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Policy and Procedure Manual for Health Services In Jails

POLICY AND PROCEDURE MANUAL
FOR HEALTH SERVICES IN JAILS
At the

Marion County Jail
- -----------South Caro-li..
na.,.__ _ _ __ _ _
Effective Date: May 1. 2013

1'1iis µub lication may nm be ropr<)duc"d in whole 0 1 in pan by any means, elec1ronic, moch,tnical, visual, or manual without Ihe
oxpr1!$s written permis~ion ofSoulhern lloullh Pnrtncrs, lnc.'s corporate office. TI1i5 is the confi<le11Liul work prorlucr of Southern
Hoallh ]'unncrs nnd is for th~ use of its i,mployccs.

COn11dential Work Product of Southern Health Partners, Inc.
SHP Polley and Procedure Manual for HealtJl Services in Jails

SHP Effective Date of Manual: May 1, 2013

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Policy and Procedure Manual for Health Services In Jails
ACKNOWLEDGEMENT

I acknowledge I have rece1ved, read, and revfewed Southern Health Partners, Inc. Polloy and
Procedure Manual for Health Services in Jails - Part 2, Governance and Adm1nistration, and I
understand that it Is my responsibTiity to mainfain and keep It/them secure.
The contents are not to be reproduced and/or given to anyone not employed by Southern Health
Partners unless prior approval is obtained from th e Corpora te office.
I also understand I may be required to return all
required.

or a portion of the manual if a major revis1on is

I understand It is my responslbility to ask questions, make comments, and to fully understand the
attached policy and procedure manual. Questions may be relayed to my site Medical Team
Administrator, Regional Administrator, or corporate Vice President.
I will review the Manual in accordance with the jail's policies and procedures, Consent Decree(s),
and other mandates, thereby making revisions, updates, e·tc. as necessary.
If my employment with Southern Health Partners, Inc. ls terminated, I must return any orfglnals or
copies I may havo in my possession.
By my signature bolow, l understand~
SHP

Region

acknowledge the, abov\:j:

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Site Provider (other th,m Medfoal
Director
SHP Employee:

Date :

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SHP Employee:
SHP Employee:

A copy ofLhis for111 111u1L be sc111 10 thet'orpornte office for inclusion in u,~ umployee's personnel file. Keep lhe originall y signcJ
lorn, wi lh lhc Policy und Prncctlure MouuuL If more sig,,aiurc spaces m-c uct-tled, j ust maku :i coitr of 1his blank fnrm ror use.
Part 2-Govema11ce and AdministraUon

Effective: August 1, 2014
Page: 15
Confidential Work Product of Soulhern Health Partners, Inc. - SHP PoOcy and Procedure Manual for Health Services in Jails

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Policy and Procedure Manual for Health Services In Jails
Part 1 - Table of Contents
STANDARD NAME

SUMMARY OF STANDARD

Part 1

TABLE OF CONTENTS
Pages 5 • 8

Part 2

GOV6RNANCE AND ADMINISTRATION
Pages 10-23
Sets clear policy/orocedure for patients to access health services.
Intent Is to note a coordinate health care and mental health system wi thtn the jail.
Clinical decisions are made for clinical purposes; health staff are otherwise subject to the
same security regulations.
Regularly scheduled meetings to be held al site, Facil itates joint monitoring, problem
solving, planning, etc. Health Staff & Corrections to meet. Minutes to be kept.
P&P Manual is on-site and being followed; All medical staff to sign off as to review of
manual, and manual Is readllv accessible.
Ensures a quality health care delivery system Is in place through quality improvement
monitoring. ReRuiar chart reviews, system reviews, etc.
Plan in place to protect health, safety, and welfare of patients, staff, and visitors during
emergencies. Disaster drill to be performed lx/vear, on each shift.
trlpn@r.,il ion of ,pPr.ial NPerts Patients; notific;,tlo11 of kry ~taff as to ptacP.ment of special
needs patients within facility.
Reasonable efforts to guard privacy of a health encounter and to protect a patient'.s dignify.
Keep In mind HIPAA regulations.
Reporting aspects In 1he event of a patient death,

Access to Care
Resoonslble Health Author1ry
Medlcal Autonomy
Administrative Meetings and
Renorts
Policies and Procedures
Quality Improvement Program
Emergency Response Plan
CAmmunk:~tion on Special

N~eds Patients
Privacy of Care
Procedure In the Event of on
Inmate Death
Grievance Mechanism for Health
Comolalnts
PART3
Infection Control Program

Sets clarlffcation t hat grievance responses are expected to be professional and t imely.
MANAGING A SAFE AND HEALTli ENVIRONMENT
·pages 24 - 31
Addresses issues relating to Infection Control. See also the Infection Control Manual.

Patient Safety

Promotes pa\ient safety through review of processes ~11d reporting adverse or near-miss
clinical events.

Staff Safety

Promotes a safe working environment for all SHP stall on-site.

Procedure In t he Event of a
Sexual Assaul t

Indicates medical response with health interventions upon report of a sexua I assault.

PART4
Credent ialing
Cllnlcal Performance
Enhancement
Professional Development

PERSONNEL AND TRAINING
Pages32 - 40
11eal th staff are legally qualified to provide the services for whlch they have been hired;
Works w it hin scope of nractlce; Credentlalinu done bv cornorate office.
Promotes peer review of the clinician's practice; Review for MD, Psych; DDS; Psycholoelsts.

Monthly in-services to be hel d; l hour per month. Documentation of such ln•serv, ces to be
kept on-site. Nurses responsible for complving with CEU requirements for licensure.

Confidential Work Prod uct of Southern Heallh Partners, Inc.
SHP Policy and Procedure Manual for Health Services in Jails

Page: 5
Effective Date of Manual: Jun e 22, 2015

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Policy and Procedure Manual for Health Services In Jails

Health Tra1ning for Correctronal
orncers

Promotes training of correcllonal orncers as to recognizing when to call medical; provision
of emereency care until medical arrives; Intake screening;

Medication Administration
Training

Proper administration of medications is being performed.
performed.

Inmate Workers

Patients are not t o work as a medical staff person. Can be cleared ror Trustee Status by
medical st,1ff.
Outlines an effective staffing plan i s set at the facility.

Staffing Plan
Health Care Liaison

Narcollc counts must be

Sets procedure as to when health care staff are not on site, ,vho Is in charge; On-call
procedures, etc,
All health services staff (FT, PT, PRN) are to receive a basic orienta\ion on the 1" day of
employment; Include security regulations; emergency responses; P&P manual; job
descrloUon/job duties: etc.
HEALTffCARE SUPPORT SERVICES

Orientation for Health Services

Staff
PAI\TS

Pages41- 48
Pharmaceutical Operations

Pharmaceutical services are being properly operated and monitored;

Medication Services

Provisi ons for medications services at the fuclllty, timely, safe and sufficient manner.

Clinical Space, Equipment and
Supplies

Provides for su fficient space and equipment for medical staff to perform tasks.

Olognostlc Services

Diagnustic ,~, viws a, ~ available when needed.

Hospltal and Specialty care
Services
PART6

Arrangements and/or agreements arc In place for hospital and special ty care services offsite, If needed.
PATIENT CARE AND TREATMENT
Pages 49-63
Patients must have knowledge about the availability of and access to h.ealth care services.
Topics addressed orally and in wrltlhg lnclude access to health; grievance process; and copay svstem ifln olace.
Intends to Identify and meet any Immedi ate health needs of \hose admitted: to obtain
urgent/emergent treatment; and to identify and Isolate patients who appear contagious.
Identify any chronic condi tions.

Information on Health Services

Recetv1ng Screen1ng

Transfer Screening

Procedure for intersystem transfers; requirement calrs for a revlew of the health record
within 12 hours of arrfval.
H&P done within 14 days of admission; Physician/Physician Provider must sign off on H&P;
TB testino Is required as part of H&P, if not done sooner.
Identify mental health needs; screening can be done by trained nurses, with further
evaluatlo11 (iJ needed) lo be done by qualified mental health profe.ssionars.

Health Assessment
Mental Health Screening and
Evaluation
Oral care

Non-emergency Health care
Requests and Services

.

Screening to be done within 14 days of admission; screening to be done bv dentist or
trained health staff; Instruction In oral hygiene & preventive education to be done Within 1
month of admission. Exam by a dentist for patients who haven't been seen and their st.ay 1$
over 12 months.
Routine heal th care needs are met; V1tal signs are t o be notecl on all patient encounters, to
be w ritten on the sick call forms. Sick call timeliness ii wllhln 24 hours (72 hrs/weekends) of

Confidential Woill Product of South em Health Partners, Inc.
SHP Policy and Procedure Manual for Health Services in Jails

Page: 6
Effective Dale of Manual: June 22, 201 S

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Polley and Procedure Manual for Health Services In Jails
t he request. Expectation of 2x/wk for /\DP of <100; 3x/wk for ADP of 100· 200; and Sx/wk
for ADP of >200.

Emergency Services
Segregated Patients
Medical Observation

Emergency health planning occurs to prevent bad outcomes In relation to emergenci,:s,
Requires community hosoital avallablllry and emergencv on-call svstem for medical.
Patients placed In segregation maintain medical & mental health whlle [solated; Correctional
staff must notlfv health staff when patients are placed in seore•atlon.
Patients placed on Medical Observation must be monitored by medical staff during
nlacementof such.

Patient Escort

Escorting staff to be prov[ded so patients can meet'health care appointments.

Nursing Assessment Guidelines

Focuses on the use of nursing assessment guidelines and treatment pro tocols.
Clinical Pathwavs.

Continuity of Care dur[ng
Incarceration

Ensures patients receive care as ordered by cllnlclans, and wlth1n a t imely fashion,

Discharge Planning

As part of the discharge/release process, patient should be given referral information to
communilv providers, i f needed.

PAR'rJ

use of

HEALTH PROMOTION 8. DISEASE PREVENTION
,. ages nu~nn

Healthy Lifestyle Promotion

Educatlon of pallenl's in self-care and promoting lnstruction for health conditions; General
educational materials t o be provided.

