Inmates have access to care to meet their serious medical, dental, and mental health needs.

Unreasonable barriers are to be avoided: 

1. punishing inmates for seeking care.

2. assessing excessive co-payments that deter inmates 

3. deterring inmates by holding sick call at 2 a.m., etc.

Responsible Health Authority

The facility has a designated health authority responsible for health care services. 

The RHA arranges all levels of health care and assures quality, accessible, and timely health services.

The RHA is on site at least weekly.

The RHA may be a physician, health administrator, or agency.

Clinical judgments rest with a single, designated, licensed, responsible physician

Medical Autonomy

Administrative Meetings and Reports

Health services are discussed at administrative meetings. In addition, health staff meetings are held to review administrative issues.

1. Administrative meetings are attended by the facility administrator and the RHA, and other members of the health and correctional staffs.

2. Administrative meetings are heald quarterly

3. Health staff meetings occur at least monthly

4. Statistical reports are made at least monthly.

Topics of discussion are quality improvement findings, infection control efforts, inmate grievances, and environmental inspection reports

Policies and Procedures

There is a manual or compilation of written policies and defined procedures regarding health care services at the facility that addresses each applicable standard in the Standards for Health Services in Prisons

1. Health care policies are site specific

2. Each policy and procedure in the health care manual is reviewed at least annually. 

3. Other policies don't conflict with health care policies.

4. The manual is accessible to all health staff.

When changes to individual health services policies are made, they msut be dated and signed individually by the RHA and responsible physician. 

Continuous Quality Improvement Program

A CQI program monitors and improves health care delivered at the facility. 

1. A CQI identifies problems, implements and mointors corrective action, and studies its effectiveness.

2. The responsible physician is involved in the CQI

3. Facilities with an average daily population of 500 or less have a basic CQI

4. Facilities with an average daily population of greater than 500 inmates have a comprehensive CQI 

Includes monitoring the fundamental aspects of the facility's health care system through one outcome study and one proces study at least annually.

Examples: Access to care, the intake process, continuity of care, emergency care and hospitalizations, adverse patient occurrences including all deaths.

Emergency Response Plan

health staff are prepared to implement the health aspects of the facility's emergency response plan.

Health aspects of the emergency response plan include: responsibilities of health staff, procedures for triage, predetermination of the site for care, telephone numbers  for calling health staff and community emergency response, procedures for evacuating patients, alternate back ups.

At least one mass disaster drill is conducted annually. 

The man down drill is practiced once a year on each shift.

Both drills are critiqued and the results shared with staff.

Communication on Patient's Health Needs

Communication occurs between the facility aministration and treating health care professionals regarding inmates' significant health needs that must be considered in classification decisions in order to preserve the health and safety of that inmate, other inmates, or staff. 

Correctional staff are advised of inmates' special needs that may affect housing, work, and program assignments; disciplinary measures; and admissions to and transfers from institutions.

Health and custody staff communicate about inmates who are: chronically ill, on dialysis, adolescents in adult facilities, infected with communicable diseases, physically disabled, pregnant, frail or elderly, terminally ill, mentally ill or suicidal, or developmentally disabled. 

Privacy of Care

Discussion of patient information and clinical encoutners are conducted in private and carried out in a manner designed to encourage the patient's subsequent use of health services. 

1. Clinical encounters and discussions occur in private, without being observed or overheard. 

2. Security personnel are present only if the patient poses a probable risk to the safety of the health care professional or others. 

3. Instruction on maintaining confidentiality is given to security staff and interpreters who observe or hear health encounters. 

Procedure in the Event of an Inmate Death

All deaths are reviewed to determine the appropriateness of clinical care; to ascertain wehther changes to policies, procedures, or practices are warranted; and to identify issues that require further study.

1. All deaths are reviewed within 30 days
2. A death review consists of an administrative review (correctional and emergency response surrounding the death); a clinical mortality review (the clinical care provided and the circumstances leading up to the death); and a psychological autopsy if by suicide (reconstruction of an individual's life with an emphasis on factors that contributed to the death)
3. Treating staff are informed of the findings of the above reviews. 
4. Corrective actions are implemented and monitored through the facility's CQI program for systemic issues.

Grievance Mechanism for Health Complaints

A grievance mechanism addresses inmates' complaints about health services

1. The grievance policy includes a time frame for response and the process for appeal.
2. Responses to inmate grievances are timely and based on principles of adequate medical care. 

Timeliness of the response to sick call requests is an important indicator of quality of care and should be tracked through the continuous quality improvement process.  

1. The facility has a written exposure control plan that is reviewed and updated annually.
2. Standard precautions are always used by health care practitioners to minimize the risk of exposure 
3. All sanitation workers are trained in appropriate methods for handling and disposing of biohazardous materials and spills.
4. Active TB patients are housed in negative pressure rooms.
5. Inmates who are released with communicable diseases are given community referrals
6. The facility completes and files all reports as required by local, state and federal laws. 
7. Effective ectoparasite control procedures are used to treat infected inmates.
8. a monthly environmental inspection is conducted in areas where health services are provided.

