(1) The purpose of intake history and physical evaluation,
provision of emergency services, pharmaceutical services and
policies, and infirmary and in-patient services;
(2) Specific sick call times and procedures;
(3) Procedures for obtaining physical and mental health care
services;
(4) Health care services staffing, and the behavior expected
of inmates while in the health care services area; and
(5) Grievance procedures .
(c)

Physical Examinations

Physical examinations shall be conducted annually or as clinically
indicated. The Contractor shall conduct physical examinations in
accordance with requirements of the National Commission on Correctional
Health Care (NCCHC) standards, including gathering of lab data.
(d)

Sick Call

Contractor will provide a sick call system which provides inmates
with unimpe ded access to health care services. Health care staff will
collect, triage and respond to all inmate requests daily. The frequency of
sick call will be consistent with NCCHC standards. If the inmate's custody
status precludes attendance at sick call, appropriate measures will be
taken to provide access to health care services.
(e)

Emergency Services

Contractor is required to provide an immediate response to inmates
with emergency health care needs. Contractor will have twenty-four (24)
hour physician coverage or telephone on-call coverage and specific
written policies and procedures to address emergency response and the
emergency transfer of inmates. Contractor shall ensure that an inmate's
medical chart accurately and completely documents all services provided
by Contractor and community health care providers in emergency
situations.
(f)

Inpatient Services

Contractor shall staff and utilize observation beds available at
Contractor's facilities for admissions which do not require hospitalization .
Inmates requiring respiratory isolation will be housed in a designated
negative air pressure room. If an inmate requiring respiratory isolation is

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housed at a Facility without the requisite equipment, Contractor shall
transfer the inmate to a properly equipped facility. The Contractor shall
comply with state and federal laws and NCCHC standards with respect to
the management and operation of observation beds .
Medical observation is a transient housing location for those
inmates with stable illnesses/injuries not requiring hospitalization.
Examples of appropriate inmates include, but are not limited to seizure
activity, infectious diseases, allergic reactions , suicide precautions, post
hospitalization convalescent care, etc. Inmates are monitored by security
staff and attended to by nursing staff as ordered by the physician. The
physician/psychiatrist orders observation status, monitors all care, and is
responsible to determine release from medical observation.
(g)

Hospitalization

Contractor shall identify the need, schedule, coordinate and pay for
any inpatient hospitalization and related services for any inmate,
consistent with terms of Paragraph (y). Contractor shall ensure that an
inmate's medical chart accurately and completely documents services
provided by community health care providers and that such
documentation is included in the medical transfer record when the inmate
returns to VTDOC .
Under no circumstances shall Contractor limit or delay access to
inpatient hospitalization, including inpatient psychiatric hospitalization for
inmates needing this level of care to the extent possible given resources
available in the community where the facility is housed. In the event that
an inmate is in need of psychiatric hospitalization that exceeds the short
term hospitalization available in the local jurisdiction, the inmate shall be
returned to Vermont. If the State believes that the Contractor is not
transporting inmates needing inpatient hospitalization in timely fashion, the
State shall audit the case. Failure to reach satisfactory resolution of such a
case may be grounds for termination of the contract by the State.
(h)

Specialty Outpatient Services

When available, the Contractor shall arrange for qualified medical
specialists to visit the facilities so that inmates may be maintained within
the security of the Contractor facility. If necessary, an . outside referral will
be made for services that cannot be provided at the facility. To the degree
possible , diagnostic testing will be performed on-site. A referral process
will be initiated to provide specialists with all pertinent information needed
to facilitate timely diagnosis and treatment. The medical specialist will
receive diagnostic testing results, substantive patient history and clinical
findings, in the form of a written referral.

- 32 -

Contractor shall be responsible for scheduling, authorizing and
coordinating all specialty services. All inmates returning from outside
hospital stays will be seen immediately upon return by a medical
professional, and a progress note regarding the review will be
documented in the inmate's health care record . Contractor shall ensure
that an inmate's medical chart accurately and completely documents
services provided by the community health care provider and that such
documentation is included in the medical transfer record when the inmate
returns to VTDOC.
Under no circumstances shall Contractor limit or delay access to
specialty services for inmates identified as needing this care. If the State
believes that the Contractor is not providing specialty services in a timely
fashion, the State shall audit the case. Failure to reach satisfactory
resolution of such a case may be grounds for termination of the contract
by the State.
(i)

Laboratory Services

Contractor shall provide lab diagnostic testing. Laboratory testing
will include routine, special chemistry and toxicology analysis. The
laboratory will meet all applicable state and federal requirements for
specimen handling, testing and reporting. All services provided shall meet
standards set forth by the American College of Pathology.

m

Radiology Services

A radiology technician will be available to provide radiology
services. Inmates will be referred off-site for procedures beyond the
scope of services provided on-site. A Board-Certified radiologist will read
the studies in a timely manner. The radiology report will be documented,
and maintained in the inmate's health care record. The Contractor's
Medical Director will review, initial and date all radiology reports. A verbal
notification of all positive findings will be furnished to the VTDOC Medical
Director or his/her designee within three working days; this verbal
notification is to be followed up by a written notice of findings within 10
working days.
(k)

Diet Therapy

Special diets will be available to inmates when medically indicated
and ordered. Contractor will document the need and dietary services
required. The inmate's orientation to the therapeutic diet will be
documented in the health care record. In accordance with NCCHC

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standards, Contractor shall coordinate reviews of all diets at least every
six months with a registered dietitian.

(I)

EKG Services

Contractor shall provide EKG services and necessary EKG
equipment. The EKG contract will provide for immediate reading and
reporting of results of EKG. Nursing staff will receive in-service training
related to EKG services.
(m)

Medical Prosthetics

Contractor shall provide prosthetic devices to inmates as medically
indicated. Prosthetics will be selected according to community standards,
but also must conform to security requirements of the State. The costs
associated with providing prosthetics may be borne by the State. In such
cases, prior approval by the contract manager is required.
(n)

Optical Services

Contractor shall identify the need, schedule, coordinate and pay for
the dispensing, evaluation, and fitting services of an optometrist. Inmates
requesting health care services for visual problems will be evaluated using
the Snellen eye chart by nursing staff. If a visual deficiency beyond 20/70
is identified, the inmate will be referred to Contractor's optical service
provider.
Contractor shall provide one (1) set of eyeglasses to inmates if
prescribed and deemed necessary by the optometrist, consistent with
Paragraph (y) of this Section. Inmates requiring treatment and services
beyond the scope of services offered on-site will be transported to
specialists in the community. Inmates shall be eligible to receive follow-up
eye exams every two years.
(0)

Pharmaceuticals

Contractor shall provide a total pharmaceutical system, including
medications prescribed by mental health care providers, which is sufficient
to meet the needs of the State inmates. Contractor shall be responsible for
the costs of drugs administered under the contract, consistent with the
limitations described in Paragraph (y) of this Section. Policies, procedures
and practices addressing pharmaceuticals will be in compliance with all
applicable state and federal regulations. The pharmaceutical system will
have the following components:

- 34 -

(1)
Medication ordered by a qualified provider (physician,
psychiatrist, nurse-practitioner, dentist) will be appropriately
documented in the MAR and health record.
(2) A pharmaceutical inventory will be established to facilitate
the initiation of pharmaceutical therapy upon the physician's
order. An inventory control system will be implemented to
ensure the availability of necessary and commonly prescribed
medications, and to protect against the loss of
pharmaceuticals. All pharmaceuticals will be prepared,
maintained and stored under secure conditions.
(3)
An adequate and proper supply of antidotes and
emergency medications will be available.
(4) Contractor will maintain a formulary listing the available
medications, and this formulary shall be available to the State.
(5)
While it is recognized that formulary prescribing is the
norm, cases may arise in which non-formulary medications are
determined to be the most effective treatment. When this
occurs, the non-formulary medication request will be
processed per the Contractor's policy. The Contractor will
provide the VTDOC Clinical Director of Health Services with a
monthly report of all non-formulary requests and their
disposition . Information will include inmate name, medication
requested, and disposition.
(p)

Medication Administration

The Contractor shall maintain a medication administration system
which meets the needs of State inmates. Medication will be administered
to inmates by nurses or other authorized personnel three times daily or as
ordered . The administration of each medication will be documented on a
medication administration record . Documentation on the medication
administration record will clearly indicate those instances when an inmate
refuses a medication or is not available to receive a medication.
Medication administration times will be adjusted to meet the needs of
inmates who participate in work details or classes. If an inmate refuses a
specific medication three times, the inmate will be counseled and
requested to sign a refusal form.
(q)

Dental Services

Contractor shall provide on-site dental services which include
preventive and restorative care. The initial dental appraisal and instruction

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in oral hygiene will be conducted at the time of the initial health appraisal
by a qualified healthcare professional and within fourteen (14) days of
admission . The Contractor's provision of a dental screening for all referred
inmates shall be conducted by a licensed dentist. Nurses who provide oral
hygiene instruction will receive in-service training.
Inmates may request dental services in accordance with the
Contractor's protocols and procedures. Inmates will be seen as soon as
practicable, based on acuity of need. Inmates who require treatment
beyond the capabilities of the Contractor's licensed dentist will be referred
to a dental specialist. Dental prostheses will be provided as determined by
a licensed dentist in accordance with the Federal Bureau of Prisons'
(FBOP) policy on dental prosthesis.
(r)

Hepatitis Treatment

It is recognized by the Parties that the prevalence of hepatitis in
prison populations is higher than the general public. The Contractor will
provide appropriate treatment, consistent with NCCHC and/or CDC
guidelines, according to protocols developed by the Contractor and
approved by the VTDOC Health Services Director.
(s)

Mental Health Services

The Contractor shall provide all services related to the mental
health needs of State inmates, including assessment, diagnosis,
treatment, pharmacology and psychopharmacology. Inmates being
transferred to the Contractor will be screened by the State for mental
health needs, restrictions and necessary accommodations prior to
transfer. Information pertaining to mental health treatment will be
conveyed in written form and, if necessary, verbal communication to
insure continuity of care. The Contractor will provide written
documentation of mental health treatment activities, including refusal of
care and will include such documentation in the medical transfer record
when the inmate returns to VTDOC .
(t)

Suicide Prevention and Crisis Intervention

The Contractor shall provide routine screening and evaluation of
inmates to assess and prevent suicidal ideation or behavior. When an
inmate is suspected of being at risk of harm to himself, the Contractor
shall take all necessary measures and interventions to insure the inmate's
safety. Compliance with standards of professional practice shall be
followed .

- 36 -

When an inmate experiences psychiatric emergencies or crisis, the
Contractor will take all necessary measures to respond to the inmate's
needs and assure safety of the inmate and staff. This shall include shortterm psychiatric hospitalization of a temporary nature to the extent
possible given the resources available in the community where the facility
is housed.
In the event that an inmate is in need of psychiatric
hospitalization that exceeds the short term hospitalization available in the
local jurisdiction, the inmate shall be returned to Vermont.
Contractor shall document all relevant information and interactions
with suicidal inmates and include relevant information in the inmate's
medical chart. Communication with the State shall be initiated if an inmate
engages in serious suicidal conduct or shows symptoms of serious
psychological deterioration. Co ntractor shall provide suicide prevention
and crisis intervention services in accordance with its policies and
procedures attached hereto as Exhibit B. Said policies and procedures
are subject to change by Contractor in accordance with best practices,
ACA, NCCHC and the changing health needs of the inmates.
Health Care Records

(u)

The Contractor shall maintain a problem-oriented health care
record, and will include medical, dental, chemical dependency, and mental
health care information. Contractor will provide full and unrestricted
access to and copies of the appropriate health care record to the State
within the scope of legal and regulatory requirements and in accordance
with the State's policies, procedures and directives. The standardized
health care record shall contain the following information:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•

Problem list;
Completed intake screening form;
Health appraisal form;
Clinical (SOAP) notes;
Physician orders;
Inmate requests for health care services, including illnesses and
injuries;
All diagnostic findings, treatments and dispositions;
Prescribed medications and their administration;
Laboratory, radiology and other diagnostic studies;
Consent and refusal forms;
Release of information forms;
Place, date and time of health care encounters;
The health care provider's name and title;
Hospital reports and discharge summaries;
Intra-system and inter-system transfer summaries;
Specialized treatment plans;
- 37 -

•
•
•
•

Consultation forms;
Health Care Services reports;
Inmate medical grievance forms;
Documentation of all medical, dental and mental health care
services provided, whether from inside or outside the facility.

A health care record will be initiated during the inmate's first health
care encounter and shall contain complete and accurate records of health
care services provided during the individual's incarceration at Contractor's
facilities. The State will provide health information at the time of transfer,
and the Contractor shall provide relevant records to the State upon an
inmate's return to the State's custody. Contractor shall return records in
tabulated or otherwise organized folders which are then placed in
individual manila envelopes or other suitable sealed package. The health
care provider's signature and title will be recorded for each encounter. All
outside health care services, such as laboratory results, or physician
consultation reports, will be filed as part of the permanent health care
record. Health care records shall be maintained securely and in a
confidential manner at all times, and in compliance with all applicable laws
and regulations, including, but not limited to, the Health Insurance
Portability and Accountability Act of 1996 ("HIPAA") (including regulations
promulgated pursuant to HIPAA, such as the Standards for the Privacy of
Individually Identifiable Health Information and the Security Standards,
at.45 CFR Parts 160 and 164: hereafter, the Privacy and Security Rules)
and the Confidentiality of Alcohol and Drug Abuse Patient Records, at 42
CFR Part 2.
(v)

Quality Assurance and Improvement Program

The Contractor shall implement a Quality Improvement Program
("QIP"), as set forth by NCCHC standards. The program will be designed
to assure that quality is provided in the most appropriate and cost-efficient
manner" for the VTDOC. The program shall allow development of sitespecific plans reflective of the facility's health care services systems.
The program shall consist of the following elements:
(1) Risk Management -Contractor shall establish a logical and
thorough system of policies and procedures to minimize
exposure to liability. Risk management activities focus on the
identification of clinical events which have or may have the
potential of placing the inmate, health care provider, or the
facility at risk. Identified risk areas are investigated and
analyzed to develop policies and procedures that reduce risk
and maintain a safe clinical setting. The QIP shall include a