Medical Diets

Special medical diets will be made available when ordered by medical staff.
srECIAl NEEDS AND srnv1ccs

P/\RT8

!'ages 61-78
Management of Chronic O[scasc

Management or chronic medical condllhl1\ P•lit:11ls. Fvcu,es v11 iuenllflca l lOlli follow-up
antJ regularly scheduled mon1toring.

Special Needs Treatment Plans

Ensures chronic or special needs patients are seen and evaluated by 11,edlcal staff.

Infirmary Care

Infirmaries may be established to provide medical needs on-site.

Basic Mental Heal th Services

Provides basic mental health services at the facility.

Suicide Prevention Program

Identifying and responding to sulc.idal ir1djvlduals

Intoxication and Withdrawal

Patients wlth alcohol and other drug problems are properly identllled and managed tlirough
medical services at the site.

Patients with Alcohol and other
drul? oroblems
Care of the Pregnant Patient

Screening for abuse ofor dependency upon alcohol or drugs at the Intake process.
Regular prenatal care to be provided, If pregnant patients are wi thin t he faclllly.

Pregnancy Counseling

Counseling provided to pregnant lemales, through community referrals.

Orthoses, Prostheses, and Other
Aids to Impairment
Care For the Terminally Ill

Resources provided to patients In need of prostheses, etc.; in case of security Issues;
al ternative accommodations rnust be made to meet the health needs of the patient.
Addresses the needs of a termir,ally ill patient; includes pain management, guidance, early
release, or hospice care.

Confidenlial Work Product of Southern Health Partners, Inc.
SHP Polley and Procedure Manual for Health Seivices in Jails

Page: 7

Effective Date of Manual: June 22, 2015

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Policy and Procedure Manual for Health Services In Jails
PART9
Health Record Format and
Contents
Confldentlallty of Health Records
and Information
Access to custody Information
Avallablllty and Use of Health
Records
PARTl0
Use of Restraint and Seclusion In
Correctional Facllltles
Emergency Psychotropic

HEALTH RECORDS
Pages79-83
Health record Is properly created and maimalned. Confidenllality Is a must.
Protects the patient's right to confidentiality of both the health and person~l lnforn,aUoh
located within the record. Health staff and correctional officers must have instruction
concerning oatlent confidentiality.
Medical to have access to custody info if deemed fmportant to patient's health needs.
Record ls used In each scheduled clinical encounter .

MEDICAL/ LEGAL ISSUE~
Pages 84-8.9
Must receive Physician/Physician Provider orcfer prior to the use of restraints for dlnfcal
reasons; monitoring and evaluation by health staff of those patients; Documentatfon is a
must!
Intent Is to prevent harm in emergency situations when patient Is a danger to self or others;
IVIU~\ , ,a..-..;! d r ,,y..n CJ91,, I , ,ysic,an 1
•rov1oer s oroer prior; uocunientiH!OO IS a must!

End-of-Lile Decision Mal<lng

Medical staff does not participate rn \he gathering of evidence; DNA testing may be
performed ff required by law, and undet consent of the patient,
Focuses on cfedsions to be made by patients; Living wllls, DNRs; etc.

Informed ConsP.nt "'"" Rleht to
Refuse Treatment

Patients retain their right to mJkc liiformcd deci5ion5 regarding health cnre issues. mght to
refuse treatment lnformallon.

Medical and Other Research

Medical staff is not to participate In medical or other research projects patients may be
oar tlcioating in at the lall.
MISCELLANEOUS
Pages 90 - 102
Medical st3ff will not participate In executions.
SHP will not utlllze the services of volunteers, students unless approved by H.R. Dept. and
Jail Administration.
SHP manuals to be nlaced on-site or on-line for all staff to review and refer to when needed
SHP oolicv/orocedure for Identi fication and Treatment of MRSA Infections
Treatment ,ind care of taser lniurles at the jail.
Coroorate oolicv and procedu re In the event of a Pandemic Flu Event.
Corporate policy and procedure If a patient lnstllutes a hunger strike, or hasn't been eating
(refuses or otherwise).

Forensic Information

PARTll
Executions
Volunteers, Students, Interns
Manuals
MRSA
Taser In furies
Pandemic Flu Planning
Hunger Strikes

Confidential Work Product of Southern Health Partners, Inc.
SHP Policy and Procedure Manual for Health Services in Jails

Page:

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Effective Date of Manual: June 22, 2015

Policy and Procedure Manual for Health Services In Jails
INTRODUCTION
Soulhem He1:1lth Partners, Inc. (SHP) has developed these pollcles and procedures to be used by our employees in
conjunction with the provision of inmate patient health care services al the jaiL Ad ministrative and operational policies
are utllfzed to ensure uniformity and consistency in the day-to-day operation of medical services, Poficies are intended to
provide direction to personoel In !heir application of professional/technical skills in the correctional setting.
By definition, the Medfcal Director is a reference term which applies to our Director of Medical SeNices at the facility,
This may be a Pl1ysician 1 Phys1cian Assistant. Nurse PraatiUoner, or any other Phys1c1an Provider and/or designee
contracted by the corporate office to provide services on behalf of Southern Health Partners, Inc,
By definit1on, the Medical Team Administrator Is a reference term wl'llch applies to our Nurse Administrator of the medical
program under contract by the County with Southern Health Partners, Inc.
By definition, the Region Representative is a reference term which applies to the oversight representative for your
location which is in place by the corporate office of Southern Health Par tners, Inc.

All SHP staff must suppo11 existing policies and procedures - although we are flexible! Never should good prudent
medical judgment be Ignored due lo the written SHP policy/procedure. Remember, the NCCHC guidelines for which our
policies and procedures are based are jt1sl that.....guidelines. These existing procedures may need lo be added lo,
deleted from or modified based on each particular institution's contract and/or needs.
In oases where a professional (Physician/Physician Provider, nurse, etc.) identifies a policy works to the disadvantage of
lhe Institution (or an individual), the policy may be mod11ied upon request. I he protessional may also request a change
in poficy based on new infonnation or partlcular circumstances.

The Medical Team Administrator and medical staff may make exceptions for existing policies and procedures if Issues of
p(Udenl medical Judgment are involved and at hand. However, a written report must be forwarded lo the corporate office
nollng the following:

·1.

2.
3.

Policy name:
Exception / change made;
Reason for making the exception I change.

The policies will be reviewed and amended as needed on an annual basis, however, suggestions may be submitted at
any time. Changes to Polley and Procedure will be re.typed at corporate office, and the updated polfcy aoa procedure
will note the effective change date within lhe poncy and procedure.
SHP's policies are to be utilized by SHP employees only. No part of this manual may be reproduced in any form by any
means without wlitten pennission [(om the corporate office.
Ple~se have all medical staff members become familiar wil11 these polieies and procedures, and always keep them in the
medical unit area for ease of employee use and reference.

Part 1 - Table of Contenls, ancl Introduction
Effective: Augl!st 1, 2014
Page: 5
Confidential Work Product of Soull1e/n Health Partners, Inc. • SHP Policy and Procedure Manual for Health Services in Jails

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Polley and Procedure Manual for Health Services In Jails

PART2
GOVERNANCE AND ADMINISTRATION

ACCESS TO CARE . .... .. ..... .. . . ....... .. .. ..... . . ... 2
RESPONSIBLE HEALTH AUTHORITY . .......... . .. ... ..... 2
MEDICAL AUTONOMY . .... ... . . .. . ..... .. ..... . . .... . .. 4
ADMINISTRA,l:we- MEETINGS ,/\ND REPORTS .. . ........ ... 5
POLICIES AND PROCEDURES . .. .... ..... .... .. .... . .... 6
QUALITY IMPROVEMENT PROGRAM . . . . . . .. , ..... . ...... 6
EMERGENCY RESPONSE PLAN . .... ...... .. , , ...... . . . . 7
COMMUNICATION OR SPECIAL NEEDS PATIENT(s) ..... .. .. 9
PRIVACY OF CARE . . .... .......... .. .................. 10
PROCEDURE IN THE EVENT OF A PATIENT DEATH . .... ... .11
GRIEVANCE MECHANISM FOR HEALTH COMPLAINTS. ...... 13
ACKNOWLEDGEMENT-GOVERNANCE & ADMINISTRATION . . .15
Thi$ mnn 11al is not u, be a sub$Ululio11 of good prudenl mooic:tl judgment. Medical situations arise in a vuricty of scenarios, some
of which may not be covered in this manunl. It is Ute expectation by SIi l' of the SIIP .staff to use good medical judgment when
raced 1vi tl1 any medical scenario, and should such not be listed by policy, procedure, and/or practice wiiJlin this manual, wil l out
preclude the aspect ( 11' care being rendered. SHP medical staff can reMh out 1.0 various levels of SHP (corporJle oCfice staff. VPs of
Opcra(ions. Regional Reprcscntalivffs. Sile Medical Director, Corporate McdicaJ Director, etc.) regHrding questions. comments.
concerns. etc:.

Part 2-Governapceand Admiriistration
Effective: August 1, 2014
Page;: 1
Confidential Work Product of Southern Health Partners, Inc. - SHP Policy and Procedure Manual for Health Services in Jails

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Policy and Procedure Manual for Health Services In Jails
ACCE.SS TO CARE
POLICY:
Southern Heallh Partners, Inc. (SI-IP) will ensure to identify and eliminate any barriers lo patients receiving and/or
requesting health ca/e while ihcarcerated al the.Jail. This policy is to ensure patienls have access lo care lo mP.el their
serious medical, dental, and mental health needs white incarcerated.
PROCEDURE:
SHP Medical Team Administrator (MTA) will review all systems patients may use to request health care services. Any
potential barriers or unreasonable barriers to access health care services should be reviewed and discussed with the Jail
Administrator. A solution of those barriers must be reached.
Examples of unreasonable barriers include, but are no\ limited to:
•
•
•
•

Punishing (hose seeking care for serious health needs;
Assessing excessive CO•payments that prevent or deter access to care;
Refusal to allow patient to see provider;
Inconvenient sick call times (2:00 a.m.) to deter Inmate patients from seeking care; etc.