Patient Safety

The RHA promotes patient safety by instituting systems to prevent adverse and near-miss clinical events.

1. The RHA proactively implements patient safety systems
2. The RHA implements an error reporting system for health staff to report errors

Federal Sexual Assault Reporting Regulations

The facility has written policy and procedures regarding the detection, prevention, reduction, and punishment of rape consistent with federal law

The intent is for correctional facilities to comply with federal law. PREA addresses the many aspects of rape in correctional institutions, including the actions to be taken by correctional administrators, and is the foundation of the standard.

Procedure in the Event of Sexual Assault

The medical and psychological trauma of a sexual assault is minimized as much as possible by prompt and appropriate health intervention

1. Victims of sexual assault are either referred to a community facility for treatment and gathering of evidence or they are performed in-house.
2. A history is taken and qualified health care professionals conduct an exam to document the extent of physical injury and to determine whether referral to another medical facility is indicated.
3. Prophylactic treatment and follow-up care for STDs are offered to all victims
4. After the phyhsical exam, there is an evaluation by a qualified mental health professional for crisis intervention counseling and long-term follow up. 
5. A report is made to the correctional authorities to effect a separation of the victim from the assailant in their housing assignments.

Credentialing

All health care personnel who provide services to inmates are appropriately credentialed according to the licensure, certification, and registration requirements of the jurisdiction.

1. The RHA assures that new hires undergo a credentialing verification process that confirms current licensure, certification, or registration.
2. The credentialing process includes inquiry regarding sanctions or disciplinary actions of state boards, employers, and teh NPDB
3. health care professionals do not perform tasks beyond those permitted by their credentials
4. The RHA maintains verification of current credentials for all qualified health care professionals at a readily accessible location.
5. A license specifically restricting practice to correctional institutions is not in compliance with this standard. 

Clinical Performance Enhancement

A clinical performance enhancement process evaluates the appropriateness of all primary care clinicians' services.

1. The clincial performance of the facility's primary care clinicians is reviewed at least annually.
2. Reviews are kept confidential and incorporate at least: the name of the individual, the date of the review, the name and credentials of the reviewer, confirmation that the review was shared with the clinician, and a summary of the findings and corrective action. 
3. A log providing the names of the primary care clinicians and the dates of their most recent reviews.
4. The RHA implements an independent review when there is seious concern about the clinician's competence.
5. The RHA implements procedures to improve a clinician's competence when necessary.

Professional Development

All qualified health care professionals participate annually in continuing education appropriate for their positions.

1. Full-time qualified health care professionals obtain 12 hours of continuing education per year.
2. Part-time professionals prorate their continuing education hours based on full-time equivalency.
3. Compliance is demonstrated by: a current license (where at least 12 hours is required); valid CCHP certification; or a list of completed courses, dates, and number of hours per course are on file. 
4. All qualified health care professionals who have patient contact are current in CPR 

Health Training for Correctional Officers

A training program, established or approved by the responsible health authority in cooperation with the facility administrator, guides the health-related training of all correctional officers who work with inmates.

1. Correctional officers who work with inmates receive health-related training at least every two years: administration of first aid; recognizing the need for emergency care; recognizing acute manifestations of chronic illnesses; recognizing signs and symptoms of mental illness; procedures for suicide prevention; appropriate referral of inmates; precautions with respect to infections diseases; CPR.
2. Verified by an outline of the course content
3. Certificate of attendance is kept on site for each employee.
4. Compliance requries at least 75% of the staff present are current in theri health-related training.

Medication Administration Training

Personnel who administer or deliver prescription medication are appropriately trained.

1. Correctional or health staff who administer/deliver prescription medication to inmates are permitted by state law to do so and are trained as needed in matters of security, accoutnability, common side effects, and documentation of administration of medicines
2. Training is approved by the responsible physician and facility administrator, or designee.
3. Documentation of completed training and testing is kept on file for staff who administer/deliver meds.

Inmate Workers

Inmates involved in health services are appropriately trained and supervised.

1. Inmates do not make treatment decisions or provide patient care.
2. Inmates do not distribute or collect sick-call slips, schedule appointments, or handle medical records, medications, or surgical instruments and sharps.
3. Inmates employed in cleaning the health services unit are appropriately trained and supervised regarding their work assignments.
4. Inmates are not substitutes for regular program staff, but may be invovled in appropriate peer health-related programs

Staffing

A sufficient nubme rof health staff or varying types provide inmates with adequate and timely evaluation and treatment consistent with contemporary standards of care. 

