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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-CurrenTerry 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 haveexamined, and where appropriate and feasible,implemented strategies that promote recycling,energy and water conservation, pollution reductionand utilization of renewable energy alternatives.



Standard ACI 4-4129Revised January 2008

The number of inmates does not exceed the maximumallowable inmate population as based on the standardscompliant 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 #125 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 thesystem 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 healthrecords

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 seducational 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 administratorand facility or program administrator of the findings of internal reviewactivities

• Requiring a provision that records of internal review activities comply withlegal 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 dentistsevery 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 transfersto maintain the provision of continuity of care. Information included doesnot 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 thehospital for an appointment, does that qualify asa “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 maintaincommunity and family ties, seek employment opportunities, and for other purposes consistent withthe 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 thestandard 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!

http://www.aca.org/

http://www.aca.org/



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 tokeep 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 readthem- 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’slife easier



Questions/Comments from the Field

• If a facility is missing documentation from oneof the three years of the audit cycle, are they

automatically in non-compliance?

• Performance-Based Standards: the intent of thispractice is to record and analyze data to identify

trends and take corrective action. Encouragefacilities to maintain and use this data for itsintended purposes, not just for satisfying therequirements of the audit process




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

▫ Helpful notes that elaborate on your observationsor various portions of the facility that the Chairdid not see

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

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




• Agency Closeouts

▫ These meetings are important to the facility and

the process- please give them their due!

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

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

• Be willing to accommodate the facility’s normalschedule of operation




• Facilities welcome and appreciate a thoroughaudit 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 OfficeStaff.

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

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

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