1. No patient is to be refused health care services due lo indigent status or inabilily to pay an established co.pay
charge established by the Joil Facility. The medical staff may need lo educate the patient os to previous
statement ii they are refusing needed medical care due to a co-pay plan in place.

2. SHP medical staff may ask jail administration to forego charging a co-pay charge for certain medical conditions
that are of an Infectious disease basis.. .i.e. Shwh Infections, suspected M.R.S.A. infections, etc. Patients may
be more apt to report sktn infections if there is not a co-pay charge associated with the sick call notification of
that condition. Please discuss this issue wi~1 lhe Jail Administrator for approval.

3. SHP medical staff may ask jatl administration to post signs and/or information In the boo~ing, intake, and cell
areas about information on how to access health care services. The Medical Procedures for Inmates form may
be used in this instance.
Reference(s)/Forms:

Form• Medical Procedures for Inmates Form (for Inmates)
Form• Inmate Sick Call Slip

RESPONSIBLE HEALTH PARTY
POLICY:
The responsible health authority for the Jail Medical Untl is SHP, effective and under the terms of the Health Services
Agreement between the County and SHP,

Part 2 - Governance and Administration
Effective! August 1, 2014
Page· 2
Confidential Work Product of Southern Health Partners, Inc. • SHP Polley and Procedure Manual for Health Services i11 Jails

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Policy and Procedure Manual for Health Services In Jails
The responslbility for coordinati11g and providing on-site medical services with the Jail rests with SHP pursuant to a
Request for Proposal and/or contractual agreement between SHP and lhe Jail. A copy of the health care services
agreement will be kept at the corporate office.
The on-site medical team will oonsisl of medical staff as agreed upon under agreement bylhe County and SHP.
It should be noted the Jail staff (Sheriff, Jail Administrator, Correctional Officers, jail staff, etc.) are also responsible for
the provision of basic mediccil services When lhe medical staff are not on-site, as required by law. The Jail staff is to
contact local emergency services for any urgent medical matters that may arise when medical staff is unreachable and
not on-site. The Jail staff is responsible for training its officers and staff in the provision of health care services to
inmates under thefr constitutional authority and/or regulations by the State.
PROCEDURE:

1. The Medical orrector and MTA designated by SHP are responsible for the overall operation of the medical
services program within the jail. The Medica'I Director is responsible for the Physician/Physician Provider
component
of the program.
Medical
is _
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contractor
providing
Physioian/Provlder
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2. SHP Regional Administrator(s), Regional Mam~ger(s), and corporate office staff will also provide oversight and
support services to the overall operation of the medical services at the Jail. These positions are assigned by lhe
corporate office and work in the unrt as designated by agreement.
3, The MTA and Medical Dirtidur are responsible for making and reviewlrig all medical decisions in regard to the
SHP medical services program at tho jail, Both will wor1< In conceI1 will, uU ,e, medical staff to ensure the delivery
of all appropriate medical program services. Both posflions will report to the corporate office 1n relation to the
contracted medical services to be provided at the site. Corporate office representatives include, but are not
limited to, the President. Vice President, and Corporate Medical Director.

4. The MTA and Medical Director's duties and responsibilities will be governed by written position descriptions
developed by SHP.

5. Final medicaVcllnlcal judgments rest with the on-site Medical Team Administrator, Medical Director, and nursing
staff at all times and neither SHP nor the facility's personnel will place any restrictions on the Physician/Physician
Provider's prudent practice of medicine.

6. A designated dentist and mental health provider will be established to work in conjunctro11 with the medical
service providers at the jail.

7. In instances where medical staff are not on-site, or are unreachable through cell phone/pager contact, the jail
staff should contact local emergency servh::es for medical emergencies at the jail.

Par1'2 - Governance and Adminislration
Effective: August 1, 2014
Page: 3
Confidential Work Product of Soulhem Health Partners. Inc. - SHP Policy anct Procedure Manual for Health Services in Jails

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Policy and Procedure Manual for Health Services In Jails
MEDICAL AUTONOMY
POLICY:
Regulations, policies, procedures, and scope of dulles/pracltce, which are established for the operation .of the facility,
apply lo all medical personnel and: employees or SHP. Matters of medical judgment are the responsibility of the medical
department and Medical Director. Matters of dental judgment are the resportsibililY of the dentist. Mal1ers of psychiatric
judgment are lhe responsibility ol the Psychiatrist and/or designated mental health provider(s). Matters of contractual
obligation are the responsibility of the SHP corporate representative and lhe County, under the terms of agreement within
the Health Care Services Agreement.
No restrrclions by SHP will be placed on any Physician/Physician Provider, denlist, and mental health provider wit11
respect to the prudent practice of medicine, dentistry, ,md psychiatry. Security regulations, policies, procedures, etc., will
apply to all medical staff members of SHP as well. It is the responsibility of SHP employees to familtarize themselves
with security regulations.
It is the responsibility of the jail to provide for the health care needs of all persons committed to the facility. The primacy of
providing prornpl, adequale, and comprehensive health care services to a correctional client population has been well
doq1111e11te,-d ill 1eleva11t fede,al litigatio11 a11d i11 11m11emus state111e11ts Oil w11ectirn1at sta11da,ds p,epaied by gruups sad,
as the Ameri(;sln Medical Associatlon, American Correctional Association, National Public Heallh Service, and others. The
need to provide proper health services are as important as any other service delivery function within a correctional facility
and the facility is committed to providin9 the best and most appropriate quality ,services at our disposal and SHP is further
committed toward meetin{l and surp;issing the applicable minimum sl,indards developed by the organizations mentioned
i:,bove. Health care delivery tnust be considered as a primary focal point of correctional decision making, recognizing the
impact of all other policy decisions on t11e implementation of a proper health care detlvery system. Compliance With
minimum standards will shortly be mandatory throughout the corrections lield: lhe jail will continue lo lie guided by
recognized nafional standards ln developing service delivery plans and modes of operatlon.
PROCEDURE;

1. Clinical decisions and actions regarding health care to intnales is a joint effort of custody and health staff.
2. It Will be the responsibility ot the County Jail Administrator, SHP Medical Team Administrator and Site Medical
Director, on a day to day basis, lo ensure proper coordination is maintained between the medical unit staff and
security st.aff.

3. This statement of policy and procedure will clearly note that in accord With numerous federal court decisions and
health care standards for corrections, no restrlcflons should be placed on the medical staff, and/or
Physician/Physician Providers that would interfere with lhe Implementation of health care-services, by the County.

4. The medical department personnel will make every effort to understand the security imperatives inherent in
operating a secure correctional facility whlle mee-ting the legitimate health care needs of the inmate patient
populat1on. Any conflicts should be worked out between the Jail Administrator (or designee), the SHP Medical
Team Administrator, and if needed, members from the SHP corporate Operations team, all of who are responsible
for ensuring patients receive mandated services. If a medical order by a Physician/Physician Provider is in direct
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Policy and Procedure Manual for Health Services In Jails
conflict with a security directive, the Physician/Physician Provider's medical order will be reviewed wilh the staff
mentioned above. This will ensure lhe delivery of needed health care serv1ces and also the degree of coopera!ion
[hat is required of operational units within the facility.

5. Administrative and medical staff, w1th the goal of resolving service delivery problems will carefully rev1ew patient
complaints. This underscores the commitment of providing quality services. While SHP cannot "force" security to
make a transport, the nursing staff must make every effort to explain the necessity of the needed service to the jail
-administrator. The Vice President of Operations must be contacted if security measures are precluding the
continuity of patient care.

ADMINISTRATIVE MEETINGS AND REPORTS
POLICY;
It is lhe pol1cy of SHP to have Administrative Meetings at the site level to review \he administrative and health care
seruices c, irreoUy being provided al lbe jail Attendees of tbe rneeliog sbrn lid ibch ide lbe Medical ream Admlnislralac,
the Ja11Administrator, lhe Sherlff, U1e Medical Director; other designated medical staff and correctional officer members.
PROCEDURE:
'I. At a minimum, the Medical Team Administrator and lhe Jail Administrator will oonducl reviews of lhe Mr-ir1ir;il
::;ervices Program on a quarterly basis. It is noted the MTA and Jail Admtnistrator may meet more frequently
based on hapµtmi11gti i11 the facility. The meetings should address concerns/issues regarding client relations
(communication, consent decree issues, compliance to contract, problems), staff relaUons (communication,
tumover/recruitmen0, patien t care (chronic condition patients, housing issues, in-house services), and any other
topics of ilnpoi1ance.
2. SHP Corporate Office will provide a Quarterly Services Report to the Jail Administration on a quarterly basis.
3. If meeUng minutes are documented, a copy of those minutes wfll be forwarded lo the corporate office of SHP. A
copy n,ust also be kept on site for review by medlcal staff on an as needed basis. The meetings should address
concerns/issues regarding client relations (communication, consent decree issues, compliance lo contract,
problems), staff relations (Communication, turnover/recruitment), patient care (chronic condition patients, housing
issues, in-house services), and any other topics of importance.
4. From time lo lime, the SHP Region Representative, or other Corporate SHP staff may meel with Ja11
Administration.
5. Any additional informalion and/or reports called for by the Ja11 Administrator regarding the current set of health
care services may be referred lo Iha corporate office for implementatron.
6. Open lines of communication are key to a successful medical program.