1. The RHA approves the staffing plan. The staffing plan lays out the FTE staff coverage required, lists current incumbents and vacancies, and addresses how full coverage will be accomplished if all positions are not filled. 
2. The adequacy and effectiveness of the staffing plan are assessed by the facility's ability to meet the health needs of the inmate population.
3. The general expectation is that the staffing plan includes, at a minimum, one physician on site 3.5 hours a week for each 100 inmates housed in the facility

Health Care Liaison

A designated, trained health care liaison coordinates the health delivery services in the facility when qualified health care professionals are not on site. 

Generally carries out the following duties: reviewing receiving screening forms for follow-up attention; triaging nonemergency sick-call requests every 24 hours; facilitating sick call by having inmates and records available for the health care professional; and helping to carry out clinicians' orders regarding diet, housing and work assignments.

The liaison may be a correctional officer or other person without a health care license who is trained by the responsible physician.

Orientation for Health Staff

Al health staff receive an immediate basic orientation and all full-time staff complete a formal in-depth orientation to the health services program.

1. The orientation lesson plan is reviewed once every 2 years or more frequently. 
2. All health staff receive a basic orientation on the first day of on-site service. 
3. Within 90 days of employment, all full-time staff complete an in-depth orientation. 
4. Completion of the orientation program is documented and kept on file. 

Pharmaceutical Operations

Pharmaceutical operations are sufficient to meet the needs of the facility and are in accordance with legal requirements. 

1. The facility complies with all applicable regulations.
2. The facility maintains a formulary for clinicians
3. Proecudes for the timely procurement, dispensing, distribution, accounting and disposal of pharmaceuticals.
4. Maintains records to ensure adequate control of all medications.
5. Maintains maximum security storage of DEA controlled substances.
6. Adequate method for notifying practitioners of the impending expiration of a drug order.
7. Medications are kept under the control of appropriate staff.
8. Inmates do not work with medications, except for KOP medications
9. Drug storage and medication areas are devoid of outdated or recalled medications.
10. A consulting pharmacist is used, not less than quarterly
11. All meds are stored under proper conditions.
12. An adequate and proper supply of antidotes are readily available to the staff

Medication Services

Medication services are clinically appropriate and provided in a timely, safe, and sufficient manner.

1. Prescription meds are administered or delivered to the patient only on the order of a physician or other legally authorized individual.
2. Responsible physician determines prescriptive practices
3. Medications are prescribed only when clinically indicated.
4. Inmates entering the facility on medication continue to receive the meds in a timely fashion.

Clinic Space, Equipment, and Supplies

Sufficient and suitable space, supplies, and equipment are available for the facility's medical, dental, and mental health care services

1. Exam and treatment rooms for medical, dental, and metnal health care are large enough to accomodate the necessary equimpent, supplies and fixtures, and to permit privacy during clinical encounters.
2. All medical equipment are available and checked regularly.
3. There is adequate office space with administrative files, secure storage of health records, and writing desks.
4. Mental health services are provided in an area with private interview space for both individual and group treatment, as well as desks, chairs, lockable file space, and relevant testing materials.
5. When lab services are provided on site, the designated area is adequate to hold equipment and records. 
6. Waiting areas have seats and access to drinking water and toilets.
7. Weekly inventories are maintained on items subject to abuse. 
8. The facility has, at minimum, the following: hand washing facilities, exam tables, light for direct illumination, scales, thermometers, blood pressure monitoring equipment, sethoscope, ophthalmoscope, otoscope, transportation equipment, trash containers for biohazard and sharps, equipment and supplies for pelvic exams for female inmates. 
9. Basic dental equipment: hand washing facilities, dental exam chair, exam light, sterilizer, instruments, trash containers, a dentist's stool. 
10. Dentaly operatory equipment (if necessary): x-ray unit with developing capability, BP monitoring equipment, oxygen. 

Diagnostic Services

On-site diagnostic services are registered, accredited, or otherwise meet applicable state and federal law

1. The RHA maintains documentation that on-site diagnostic services are certified or licensed.

2. When the facility provides on-site diagnostic services, there is a procedure manual for each service, including protocols for the calibration of testing devices to ensure accuracy.

3. Facilities with full-time health staff have multiple-test dipstick UA, finger-stick blood glucose tests, peak flow meters, stool blood-testing material, and in pregnancy test kits (for female inmates).

Hospital and Specialty Care

Arrangements are made to provide hospitalization and speciality care to patients in need of these services. 

1. For each community hospital or off-site speciality services used regularly for medical and mental health care, there is a written aggreement that outlines the terms of the care to be provided.
2. The agreements require that the off-site facilities or health professionals give the inmate a summary of the treatment given and any follow-up instructions
3. For on-site specialty services used regularly for medical and mental health care, there are appropriate licenses and certifications. 

