew? ▫ Nadine Lee- Accreditation Administrator ▫ nadinel@aca.org ▫ Certificates of Completion- same process

• What are the differences between being an audit chair and being a member of the audit team? ▫ Increased responsibility ▫ Report writing ▫ Managing competing personalities ▫ Working with, not against, the facility ▫ Using your experience and skills

Questions/Comments from the Field

• If a facility is missing documentation from one of the three years of the audit cycle, are they automatically in non-compliance?

• Performance-Based Standards: the intent of this practice is to record and analyze data to identify trends and take corrective action. Encourage facilities to maintain and use this data for its intended purposes, not just for satisfying the requirements of the audit process

Questions/Comments from the Field

• If I am an audit team member, what does the Audit Chair need from me?

▫ Helpful notes that elaborate on your observations or various portions of the facility that the Chair did not see

▫ Keep detailed information and share your notes with the chair for the report

▫ If you are a relatively new auditor or need a refresher of the process, review the relevant documents prior to going out on an audit

Questions/Comments from the Field

• Agency Closeouts

▫ These meetings are important to the facility and the process- please give them their due!

▫ Communicate with the staff- acknowledge their hard work and their successes

• Be professional, well-prepared, and well versed in the facility you are auditing

• Be willing to accommodate the facility’s normal schedule of operation

Questions/Comments from the Field

• Facilities welcome and appreciate a thorough audit process. Give each individual/area the time and attention they deserve.

• Do not ask for additional information that is not required by the Standards or by ACA Office Staff.

• Do not have the facility write the report for you • Facilities are responsible for the information

provided- do not manipulate or change the information provided by the facility/agency.