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Policy and Procedure Manual for Health Services In Jails
POLICIES AND PROCEDURES
POLICY:
SHP has a manual of written policies and procedure regarding the implementation of health care services at the facility.
One complete and current copy must be maintained at each facility medical unit. Policies are established only by the
corporate office Operations and Quality Assurance Department representatives and are lo be used as a guideline in
providing services. However. these policies and procedure are not to be substitution for prudent medical judgment when
dealing with patient care. All medical staff members are encouraged to submit ideas or recommendations they believe will
improve the operation of the medical services program. Procedures are to be specific to the facility and therefore some
deviation, or changes due to prudent medical judgment, are warranted. The Medical Team Administrator, Medical
Director, medical staff, and Region Representative, al the site level, will have such authority to deviate from the policies
and procedures if warranted. Policies and procedures should be reviewed at least once per year for compliance issues
and updates will be made as necessary. Policies and procedures which reference jaiVsecurity measures such as custody
issues, kitchen industries. exercise programs are the responsibility of the Jail.
Th ese policies and procedures are not to be confused with common practices as established by th e Company.
PROCEDURE:
1. SHP staff will review the SHP Policy and Procedure Manual upon hiring, on an annual basis, and as needed or
directed.
2. Any updates to the manual must be submitted to the corporate office, Attn: Operations, for typing and inclusion
into the Facility manual.
3. It is the responsibility of the MTA to facilitate the education of all medical staff members of the policies and
procedures, as well as any updates.
4. All SHP medical staff and SHP Medical Director must sign off on all site manuals.
5. Compliance under any Consent Decree(s) or local laws will also be maintained throughout the manual.
6. All SHP medical staff members are responsible for educating themselves as to security directives, restrictions, and
practices.
This manual is not to be construed as final judgment in place of prudent medical services and/or procedures.

QUALITY IMPROVEMENT PROGRAM
POLICY:
SHP will implement a monitoring system assuring the provision of appropriate health care services is being delivered and
documented. The Regional and/or Corporate representatives will perform regular reviews for Quality Improvement. The
evaluations will comprise of quality and appropriateness of diagnostic and treatment procedures, as well as a review of the
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Policy and Procedure Manual for Health Services In Jails
medical records.
PROCEDURE:
1. The SHP Corporate Office will provide QI Criteria Reports for completion on-site by the Medical Team
Administration and/or medical staff. Follow the instructions on the applicable QI Criteria Report.

2. The SHP Regional representative or corporate designated representatives will perform an annual audit as well
as two (2) QI Criteria Reports, as designated by the SHP Corporate Office Operations and Quality Assurance
Department.

3. The results of the audits will be reported to the Vice President of Operations.
4. Any correclive action or discrepancies will be discussed with Medical Team Administrator by either the VP of
Operation or the Region Representative.
5 Ibe Medical [)Jrector must re1dew the actiuities aAd sertices provided by the medical~udit..ol.
the medical records should be performed to maintain compliance with all aspects of the provision of health care
services. The Medical Director will be required to implement chart reviews/audits on a regular basis. Evidence of
such reviews will be kept on-site by the MTA (this could be by inilials/signature by the Physician/Physician
Provider in the patient's chart as well).
6. The MTA and Medical Director may develop their own site specific QI criteria's to ensure compliance with key
health service timelines. It will be their on-going monitoring of on-site hec:11lh care services. Each staff member is
responsible for assisling in the collection of data. RP.suits of data collected are analyzed and will be reported back
to the MTA for discussion purposes at the medical staff meeling.
7. The Q. I. program is ulilized to make necessary changes and develop solulions which ultimately improve patient
care.

References:

QI Manual
Form - QI Criteria Forms

EMERGENCY RESPONSE PLAN
POLICY:
SHP and its on-site medical staff will work with security staff to coordinate the health care aspects of the facility's
emergency response plan in the event of a disaster.
PROCEDURE:
A copy of the facility's disaster plan must be obtained from the Jail Administrator by the MTA and kept within the medical
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unit for review by all employees. The emergency plan should be updated as necessary and reported to all medical staff
members as to compliance and understanding of the medical role within the plan. All new employees must be oriented to
the plan as well.
1. The Chain of Command in the event of an emergency is as follows: Notification of such emergency - Jail
Commander and Medical Team Administrator.

2. The Jail Commander will notify all applicable security personnel.
3. The Medical Team Administrator will notify applicable medical staff personnel, as well as all SHP Corporate
Staff, if needed/required.
4. The MTA must communicate to the Jail Commander any changes in staffing plans, etc. due to the emergency
situation (impending weather alert, etc.). The MTA should also notify his/her Regional Representative of the
emergency plan of the facility and how medical staff will report to the facility.
5 A triaging process lNill.. he established to coordinale-lbe..medicaLstaff iA the roles..tl:ley..pla11-witl1iA-lhe;ila,+..--lnciuding procedures and telephone numbers of off-duty staff members will be helpful. Off-duty staff members
may be dispatched to come to the aid of the facility in the event of an emergency and/or disaster, either natural
or man-made.
fi.

An emergency supply of medical supplies should be stored ond regularly checked for expiration dates and/or
r~pli:lcement materials. The MTA should establish contact with local vendors (phamiacies, etc.) for supplies that
may be needed if regular shipments cannot arrive timely at the facility.

7. Depending upon weather emergencies, regular staff who are covering at the site, or stay at the site, may want to
prepare a care package for themselves with a clean outfit, toothbrush, crackers, fruit, bottled water, etc.
8. A practice run of a disaster drill should be performed on a yearly or on as needed basis for each working shift. All
medical staff must participate in the practice run(s). Security should also participate to ensure the plan runs
smoothly. The MTA will coordinate the practice run with the Jail Administrator. After the practice, the Disaster
Drill Evaluation form should be completed and reviewed by the MTA and Jail Administrator. Any changes or
corrective actions must be implemented on the emergency plan and such changes distributed for review by all
medical staff. It is recognized not all medical staff may be present when a drill occurs. In those cases, the staff
member(s) must review the written documentation of the drill.
Reference: Administrative Resources Manual
Form • Disaster Drill Evaluation Form

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COMMUNICATION ON SPECIAL NEEDS PATIENTS
POLICY:
In order to develop and maintain maximum cooperation between correctional and medical staff in ensuring appropriate
management of patients who are diagnosed as having significant medical or mental health illnesses or disabilities, SH P
requires notification of correctional personnel by medical staff of those patients. Correctional officers are to be notified by
medical staff of any patients who have a significant medical or mental health illness or developmental disability. This
notification will help in the correctional officer's placement of the patient within the facility. Further, the patient's special
needs status may affect the imposition of disciplinary measures or transfers to another institution.
PROCEDURE:
1. Upon notification from correctional staff of the inmate patient's arrival, either verbally or by review of the intake
information, the inmate patient will need to be :;e!:ln I.Jy the designated medIcal staff member.

2. The inmate patient's housing assignment may be requested by written medical order, and such information must
be presented to the designated correctional officer.

Medical staff should document the passing of such

i11fu1111at1011 tu the correctional offloor In tt1e patient's medical record as Well (can □tlllze the Special Needs Report~
to Corrections form for documentation). Also consider reporting to officers any patient who may have withdrawal
issues, so the officers can report back to medical any odd or emergent behavior for follow up.
Special Needs Patients are classified as:
Chronically Ilifferminally Ill Patients
Infectious Disease Patients
l:lderly/Frail Patients
Handicapped/Developmentally Disabled/Mentally Ill Palients
Pregnant Patients
Psychotic Patients
Adolescents in Adult Jail
Suicidal Patients
•~consider Possible Withdrawal and/or Detox Patients

3. In such cases where correctional staff initiates action, medical staff must consult identified/verified special needs
patients either before changes are implemented or as soon thereafter upon notification. In an emergency,
correctional officers may take action immediately to protect the inmate, patient, staff, or others.
4. Typical cases where such medical and correctional staff consultation is required include, but are not limited to:
Housing Assignment/ Program Assignment
Disciplinary segregation/ Medical segregation
Intra-system transfer
Court appearance for inmate patients on psychotropic medications
Hospitalized patients
5. Patients with mental disorders may receive special care as defined below. All inmate patients will be evaluated for
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Policy and Procedure Manual for Health Services In Jails
mental health problems either through intake screening or during their history and physical. Inmate patients
exhibiting problematic/questionable behavior may be seen sooner. Inmate patients exhibiting severe psychiatric
disturbances should be housed in separate cells or in a housing unit designated for psychiatric patients. Patients
with continuous severe psychiatric disturbances should be transferred to either a state or local mental health
facility for further evaluation and/or care, if available. For every referral, there must be a documented medical
history.
6. Cooperation between the medical staff and the legal system regarding the use of psychotropic drugs is required.
Whenever inmate patients are currently receiving psychotropic medications and they are scheduled for a court
appearance or for court ordered evaluations, the judge, plaintiffs attorney, or other affected party, may contact the
medical staff for patient medication information. The medical staff needs to verify the person to who they are
speaking and then may acknowledge the fact if inmate patient is or is not receiving such medication. Specific
information is not given without written consent from the inmate patient. Documentation of such conversation
should be made within patient's chart as well. Scheduled medications are not to be withheld because of
scheduled legal appearances, unless under written medical order.
_ ___,_7-...rMim::edir,aLslafLls..to...oolify. mrrectiaoal staff whenever significant earn 1gb medir.al or psychiatric illness exists ta affect
housing placement or activities. Nursing staff may request an inmate patient be housed out of the general
population or checked by the detention staff at fifteen (15) minute intervals when there is a medically based
reason, i.e. suicidal ideation, etc.
See also:

Special Needs Treatment Plans
Ma11aye111e11t ur Chru11ic Disease

Reference: Form - Special Needs Report to Corrections

PRIVACY OF CARE
POLICY:
SHP respects the privacy, dignity, and feelings of each patient. To assure privacy while medical procedures are being
performed, medical staff is to perform services or interviews in a fashion which affords dignity and respect for each patient
seen. SHP medical staff will provide health care services to all patients without consideration to age, sex, race, color,
religion, or culture.
PROCEDURE:

1. All medical evaluations and services are to be performed in as much privacy, with respect to security issues, as
possible. The discretion is with the Medical Director, Physician/Physician Provider, or nurse providing the service.
2. Security personnel may be asked to be present if the patient poses a probable risk to the safety of the medical
staff.
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3. Correctional Officers should be trained and informed by Jail Administration as to maintaining confidentiality for
observing or hearing health encounters. If medical staff feel correctional officers are not maintaining
confidentiality, they can report such to their Medical Team Administrator who will then report such to the Jail
Administrator.
4. When cell side triage is required, medical staff must take extra precautions as to promote private communication
with the patient.
5. Medical staff are not to discuss private, confidential medical information for one patient with another patient.
6. Medical staff are not to discuss private, confidential medical information with outside individuals without first
notifying the SHP Risk Management Department. This includes but is not limited to medical records request. See
the Risk Management Manual for more Information as to the disclosure of HIPM information.