Information on Health Services

Information about the availability of, and access to, health care services is communicated orally and in writing to inmates on their arrival at the facility, in a form and language they understand.

1. A sign explaining how to access health services is posted in the intake/processing area.
2. Within 24 hours of their arrival, inmates are given written information about: how to access emergency and routine health services, the fee-for-service program (if one exists), and the grievance process for health-related complaints.
3. Special procedures ensure that inmates who have difficulty communicating understand how to access health services.

Receiving Screening

Receiving screening is performed on all inmates on arrival at the intake facility to ensure that emergent and urgent health needs are met.

1. Persons who are unconscious, semiconscious, bleeding, mentally unstable, or in need of urgent medical attention are referred immediately for care and clearance into the facility. 
2. Immediate health needs are identified and addressed.
3. A receiving screening takes place for all inmates as soon as possible. 
4. Reception personnel conduct a basic receiving screening on: current and past illnesses and health conditions, past infectious diseases, recent communicable illness symptoms, past or current mental illness and hospitalizations, history of or current suicidal ideation, dental problems, allergies, legal and illegal drug use, drug withdrawal symptoms, current or recent pregnancy
5. Reception personnel record their screening observations.
6. The disposition of th einmate is indicated on the receiving screening form
7. Receiving forms are dated and timed immediately on completion and include the signature and title of the person completing the form. 
8. Prescribed medications are reviewed and maintained.
9. Screening test for TB is completed. 

Transfer Screening

A transfer screening is performed by qualified health care professionals on all intrasystem transfers. 

1. Qualified health care professionals review each transferred inmate's health record or summary within 12 hours of arrival to ensure continuity of care
2. Inmates transferred from an intake facility who do not have initial medical, dental, or mental health assessments are to be evaluated at the receiving facility in a timely manner. 

Initial Health Assessment

(Full Population Assessment)

1. All inmates receive an initial health assessment as soon as possible, but no later than 7 calendar days after admission to the facility. 
2. Includes (at minimum): review of screening results, collecting additional data to complete the history taken at receiving screening and subsequent encounters, recording vital signs, a physical examination performed by a physician, PA, NP, RN, or other practitioner (including a hands on health assessment), laboratory/diagnostic tests for communicable diseases, pap tests, initial problem list with treatment plan, immunizations when appropriate. 

Initial Health Assessment

(Individual Assessment when Clinically Indicated)

1. Inmates identified with clinically significant findings as the result of a comprehensive receiving screening receive an initial health assessment as soon as possible, but no later than 2 working days after admission. (Facility has 24/7 on-site health staff; allows licensed health care personnel to conduct the screening with further inquiry to history, finger stick on individuals with diabetes, vital signs, and further inquiry to medications)
2. Include, at minimum: review of screening, collection of additional historical data, vital signs, a physical exam, lab and/or diagnostic tests of communicable diseases, lab/diagnostic tests for disease, immunizations when appropriate, pap tests
3. All assessment data are reviewed by treating clinician and specific problems create an initial problem list and developed as clinically indicated. 

Mental Health Screening and Evaluation 

All inmates receive mental health screening; inmates with positive screens receive a mental health evaluation. 

1. Within 14 days of admission to the correctional system, qualified mental health professionals conduct initial mental health screening. 
2. Structured interview with inquiries into: history of hospitalization or outpatient treatment, suicidal behavior, violent behavior, victimization, special education placement, cererbral trauma or seizures, and sex offenses; the current status of psychotropic medications, suicidal ideation, drug or alcohol use, and orientation to PPT; emotional response to incarceration; a screenign for intellectual functioning. 
3. The patient's health record contains the results of the screening
4. Inmates who screen positive are referred for further follow up.
5. The health record contains the results of the evaluation with documentation of referral or initiation of treatment
6. Acute mental health services beyond those available are transferred to an appropriate facility. 

Oral Care

Oral care under the direction and supervision of a dentist is provided to each inmate. Care is timely and includes immediate access for urgent or painful conditions. There is a system of established priorities for care when, in the dentist's judgement, the inmate's health would otherwise be adversely affected. 

1. Oral screening is performed within 14 days of admission.
2. Oral hygiene and preventative oral education are given within 1 month of admission.
3. An oral exam is performed by a dentist within 12 months of admission.
4. Oral treatment is provided according to a treatment plan based on a system of established priorities for care.
5. Radiographs are appropriately used in the development of the treatment plan. 
6. Consultation through referral to oral health care specialists as needed. 
7. Each inmate has access to preventative benefits of fluorides in a form appropriate for the needs of the individual.
8. Contemporary infection control procedures are followed. 
9. Extractions are peformed in a manner consistent with community standards. 

Nonemergency Health Care Requests and Services

All inmates have the opportunity daily to request health care. Their requests are documented and reviewed for immediacy of need and the intervention required. Sick call and clinicians' clinics are conducted on a timely basis and in a clinical setting by qualified health care professionals. 

