13-748

[ Authorization for Release of Protected_Health ·Information
Inmate/Resident Name _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

I

Date of Birth

----------

Inmate/Resident # _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Facility Name _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
I authorize Corrections Corporation of America to use or disclosure of PHI to:
(Name)

(Address)

Specific description of the information to be used or disclosed to include treatment dates:

following

the

For

purpose:

including the following portions of the record(s):

D

All Records
Information

D

Lab Tests Only

D

Addiction Treatment

D

Psychiatric Records

0

All HIV

I understand that the information used or disclosed may be subject to re-disclosure by the person(s) or class of
person(s) receiving it and no longer protected by the Federal privacy regulations .
I understand that I may revoke this authorization by notifying
in
writing of my desire to revoke it. However, I understand that if I revoke this authorization, it will not have any
affect on actions taken by Corrections Corporation of America in reliance on it before I revoked it.
I understand that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to
obtain treatment.
I understand this authorization will expire on (check and complete one):

D
D

120 days from the date below and covers only treatment prior to that date.
On the happening of the following event that relates to me or the purpose of the use of disclosure:

CCA is released and discharged of any liability, and the undersigned will hold the company, its employees ,
agents, and contractors harmless for complying with this information request.
I understand that CCA may assess a charge for photocopying of records which I may be required to pay
prior to receipt of the records.

Signature of Inmate or Personal Representative
(If Personal Representative, please attach proof of such)

Print Name

Date
Property of Corrections Corporation of America

MAR 2006

13-748

NOTICE to person or agency receiving information: Federal laws and regulations prohibit further disclosure
of the information whose confidentiality is protected in the absence of specific authorization of the inmate or
his/her personal representative .

Property of Corrections Corporation of America

MAR 2006

3-23A

Employee Authorization for Release of
Protected Health Information
Name of Employee _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Social Security Number (for identification purposes only) _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Facility Name _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
I authorize the disclosure of the following protected health information :
•
•
•
•
•
•
•

Post-offer employment physical
T8 Screening Information
Hepatitis 8 Vaccine Information
Treatment for on-the-job injury
PPE-respirator screening
SORT Team evaluations
Other (please describe) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

During my employment with CCA, I may receive medical treatment from CCA's health services
providers to include the following: post-offer employment physical, T8 screening, Hepatitis 8
Vaccines, and/or treatment for on-the-job injuries.
I understand that the information used or disclosed may be subject to redisclosure by the person(s)
or class of person(s) receiving it and may no longer be protected by the Federal privacy regulations.
I understand that I may refuse to sign this authorization and that my refusal to sign will not affect my
ability to obtain treatment.
However, my refusal to sign the authorization may affect my
employment with CCA in that the release of this information is necessary for employment-related
purposes.
I understand that I may revoke this authorization by written notification to the person or department
designated by CCA. Any action taken by Corrections Corporation of America in reliance on this
authorization will not be affected if I revoke the authorization in the future.
I understand this authorization will expire if the processing of my application does not result in
employment with CCA or, if I become employed, upon the termination of my employment with CCA
and closure of any related matters that may be pending at that time.

Signature

Date

Property of Corrections Corporation of America

JULY 2006

CC!.

POLICY
TITLE
CHAPTER

Suicide Management/Risk Reduction

13

I

POLICY
NUMBER

13-84

1

EFFECTIVE DATE

SUPERSEDES DATE

CORRECTIONS CORPORATION OF AMERICA

JUL Y 17, 2006

JANUARY 1, 2005

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

FACILITY
NAME

SIGNA TURE ON FILE AT FACILITY SUPPORT CENTER
Richard P. Seifer

Page

1 of 8

LEE ADJUSTMENT CENTER

FACILITY EFFECTIVE DATE

FACILITY SUPERSEDES DATE

SEPTEMBER 15, 2006

AUGUST 1, 2006

Executive Vice President/Chief Corrections Officer
SIGNA TURE ON FILE A T FACILITY SUPPORT CENTER
G.A. Puryear, IV

