Standards Interpretation and FAQs

NCCHC Standard A-09, compliance indicator 5h, specifically requires the death log to document the location where the patient was found. If the patient was pronounced deceased in a different location (for example, at a local hospital or other location within the facility), the log should still identify the location where the patient was found to satisfy this requirement. The facility may choose to document the location of pronouncement in the log as a separate, clearly labeled entry, but that information does not replace the required “location found” information. The location of pronouncement should also be documented in the health record and addressed in the mortality review, as applicable.

NCCHC distinguishes between preparing medications for multiple patients well in advance of administration as “pre-pouring” and preparing medications immediately before administering them to the patient as the “point of care administration”.

For a two-tiered housing unit where the medication cart cannot be taken upstairs, nursing staff may bring the cart into the housing unit, prepare medication immediately before going upstairs to the patient cells, transporting medications securely, verifying the patient’s identity, administering and observing ingestion as appropriate, and then document the administration similarly to when a patient approaches a medication cart/line on their own. This may reasonably be considered a point-of-administration medication pass process, rather than full pre-pouring, as medications are prepped in the housing unit immediately before administering to the patient versus in another location prior to medication pass starting.

Another acceptable operational approach may be for custody staff to allow patients to approach the medication cart individually, when clinically and operationally appropriate.

In contrast, preparing medications for several patients simultaneously or substantially in advance, leaving prepared medications unattended, or transporting multiple labeled envelopes would constitute pre-pouring and would require the facility to follow the applicable NCCHC requirements for that practice as outlined in standard D-02 Medication Administration Services compliance indicators #7-10, as well as potential dispensing and scope of practice guidelines within their state.

NCCHC does not require mental health professionals to complete annual dental screening training simply because they are considered health staff.

Dental screening training is required for staff members who perform oral or dental screenings. The training must be documented and approved or provided by a licensed dentist. Therefore, mental health professionals may be exempt if dental screening is not included in their assigned responsibilities and they do not perform that function.

Under the NCCHC discharge-planning standard, providing a valid written prescription may satisfy the requirement to make provisions for medication needed at the time of a planned release from custody. The standard does not specifically require facilities to confirm pharmacy availability, payment coverage, dispensing, and acceptance by a receiving community provider. However, discharge arrangements for planned releases should be clinically appropriate to the patient and should reasonably support continuity of necessary treatment, particularly when interruption could pose a significant risk to the patient. Each facility should have policies and procedures regarding planned releases that offer guidance as to how the health care team will address potential continuity of care clinical treatment needs for those with a planned release date.

Under NCCHC Standard C-02, Clinical Peer Review and Competency Assessment, the facility should establish a structured process for evaluating the clinical performance of each provider and licensed qualified mental health professional at least annually. The purpose is to improve the quality of clinical care—not to complete an employee evaluation.

A practical peer-review program includes a written policy and procedure which identifies:

• Which staff require an annual peer review (the providers, including telehealth providers) and licensed qualified mental health professionals
• Who is qualified to conduct each review
• How records or cases will be selected
• The clinical areas to be evaluated
• How results, feedback, and corrective actions will be documented

The facility is expected to select a meaningful sample of health records or clinical cases for each individual being evaluated. Selection may include both randomly chosen records and targeted areas focusing on the following:

• Adherence to clinical practice and immunization guidelines
• Ensuring that care is provided aligns with community standards
• Ensuring chronic care is managed in line with protocols and follow-up is conducted consistently
• Medication prescribing and monitoring
• Ensuring any deviation from clinical practice guidelines is justified and explained
• Requests for tests and procedures
• Use of consultants and specialists
• Patient send-out patterns

NCCHC does not require a specific sample size when conducting the review. However, the sample size needs to be sufficient to evaluate the individual’s practice meaningfully.