1. Oral or written requests for health care are triaged within 24 hours.
2. During sick call, health care professionals make timely assessments in a clinical settings.
3. All inmates, regardless of housing assignment, have access to regularly scheduled sick call.
4. The frequency and duration of sick call is sufficient to meet the health needs of the inmate population.

Nonemergency requests are to be reviewed within 24 hours and the inmate seen by a qualified health care professional at sick call within the next 24 hours (72 hours on weekends).

Emergency Services

The facility provides 24-hour emergency medical, mental health, and dental services. 

1. A written plan includes arrangement for emergency transport of the patient from the facility, use of an emergency medical vehicle, use of one or more designated hospital emergency departments, emergency on-call physician, mental health, and dental services when the ER is not nearby, security procedures for the immediate transfer of patients for emergency medical care, and notification to the person legally responsible for the facility. 
2. Emergency drugs, supplies, and medical equipment are regularly maintained. 

Segregated Inmates

When an inmate is segregated, health staff monitor his or her health. 

1. Upon placement in segregation, a qualified health professional reviews the inmate's health record to determine whether existing medical, dental, or mental health needs contraindicate the placement or require accommodation. 
2. The health professional's monitoring of segreated inmates is based on the degree of isolation: with little or no contact with other individuals, the inmate is monitored by daily by medical staff and at least once a week by mental health staff; inmates who have limited contact with staff, they are monitored 3 days a week by medical or mental health staff; inmates who are allowed periods of recreation while being segregated are checked weekly by medical or mental health staff
3. Documentation of segregation rounds is made on individual logs or cell cards, or in an inmate's health record and includes: the date and time of the contact and the signature or initials of the staff making the rounds. 
4. Any significant health findings are documented in the inmate's health record.

Patient Escort

Patients are transported safely and in a timely manner for medical, mental health, and dental clinic appointments both inside and outside the facility. 

1. When a patient is escorted, health staff alert transporting custody staff to accommodations needed during the transport process, including instructions for administgration of necessary medications. 
2. Patient confidentiality is maintained during transport. 

The facility provides sufficient escorting staff so that patients can meet scheduled health care appointments.

Nursing Assessment Protocols

Nursing assessment protocols are appropriate to the level of skill and preparation of the nursing personnel who will carry them out, and comply with the relevant state practices acts. Standing orders may be used only for preventative medicine practices. 

1. Protocols are developed and reviewed annually by the nursing administrator and responsible physician.
2. Documentation of nurses' training in protocol use exists: evidence that all new nursing staff are trained, demonstration of knowledge and skills, evidence of annual review of skills and evidence of retraining when protocols are introduced or revised.
3. Nursing assessment protocols do not include the use of prescription medications except for those covering emergency, life-threatening situations. 

Continuity of Care During Incarceration

Inmates receive treatment and diagnostic tests ordered by clinicians. 

1. Ordered diagnostic tests and specialty consultations are completed in a timely manner, with evidence in the record of the ordering clinician's review of results. 
2. When an inmate returns from an ER visit, the physician sees the patient, reviews the discharge orders, and issues follow-up orders as indicated. 
3. When an inmate returns from hospitalization, the physician sees the patient, reviews the discharge orders, and issues follow up orders. 
4. Clinicians use diagnostic and treatment results to modify treatment plans. 
5. If changes are clinically indicated, justification for an alternative course is noted. 
6. Treatment plans are used and include: the frequency of follow up for medical evaluation and adjustment of treatment modality, the type and frequency of diagnostic testing and therapeutic regimens, and when appropriate, instructions about diet, exercise, adaptation to the correctional environment, and medication. 
7. The responsible physician determines the frequency and content of periodic health assessments on the basis of protocols promulgated by nationally recognized professional organizations.
8. Physicians' clinical chart reviews are of sufficient number and frequency to assure that clinically appropriate care is ordered and idmplemented by attending health staff. 

Discharge Planning

Discharge planning is provided for inmates with serious health needs whose release is imminent

1. For planned discharges, health staff: arrange for a sufficient supply of current medications to last until the inmate can be seen by a community health professional, and for inmates wiht critical medical or mental health needs, arrangements or referrals are made for follow-up services with the community. 
2. Discharge planning includes: (1) formal linkages between the facility and community-based organizations, (2) lists of community health professionals, (3) discussions with the inmate that emphasize the importance of appropriate follow-up and aftercare, and (4) specific appointments and medications that are arranged for the patient at the time of release. 

Healthy Lifestyle Promotion

Health education is offered to all inmates; individual health instruction is provided to all patients. 

1. The health record documents that patients receive individual health education and instruction in self-care for their health condition.
2. For general health education of inmates, compliance requires, at a minimum, the availablility of brochures and pamphlets on a variety of health topics in areas accessible to all inmates. 

