Policies and Procedures

Home Standards Q&A Policies and Procedures

I am a new HSA and am trying to find where the NCCHC standards are addressed in my policies and procedures. Is there an easy way to keep track of this? Is it OK that my policies are not numbered the same as the NCCHC standards manual?

Yes and yes. This is actually a very common situation. Your health services policies and procedures are not required to mirror the numbering system used in the NCCHC standards manuals, although each NCCHC standard must be addressed in your policies and procedures. If your policies do not mirror the NCCHC standards numbers, we highly recommended creating a policy and procedure crosswalk document to quickly identify the NCCHC standard that corresponds to each health services policy. Make a spreadsheet that has all the NCCHC standards in one column. In the next column put the corresponding health services policies and procedures that address the compliance indicators within that standard. This document is a great resource when you are revising policies and an invaluable tool during your NCCHC accreditation surveys.

From CorrectCare Volume 36, Issue 2, Fall 2022

Our facility is about to contract with an organization to provide health services. The contractor has its own policies and procedures that we would be using. Will we meet the requirements of standard A-05 if we use the contractor’s policies and procedures, or must we develop our own?

You may use the contractor’s policies and procedures only if they meet your facility’s unique needs. For example, the policies and procedures must address infirmary-level care if your facility houses these types of patients and they must address prenatal care if it houses female inmates. In other words, if the policies and procedures are to perform their function of providing guidance to staff, they must be tailored to fit the needs of your facility and to address each applicable NCCHC standard.

— From CorrectCare Volume 33, Issue 3, Summer 2019

We are preparing for NCCHC accreditation and are developing a policy and procedure manual (standard J-A-05). Policies covering some of the NCCHC standards (e.g., medical diets, environmental inspections, grievances, emergency response plan) already exist, but they are part of the jail’s policy and procedure manual. Do we have to write new policies for health services on these topics if they are already covered in the jail’s procedural manual?

You need not develop a new policy statement for the health services policy manual if the topic has been addressed elsewhere. You simply can place a copy of the relevant institutional policy in the health services policy manual or include a page in the health services manual that cross-references the institutional policy statement. What is most important is that there are policy statements covering all of the specific topic areas listed in NCCHC’s standards, but it is not necessary that all facilities do it exactly the same way.

— From CorrectCare Volume 32, Issue 2, Spring 2018

In our jail’s accreditation survey report, the findings for standard J-A-05 Policies and Procedures stated that a procedure with the title “Patient Safety” was not found, but that all components of standard J-B-02 Patient Safety are addressed in several of our policies. Do we need to have “Patient Safety” in the title of one or more of the policies if the content of the policies meets the standard?

Although the policies do not need to be numbered or titled to match NCCHC standards, we do need to see that they contain the wording for each compliance indicator along with a description of how each compliance indicator is met. If the policies you mentioned clearly outline compliance indicators #1 and #2 of standard B-02, along with a description of how each indicator is met, then it should satisfy the requirements of the standard.

— From CorrectCare Volume 30, Issue 2, Spring 2016

Our facility is about to contract with a company that provides health services. The contractor has its own policies and procedures that we would be using. Can we follow the contractor’s policies and procedures, or must we develop our own?

You certainly may use a contractor’s policies and procedures as long as they have been tailored to meet the needs of your particular facility with regard to construction, services and staffing. The Policies and Procedures standard (A-05) requires that a manual or compilation of written policies and defined procedures regarding health care services at the facility addresses each applicable standard, and that the policies and procedures are site specific. For example, if your facility houses females, then care of the pregnant inmate should be addressed. If you operate an infirmary, then there should be policy and procedure on infirmary care. As long as the policies and procedures are site specific to provide guidance to the staff, then they would be in compliance.

— From CorrectCare Volume 23, Issue 3, Summer 2009

Policies and Procedures

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