Documentation must reflect that findings were discussed with the individual reviewed and recorded in a log or other written record containing:

• The name and credential of the individual being reviewed
• The date of the review
• The time period of the review
• The name and credentials of the reviewer
• A summary of the findings and corrective action, if any
• Confirmation that that individual being reviewed is provided with the peer review results as a learning opportunity

The responsible health authority (RHA) is responsible for implementing an independent focused review when concerns arise regarding an individual’s competence and for identifying measures to address and resolve those concerns. Documentation must reflect that findings were discussed with the individual reviewed and recorded in a log or other written record containing. Detailed peer-review materials should be maintained confidentially.

As a general reminder, NCCHC does not review or approve facility-specific forms, as workflows, documentation systems, and individual circumstances vary considerably among facilities. Rather than focusing on whether a particular form is acceptable, we encourage the facility to evaluate its overall peer review process and documentation against the requirements of C-02 and its related Interpretive Guidance to ensure all required elements are consistently addressed.

Based on the scenario you provided, If health care staff are performing an on-site X-ray that could result in criminal charges, this act meets the definition of forensic information within the standard, and is in violation of compliance indicator #1 of G-04 Therapeutic Relationship, Forensic Information, and Disciplinary Actions.

• Compliance indicator #1 states, “Health staff are not involved in the collection of forensic information.”
• Forensic information is defined as “physical or psychological data collected from an incarcerated individual that may be used against them in disciplinary or legal proceedings.” It should be noted that NCCHC has designated this standard as an important standard (versus an essential standard), which means that noncompliance with this standard will not affect your accreditation status as long as you are compliant with 85% of the important standards and 100% of the essential standards.

Sarajoy entered it. I’m testing, so it’s very important.

NCCHC standard P-A-07 Confidentiality and Privacy of Care states that the health care delivery system has procedures in place to ensure privacy and confidentiality of health care information. This includes:

• Discussions of protected health information
• Clinical encounters
• Physical exams

To meet the intent of the standard, conversations concerning a patient’s health status, diagnosis, or treatment should not be conducted where it can be easily overheard. Health records should not be in places where they can be observed or read in violation of privacy standards. All ancillary staff, including custody staff, must also maintain privacy and confidentiality when they are present and/or observe the exchange of protected health information either written or verbally. This also applies to interpreters. When safety is a concern and full privacy is lacking, alternative strategies for partial visual or auditory privacy should be considered (for example, privacy screen, curtain, private area, white noise machine).

Many helpful resources can be found on the Standards and Resources section of our website. These resources are reviewed and updated frequently, and additional resources may be added at any time, so please check back periodically to ensure you have the latest information.

Based on the scenario you provided, If health care staff are performing an on-site X-ray that could result in criminal charges, this act meets the definition of forensic information within the standard, and is in violation of compliance indicator #1 of G-04 Therapeutic Relationship, Forensic Information, and Disciplinary Actions.
• Compliance indicator #1 states, “Health staff are not involved in the collection of forensic information.”
• Forensic information is defined as “physical or psychological data collected from an incarcerated individual that may be used against them in disciplinary or legal proceedings.” It should be noted that NCCHC has designated this standard as an important standard (versus an essential standard), which means that noncompliance with this standard will not affect your accreditation status as long as you are compliant with 85% of the important standards and 100% of the essential standards.

NCCHC understands that housing assignment and placement into mental health residential units in any facility are based on an individual meeting facility-identified criteria to be placed in such housing. Your inquiry as to whether placement into the housing unit and/or program not being something open to all inmates or the general population is understood and common to facilities nationwide.

By definition (in the 2026 MH Standards manual), nonacute MH residential units are “short-term or permanent housing areas that provide services for those who are chronically mentally ill, experiencing an increase in symptoms of mental illness, demonstrating functional deficits that impair their ability to live in a general population setting, and/or experiencing situational stresses. Patients housed in such units typically require a lesser degree of mental health programming and supervision than patients in acute-care residential units, and more than patients in nonresidential programs. Examples of nonacute care units include transitional care units, step-down units, and behavioral health housing units”. If the purpose of individuals being housed in the JBCT unit meets the definition, then it would qualify as a nonacute mental health residential unit within your facility.