Executive Vice President/General Counsel

13-84.1 POLICY:
Every CCA Facility will have a Suicide Management/Risk Reduction Training Program. The program will
be implemented by trained qualified Health Services Staff.
13-84.2 AUTHORITY:
CCA Company Policy
13-84.3 DEFINITIONS:
Licensed Independent Practitioners (LIP) - Physicians, Physician's Assistant, Advanced Registered
Nurse Practitioner, Dentist, and Psychiatrist. Each LIP shall perform duties according to the state scope
of practice guidelines.
Licensed Mental Health Professional (LMHP) - Psychiatrist, Psychologist, Licensed Clinical Social
Worker, and other individuals with appropriate mental health licensure in accordance with state scope of
practice guidelines.
Qualified Health Services Staff (QHSS) - Includes physicians , physician assistants, nurse practitioners,
nurses, dentists, mental health professionals, and others who by virtue of their education, credentials,
and experience are permitted by law within the scope of their professional practice acts to evaluate and
care for patients .
Self-Injurious Behavior - Actions that result in self-harm.
Suicidal - Pre-occupation with thoughts of self-harm or actively engaging in behavior that is likely to
cause serious bodily harm, with the intended and explicit purpose of ending one's life.
Suicidal Gestures - Statements, threats and behavior that suggests thoughts, intent or plan to harm
oneself.
Suicide Precautions with Constant Observation -Twenty-four (24) hour direct one-on-one observation
(per written order of a psychiatrist, physician, or mid-level practitioner) of inmates/residents who are
actively suicidal as evidenced by engaging in behavior that is likely to cause death.
Suicide Precautions without Constant Observation - Twenty-four (24) hour observation (per written
order of a psychiatrist, physician, or mid-level practitioner) of inmates/residents who are engaged in
suicidal ideation, verbal threats, self-harm, or who exhibit self-injurious or destructive behavior, or
demonstrating other concerning behaviors. This type of observation requires staff to be present, within
sight or sound distance, and to perform direct visual observation on a varied schedule of one (1) minute
to fifteen (15) minutes but not to exceed fifteen (15) minutes .
13-84.4 PROCEDURES:

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JULY 17, 2006

13-84

PROCEDURES INDEX
SECTION
A
B
C
D
E
F
G
H
I
J

A.

SUICIDE PREVENTION PLAN
1.

B.

SUBJECT
Suicide Prevention Plan
Training
Initial Identification/Screening
On-Going Identification/Screening
Intervention
Suicide Precaution Levels
Downgrading and Discontinuation
Safe Housing
Transfer
Fo"ow-Up

Each facility wi" develop a Suicide Prevention Plan that addresses specific facility
initiatives and the facility's plan for compliance with this policy. The 13-84AA Suicide
Prevention Facility Risk Assessment (Sample) may be used as a guide for the
development of the Suicide Prevention Plan. At a minimum, the Suicide Prevention
Plan wi" include:
a.

Facility overview addressing facility size, population, annual intakes, and other
facility facts that may be relevant in developing the plan;

b.

Areas of focus needing improvement;

c.

Program structure to include coordinator, facility multi-disciplinary taskforce,
meeting schedules, drills, and other structural aspects of the facility program ;

d.

Monitoring and quality improvement activities; and

e.

Pre-service and in-service training plans.

2.

The facility Suicide Prevention Plan requires review and approval from the FSC
Regional Director, Health Services and the Warden/Administrator.

3.

Each facility will conduct an annual review of the Suicide Prevention Plan. The plan will
be updated as necessary utilizing a risk assessment process to identify areas of
potential risk and target the facility plan toward continuous improvement. Revisions to
any approved Suicide Prevention Plan require review and approval from the FSC
Regional Director, Health Services.

TRAINING
All facility personnel receive training during pre-service orientation and at least annually in inservice training on the following:
1.

Facility Suicide Prevention Plan;

2.

Identifying the warning signs and symptoms of impending suicidal behavior;

3.

Understanding the demographic and cultural parameters of suicidal behavior, including
incidence and variations in precipitating factors;

4.

Responding to suicidal and depressed offenders;

5.

Communication between correctional and health services staff;

6.

Referral procedures;

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C.

13-84

JULY 17, 2006

7.

Housing obseNation and suicide watch procedures;

8.

Follow-up monitoring of inmates/residents who make a suicide attempt; and

9.

Avoiding obstacles (negative attitudes) to prevention.

INITIAL IDENTIFICATION/SCREENING
1.