- 38 -

safety component to provide a safe environment for inmates,
employees and visitors.
(2) Infection Control -Contractor's infection control policies
and procedures shall focus on the prevention , identification
and control of diseases acquired in the facility setting or
brought in from the outside community. The infection control
program will address hand washing, housekeeping,
decontamination, disinfection and sterilization of equipment
and supplies, medical isolation, infectious and parasitic
laundry, infectious waste, pest control and parasite infected
environments.
(3) Utilization of Services -Contractor shall collect and monitor
statistical data to detect potential problems . Volume data
reporting forms will be used to report data and to track the
utilization of health care services on a year-to-date basis. All
deviations will be reviewed for problem identification.
Contractor will monitor the utilization of all health care services
provided off-site, as compared to national data on incarcerated
populations, and will be readily available for telephone
consultations. Contractor shall provide the State with a
monthly report identifying utilization patterns; those inmates
transferred offsite to the hospital emergency department; and
a status report on all inmates in local hospitals and infirmaries.
Contractor's volume data reporting forms will also be used to
prepare a narrative report on the types and numbers of
services provided.
(4) Inmate Grievances -Grievances are reviewed to identify
potential areas of concern and to determine if problematic
patterns exist. Inmate grievances will be documented in a log
to assist in monitoring compliance with policy and procedure
related to inmate grievances and to summarize those areas
which are frequently the topic of inmate dissatisfaction. All
inmate grievances will be responded to within ten days of
receipt and included in monthly reporting .
The State and Contractor shall identify personnel who will
communicate about the QIP program. The Contractor shall provide
monthly reports to the State detailing levels of service provided and
systems issues encountered. The content and form of these reports shall
be determined by the Parties .
(w)

NCCHC Standards and ACA Accreditation

- 39 -

Lee Adjustment Center, North Fork Correctional Facility,
Tallahatchie County Correctional Facility and West Tennessee Detention
Lee Adjustment Center,
Center shall follow NCCHC standards.
Tallahatchie County Correctional Facility and West Tennessee Detention
Center are all ACA accredited and shall maintain such accreditation
throughout the term of this Agreement. North Fork Correctional Facility
shall obtain ACA accreditation within eighteen (18) months of the
execution of this Agreement and , once such accreditation is obtained, it
shall be maintained throughout the term of this Agreement. Other
Contractor facilities that may be used to house VTDOC inmates will follow
ACA and NCCHC standards.
(x)

Inmate Death

In the event of the death of an inmate, the Contractor shall
immediately notify the contract monitor. Arrangements shall be made for a
fingerprint (right thumb or right index) to be taken . The coroner of the local
jurisdiction shall be requested to perform an autopsy for any death of a
Vermont inmate. The contract monitor shall furnish instructions and
information regarding the disposition of the body. All expenses relative to
the autopsy, any necessary preparation of the body and shipment or
express charges, pursuant to the contract monitor's instructions, shall be
reimbursed by VTDOC. The parties may arrange to have the Contractor
take care of the burial and all matters related or incidental thereto and all
such expense shall be paid by VTDOC. The provisions of this paragraph
shall govern only the relations between the parties and shall not affect the
liability of any relative or other person for the disposition of the deceased
or for any expenses connected therewith.
(y)

Contractor Limitations

The Contractor shall be responsible for the cost of providing all
outpatient medical, dental and medication services, including specialty
clinics and all medically related transportation, both routine and
emergency. The Contractor shall be responsible for inpatient hospital and
surgery charges for the first Two Thousand Dollars ($2,000.00) in costs
per inmate, per incident. Thereafter, VTDOC shall be liable for all inpatient
hospital and surgery charges . The Contractor shall be responsible for all
outpatient surgery, including oral surgery. As the VTDOC will pay inpatient
hospital and surgery charges after the first $2,000.00, the Contractor shall
cause the medical provider's invoice(s) to detail the cost to be paid by the
VTDOC and the Contractor separately. In the event the medical provider
is unwilling to separate these costs, the VTDOC and Contractor shall
allocate the costs between them in accordance with the terms set forth
herein .

- 40-

All medical bills will be submitted for re-pricing by the Contractor.
Both parties acknowledge the industry standard of six months for
providers to submit a clean claim for services. The Contractor shall make
all reasonable efforts to ensure that invoices are submitted to VTOOC as
soon as reasonably practical after such re-priced invoices are received by
the Contractor. In no instance shall the time period exceed one year.
The Contractor shall be required to obtain written VTOOC approval
of all scheduled inpatient hospitalization and surgery as soon as
Contractor can reasonably be expected to anticipate the length of stay
and/or the cost of treatment. In the event of emergency hospitalization, the
Contractor shall notify the VTOOC within 24 hours thereafter. VTOOC's
contact person for such approvals and notifications shall be VTOOC's
Oirector of Health Services.
The Contractor shall inform the medical care facility that
certification for continued hospital stay is required by the VTOOC and
must be initiated by the medical care facility if the cost of the inmate's
anticipated stay will exceed $2,000.00.
Notwithstanding any provision contained herein to the contrary, any
inmate's medical expenses resulting from the negligence or willful
wrongdoing of the Contractor, its officers, agents or employees, shall be
fully paid for by the Contractor.
Except as otherwise indicated herein, the Contractor shall furnish
eyeglasses and shall be responsible for the purchase of special limiteduse equip ment. Except as otherwise indicated herein, prosthetics and
durable medical equipment shall be furnished by the Contractor. Ourable
medical equipment, a standard medical term, shall include, but not be
limited to, such items as crutches, orthopedic braces, nebulizers, etc. Cost
of medical equipment which exceeds $2,000.00 shall be the responsibility
ofVTOOC.
The Contractor shall continue to provide security for an inmate
assigned to the facility at an off site medical facility after the first 72 hours,
if requested to do so by the VTOOC. In that event, the VTOOC shall
reimburse the Contractor in the amount of time and a half at the starting
wage of a Correctional Officer in the facility providing such service. Prior to
submitting an invoice for reimbursement for security provided a VTOOC
inmate at an off site medical facility, Contractor shall ensure that the
invoice is submitted only for the provision of such service and not for any
additional hours that the Correctional Officer may have worked that are
not for the provision of such service.

- 41 -

Provided that the VTDOC is aware or has been notified prior to the
hospitalization of the inmate, the Contractor shall not be responsible for
inpatient hospitalization costs, including any surgery and specialty
services, associated with the treatment of persons with known Acquired
Immune-Deficiency Syndrome (AIDS), as defined by the Center for
Disease Control, organ transplants, renal dialysis, cancer treatment and
Hep. C treatment. The Contractor shall be responsible for inpatient and
outpatient hospitalization costs for HIV infected patients, as noted above
when not associated with treatment of their HIV disease. The Contractor
shall not be responsible for the cost of providing AZT, or other medications
therapeutically indicated for the treatment of inmates with AIDS or HIV
infection. Such treatment will be at the VTDOC's discretion and expense
and requires pre-authorization. The VTDOC will screen all transfers to
exclude inmates currently being treated for active AIDS, cancer, renal
dialysis, Hep C and Axis I mental conditions that have required psychiatric
care within the last six (6) months. Any inmate who is first diagnosed with
any of these conditions while at the Contractor's Facility will be evaluated
by VTDOC and the Contractor's Health Services Administrator for the
Facility for a mutual determination of whether the acuity of the condition is
appropriate for housing at the Contractor's Facility. If, upon mutual
decision of the parties, the inmate remains at the Facility, VTDOC will
reimburse the Contractor for all costs associated with treating the
condition.
The Facility shall have first aid equipment, which meets American
Correctional Association standards, available at all times for medical
emergencies. Staff trained in emergency first aid procedures, including
cardio-pulmonary resuscitation shall be present on each shift. State
licensing and certification requirements shall apply to health care
personnel working in the Facility to the same extent as they apply to
equivalent personnel in the community. The Facility shall make provisions
for medical examination of any employee or resident suspected of a
communicable disease.
The Facility shall have written policies and procedures regarding
the possession and use of controlled substances, prescribed medications
and over-the-counter drugs. The policies and procedures shall stipulate
that prescribed medications are administered according to the directions
of the prescribing physician. There shall be written policies and
procedures which specify that the records of all medications distributed by
Facility staff shall be maintained and audited monthly, and include the
date, time and name of the resident receiving medication, and the name of
staff distributing it. Health history records shall accompany the resident to
the facility and shall be kept current. Staff shall be made aware of
resident's special medical problems.