Medical Diets

Medical diets are provided that enhance patients' health, and are modified when necessary to meet specific requirements related to clinical conditions. 

1. Orders for medical diets include the type of diet, the duration for which it is to be provided, and special instructions. 
2. A registered or licensed dietitian reviews medical diets for nutritional adequacy at least every 6 months and whenever a substantial change in the menu is made. 
3. Workers who prepare medical diets are trained in preparing the diets, including appropriate substitutions and portions. 
4. When inmates refuse prescribed diets, follow-up nutritional counseling is provided. 

Use of Tobacco

There is no smoking inside the facility. There are prevention and abatement activities regarding the use of all tobacco products. 

1. Smoking is prohibited in all inside areas. 
2. At a minimum, the prevention and abatement program includes nicotine replacement products and written materials on prevention and abatement of tobacco use. 

Chronic Disease Services

Patients with chronic diseases are identified and enrolled in a chronic disease program to decrease the frequency and severity of the symptoms, prevent disease progression and complication, and foster improved function. 

1. The responsible physician establishes and annually approves clinical protocols consistent with national clinical practice guidelines for chronoc diseases: asthma, diabetes, high cholesterol, HIV, hyhpertension, seizure disorder, TB, and major mental illnesses. 
2. Documentation in the medical record confirms that clinicians are following chronic disease protocols: determining the frequency of follow up for medical evaluation, adjusting treatment modality as clincially indicated, indicating the type and frequency of diagnostic testing and therapeutic regimens, writing appropriate instructions for diet, exercise, adaptation to the correctional environment, and medication
3. Chronic illnesses are listed on the master problem list. 
4. The facility maintains a list of chronic care patients. 

Patients with Special Health Needs

A proactive program exists that provides care for special needs patients who require close medical supervision or multidisciplinary care. 

1. Individual treatment plans are developed by a physician or other qualified clinician at the time the condition is identified.
2. The treatment plan includes: the frequency of follow up and adjustment of treatment modality, the type and frequency of diagnostic testing and therapeutic regimens, and when appropriate, instructions about diet, exercise, adaptation to the correctional environment, and medication. 
3. Special needs are listed on the master problem list.
4. The facility maintians a list of special needs patients. 

Infirmary Care

1. Patients are always within sight or hearing of a qualified health care professional.
2. Staffing is based on the number of patients, the severity of their illnesses, and the level of care required. 
3. A supervising RN is on site at least once every 24 hours.
4. Nursing care procedures are consistent with the state's nursing requirements.
5. Admission to and discharge from infirmary care occur only on the order of a physician.
6. The frequency of physician and nursing rounds is specified based on the categories of care provided.
7. A complete inpatient health record is kept for each patient. 
8. A copy of the discharge summary from infirmary care is placed in the patient's outpatient chart.

Basic Mental Health Services

1. Mental health needs are addressed on site or by referral.
2. Basic on-site outpatient services include: identification and referral of inmates with MH needs, crisis intervention services, psychotropic medication management, individual counseling, group counseling, psychosocial/educational programs, and treatment documetnation
3. When transfer to an inmpatient setting is indicated, transfer occurs in a timely fashion. 
4. Outpatients receiving basic mental health services are seen as indicated, but not less than every 90 days. 
5. Services are sufficiently coordinated such that management is appropriately integrated and medical issues are adequately addressed.

Suicide Prevention Program 

The facility identifies suicidal inmates and intervenes appropriately. 

1. A suicide prevention program includes: facility staff identify suicidal inmates and immediately initiate precautions, suicidal inmates are evaluated promptly by the designated health professional, actively suicidal inmates are placed on constant observation, and potentially suicidal inmates are monitored on an irregular schedule with no more than 15 minutes between checks. 
2. Key components of suicide prevention program include: training, identification, referral, evaluation, treatmetn, housing and monitoring, communication, intervention, notification, review, and debriefing. 
3. The use of other inmates in any way is not a substitute for staff supervision
4. Treatment plans addressing suicidal ideation and its reoccurrence are developed, and patient follow-up occurs as indicated
5. The responsible health authority approves the facility's suicide prevention plan; training curriculum for staff, including development of intake screening for suicide potential and referral protocols; and training for staff conducting suicide screening at intake. 

Intoxication and Withdrawal

Specific protocols exist for inmates under the influence of alcohol or other drugs or those undergoing withdrawal.

1. Protocols are approved by the responsible physician.
2. Detoxification is done only under physician supervision in accordance with laws.
3. Inmates experiencing severe, life-threatening intoxication or withdrawal are transferred immediately to a licensed acute care facility.
4. Individuals at risk for progression to more severe levels of intoxification or withdrawal are kept under constant observation. 
5. If a pregnant inmate is admitted with a history of opiate use, a physician is contacted so that the opiate dependence can be assessed and treated.
6. The facility has a policy that addresses the management of inmates on methadone. Inmates entering the facility on such substances have their therapy continued.