Reference(s):

SHP Risk Management Manual

PROCEDURE IN T HE EVENT OF PATI ENT DEATH
POLICY:
All deaths must be reported immediately to the MT,' \ Mcdic;il Director, Jail Administrator, and corporate office
representative. Information reported is considered confidential, and may be used in the prep,mition of a lawsuit.
PROCEDURE:
In the event of a patient's death:
1. The medical staff member who is on-site at the time of the event must immediately notify the Medical Team
Administrator and the Medical Director. The on-site Jail Shift Supervisor will notify the Jail Administrator. If there
is no SHP medical staff on-site at the time of the event, the jail staff will notify the Medical Team Administrator.
2. The Medical Team Administrator will notify their Regional Representative of the event.
3. The Regional Representative will notify their VP of Operations, the President, and the VP of Quality Assurance.
For after business hour notification, the SHP corporate office has email and voicemail where a message can be
left as to the incident.
4. In the event of suicide, homicide, accidental or suspicious death, the Medical Examiner and appropriate law
enforcement officials will be notified by the Jail Administrator or designated correctional officer. The MTA and
Medical Director will be advised of such findings where necessary.
5. The designated security staff will notify the il)mate patient's next of kin.
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6. The medical staff is not to have any discussions regarding the incident with family members, media, or other
outside parties. All such requests must be forwarded to the VP of Quality Assurance for handling and response.

7. A progress note must be made by the nurse on duty citing witnessed facts concerning:
Time of expiration, Nature of death;
Circumstances surrounding nature of death at that time;
Treatment rendered, if any;
Persons notified of death;
Whether an autopsy was/was not requested;

8. The Medical Team Administrator and/or on-site medical staff must cooperate with the State Bureau of
Investigation who will be on-site and they seize the original medical record for review. Please alert the investigator
of any additional notations which need to be documented in the record. The medical staff must make a copy of
the medical record to send to the corporate office for reporting purposes as well.

9 Witbio 24 hours of the incident the MIA will..coroplete and forward the Report of loroate..De.alh...Eo.tm..1cL1ha__
corporate office, along with a copy of the inmate patient's medical record. If the state investigation team has
control of the record before medical can make a copy for the corporate office, send a copy once the original record
is returned.
10. A SHP corporate representative will conduct an initi;it intP.rviP.w with st;iff members involved. This is standard
practice. All reports, along with a copy of U1e meuical 1ecu1u, a,e fu1wc11llell to the cump,my's attorney and
insurance company for work-up and review, which is why it is imperative to get the information as quickly as
possible. The review may include the role of medical staff in the event of patient's death, as well as determine the
appropriateness of clinical care given to the patient.

11. Review the Risk Management Manual for more information regarding reporting a critical incident and/or death.
Critical Incident Stress Debriefing:
Remember a death (i.e. Suicide) can be extremely stressful for staff and they may be feeling misplaced guilt over the
incident (maybe I should have checked a minute before, maybe I could have done harder chest compressions, etc.).
Critical Incident Stress Debriefing is a process that prevents or limits the development of post-traumatic stress in people
exposed to critical incidents. Debriefings help people cope with, and recover from an incident's aftereffects. Staff need
to understand they are not alone in their reactions to a distressing event, and this process provides them with an
opportunity to discuss their thoughts and feelings. The review/debriefing should occur within 24 to 72 hours of an
incident.
On-site Critical Incident Review/ Morbidity-Mortality Review:
To ensure good communication between the medical staff and the correctional officers, a review of the critical incident
must be done within 72 hours of the incident. The review process meeting should be attended by both the Jail
management and SHP medical team management staff to perform a critical inquiry into the circumstances of the event,
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and the subsequent response by all involved in the incident. The intention of this meeting is to identify any corrective
action going forward, and to recommend any changes in policy, procedures, training or services to possibly prevent
another event such as this from happening in the future.
The review process shall comprise a critical inquiry of the following:
• The circumstances surrounding the incident.
• The facility procedures relevant to the incident.
• All relevant training received by involved staff.
• Any pertinent medical and mental health reports/services involving the victim.
• Any positive precipitating factors leading to the suicide or serious suicide attempts and follow-up
recommendations, if any, for changes in policy, training, physical plant, medical or mental health services, and
operational procedures. When appropriate, the Morbidity-Mortality Review Team should develop a written plan
and timetable to address areas that require corrective action.
The Medical Team Administrator will need to send notification to the corporate office Risk Management Department that
such a review process has been completed.
Reference: Form(s) - Incident Report Form; Report of Inmate Death Form; Risk Management Manual

GRIEVANCE MECHANISM FOR HEALTH COMPLAINTS; J-A-11
POLICY:
SHP requires compliance with the facility's written grievance procedure for patients regarding health care services'
complaints, providing action in a timely manner and a process for appeal. All reported grievances to the medical staff must
be reviewed and appropriate action taken when necessary.
PROCEDURE:
1. Correctional officers will provide grievance forms to patients upon their request. The patient will give the
completed form to a correctional officer who then gives the form to the medical staff for resolution. SHP will also
follow the Jail's formal grievance mechanism if one is established.
2. All non-emergent medical grievances must be responded to Jail Administration within 48-72 hours of receipt by
medical staff; emergent medical grievances will be responded to within 24 hours.
3. Be factual, be concise, and be brief. Remember - grievances are reviewed by the Jail Administrators, Jail
Inspectors, sometimes attorneys, etc. - you should respond appropriately and professionally at all times.
4. If the corporate office Risk Management needs to be involved in the resolution of the problem, the Medical Team
Administrator should notify SHP Risk Managements as to their need of involvement.
Copies of Grievances are kept in an "Inmate patient Grievance File", not in the patient's medical record.
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If no formal written grievance process exists in the facility: The MTA may review the information presented in the
medical grievance with the Jail Administrator. If allowed by Jail Administration, the MTA may speak with the patient about
the problem and possible resolution. All information about the conversation should be documented on the grievance form.
5. Copies of completed/resolved medical grievances can be sent to the SHP Risk Management Department if the
MTA feels they may evolve into a claim/lawsuit.

6. All responses to inmate patient grievances must be timely and based on principles of adequate and prudent
medical care.
Patient Grievance Appeal ProcesOs - If the patient does not agree with the resolution, an appeal may be filed citing
additional information. The appeal request must include a copy of the original grievance and supporting information as to
reason for appeal. An appeal must be responded to within 72 hours. Only the MTA will respond to the appeal. A copy of
the appeal request and resolution must be forwarded to the corporate office.

Grievances are kept in an "Inmate patient Grievance File' not in the patient's medical recocd
Reference: Form - SHP Inmate Grievance Form

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PART3

MANAGING A SAFE AND HEALTHY ENVIRONMENT

INFECTION CONTROL PROGRAM .................. 2
PATIENT SAFETY . .......... . .... . ...... . .. . ..... 4
STAFF SAFETY. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
PROCEDURE IN THE EVENT OF SEXUAL ASSAULT . 6
Acknowledgement Page . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
T11is manual is not to be a subsLilution of good prudent medical judgment Medjcal situatjons arise in a variety of scenarios. some
of which may not be covered in this manual. It is the expectation by S HP of the SHP staff 10 use good medical j udgmem when
faced with any medical scenario, and should such not be listed by policy, procedure, and/or practice within this manual, will not
preclude the aspect of care being rendered. SHP medical staff can reach 0111 10 various levels orSHP (corporate office staff, VPs of
O peratio ns, Regio nal Rcpresen1a1ivcs, S ite Medical Di recto r, Corporate Medical Director, etc.) regarding q uestions, commcnL~,
concerns. etc.

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INFECTION CONTROL PROGRAM
POLICY:
SHP will established an Infection Control Program to set up prevention techniques and treating/reporting infections in
accordance with local and state laws. Each facility will implement an infection control program.
PROCEDURE:
SHP will equip each facility with a SHP Infection Control Manual. A review of the manual will be done with the medical
staff on a consistent basis (annually at a minimum), as well as upon new hire orientation. A copy of the manual should be
shared with the Jail Administrator and correctional officers as needed and/or if requested. Any site specific updates to the
Infection Control Manual mus! be reported to the corporate office for approval and implementation. Universal precautions
must always be used by all SHP employees to minimize the risk of exposure to blood and body fluids.
PRECAU TIONS TO BE USED FOR ALL PATIENT CARE ISSUES·
PROCEDURE
HAND-WASHING
Adjusting IV Fluid or
V

uvrr-tnva.,.;v..,

""uiomenl
Examining
Patient
without touching body
substances. mucous
membranes,
noninta.;I
s~in a,1J
contaminated items.
Examining
r otient
including contact with
body
substances,
mucous membranes,
nonintact skin and
contaminated items.
Drawing Blood
Inserting
venous
access
Inserting NC, GT or
Folev Catheters
Handling soiled waste,
linen. other materials
Operative and other
procedures
which
produce
extensive
bodv fluid solatterino

WEAR GLOVES

WEAR GOWNS

WEAR PROTECTIVE
MASK/EYEWEAR

--

X

X

X

X
X
X
X

X

X
X
X

X

X

Use gown, mask, eyewear if body fluid
splattering is likely.

-

Use gown, mask, eyewear only if waste or
linen are extensivelycontaminated and
solatterino isliketv.