At the time of receiving inmates/residents, the receiving personnel will make every effort
to obtain information from the arresting and/or transporting officer(s) regarding their
assessment of the inmate/resident's medical, mental health, or suicide risk to include
any obseNed behavior. The type of information requested should include :
a.

Whether the inmate/resident appeared to be under the influence of alcohol or
drugs;

b.

Whether the inmate/resident or other individual was making any comments that
would be cause for concern;

c.

Whether the inmate/resident appeared to be overly ashamed, embarrassed,
scared, depressed, or exhibiting bizarre behavior;

d.

Whether there were any facts or circumstances surrounding the arrest and/or
alleged crime that would suggest the inmate/resident to be a suicide risk;

e.

Whether the inmate/resident received a sentence; and

f.

Any other information that may be helpful.

NOTE: The 13-8488 Arresting/Transporting Officer Questionnaire may be used as a
guide for obtaining and documenting appropriate medical, mental health, or
suicide risk information.
In the event the assessment reflects medical, mental health, or suicide risk, the
receiving officer will notify the health service department immediately.
2.

D.

An initial mental health screening will be performed by health trained or qualified health
seNices staff upon inmate/resident arrival to the facility .
a.

Inmates/residents will be screened utilizing the 13-508 Intake Mental Health
Screening Form . Screening will include inquiry regarding past suicidal ideation
and/or attempts; current ideation , threat, plan; prior mental health
treatment/hospitalization; recent significant loss Uob, relationship , death of
family member/close friend, etc.); history of suicidal behavior by family
member/close friend; and suicide risk during prior confinement.

b.

The 13-508 Intake Mental Health Screening form is a screening inventory and
IS NOT the only guide for referral to mental health seNices .

c.

The inmate/resident's prior medical, mental health, and suicide risk during prior
confinement will be verified through either manual or management information
system review.

3.

During the full health appraisal , the LIP will evaluate any signs, symptoms, or
information received by the inmate/resident that may necessitate a referral to mental
health staff.

4.

A comprehensive mental health evaluation will be completed in accordance with CCA
Policy 13-61 Mental Health SeNices.

ON-GOING IDENTIFICATION/SCREENING

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13-84

JULY 17, 2006

1.

Any staff member identifying an inmate/resident who appears to be potentially suicidal
will complete a 13-618 Referral for Mental Health or Chemical Dependency Services
form and immediately forward it to health services staff.

2.

Correctional Officers or other personnel are to immediately advise the Unit Manager
and/or Shift Supervisor of any potentially self-destructive behavior (related to potential
suicide) displayed by the inmate/resident. Health Services staff will receive immediate
notification of such behavior.

3.

If an inmate/resident declares a Psychological Emergency, the Shift Supervisor will be
advised . The Shift Supervisor will notify the appropriate OHSS.

4.

In ALL cases of attempted suicide, security personnel will immediately notify health
services staff and the Warden or Administrative Duty Officer.
AT THIS FACILITY
FOLLOWS:

ADDITIONAL

NOTIFICATION

PROCEDURES

ARE

AS

1ST Notification:

Kentucky DOC Duty Officer (for Kentucky inmates only)
Vermont DOC Out-of State Unit (for Vermont inmates only)
CCA Facility Support Center (refer to CCA Policy 5-1
requirements)

for notification

2 nd Notification OR after regular hours:

Kentucky DOC Duty Officer (for Kentucky inmates only)
Vermont DOC Out-of State Unit (for Vermont inmates only)
CCA Facility Support Center (refer to CCA Policy 5-1
requirements)

5.

E.

for notification

Due to the strong association between inmate/resident suicide and special
management housing assignment (e .g. disciplinary, administrative, or protective
custody segregation), any inmate/resident assigned to a special management unit will
receive a pre-segregation health evaluation (See CCA Policy 13-42, Health Evaluations
for Pre-Segregation/Segregation Access to Health Care) for early detection of potential
suicide risk.

INTERVENTION
1.

In the event information obtained during the initial intake process , observation, history,
or interview information suggests that an inmate/resident is potentially suicidal, the
OHSS will be immediately notified. The following steps may be directed by the OHSS
and implemented by appropriate staff:

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JULY 17, 2006

a.

2.

F.

13-84

Inmate/resident may be temporarily held or housed in a cell that is as suicide
resistant as is reasonably possible (free of all obvious protrusions and provides
full visibility to staff) and placed on Suicide Precautions. Appropriate referral
will be made to mental health staff for further evaluation/directions.