Care of the Pregnant Inmate

Pregnant inmates receive timely and appropriate prenatal care, specialized obsetetrical services when indicated, and postpartum care. 

1. Prenatal care includes; medical examinations, lab and diagnostic tests (including HIV testing), and advice on appropriate levels of activity, safety precautions, and nutritional guidance.
2. A list of specialized obstetrical services is maintained.
3. There is a written agreement with a community facility for delivery.
4. There is documentation of appropriate postpartum care. 
5. A list is kept of all pregnancies and their outcomes. 

Inmates with Alcohol and Other Drug Problems

Inmates with alcohol or other drug problems are assessed and properly managed by a physician or, where permitted by law, other qualified health care professionals. 

1. There are written clinical guidelines for the management of AOD patients
2. Disorders associated with AOD (e.g., HIV, liver disease) are recognized and treated. 
3. The correctional staff are trained in recognizing AOD problems in inmates. 
4. There is evidence of communication and coordination between medical, metnal health, and substance abuse staff regarding AOD care. 
5. There is on-site individual counseling, group therapy, or self-help groups. 

Inmates with Alcohol and Other Drug Problems

Health care responsibilities

1. Appropriate assessment of intoxication and withdrawal
2. Treatment of disorders associated with AOD
3. Appropriate prescription of psychoactive drugs as required. 
4. Supportive and appropriate motivational cousneling during clinical encounters. 

Aids to Impairment

Medical and dental orthoses or prostheses and other aids to impairment are supplied in a timely manner when the health of the inmate would otherwise be adversely affected, as determined by the responsible physician or dentist. 

1. Evidence that prescribed aids to impairment are received is confirmed through health record documentation. 
2. Where the use of specific aids to impairment are contraindicated for security reasons, alternatives are considered so the health needs of the inmate are met. 

Care for the Terminally Ill

A program to address the needs of terminally ill inmates includes pain management. When the responsible physician determines that care in a community setting is medically preferable, he or she recommends to the appropriate legal authority the patient's transfer or early release. 

1. Consistent with state regulations, qualified health care professionals initiate or facilitate the early release of terminally ill inmates in a timely manner.
2. If there is a hospice program: enrollment is a patient's informed choice, qualified health care professionals working in the program have received training in basic hospice theory and techniques, and inmate workers or volunteers providing services in the program are properly trained and supervised. 

Health Record Format and Contents

The method of recording entries in the health record and the format of the health record are approved by the responsible health authority

1. At minimum, the health record contains: identifying information, a problem list with diagnoses and treatments, allergies, receiving screening and assessments, progress notes of all findings and treatments, clinician orders for medications, reports of lab work, flow sheets, consent and refusals, ROI forms, results of speciality consultations, discharge summaries of hospitalizations and inpatient stays, special needs treatment plan, immunization records, place and date of each clinical encounter, and signature and title of each documenter. 
2. If electronic records are used, procedures address integration of health information in electronic and paper forms. 
3. Where mental health or dental records are separate from medical records, a process ensures that pertinent information is shared. 

Confidentiality of Health Records

The confidentiality of a patient's written or electronic health record, as well as orally conveyed health information, is maintained. 

1. Health records stored in the facility are maintained under secure conditions separate from correctional records.
2. Access to health records and health information is controlled by the RHA.
3. Evidence exists that health staff receive instruction in maintaining confidentiality. 
4. If records are transported by nonhealth staff, the records are sealed. 

Access to Custody Information

Qualified health care professionals have access to information in the inmate's custody record when the RHA determines that such information may be relevant to the inmate's health and course of treatment. 

A written policy and defined procedures specify which health services staff have access to custody records, and under what circumstances. 

Management of Health Records

A health record is maintained to facilitate continuity of care. 

1. Evidence exists that the health record is available and used.
2. When an inmate is transferred to another correctional facility: a copy of the current health record or a comprehensive health summary accompanies the inmate, and unless otherwise provided by law or administrative regulation, written authorization by the inmate is required to transfer health records and information to facilities outside the correctional system's jurisdiction.
3. The jurisdiction's legal requirements regarding records retention are followed.
4. There is a system for the timely reactivation of records when requested by a treating health professional. 

Restraint and Seclusion

Clinically ordered restraint and seclusion are available for patients exhibiting behavior dangerous to self or others as a result of medical or mental illness.  Except for monitoring their health status, the health services staff does not participate in the restraint of inmates ordered by custody staff. 