X

X

MEDICAL EMERGENCY SITUATIONS • Medical emergencies may arise when the patient demands immediate attention and quick
responses. In these situations, staff members may feel they have only a limited amount of time in which to take all necessary
precautions. Even in these emergency situations, medical personnel have both the right and the responsibility to protect themselves
from exposure to potentially infectious blood and body substances. As an absolute minimum, medical personnel responding l0 'I

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medical emergency are required lo wear gloves when in contact with blood and body substances. Other barrier protection should be
put on as time permits or when other personnel become available to assist. In addition, the staff must continue to use the utmost care
and caution in handling contaminated materials, needles and sharp instruments. Manual respiratory resuscitation equipment is lo be
available and all medical personnel should be trained in the proper use of these devices. Medical personnel should avoid direct
mouth-lo-mouth resuscitation whenever possible.
REPORTING OF EXPOSURES/ INCIDENTS INVOLVING SHP STAFF MEMBERS· SHP Staff should report exposures and/or
incidents to !he corporate office using the Employee's Report of Injury Form. The form is to be completed and faxed to 423-553-5645.
Any emergent situations should be called into the corporate office to Katie Utz, VP of Human Resources, at 423-553-5635 ext. 917.
EXPOSURES/ INCIDENTS INVOLVING INMATE PATIENTS· At times, inmate patients may be faced with exposures
and/or incidents involving exposure. As a reminder, for bloodbome infections, the mode of transmission are
needlesticks/sharing of drug user needles; contact with blood or body fluids at the site of an open wound; cut or broken
skin and exposure to mucous membranes, and sexual contact. You do NOT contract HIV, HBV, or HCV from casual or
environmental contact such as shaking hands, using telephones, toilet seals, drinking fountains, or donating blood.
For inmate patients who you suspect have an infectious disease, either due lo history, receiving screening information, or
--~
sle1n:'a:11informatlorrpresented-t>y-ttfe7:ratient;-refericryourMedicaH3irectorfortestinr,-Forany-sospected--airbomeinfectious disease, use proper precautions such as isolation, wearing of masks, etc. Make sure you alert the Jail
Administrator as well, so any contact with this patient is properly contained.
For post exposure response and medical evaluation, wash the exposed area immediately. Consult with your Medical
Director as lo any medb!I treatment necessary. Testing may be ordered and therefore blood can be drawn to be used as
a baseline. Follow up testing will then determine if transmission of any exposure has occurred. Whenever feasible and
permitted by law, the source individual's blood will be tested lo determine if there was infection. If medically indiGc:1led, U1e
exposed individual is entitled to post exposure prophylaxis (2 hour window in most cases). Medical counseling about the
risk of infection and risk of infecting others may be needed, depending upon the exposure. This can be schedule through
the local health department.
An inmate patient may refuse treatment for a blood-borne injury and any post blood-borne exposure treatment, but all
such refusals must be made in writing and witnessed by the medical staff. The refusal should then be communicated to
the Medical Director so the inmate patient can be once again properly alerted as to possible effect of such refusal. If the
patient from whom the exposure occurred refuses to submit to blood tests identifying the presence of blood-borne
diseases, such refusal should be documented and communicated to the Medical Director as well. Testing will still be
performed on the inmate patient in accordance with a private physician's order.
Reference: SHP Infection Control and Employee Safety Manual & Guidelines

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PATIENT SAFETY
POLICY:
SHP medical staff promotes patient safety through review of processes and symptoms regarding adverse and/or possible
near-miss clinical events.
PROCEDURE:
In an effort to reduce risk and/or harm to patients, SHP encourages medical staff members to identify potential problems to
the MTA and/or corporate Risk Manager. All medical staff members should be trained as to incident reporting upon their
orientation. An open forum is encouraged to properly identify problems, risks and the potential for risks within the jail
medical unit.
A review of the incident report will be done by the MTA and the corporate Risk Management Department. The MTA may
share incident report data with their Regional Representative as well.
SHP considers the following as reportable incidents to the corporate Risk Management Department:
All Deaths
Acute neurological deficits/injuries
Delays in treatment and/or diagnosis
Repeat visits to the ER for the same complaint
Suicide attempts
Miscarriages/ reproductive organ loss/impairment
Infections/Sepsis/Suspected MRSA/St;:iph
Detoxification - days in treatment, from bad to worse, had to be sent to ER for further treatment, etc.
Amputations/Loss of use of timb(s)
Spinal cord injuries
DisfiguremenVburns (2nd/3ro degree)
All Attorney Contacts, including records requests
Threatened litigation
Forced medication and/or psychiatric intervention
Medication errors
Press/Newspaper inquires/lnv.estigations
Needle sticks (with all employee injuries, please contact the HR department at the corporate office as well. This will fall
additionally under Worker's Compensation
Incident reporting should take place within 24 hours of the incident. The original incident report form is to be mailed to the
corporate office, Attention Risk Management. No copies of the report to be kept at the site level nor are they to be copied
and shared with others. Incident reports are to be kept strictly Confidential and are the legal work product of Southern
Health Partners, Inc.
Reference: SHP Incident Report Form

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STAFF SAFETY
POLICY:
SHP encourages and promotes a safe working environment for all SHP staff on-site al lhe.j,;il.
PROCEDURE:
Remember where you are, you are working in a jail. The medical offioe/unit is to be non-confrontational zone. Be secure
of yourself and your surrounding work items,
Nurses and/or medical staff should never be Involved ih securing or restraining an inmale. Call an OfficerI
The following are mandates from Southern Health Partners lo all employees:
• Do NOT provoke an inmate.
• Do NOT give an inmate patient contraband (check With your Jail as to what contraband consists off, every jail is different)
• Do NOT enter into a personal relationship with an Inmate patient,
• Do NOT put your haods through a door slot or inside the bards. Lei the inmate patlenl put hfs hands out lo you. Always
- - - -- -ltn0w-ye11r-safe.- aistan1e&.-.---- - - - - - -- - - -- - - -- -- -- - - - - - - • Do NOT tell an inmate patient at appointment times, appointment dates. etc. lnrnate patients plan escapes.
• Do NOT gilie your full name lo an inmate patient Our name badges should be written as "Nurse Judy'.
• Always maintain knowledge of and/or location and possession your keys.
• Several Jails have inmate trustees emptying trash, Beware of What wo think of innocent items which can be used as
weapons.
• I imit tile use of Ace bandages and/or medical tape; !hey too can be used as weapons.
• In the event of an emergency, do not go into a cell until the officers have it secured. The officers do not need to worry
about you in an unsecured situatioA when they are dealing with a11 inmate patlent's situation. They will call you when they
neE!(l you- When you hear of a confrontation between officers and inmate or inmate to inmate, stay out of site. They will
call you when and if they need you.
• If there are situations Where inmates can get to the medical unit (trustees, work release, etc.), always have a radio or a hot
switch in your unit or in yout pocket for cases of emergencies.
• Always let the lead officer know when you are leaving the medical unit and where you are going, and espec:lally when you
leave ior the day. They get nervous when they don't know where you are.
• Do alert officers if you feel unsafe. Sometimes a preplan and conslstent slgnal used lo alert your officers can avoid
conrtonlation in your unit.
• Do alert your Region Representative(s) or the SHP corporate omce Human Resources Department if you feel unsafe.
• Always plan an exit.
• Always take a visuar survey otyour surrounclings (pens, rulers, staplers, etc.) especially when inmate patients may have to
walk through an office area to gel lo the medlcal exam room.
• Always maintain your role as a medical professional.

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PROCEDURE IN THE EVENT OF SEXUAL ASSAULT
POLICY:
SHP medical staff will respond with health interve11t1onsupon the report of a sexual assault against an inmate patient.
SHP prohibits any acts of sexual misconduct. sexual violence and sexual abuse by inmates, slaff, contractors/vendors,
volunteers or any SHP employee. An offender alleging victimization of a sexual manner Will be provided the same level
of law e11forceme11t service, treatment and care as non-offenders.
Sexual Misconduct is any behavior or act of a sexual nature directed toward an inmate, stair, conlractor/vendor,
volunteers or arw SHP employee whether consensual or non-consensual acts or attempts lo cornmit such acts including
but not limited to sexual assault, se)(ual harassment, sexual violence, sexual contact of a sexual nature or implication,
sexual gratification, obsceni\y and unreasonable invasion of privacy or voyeurism. Sexual misconduct also inoltides but
is not limited to conversation or correspondence which suggest a romantic or sexual relationship between an inmate and
any party mentioned in this facility policies and procedures:

'Any sexual advances
•Reque$Hor--sexuaHavo•,..,__ _ _ __ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
'Threats for refusing sexual advances
•invasion of privacy beyond what is reasonably necessary for the safety and security of the facility
' Verbal or physical conducUconlact including but not limited to lour.hinglhorsP.pl;:iy of a ~P.x11r1I n;i,11rP. tnw;:irrt ;:in
offender
Sexual Contact includes but is not limited lo: all forrns of sexual contact. Intentional sexual 1ouohing or pl,ysical .contaca
in a sexual manner, either directly or through clothing, of tile genitalia, anus, groin, breasl, inner !high, buttocks, wilh or
without consent of the person; or any unwanted !ouching with intent to arouse, humnrate, harass, degrade or gratlfy the
sexual desire of any person,
Sexual Assault is any contacl between the sex organ of one person and sex organ, moulh or anus of another person or
object, by the use of force or threat of force. **this includes: complainant touching lhernselves, lhe accused or another
person,

Unauthorized Relationship is a relationship wilh any inmate incarcerated at the jail and includes all Inmates, staff,
contractors/vendors, visitors, volunteers, or any other government employee olher than a. business/professional
relationship. Sexual acts or sexual contact between an offender a11d any other inmates, staff, contractors/vendors,
visitors, volunteers, or any SHP employee, even if the offender consents, tnitlates or proposes. are always prohibited and
may be considered illegal under the state legal law code.