Procedures Following a Suicide Attempt
a.

Any correctional officer or other staff member who discovers an inmate/resident
engaging in self-harm shall immediately survey the scene to assess the
severity of the emergency, alert other staff to call for health services staff,
retrieve the housing unit's first aid kit and cut-down tool; and begin standard
first aid and/or CPR as necessary.

b.

The first responder shall always enter the cell and initiate appropriate lifesaving measures. Further, staff shall never presume that the victim is dead, but
rather initiate and continue appropriate life-saving measures until relieved by
arriving medical personnel.

c.

Although not all suicide attempts require emergency medical intervention, all
suicide attempts shall result in immediate intervention and assessment by
qualified health services staff.

SUICIDE PRECAUTION LEVELS
1.

When observation, history, or interview suggests that an inmate/resident is potentially
suicidal or following a suicide attempt, the following steps are to be implemented by
QHSS .
In the absence of QHSS, the Warden/Administrator, Assistant
Warden/Administrator, Chief of Security, or Shift Supervisor will implement the following
steps:
a.

The inmate/resident will be placed on SUICIDE PRECAUTIONS:
•

In order to provide immediate safety, QHSS will place an
inmate/resident on suicide precautions upon recognition of or
notification of suicidal ideation/behavior. The appropriate LIP will be
notified and an order will be written in the chart with a SOAP note
detailing reasons for placement.

•

Suicide precautions with or without constant observation may be
authorized by a Licensed Independent Provider who has order-writing
privileges. The inmate/resident will be evaluated by an LMHP as soon
as reasonably possible but within forty-eight (48) hours of placement.
At that time, the LMHP will develop a plan of care for the
inmate/resident that will include at least daily assessment by the LMHP
or QHSS.

•

Initially inmates/residents will be placed in a cell that is as suicide
resistant as is reasonably possible (free of all obvious protrusions and
provides full visibility to staff). Personal belongings , objects, and
clothing that could be used in a suicidal manner are to be initially
removed. When clothing is removed from a suicidal inmateiresident,
the inmate/resident will be issued a safety garment or other protective
clothing that is suicide resistant and prevents humiliation and
degradation . Finger foods only, eating utensils will not be permitted
•

Upon assessment from an LMHP, certain personal belongings
that could not be used in a suicidal manner may be returned to
the inmate/resident.

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Page 6 of 8
•

b.

G.

13·84

The inmate/resident's behavior will be observed and documented by
staff on the 13-63A Observation Monitoring form.
•

Inmates/residents under suicide precautions with constant
observation will have twenty-four (24) hour direct one-on one
observation.

•

Inmates/residents under suicide precautions without constant
observation will have twenty-four (24) hour observation with
staff present, within sight or sound distance. Observation will
include direct visual observation on a varied schedule of one
(1) minute to fifteen (15) minutes but not to exceed fifteen (15)
minutes.

Use of soft restraints and protective helmets may be authorized by the LIP or
by QHSS with verbal approval from the LIP. Written orders must be secured
within twenty-four (24) hours. RestrainUEquipment use must be in accordance
with CCA Policy 13-69, Personal Restraint. QHSS are to use the least
restrictive management orders that are consistent with clinical conditions.

DOWNGRADING/DISCONTINUATION
Inmates/residents under suicide precaution with or without constant observation may not be
downgraded or discharged from suicide precautions until an LMHP reviews the
inmate/resident's healthcare record, confers with correctional personnel regarding the
inmate/resident's behavior, assesses the inmate/resident, writes a progress note, develops
and/or updates a written plan of care, and writes an order to remove the inmate/resident from
suicide precaution or level of precaution. The LMHP will communicate with the appropriate LIP
to confer on the inmate/resident's status. In the event that the state does not permit orders by
an LMHP, the LIP will write the order based on the LMHP consultation and recommendation.

H.

SAFE HOUSING
Any inmate/resident placed on suicide precaution shall be housed in a cell that is as suicide
resistant as is reasonably possible, free of all obvious protrusions, and provides full visibility to
staff.

I.

TRANSFER
In the event an inmate/resident on suicide precaution is being transferred from the custody of
CCA, the inmate/resident's suicide precaution status will be documented on the 13-86A
Transfer In/Transfer Out Screening form and the 13-868 Special Instructions for Transporting
Officers form to ensure continuity of care.