- 42-

At this time, there is no medical co-pay program for VTDOC
inmates. If, at some point in the future, an inmate medical co-pay is
instituted, the Contractor shall be allowed to institute the same.
27 .

REMOVAL FROM INSTITUTION

The contract monitor shall be informed within twenty-four (24) hours of all
cases where an inmate is removed from the Contractor's institution for
emergency medical treatment or any other reason. All reasonable care shall be
exercised for the safekeeping and care of the inmate.
28.

ACCESS TO COURTS , LEGAL RESEARCH & SUPPLIES.

The Contractor will ensure all VTDOC inmates court related access is in
compliance and consistent with the US Constitution and US Supreme Court. The
Contractor will provide opportunity for meaningful access to federal and Vermont
State legal materials at the Facility in accordance with security and operating
needs. The Contractor will provide VTDOC inmates in segregation and protective
custody access to the law library collection established pursuant to this section
providing their participation is consistent with the safety and security of the
Facility. If direct access cannot be provided VTDOC inmates in segregation or
protective custody, a process shall be established allowing VTDOC inmates in
segregation or protective custody to request reasonable numbers of materials
from a law library. The Contractor shall provide federal VTDOC legal research
materials required to meet constitutional standards. Vermont specific material
shall be furnished by VTDOC. In the event the materials are furnished via
computer and appropriate software the Contractor shall provide a secure and
monitored location to house said computer and associated peripherals. The
Contractor shall provide federal law material; typewriters, including ribbons, and
typing paper; notary services; copying services, including copier paper; legal size
envelopes; sufficient to meet constitutional standards. Items such as paper and
typewriters shall be provided and shall be available free of charge to indigent
VTDOC inmates. VTDOC inmates need not be afforded access to copiers;
however, the Contractor shall provide a copy of specific information, such as a
page from a law book, upon request by a VTDOC inmate. A common copy fee
shall be set by the Contractor accord ing to each Facility's policies and
procedures. The Contractor shall provide access to law material when staff has
scheduled absences, due to vacations, extended leave or training.

29.

VERMONT LEGAL MATERIALS and LAW LIBRARY ACCESS

Contractor shall provide VTDOC inmates with access to courts, legal
materials, and law library abiding with the requirements of the US Constitution
and US Supreme Court decisions. Legal reference materials and library access
will be available during hours that facilitate reasonable access during non

- 43 -

working, visiting or program hours by VTDOC inmates/residents including
weekends and evenings, provided that such access will be available at least
twelve (12) hours each week and, provided further that the minimum hours of
library access will be increased if such is required by any court orders relative to
VTDOC inmates.
VTDOC shall be responsible for designating and providing the first set of
texts and legal forms (materials) and all supplements and updates of the
Vermont specific legal reference materials to Contractor facilities housing 60 or
more VT inmates. If the initial set of materials is lost or destroyed, Contractor
shall provide replacements. Contractor shall provide adequate on-site-facilities
to accommodate VTDOC legal materials, computers and VT inmates. Such
facilities shall include chairs, writing tables, file cabinets, book cases and
typewriters. Contractor will institute (2) two paid work assignments for Vermont
Law Librarians in facilities housing 60 or more Vermont inmates.
30.

ATIORNEY CALLS

Contractor shall provide adequate on-site facilities for all attorney calls to
insure confidentiality and privacy on a non-monitored telephone line.

31.

MAIL.

Offenders will be provided with mail service. Indigent Offenders shall be
provided with supplies for correspondence for up to the price of five (5) one
ounce first class letters per month. However, no request for mailing of verified
legal pleading will be denied under this provision regardless of postage limit or
financial status of the offender. The Contractor is entitled to recoup postage fees
when the Offender has sufficient funds in his account.
32.

GOVERNING LAW

Except where expressly otherwise provided, the laws and administrative
rules and regulations applicable to the state where the Contractor's correctional
facilities are located shall govern in any matter relating to an inmate confined
pursuant to this agreement. Vermont law shall govern in matters related to the
interpretation and enforcement of this Agreement.
33.

INDEPENDENT CONTRACTOR STATUS

The Contractor shall perform its duties hereunder as a Contractor and not
as an employee. Neither the Contractor nor any agent or employee of the
Contractor shall be or shall be deemed an agent or employee of the State of
Vermont.

- 44-

Contractor shall pay when due all required employment taxes and income
tax withholding including all federal and state income tax and local health tax on
any monies paid pursuant to this agreement. Contractor acknowledges that the
Contractor and its employees are not entitled to unemployment insurance
benefits unless the Contractor or a third party provides such coverage and that
the State does not pay for or otherwise provide such coverage. Contractor shall
have no authorization, express or implied, to bind the State of Vermont to any
agreements, liability or understanding except as expressly set forth herein.
34.

NOTICES

Any notice provided for in this agreement shall be in writing and served by
personal delivery or by certified mail, return receipt requested, postage prepaid,
at the addresses listed in Section 23 unless written notice of a change is received
from the other party. Any notice so mailed and any notice served by personal
delivery shall be deemed delivered and effective upon receipt or upon attempted
delivery. This method of notification will be used in all instances, except for
emergency situations when immediate notification is required pursuant to the
appropriate sections of this agreement.
35.

ASSIGNMENT

No right or interest pursuant to this agreement shall be assigned or
delegated by the Contractor without the prior written permission of the VTDOC.
However, the Contractor is authorized to subcontract with any entity for the
performance of the Contractor's obligations hereunder provided each such
subcontractor agrees to be bound by all applicable provisions of this Contract.
The Contractor acknowledges it will not by the act of subcontracting be absolved
or released from any obligations under this Contract and will remain responsible
for all performance under this Contract. Contractor shall not assign its rights and
responsibilities under this Agreement without the prior written approval of
VTDOC.
36.

NO THIRD-PARTY BENEFICIARY ENFORCEMENT

It is expressly understood and agreed that enforcement of the terms and
conditions of his Agreement, and all rights of action relating to such enforcement,
shall be strictly reserved to the VTDOC and the Contractor, and nothing
contained in this Agreement shall give or allow any claim or right of action
whatsoever by any other person on this Agreement. It is the express intention of
the VTDOC and the Contractor that any entity, other than the VTDOC or the
Contractor receiving services or benefits under this Agreement, shall be deemed
an incidental beneficiary only.
This agreement is not intended to create any right, liberty interest or
entitlement in favor of any inmate. The agreement is intended only to set forth the

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contractual rights and responsibilities of the contract parties. Inmates shall have
only those entitlements created by Federal or State constitutions, statutes,
regulations or case law.
37.