A person is guilty of sexual misconduct as defined by legal law code (as reference)
• Sexual abuse is an act committed with the in ten I to sexually molest, arouse or gratify a person.
• Carnal knowledge for lhe purposes of this section ls an lnmate, parolee, probationer or pretrial or post trial offender or
any person under the jurisdiction ol the Department of Corrections, work program, a local community-based probation
services agency, a pretrial services agency or a local or regronal jail are considered persons who is unable to covisent or
refuse. Violation occurs even without the use of force, threat or intimidation. Such offense is a felony. "Carn>''
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Knowledge' includes the acts of sexual intercourse, cunnilingus, fellatio, anal inlercourse and animate or Inanimate
object sexual penetration.
• Sexual batle!Y an accused is guilty of sexual battery it he/she sexually abuses, as defined by legal law code.
Exempted Processes Medical activities or actions taken by SHP, which are supported by the SHP J')Olicies .md
procedures, and deemed necessary for the safety and care of the patient will nol be defined as staff sexual harassment,
misconducL assault or rape. These policies and procedures include, but are not limited to the taking of photographs
and/or medical exams.
Prevention of Sexual Misconduct• DO NOT make sexual comments lo anyone (staff/inmates/etc.) •Do NOT engage
in conversations of a sexual nature with other persons 'DO NOT expose yourself to others in a sexual manner •DO NOT
participate in any acts of sexual misconduct with another person •IF SOMEONE MAKES SEXUAL COMMENTS OR
EXPOSES THEMSELVES TO YOU, REPORTTHEM IMMEDIATELY!

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Reporting and Procedures for Dealing with Sexual Misconduct
Staff, contraolor/vendors, Visitors, volunteers, or any other SHP employee Who becomes aware of reasonably suspects
tt-lat-aA-inmate,-stafl.eeAtr-aeter./veAElef;-VisfteF,VeluAteer-er-aAy-ether-SHP--O"iJGl'emmeAl-ami.iloyee-are-.involved-ln-an
unavthorlzed relationship has an affirmaUve duty to immediately report any such knowledge or suspicion to the Ja11
Adminislralion and SHP Risk Management Department by way of confidential means verbally or wrillen. FAILURE TO
REPORT the lnformationnncident shall subJect the individual to disciplinary -action, up to and Including
tlisn1issal/revocation/lermlnation.
Non-staff sl,all report this infom1ation to a staff member immediately who will then report it to the Jail Admlnlstration
and SHP Risk Management Department.
Inmates and their families/associates may report any knowledge or suspicions of an unauthorized relationship,
allegations ot sexual harassment, misconduct, assault and/or rape between inmates, staff, contractors/vendors,
volunteers or any other SHP or government employee, Ways to communie'1te this information will be provided in the
Inmate Handbook by the jail.
' Inmates do l)ol liave to name other inmates lo receive assistance - however specific information will make il
easier for staff lo help.
*Reports may be made verbally or in writing to any staff/contractor-vendor/visitors/volunteers or any other SHP
or governmenl' employee.
'Inmates are subject to being sanctioned for not reporting sexual misconduct U1at they witness.
~victims of sexual violence will be provided medical assessment, medical treatment and counseling, as
necessary.
' Vlcllms of sexual violence and perpetrators of sexual violence tnay be tested for communicable disease.
wIndMduals will be subject to disciplinary action, up to and including administraOve, criminal prosecution and/or
civil action if charges are filed falsely or frivolously.
•All reports of s.exual assault shall be forwarded directly to the Jail Administration and SHP Risk Management
Department immediately.
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PROCEDURE:
Definitions:
Inmate-on-Inmate Se~ual A~use/Assault - one or mo,e inmates loucl11n9, or other a<:UOfls and/or com111u111ca6ons by one or more mmates
aimed at coercing and/or pressuring another i11111ate lo engage in a sex11al act. Sexual acts or contacts between inmates. even when 110
objections are raised. ,,re proh1bite<J acts,
Staff-on-inmate sexual Abuse/Assault - Staff engaging in. or attempUny to engage in a sexual acl wilh any i11111ates or the mtenllonal touching
or an Inmate's genitalia. lll\US, .groin, breast. ln11e1tblgb. or buttocks wilh 11\e intent to abuse. humiliate, ha,~s. degraoe, arouse. or gratify the
sexual desire of any pe1so11 Sexual acls or contacts between an f111nate and a stalf me111be1. even when 11u obfeclions are raised, are always
illegal
The MTA and medical stall should review the facllity's policy and procedure on a sexual assault against an inmate.
All medical staff are lo receiving training upon hi!ing and a11nual training thereafter on how to detect, assess, and resp1md to signs of
sexual assault.
Intake Screening. All inmates entering U1e facility are screened for classifrcation, When an inmate patient reports having been a
victim of sexual assault/abuse and expresses a willingness to participate in treatment, staff shall refer the inmate pa6ent to medical
and mental health services. Health services staff shall access the inmate patient patients need for treatment and discuss available
treatment options when appropriate. Preventihg sexual abuse/assault also suggests that staff should attemµt lo Identify sexually
assaultive inmate patients. Care must be taKen to Identify and document any history of sexually .issaultlve behavior. Accordingly,
during intake screening procedure, staff shall review available documentation for any indic;ation that an inmate patient has a history of
sexually aggressive behavior.

Upon Report. Upon report of a sexual assault on an inmate 1>atien1, medical staff will see lhe patient for treatment of any physir ·
ihjuries. Th., l)ali1;111l ~huul() l11t111 Lt: 11::fll11tlll lu U1" lwc1I 1::11ie1ytl11~y 1w111 lu1 fu1th1::1 h1::c1l111.,11t and 11ol11t11i11y uf t:viut:1M:<. S.
sP.nsitivily tnw11rrt inm~le patients who are victims of sexual abuse/a~sault is critical. St~ff shall tlike sariously All statements Imm
inmate patients that they have been victims of sexual assault and respond supportively an~ non Judgmentally. Any inmate who
alleges that he or she has been sexually assaulted shall he offered immediate prote~tions from the assailant and will be referred for
a medical examination as well as clinical assessment of the potential for suicide or other related symptomatology.

A report by the medical staff member will be prepared as lo the medical stafrs finding prior to patient's transfer to the emergency
room. This report should be given lll the Jail.Administrator, wilh a copy lo be attached to a SHP Incident Repott Fom1 and sent lo
the corporate office Risk Management Department. When a staff rnember(s) is alleged lo be the perpetralor of the inmate sexual
abuse/assault, the Jail Administrator shall be advised immediately. The timely reportlng of all Incidents and allegations Is of
paramount importance.
A referral lo mental health staff .should be made, notifying them of assaull in otder for their providing support lo the victim upon
request.
Appropriate infectious disease testing, as determined by health services staff, may be necessary. Part of the investigation process
may also Include an examination of and collection of physicai evidence for the suspected assailant(s).
Reference-s: WebEx Training (Mandatory)

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ACKNOWLEDGEMENT

I acknowledge I have received, read, and reviewed Southern Heallh Partners, Inc. Policy and
Procedure Manual for Health Services Tn Jails - Part 3, Managing a Safe and Healthy
Environment, and I understand that it is my responsibility to maintain and keep rt/them secure,
The contents are not to be reproduced and/or given to anyone not employed by Southern Health
Partners unless prior approval is obtained from the corporate office.
I also understand I may be required to return all or a portion of the manual if a major revision is
required.
I understand it is my responsibility to ask questions, make comments, and lo fully understand the
attached policy and procedure manual. Questlons may be relayed to my site Medical Team
Administrator, Regional Adm inistrator, or corporate Vice President.
I will review the Manual in accordance with lhe jail's policies and procedures, Consent Decree(s),
and other mandates, thereby making revisions, updates, etc, as necessary.
If my employment w·ith Southern Health Partners, Inc. is termlnated, I must retu rn any originals or
copies I may have in my possession.
By my signature below, I understand and acknowledge the above:
SHP
Region
Si nature:
Medical Team Administrator:

Date:

ID-2.€>-14

LltD
Sile Medical Oireclor/f'lovider:

71<
She Provider (other than Medical
Director
SHP Employee:

Date:

SHP Employee:

Date:

SHP Employee:

Date:

Date:

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Sf-1P Employee:

iTA
SHP Employee:

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rr..-r rt

A oopy or this foml musl be sent to the corporate office for inclusion , the employee's personne l lite. Kc<,1> the onginally signed
fo,·m Ylilh lhc !lc,licy a,nd Proc.,dnrc M,u,md . Lf 11101-c signature spaces are needed. j ust make a copy of this hl:mk form for t~W-

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PART4

PERSONNEL AND TRAINING

CREDENTIALING . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
CLINICAL PERFORMANCE ENHANCEMENT . . . . . . . . .
PROFESSIONAL DEVELOPMENT. . . . . . . . . . . . . . . . . .
HEALTH TRAINING FOR CORRECTIONAL OFFICERS .
MEDICATION ADMINISTRATION TRAINING. . . . . . . . . .
INMATE WORKERS .. . .. ..... .... ..... ........ ..
STAFFING PLAN. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
HEALTH CARE LIAISON.. . .. .. . . . .. . . . . . .. . . . . . . .
ORIENTATION FOR HEALTH STAFF .. . .. . . .. . . . .. . ,

