Collection of Forensic Information
- Published Date: 02/13/2023
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.
Mental Health Residential Units
- Published Date: 05/23/2025
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.
Chart or Health Record Review Expectations
- Published Date: 04/21/2024
Chart reviews involve systematically reviewing the medical records, or charts, of a patient population to gather information on a specific clinical issue, treatment, or outcome. NCCHC does not require a specific number or percentage of the overall population when determining health record review sample sizes for routine chart review. The appropriate sample size depends on the topic being studied and the frequency of occurrence, similar to how sample sizes are determined for CQI studies. However, for routine chart reivewis, industry standards often suggests 10 charts per topic. For CQI studies, it is often suggested that a higher percentage of charts are reveiwed to ensure a facility has an understanding regarding the scope of an issue.
For example, when reviewing a topic such as pregnancy, the population may be small and limited to the number of pregnant patients in the facility; in these cases, the sample may include all pregnant patients. In contrast, when reviewing timeliness of receiving screenings or health assessments, a larger sample is more appropriate. In these situations, a defined sample—such as a random selection of 20 charts from individuals admitted during a specific month—may be used.
When identifying the sample size, the responsible physician will want to identify a sufficient number that will achieve results representative of what is happening in the facility. When doing surveys, NCCHC surveyors most commonly see a range with facilities using the entire population (as mentioned in the example of pregnant population above) or a random selection of 15-25 charts/patients reviewed each month. NOTE: Any examples provided are for illustrative purposes only.