MODIFICATION AND WAIVER

This Agreement contains the entire Agreement and understanding
between the parties and supersedes any other agreements concerning the
subject matter of this transaction, whether oral or written . No modification,
amendment, notation , renewal or other alteration of or to this agreement shall be
deemed valid or of any force or effect whatsoever, unless mutually agreed upon
in writing by the parties. No breach of any term, provision or clause of this
agreement shall be deemed, waived or excused, unless such waiver or consent
shall be in writing and signed by the party claimed to have waived or consented.
Any consent by any party to, or waiver of, a breach by the other, whether express
or implied, shall not constitute consent to, waiver of, or excuse of any other
different or subsequent breach.
38.

HEADINGS

Headings herein are for convenience of reference only and shall not be
considered any interpretation of this agreement.
39.

TIME OF THE ESSENCE

Time is of the essence in the performance of all of the parties' obligations
and duties under this Agreement.
40.

SEVERABILITY

If any term or condition of this Agreement shall be held to be invalid, illegal
or unenforceable, this agreement shall be construed and enforced without such
provision to the extent this Agreement is then capable of execution within the
original intent of the parties.
41.

RISK OF PHYSICAL DAMAGE TO FACILITY

The risks and costs of physical damage to the Contractor's facility incurred
as a direct result of the placement of the VTDOC's inmates in the Contractor's
facility shall be considered usual costs incidental to the operation of the facility
and part of the costs reimbursed by the fixed rate per inmate day as provided by
Section 21.
42.

COMPLIANCE WITH APPLICABLE LAWS

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The Contractor shall, at all times during the performance of its obligations
of this Agreement strictly adhere to all applicable federal laws and regulations,
including protection of the confidentiality of all applicanUrecipient records, papers,
documents, tapes or any other materials that have been or may hereafter be
established which relate to this Agreement. The Contractor acknowledges that
the following laws are included: Title VII of the Civil Rights Act of 1964, Section
504 of the Rehabilitation Act of 1972, the Education Amendments of 1972, the
Age Discrimination Act of 1975, the Americans With Disabilities Act, including
Title 11, Subtitle A, 24 U.S.C. Sec. 12101, et seq. and all rules and regulations
applicable to these laws prohibiting discrimination because of race, religion ,
color, national origin , creed, sex, age and handicap in federally assisted health
and human services programs. This assurance is given in consideration of and
for the purpose of obtaining any and all federal grants, or other federal financial
assistance.
The Contractor assures the VTDOC that at all times during the
performance of this Agreement that no qualified individual with a disability shall,
by reason of such disability, be excluded from participation in, or denied to
benefits of service , programs, or activities performed by the Contractor, or be
subjected to any discrimination by the Contractor upon which assurance the
VTDOC relies .
Contractor shall provide any information and assistance necessary for
VTDOC to fulfill any federal VOIITIS grant requirements for funds for the
financing of this agreement.
43.

CONFIDENTIALITY OF RECORDS

Contractor acknowledges that it has components that are covered entities
within the meaning of HIPAA, including the HIPAA Privacy and Security Rules,
and that the component which provides services under this Attachment G is
such a covered entity. Contractor represents to the VTDOC that the component
providing services under this Attachment G will honor and abide by its
obligations as a covered entity under the Privacy and Security Rules.
VTDOC acknowledges that it may act as a covered entity under HIPAA,
including the HIPAA Privacy and Security Rules . Accordingly, VTDOC requires
that Contractor honor and abide by the Business Associate terms attached
hereto and incorporated into this Agreement as Attachment E, and Contractor
represents to VTDOC that it shall do so.
Furthermore, unless otherwise provided, and without in any way limiting the
meaning or effect of any of the terms of Attachment E:
(a)
In the event the Contractor shall obtain access to any records or
files of the VTDOC in connection with this Agreement, or in connection

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with the performance of its obligations under this or any other Agreement,
the Contractor shall keep such records and information confidential and
shall comply with all laws and regulations concerning the confidentiality of
such records to the same extent as such laws and regulations apply to the
VTDOC.
(b)
Contractor shall specifically keep confidential all records and files of
VTDOC inmates; Contractor shall obtain prior written approval from
VTDOC before releasing or disclosing the contents of any such records or
files, except where it is impracticable for Contractor to obtain such prior
written approval (e.g., in the context of referrals for specialty outpatient
services or an emergency circumstance); provided, however, that
Contractor may only release or disclose the contents of any such records
or files in accordance with the requirements of this Agreement, including
Attachment E, and must notify VTDOC of any such release or disclosure
made without the prior written approval of the VTDOC, promptly after such
release or disclosure occurs . Contractor further acknowledges that this
requirement is in addition to and not in lieu of any other laws respecting
confidentiality of inmate files and records. The VTDOC acknowledges that
officials from other state Department of Corrections may be entitled to
access VTDOC inmate records from time to time; however, the Contractor
will not permit such access without the prior written approval of VTDOC.
The VTDOC acknowledges that it will not invoke this subsection (b) to
preclude Contractor from releasing or disclosing any such records or files
to the extent that Contractor is compelled by applicable law to make such
a release or disclosure.
(c)
Contractor agrees to notify and advise in writing, all employees and
agents (including subcontractors, consultants, and licensees) of the said
requirements of confidentiality and of possible penalties and fines imposed
for violation thereof, and secure from each an acknowledgment of such
advisement and agreement to be bound by the terms of this agreement as
an employee or agent (including a subcontractor, consultant, or licensee)
as the case may be.
(d)
Any breach of confidentiality by the Contractor or third party agents
(including subcontractors, consultants, or licensees) of the Contractor
shall constitute good cause for the VTDOC to cancel this Agreement,
without liability; and within thirty (30) days after such cancellation, and at
the direction of VTDOC, Contractor shall return or destroy all information
received from VTDOC, or created or received by Contractor on behalf of
VTDOC. Contractor shall not retain any copies of such information except
as needed to address claims and/or lawsuits, and shall certify for VTDOC,
in writing, when all such information has been returned or destroyed, and
that Contractor does not continue to maintain any such information, with
such certification to be provided during such thirty (30) day period.

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(e)
Any VTDOC waiver of an alleged breach of confidentiality by the
Contractor or third party agents of the Contractor is not to imply a waiver
of any subsequent breach.
The parties understand and agree that subsections (a) through (e) apply
to information that is considered protected health information ("PHI") within the
meaning of HIPM, including the HIPM Privacy and Security Rules, as we" as
information that is not considered PHI. As required by Section 15.1 of
Attachment E, in the event of any conflict or inconsistency between the terms of
Attachment E and the terms of subsections (a) through (e) of this Section 35,
the terms of Attachment E shall govern; provided, however, that there is no such
conflict or inconsistency to the extent that subsections (a) through (e) create any
obligation or responsibility for Contractor that is not identified in Attachment E. In
addition, there is no such conflict or inconsistency as it concerns the use or
disclosure or other handling by Contractor of information that is not PHI, and
subsections (a) through (e) unquestionably apply to all such uses, disclosures
and other handling, without the necessity for comparing such subsections to the
terms of Attachment E.
IN WITNESS WHEREOF, the parties have caused their representatives to
execute this Agreement as of the date first written above.