Clinically ordered restraints:

1. Plicies specify the types of restraints that may be used, when, wehre, how, and for how long restraints or seclusion may be used, how proper peripheral circulation is maintained, and that proper nutrition, hydration, and toileting are provided. 
2. Use is authorized by a physician or other qualified health care professional where permitted by law, after reaching the conclusion that no other less restrictive treatment is appropriate. 
3. Every 15 minutes, health trained personnel or health services staff check on any patient placed in clinically ordered restraints or seclusion. Checks are documented. 
4. The treatment plan provides for removing patients from restraints or seclusion as soon as possible. 
5. The same types of restraints that would be appropriate for patients treated in the community are used in the institution. 
6. Patients are not restrained in a manner that would jeopardize their health. 

Restraint and Seclusion

Clinically ordered restraint and seclusion are available for patients exhibiting behavior dangerous to self or others as a result of medical or mental illness.  Except for monitoring their health status, the health services staff does not participate in the restraint of inmates ordered by custody staff. 

Custody ordered restraints

1. When restraints are used by custody staff for security reasons, health services staff are notified immediately in order to: review the health record for any contraindications or accommodations required, which, if present, are immediately communicated to appropriate custody staff, and initiate health monitoring, which continues at designated intervals as long as the inmate is restrained. 
2. If the restrained inmate has a medical or mental health condition, the physician is notified immediately so that appropriate orders can be given. 
3. When health services staff note improper use of restraints that is jeopardizing the health of an inmate, they communicate their concerns as soon as possible to appropriate custody staff. 

Emergency Psychotropic Medication

Health services staff follow policies developed for the emergency use of forced psychotropic medications as governed by the laws applicable in the jurisdiction.

Policies on forced medication:

1. Require physician authorization prior to use
2. Specify when, where, and how the psychotropic medication may be forced. 

When a physician orders psychotropic medication to be forced, he or she documents in the inmate's record:

1. the inmate's condition, 
2. the threat posed
3. the reason for forcing the medication,
4. other treatment modalities attempted, if any, and
5. treatment plan goals for less restrictive treatment alternatives as soon as possible. 

Forensic Information

Health services staff are prohibited from participating in the collection of forensic information. 

Health services staff are not involved in the collection of forensic information, except when:

1. Complying with state laws that require blood samples from inmates, so long as there is consent of the inmate and health services staff are not involved in any punitive action taken as a result of an inmate's nonparticipation in the collection process. 
2. Conducting body cavity searches, and blood or urine testing for alcohol or other drugs when done for medical purposes by a physician's order. 
3. Conducting inmate-specific, court-ordered lab test, examinations, or radiology procedures with consent of the inmate, and 
4. in the case of sexual assault, gathering evidence from the inmate victim with his or her consent. 

End-of-Life Decision Making

Inmates approaching the end of life are permitted to execute advance directives including living wills, health care proxies, and "do not resuscitate" (DNR) orders. These directives are signed only after the patient receives appropriate information regarding the meaning and consequences of such decisions. 

1. Advance directives are written protocols that specify end-of-life decisions and that: ensure that such patient decisions are voluntary, uncoerced, and based on medical information that is complete and comprehensible to the patient; specify how competency to make the decisions is evaluated; and include the process to follow when the inmate is judged incompetent to make end of life decisions.
2. Written evidence exists, through documentation in the health record, that terminally ill patients executing such documents have been provided with sufficient and appropriate information to make voluntary and informed decisions. 
3. Before a health care proxy, living will, or DNR order is used as the basis for witholding or withdrawing care, there is an independent review, by a physician not directly involved in the patient's treatment, of the patient's course of care and prognosis. 

Informed Consent and Right to Refuse

All examinations, treatments, and procedures are governed by informed consent practices applicable in the jurisdiction.

1. The policy and procedures specify circumstances under which risks and benefits of an intervention are explained to the patient. 
2. For invasive procedures or any treatment where there is risk and benefit to the patient, informed consent is documented on a written form containing the signatures of the patient and health services staff witness. 
3. Any health evaluation and treatment refusal is documented and must include: description of the nature of the services being refused, evidence that the inmate has been made aware of any adverse consequences to health that may occur as a result of the refusal, the signature of the patient, and the signature of the health services staff witness.
4. In the event the patient does not sign the refusal form, it is to be noted on the form by a health services staff witness. 

Medical and Other Research

Biomedical, behavioral, or other research using inmates as subjects is consistent with established ethical, medical, legal, and regulatory standards for human research. 

All aspects of the standard are addressed by written policy and defined procedures that specify: 

1. The process for obtaining approval to conduct the research, and
2. the steps to be taken to preserve the subject's rights.

When inmates who are participants in a community-based research protocol are admitted to the facility, procedures provide for: 

1. Continuation of participation, or
2. Consultation with community researchers so that withdrawal from the research protocol is done without harming the health of the inmate. 

Executions 

The correctional health services staff do not participate in inmate executions

1. Executions do not occur in the medical unit or area
2. Health services staff do not assist, supervise, or contribute to the ability of another individual to directly cause the death of an inmate.