2
2
3
4
5
6
7
8
8

Acknowledgment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

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CREDENTIALING
POLICY:
SHP requires all personnel providing health care services be certified/licensed in accordance with state laws. Further t.he
corporate office will credential all certified/licensed health care workers. Copies of all licenses are to be kept on file by the
MTA il'I a secure location within the medical unit. All other personnel d6cuments must be sent to the corporate office for
confidential safekeeping under HIPAA and company regulations.
PROCEDURE;
Al U,e start or the hiring process, eacl1 SHP employee and/or fndependent contractor will be asked to complete an
Application for Employment or Application for Medir.al Slaff Membership, respectively. The information gathered from
these completed documents t'lill be used by the corporate office to verify current licenses heltl, references, etc.
The MTA and/or the SHP corporate Human Resources department staff Will verify via telephone or internet serl/ice[s) the
current medical license Rnd given references prior lo the applicant's slilrt dale. At no lime should a person be hired1
with@ul having lheir medical license verified within the slate or without notifying the Jail Ad,ninistrator of the applicant or
without the approval the SHP Human Resources Department. 1he applicant must show the aolual medical license held,
not a copy, A copy can lfien be made of the license and kept on file appropriately.
The corporate HR Department will also search under applicable child and sexual abuse registries.
The Jail Administrator must be alerted prior to the hlring of any staff member, A separate credentialing and/or securitv
clearance may be required in order for access into the jail. All derogatory finding:i must be report to the corporate offi,
and an offer of employment may be reversed or termirialad hRsed on those findings.
All completed original documents must be sent lo the corporate office. The only information lo be kepi in a secured site File
should be the Personnel Update Form arid a copy of the staff member's current medlcal licensure. Updates of any
information should also be sent to the corporate office for proper processing into the employee's file.
The corporate Human Resoµrces departmenl Will handle and/or request l1pdales of medical licensure on an as needed
basis. Fur(J,er, a random Qheck will be done on medlcat lfcensures lo ensure good standings and disciplinary action
findings. The MTA. will be notified of all findings and any n~ds of updates as well,
Health providers must not perform tasks beyond those permitted by their credentials and/or licensure. Any health provider
working under a restricted license which specifically limits practice to correctional institutions will not be hired by SHP.
Reference/Form(s): SHP Application for Employment; SHP Applicatiori for Medical Slaff Membership (for Physicians)

CLINICAL PERFORMANCE ENHANCEMENT

POLICY:
A clinical performance enhancement process evaluates the appropriateness of alt primary care providers' services on-site.
SHP corporate office may perform reviews to determine the appropriateness of serv1ces and care delivered at the facility
by the primary care providers, as well as ancillary staff.
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PROCEDURE:
All reviews are to be kept confidenilal and reports will be housed Ill ihe corporate office - no copy 1vill be kept on site. A short report
listll\g the names and dates or the review may be kepi by the MTA for iuture audit purposes.
The evatuation process ts a1med c1t providing the Providers and SHP staff me1nbers 1t1ill\ 'obJeclive and factual data on their palienl
care performance.

PROFESSIONAL DEVELOPM ENT
POLICY:
SHP recommends atl health care professionals wnl receive initial and participate annually in continuing education in their
Reid as well as retraining in CPR as stated by stale law.

- --

PROCEDURE!
The MTA may establish on•site training classes for participation by medical staff. The trafning wilt be documented
,consfstiAg-0f..aeot.1cse..outlioe..atld-Elttendance...i:oster. Jbe est:aWisbedJra1nlng program may be provided one (1) .bo.LtJ:...,.p_e_
r_
month and is.scheduled by topic, time, place, dale, and speaker. The program requires attendance ifU,e subject matter is
essential lnform11tion and mandatory compliance by SHP corporate office. SHP will provide and/or reimburse CPR training
which is required for all health care staff members. An approved certified Instructor must provide CPR training {American
R~d Cross, An1e1 ica11Hearl Ass()ciatfon, t:tc.). A coµy uf lhe1 CPR l.'a1tl il;sueu lu t::ach e111ptuyet1 111usl l,e µ1uvju~u lv l11t::
corporate office.
Adc1i(lonally, general staff meetings will be held a~ ut:t:ut:u, 9m1erally once per month, lo ensure communica~on ot
important information lo all employees. Minutes will be kept for all in-services and staff meetings, with copies dlstrlbuted to
all employees. The SHP corporate office will provide discussion topics and materials lo the siles on a <:onsistent basis.
The MTA will be responsible for distribution of such materials and/or seWng up meeting times to discuss such topics with
medical staff.
The corporate office HR department will issue Monthly Training Topics via the SHP webslte, Web-based training
participation is tracked per Individual user login, A stgn-in roster will need to be completed as verification of participation
for any additional persons in attendance if training is taken during the monthly staff meeUngs.
CEU's may be granted for some on-site training classes - the MTA should check w1th the State Nursing Board for
oompllance and fssuance of credits, if available. State CEU compliance for maintaining medical licensure is the
responslbllity of1he individual, not SHP.
Also, SI-IP corporate office has videos whlc)l may be Used for CEU training .is well. Coordination of security CEU's In !his
regard must be communicateci through the Jail Administrator and lhe SHP corporate office.
The following publications must be maintained on-site in the medical unit for healll, servic.e employees lo review or to use
as a reference guide when needed:
Medical Dictionary; Nursing Drug Book/Physicians Desk Reference; SHP Corporate Manuals
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HEALTH TRAINING FOR CORRECTIONAL OFFICERS
POLICY:
SHP will provide heallh training for correctional officers based on the services to oo provided by SHP at the facility upon
their effective date. Ongoing health training will be provided upon request by the County to SHP, and training malerials will
be sent to the facilities in mailings on a quarterly basis.

PROCEDURE:
All correctional•officers al the facility should have received training whicn includes first-aid, CPR, and screening techniques
to recognize signs and symptoms of chronic and emergent conditions through their employer, the County. By most
standards, health training will be performed at least every 2 years, if not sooner, and may be audited by the Jail Inspector.
SHP will ensure officers are to be lnstructec/ on how lo summon medical personnel In the event of an emergency.
SHP requests sufficient numbers of correctional officers be CPR trained by its staff to allow a min1mum of 1 trainerl stall
member per shift. This Will help in responding to man-down emergencies when medical staff need help, or in lhe chance
medical stali are not on-site.
All training programs provided by SHP must be documented. For in person training by SHP staff, a sign in roster will be
made available for partlcfpants. Acopy of this roster form will be sent to the SHP corporate office, Attn: Operallons, and
the original form will be given to lhe Jail Training Coordinator as proof or attendance and participation.
Upon request by the Jail Administrator to SHP, lhe MTA and/or Regional Representative shall coordinate training on lht
topics listed below u,rough their Region Representative. These training topics may be provided in written form, WebEx. or
in person training. As a reminder, SHP sends written Correctional Officer Tra1ning Material Topics In quarterly letters to
the Jail Administrator. Topics:
•
•
•
•
•
•
•
•
•
•
•

First Aid;
Su1cide Prevention;
CPR:
AEDUse;
Intake Screening Techniques:
Recogntzing an Emergency;
Medication Administration;
Recognizlng chronic condttionsfillnesses;
Signs and Symptoms of Mental Illness;
HIPPA & Confidentiality;
Infection Control and BloodBorne Pathogens

Further, the MTA and medical staff should participate in tlie on•going training program currently set-up through the Facillly,
whenever availaole lo do so.
Reference:

SHP Correctional Officer In-service Malerials; Correctional Officer TraihinQ Roster Form

PM 4- Personnel andTraining
Effective: October 15, 2014
Page: 4
Confidential Work Product or Sou1J1ern Heallh Partners, Inc. - SHP Polley and Procedure Manual ror Heallh Services in Jails

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Policy and Procedure Manual for Health Services Jn Jails
MEDICATION ADMINISTRATION TRAINING
POUCY:
SHP requires only those individuals who are qualified to propeny administer medication. SHP will provide training to the
personnel who deliver medication II personnel are not licensed health care providers. Medications are passed as per
facilily procedure. Policy requires all adrninistefed medications be recorded on a Medication Administration Record form.
All medications are passed purs1,1ant to direct medical ordern or telephone medical orders signed by the
Physician/Physician Provider or, in the case of over-the-counter medications, pt.1rst1anl to eslablished recommendatrons for
administration.
PROCEDURE:
The MTA will admi11ister lhe SHP training course and test to all personnel whose responsibilities and duties include the
passing of medication to an inmate patient. This !raining will be reviewed and updated by the MTA as necessary. Upon
intake, verify all medications presented with the patient lhrough lhelr pharmacy and/or prescribing Physician/Physician
Provider. II a patient's medications are unable lo be verified, the site Physician/Physician Provider should evaluate the
patient before medications are administered. The site Physician/Physician Provider may ctiange a patient's current
medication to a generic form, or adjust medicallon due to a patient's history.
The Physician/Physician Provider will establish the applicable medication pass times in accordance with the prescribed
medication. All administered medications must be recorded on a Medication Administratton Record (MAR) form .
Medication passes may vary from site to site due to security restraint and/or policles. so alter lhe procedure to best fit the
facil1ty. Due lo security constraints, unforeseen emergencies, etc. medications may be passed within 1 hour of the
prescription time.
A drug handbook sliould be made available to all staff that are passing rnedicatlons. Any questions regarding the passing
of medications or the types of medications should be referred lo the MTA for discussion. If officers are used at the site to
pass medications, lhe medical staff w1U provide assistance and/or training to those offioers.
other issues to be discussed are procedures for hoarding of medlcations, common side effects, refusal of medications and
overdoses.
Sick call is nol lo be pe1formed during med pass limes. The nurse can and may take sick call slips from the inmate patient
patienls during med pass, but no services (unless ernergenU should be performed during med pass time. Ah officer must
accompany the nurse during U1e. med pass. Medications will not be administered without a P)1yslcian/Physlc1an Provider's
order. All refused or missed medication must be noted and deslroyed in the proper state l11w format for pharmaceuticals.
The nurse may distribute the inmate patient patient's medicatton directly 'from the blister pack into the medicine cup and/or
medicine packet. The Inmate patients should line up wilh a cup of water lo receive !heir medication. Upon calling the
Inmate patient's name and verifying that it is the inmate patient, the nurse can then distribute the medication to the inrnale
patient, noting the distribution on the MAR form. If the inmate patient does not present himself up0n being called, the next
name will be called.
All narcotic and controlled substance medications are to be counted at each shill and noted on the Narcotic Count Sheel.
All Sharps (needles, lancets, etc,) must be counted on each shill and noted on Ille Shams Inventory Control Sheet.
Part 4 - Personnel and Training
Effective: October 15, 2014
Page: 5
Confidential Work Product of Southern Heallh Partners. Inc. - SHP Policy and Procedure Manual for Heallh Services inJails