VERMONT DEPARTMENT OF CORRECTIONS

BY:

-----------------------------ROBERT HOFMANN

DATE:

COMMISSIONER OF CORRECTIONS

CORRECTIONS CORPORATION OF AMERICA

BY:~

~~e*nMo.yl:e(rv

DATE:

1.;)4'07

VICE PRESIDENT, STATE CUSTOMER RELATIONS
~ ("ch,
(Clefs a.:nd..--Pl"b-yo~q 15

Cont

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cc~

POLICY
TITLE
CHAPTER

Privacy of Protected Health Information

13

I

POLICY
NUMBER

13-74

I

EFFECTIVE DATE

SUPERSEDES DATE

CORRECTIONS CORPORATION OF AMERICA

MARCH 13, 2006

JANUARY 1, 2005

SIGNA TURE ON FILE AT FACILITY SUPPORT CENTER
Bill Andrade, MD
Chief Medical Officer

FACILITY
NAME

SIGNA TURE ON FILE A T FACILITY SUPPORT CENTER
Richard P. Seiter
Executive Vice President/Chief Corrections Officer
SIGNATURE ON FILE AT FACILITY SUPPORT CENTER
G.A . Puryear, IV
Executive Vice President/Gen eral Counsel

Page

1 of 10

LEE ADJUSTMENT CENTER

FACILITY EFFECTIVE DATE

FACILITY SUPERSEDES DATE

AUGUST 1, 2006

OCTOBER 15, 2005

13-74.1 POLICY:
CCA will provide procedures for the privacy of individually identifiable health information in compliance
with the federal Health Insurance Portability and Accountability Act of 1996 (HIPAA).
Protected health information (PHI), whether in the form of a prescription, medical chart (hard copy or
electronic), vital signs or conversations between an inmate/resident and a health care provider, is strictly
confidential and may be disclosed only within the procedures set out in this policy. Health Services
Staff will share with other correctional staff members only such information that has a potential impact
on classification, institutional security, ability of the inmate/resident to participate in programs or other
facility activity or for the health and safety of the inmate/resident or others. Only the "minimum
necessary" protected health information will be disclosed to correctional staff to satisfy the particular
instance or circumstance.
13-74.2 AUTHORITY:
CCA Company Policy
13-74.3 DEFINITIONS:
Authorization - A detailed document that gives covered entities permission to use protected health
information for specified purposes, which are generally other than treatment, payment or health care
operations or to disclose protected health information to a third party specified by the individual.
Business Associate - A person who performs certain functions on behalf of CCA but is not a member of
CCA workforce who has access to protected health information. A "business associate" can be one
who performs legal, actuarial, accounting, consulting, data aggregation, management, administrative,
accreditation, or financial services to or for CCA.
HIPAA Privacy Rule - The federal Health Insurance Portability and Accountability Act of 1996 as
amended administered by the U.S. Department of Health and Human Services . Under HIPAA, certain
entities are covered by the Privacy Rule. CCA is covered by HIPAA because it is a health care provider
to inmates/residents in its custody.
Privacy ContacUOfficial - Staff member(s) responsible for providing HIPAA training, administering
sanctions, and receiving complaints regarding violations under HIPAA as it pertains to inmate/resident
protected health information.
Protected Health Information (PHI) - Individually identifiable health information that is created or
received by a health care provider, health plan, employer or health care clearinghouse; relates to past,
present, or future physical or mental health or condition of an individual ; relates to past, present, or
future payment for the provision of health care to an individual; and health information that identified the

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individual or to which there is a reasonable basis to believe the information can be used to identify the
individual.
Psychotherapy Notes - Notes recorded (in any medium) by a health care provider, who is a mental
health professional, documenting or analyzing the contents of conversation during a private counseling
session or a group, joint, or family counseling session and that are separated from the individual's
medical record. Excludes medication prescription and monitoring, counseling session start and stop
times, the modalities and frequencies of treatment furnished, results of clinical tests and any summary
of the following items: diagnosis , functional status, the treatment plan , symptoms, prognosis, and
progress to date.
13-74.4 PROCEDURES:

PROCEDURES INDEX
SECTION
A
B

C
D
E
F
G
H
I
J
K

A.

B.

SUBJECT
Privacy Contact/Official
Identification of Job Classes with Access
to PHI
Clinical/Health Care Encounters
Minimum Necessar1' Standard
Permitted Use and Disclosure of PHI
Authorization Required for Disclosure of
PHI
General Information
Business Associates
Employee Protected Health Information
Records
Pre-Emption of State Law

PRIVACY CONTACT/OFFICIAL
1.

Each facility Health Services Administrator must designate a "privacy contact/official"
who is responsible for implementation of and compliance with this policy, conducting
training, and responding to complaints regarding the disclosure and protection of
inmate/resident's protected health information .

2.

An inmate/resident can complain about the application of this policy and procedure
through the inmate/resident grievance or administrative remedy procedure. The facility
grievance coordinator will obtain assistance in the grievance response from the
designated facility "privacy contact/ official".

3.

The "privacy contact/official" must provide training to all members of its workforce on
policies and procedures with respect to HIPAA as necessary and appropriate for the
members of the workforce to carry out their specific job functions. In addition,
employees will sign the 13-74A CCA Privacy of Protected Health Information
Acknowledgement at the conclusion of the training.

4.

The Privacy Rule also requires CCA to designate a "corporate privacy official" who is
responsible for the development and implementation of the policies and procedures
relating to the Privacy Rule. CCA has designated the Assistant General Counsel,
Operations as the corporate privacy official. Any communication from the Department
of Health and Human Services Office for Civil Rights relating to HIPAA violations must
be immediately directed to the Assistant General Counsel located at CCA's Facility
Support Center.

IDENTIFICATION OF JOB CLASSES WITH ACCESS TO PHI

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1.

2.

C.

Under HIPAA, CCA must identify the job classes of persons who have access to PHI in
order to carry out their job duties. The following job classes require access to the entire
medical record on an unlimited basis:
•

Health Service Administrators

•

Physicians, Dentists, Psychiatrists

•

Nurses

•

Medical Records Clerks

•

Other designated health care personnel

The following staff members may have limited access to the "minimum necessary"
amount of PHI in conjunction with the administration and maintenance of the safety,
security and good order of the correctional institution:
•

Unit Managers

•

Classification Officers

•

Transportation Officers

•

Quality Assurance Managers/Grievance Coordinators

•

Warden , Assistant Warden, or Designee

•

Manager, Operations Finance/Business Manager or clerks for payment
purposes

CLINICAL/HEALTH CARE ENCOUNTERS
1.

2.

D.

13·74

Clinical Encounters
a.

All clinical encounters shall be conducted in private .

b.

In the event the inmate/resident poses a serious probable risk to the safety of
him/herself, the health care provider, or others, security staff may be present.
When the presence of correctional staff is required for disruptive patients, every
effort shall be made to protect the privacy of the protected health information .

Health Care Encounters
a.

The responsible health authority will ensure that health care encounters,
including medical and mental health interviews, examinations, and procedures
are conducted in a setting that respects the inmate/resident's privacy.

b.

Intake screenings, sick call assessments, physical exams, chronic-care exams,
and any other health care encounter will be performed in an area that provides
appropriate visual and auditory privacy.

c.

Female health services staff will be present during female patient encounters
performed by a male health care provider.

d.

Additionally, correctional staff observing health encounters are to be instructed
to keep confidential all information obtained.

MINIMUM NECESSARY STANDARD
1.

The "minimum necessary" standard requires that CCA limit how much PHI is used ,
disclosed, and requested for certain purposes . Whenever practical, only the least
amount of information necessary for that purpose is to be disclosed . For example

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disclosure to non-medical correctional staff under this policy must be the "minimum
necessary".
2.

E.

The "minimum necessary" standard does not apply to the following :
•

Disclosures to the individual who is the subject of the information;

•

Uses or disclosures made pursuant to an individual's authorization;

•

Uses or disclosures required for compliance with HIPAA;

•

Disclosures to the Department of Health and Human Services (DHS) when
disclosure of information is required under the Privacy Rule for enforcement
purposes.

PERMITTED USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION
1.

CCA Health Services Departments are permitted to use or disclose protected health
information without specific authorization as follows:
a.

b.

Inmates/Residents
i.

Inmates/residents can have access to their medical record after
submitting a written request for such access.

ii.

Inmates/residents have a right to inspect and obtain a copy of their
protected health information except for psychotherapy notes. The
privacy contact may deny in whole or part the request to obtain a copy
if obtaining a copy of the PHI would jeopardize the health, safety,
security, custody or rehabilitation of the individual or other
inmates/residents, or the safety of any officer of correctional institution.
•

A licensed health care professional must determine that access
requested is reasonably likely to endanger the life or physical
safety of the inmate/residents or another person or the
protected health information makes reference to another
person and the licensed health care professional has
determined that access is reasonably likely to cause
substantial harm to such person.

•

If parts of the record are likely to cause harm to the individual
or others, those parts can be denied and the rest of the file sent
to the inmate/resident.

Inmate/Resident Personal Representatives
i.

A personal representative includes a court appointed legal guardian; a
person with a health care power of attorney; an executor or next of kin
of a deceased patient.

ii.

The facility's privacy officer is required to verify a personal
representative's authority by requiring proof through review of the
document granting the authority of the personal representative.

iii.

For the purposes of disclosure of PHI, a personal representative is to
be treated as the individual only with respect to the PHI that is relevant
to the representation. If the authority is limited to certain circumstances
such as making relevant decisions regarding life support, then the
personal representative's access to the protected health information is
limited to that information which may be relevant to decisions about

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artificial life support. It does not include phone calls from concerned
family members who do not have power of attorney.
NOTE: See CCA Policy 13-3, Advance Directives: Living WililDurable
Power of Attorney for Health Care for more information on health care
powers of attorney and as to when the authority of the health care
power of attorney begins.

c.

d.

e.

Outside Medical Providers/Hospitals/Ambulatory Providers
i.

PHI may be disclosed to an outside medical provider or facility
requiring exchange of information for treatment purposes. Example: to
doctors, nurses, hospitals , laboratory technicians.

ii.

A hospital can release PHI to an ambulance company so that the
ambulance company can be reimbursed for services provided.

iii.

Hospitals and medical staff members can exchange PHI for health care
operations purposes, including credentialing.

Peer Review/Quality Assurance/Accreditation
i.

PHI may be disclosed to another entity for health care operations, such
as peer review and quality assurance.

ii.

PHI may be disclosed to accrediting agencies in conjunction with an
audit after signing a Business Associate agreement. Example: ACA,
NCCHC, JCAHO. This also allows facility and DOC auditors to access
PHI in order to determine compliance with various agency standards.

Court Order/Subpoena
i.

PHI may be disclosed with a court order from a court of competent
jurisdiction requiring the release of the information.

ii.

PHI may be disclosed with a subpoena or litigation discovery request.
NOTE: Before responding, please obtain guidance from CCA's Facility
Support Center legal department.

f.

Public Health Authorities
PHI may be disclosed to public health authorities who are legally authorized to
received such reports for the purpose of preventing or controlling disease,
injury, or disability or public health surveillance. Generally, CCA is required
reasonably to limit the PHI disclosure for public health purposes to the
"minimum necessary" amount to accomplish the public health purpose.
Example: Disclosures of specific contagious diseases information to State
Departments of health or Centers for Disease Control instead of forwarding the
entire medical record; or state departments of health for the purposes of audit
or review.

g.

Individuals at Risk
i.

PHI may be disclosed to another individual who is at risk of contracting
or spreading a disease or condition if other law authorizes CCA to
notify such individuals as necessary to carry out public health
interventions or investigations .
Example: Hepatitis, TB, H IV exposure.
Infection Control.

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See CCA Policy 13-47,

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ii.

h.

13·74

To avert a serious threat to health or safety if CCA, in good faith,
believes the use or disclosure is necessary to prevent or lessen a
serious and imminent threat to the health or safety of the person or the
public and is to a person reasonably able to prevent or lessen the
threat, including the target. Example: A seriously mentally ill patient
with overt violent ideations toward a specific individual.

Correctional Officials/Law Enforcement
PHI may be disclosed to correctional officials or law enforcement officers
having lawful custody if the individual can represent that such PHI is necessary
for the following:
i.

To identify or apprehend an individual.

ii.

The provision of health care to such individuals . Example: Disclosure
of inmate/resident's medical condition to correctional unit staff in order
to secure a lower bunk.

iii.

The health and safety of such individual or other inmates/residents .
Example: Medical or mental health staff can disclose the mental health
status of an inmate/resident that is on suicide watch.

iv.

The health and safety of the officers or employees of or others at the
correctional institution .
Example: Disclosure of inmate/resident's
contagious airborne disease to correctional staff assigned to that post.

v.

The health and safety of such individuals and officers or other persons
responsible for the transporting of inmates/residents or their transfer
from one institution, facility or setting to another. Example: Disclosure
of information to a transportation officer that an inmate/resident is
diabetic and frequently has seizures as well as information about the
appropriate action to take if the inmate/resident has a seizure during
transport.

iv.

Law enforcement on the premises of the correctional institutions.
Example: Staff can disclose the nature of specific injuries to law
enforcement in the investigation of a criminal assault or homicide; as
required by law, including laws that require the reporting of certain
types of wounds or other physical injuries as follows:
•

in compliance with a court order or court-ordered warrant, or a
subpoena or summons issued by a judicial officer or a grand
jury;

•

without a court order, etc. for the purpose of identifying or
locating a suspect, fugitive, material witness or missing person
provided that only very limited information is released ;

•

without a court order, etc. in response to a request for
information about an individual who is a victim of a crime if the
individual agrees to the disclosure or if incapacitated the
disclosure is in the best interest of the individual and is needed
to determine if a violation of law occurred; or

•

without a court order, if CCA believes in good faith that the
information constitutes evidence of criminal conduct that
occurred on the premises .

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13-74

v.

The administration and maintenance of the safety, security and good
order of the correctional institution. Example : Staff can disclose the
nature of an inmate's/resident's injuries that has been assaulted by
fellow inmates/residents since disclosure could assist in the institution's
investigation and may protect the safety of the inmate/resident in the
future .

vi.

After the inmate/resident is released from incarceration , stricter
confidentiality measures apply, procedures outlined in this section
(E.1.h.) do not apply.

Coroners/Medical Examiners/Funeral Homes
PHI may be disclosed to coroners, medical examiners and funeral home
directors for the purpose of identifying a deceased person, determining the
cause of death or other duties as authorized by law.

F.

AUTHORIZATION REQUIRED FOR DISCLOSURE OF PHI
An authorization from the patient is required for use and disclosure of PHI for purposes other
than those outlined above in 13-74.4.E. The 13-74B Authorization for Release of Protected
Health Information will be used when required. A copy of each signed 13-74B will be
placed/scanned in the inmate/resident medical record .
1.

G.

Except when psychotherapy notes are used by the mental health care provider to carry
out treatment, or by CCA for certain other limited health care operations, uses and
disclosure of psychotherapy notes for treatment, payment. and health care operations
require the individual's authorization. CCA can also use psychotherapy notes, without
an authorization to defend itself in a legal action.

GENERAL INFORMATION
1.

In the health care environment, the potential exists for an individual's protected health
information to be disclosed incidentally. Example: A patient may glimpse another
patient's name on a sign-in sheet. The HIPAA privacy rule is not intended to impede
these customary and essential communications. However, reasonable safeguards
must be in place to protect against use and disclosures not permitted by the privacy
rule. These reasonable safeguards include appropriate administrative, technical and
physical safeguards such as:
a.

Maintaining the active medical record separately from the confinement case
record.

b.

Speaking quietly when discussing a patient's condition
inmates/residents or non-medical personnel are nearby;

c.

Avoiding the use of patient names in public cafeterias, hallways, elevators and
break rooms;

d.

Isolating or locking file cabinets or medical records rooms;

e.

Allowing only one inmate/resident at a time access to pill call lines. Other
inmates/residents waiting for their pills should be reasonably separated so that
PHI will not be overheard;

f.

Speaking softly when making nursing rounds in the Segregation Area;

g.

Not discussing a patient's condition when facility tours are present in the Health
Services Area; and

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h.

13-74

Not allowing the Health Services Department to discuss a patient's medical
condition with a patient's family member over the telephone.

2.

If an inmate/resident reviews or obtains a copy of his/her individual medical records ,
documentation of such will be made in the inmate/resident's medical record .

3.

A record of disclosure of PHI to any party is to be documented in the inmate/resident's
medical record.

4.

A record of communications of any PHI made for classification or institutional security
purposes will be documented and filed in the individual medical record.

5.

Each inmate/resident has a right to request and receive an accounting of disclosures of
protected health information made by CCA in the six (6) years prior to the date of
request other than those permitted under 13-74.4.E. "Permitted Use and Disclosure of
PHI". excluding public health agency disclosures. CCA must provide the individual with
a written accounting that contains the following requirements:
a.

Date of disclosure;

b.

Name of person/entity who received the information ;

c.

Brief description of the PHI disclosed ; and

d.

Brief statement of the purpose of the disclosure or a copy of the written request
for the disclosure.

If requested for an accounting of disclosures, CCA is required to account to the patient
disclosures of protected health information to third parties such as the public health
authorities . CCA must act on the request for an accounting of disclosures no later than
sixty (60) days after receipt of the request.

H.

6.

Any copies of the inmate/resident's medical record which may be disseminated will
have attached a clear statement regarding re-disclosure of information. The statement
will read, "Further re-disclosure of this information is prohibited, except as
provided in state and federal laws."

7.

Facsimile transmission (faxing) of confidential patient information shall be avoided due
to the possibility that privacy may not be preserved on the receiving end of the
transmission. In situations where transmission via fax is necessary, the Health
Services staff which transmits via fax shall be responsible for ascertaining to the best of
their ability that the receiving machine is in a secure location and that the confidentiality
of the material can be preserved.

BUSINESS ASSOCIATES
The HIPAA Privacy Rule allows CCA to disclose PHI to "business associates" if CCA obtains
satisfactory assurances that the business associate will use the information only for the
purposes for which it was engaged by CCA, and will comply with the Privacy Rule . CCA will
obtain these "satisfactory assurances" from each "business associate" in writing through a
contract or other agreement. These agreements will be initiated through CCA's Facility
Support Center Legal Department and are not to be handled through each faCility's
health services department.

I.

EMPLOYEE PROTECTED HEALTH INFORMATION
1.

CCA often obtains health information in the course of carrying out employment related
activities , for example, drug testing , making FMLA determinations, administering
workers compensation plans and making disability assessments. Under HIPAA, CCA
may continue to collect and use protected health information in connection with such

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13·74

employment related functions without obtaining any specific authorization from the
employee.
2.

J.

CCA's own employment records such as those described above are not considered PHI
under HIPAA. However, CCA is in a unique position in that from time to time it acts as
a health care provider to its employees. In these instances , CCA must distinguish
between records that it keeps in its role as an employer from records that it keeps in its
role as a health care provider. For instance, when CCA administers a TB test for
screening purposes, the results of the test are considered to be PHI. However, if the
employee authorizes disclosure of the test results to CCA as its employer for placement
in his/her employment record, then the test results are not considered PHI. Under
HIPAA, CCA can condition employment on requiring that the employee sign the
authorization. Therefore, each employee must sign the 13-35A Employee Authorization
for Release of Protected Health Information.

RECORDS
CCA must keep training records, grievances, and compliance reports to enable the U.S.
Department of Health and Human Services to determine that CCA is complying with the HIPAA
Privacy Act.

K.

PRE-EMPTION OF STATE LAW
The HIPAA Privacy Rule pre-empts state law unless the state law is more stringent than HIPAA.
If questions arise, please obtain guidance from CCA's Facility Support Center legal department.

L.

AT THIS FACILITY, ADDITIONAL STATE ANDIOR CONTRACTUAL PROCEDURES
RELATING TO PRIVACY OF PROTECTED HEALTH INFORMATION ARE:

13-74.5 REVIEW:
The Chief Medical Officer or qualified designee will review this policy on an annual basis.
13-74.6 APPLICABILITY:
All CCA Facilities (Provided contractual requirements do not mandate otherwise)
13-74.7 APPENDICES:
None
13·74.8 ATTACHMENTS:
13-74A

CCA Privacy of Protected Health Information Acknowledgement

13-74B

Authorization for Release of Protected Health Information (English and Spanish)

13-35A

Employee Authorization for Release of Information

13-74.9 REFERENCES:
CCA Policy 13-3
CCA Policy 13-35

Proprietary Information - Not For Distribution - Copyrighted

Property of Corrections Corporation of America

Page 10 of 10

13-74

MARCH 13, 2006

CCA Policy 13-47
ACA

4-4396M/4-ALDF-4D-13
4-4403M/4-ALDF-4D-19M
4-4414/4-ALDF-4D-27

NCCHC P-A-08/J-A-08
P-A-09/J-A-09
P-E-10/J-E-10
P-H-02E/J-H-02E
JCAHO R1.2 .10
R1.2.130
R1.1 .30
IM.2.10
IM.2.20
www.hhs .gov/ocr/hipaa , www .hhs.gov/ocr/hipaa/privacy.html

Proprietary Information - Not For Distribution - Copyrighted

Property of Corrections Corporation of America

13-74A

CORRECTIONS CORPORATION OF AMERICA
PRIVACY OF PROTECTED HEALTH INFORMATION ACKNOWLEDGEMENT

I,
PROTECTED

, HAVE READ CCA POLICY 13-74, PRIVACY OF
HEALTH

INFORMATION.

I

UNDERSTAND

THE

CONTENTS

AND

PROCEDURES OUTLINED IN THE POLICY AND THAT THESE STANDARDS MUST BE MET.

Printed Name

Signature

Date

Original: Personnel File
Copy:
Training File

MAR 2006