J.

FOLLOW-UP
1.

In order to ensure continuity of care for suicidal inmates/resident, all inmates
discharged from suicide precautions shall remain on the mental health caseload and
receive regularly scheduled follow-up assessments by mental health staff until the
inmate/resident is transferred or released from the facility. Unless the inmate/resident's
individual treatment plan directs otherwise, the reassessment schedule shall be as
follows: daily for the first five (5) days, then once a week for two (2) weeks and then
once every month until the inmate/resident is released from treatment by the LMHP. In
the absence of an LMHP, follow-up assessments may be performed by an LIP.

2.

Mortality and Morbidity Review Process

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13·84

JULY 17, 2006
a.

All completed suicides and suicide attempts requiring outside medical treatment
shall be examined through a mortality and morbidity review process in
accordance with CCA Policy 13-52, Quality Management Program.

b.

The review shall be multidisciplinary and include correctional , medical, and
mental health personnel.

c.

The review process shall include a critical inquiry of the following :
i.

Circumstances surrounding the incident;

ii.

Facility procedures relevant to the incident;

iii.

All relevant training received by involved staff;

iv.

Pertinent medical and mental health services/reports involving the
victim;

v.

Possible precipitating factors leading to the suicide or serious attempt;

vi.

Recommendations, if any, for changes in policy, training, physical
plant, medical or mental health services, and operational procedures.

Critical Incident Debriefing

3.

Health Services staff will participate in critical incident debriefings as described in eCA
Policy 5-1, Incident Reporting . The Chaplain , mental health staff or appropriate
designee will provide debriefing to staff and inmates/residents who are affected by
critical incidents at the facility .

13-84.5 REVIEW:
The Chief Medical Officer or qualified designee will review this policy on an annual basis.

13-84.6 APPLICABILITY:
All CCA Facilities (Provided contractual requirements do not mandate otherwise)

13-84.7 APPENDICES:
13-84AA

Suicide Prevention Facility Risk Assessment

13-8488

Arresting/Transporting Officer Questionnaire

13-84.8 ATTACHMENTS:
13-508

Intake Mental Health Screening

13-618

Referral for Mental Health or Chemical Dependency Services

13-63A

Observation Monitoring Form

13-86A

Transfer In/Transfer Out Screening

13-868

Special Instructions for Transporting Officers

13-84.9 REFERENCES:
CCA Policy 5-1
CCA Policy 13-42
CCA Policy 13-50
eeA Policy 13-52

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13-84

JULY 17, 2006

CCA Policy 13-61
CCA Policy 13-63
CCA Policy 13-69
CCA Policy 13-86
ACA

4-4373M/4-ALDF-4C-32M/3-JTS-4C-37M/3-JCRF-4C-06
4-4416/4-ALDF-4C-33

NCCHC P-G-05E/J-G-05E
JCAHO EC .1.10
EC .1.20
PC .5.60

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13-84AA

Suicide Prevention Facility Risk Assessment
Date: _________________________________

Facility: __________________________________________

Coordinator: ___________________________

VVarden: _________________________________________

This tool is intended to assist you in assessing your suicide risk , with the sole purpose of identifying strengths,
weakness, threats, and opportunities to improve the capability of the facility to prevent suicides in the correctional
setting .
1.0

FACILITY ASSESSMENT OF ISOLATION MANAGEMENT ROOM(S)
1.1

VVhen inmates are placed into suicide precautions, where are they housed?

0
0
0
1.2

0
0
0

medical observation
segregation
other

(specify)

Sometimes
Sometimes
Sometimes

0
0
0

Always
Always
Always

For each of the locations used (as listed above), please complete the following checklist. (Note: this
checklist is consistent with and modified from Florida DC4-527)

CHECKLIST FOR REVIEW OF ISOLATON MANAGEMENT ROOM I OBSERVATION CELL
Location:

o

Medical Observation

o

o

Seg

Reviewer (Printed NamelTitle): ___________________

Yes

Review Item
1.

2.

3.

4.

No

Date:__________________

Other

Cell Number.:..:_ _ _ _ _ __

N/A

Comments

a. The door is made of solid hardwood or metal and has a shatterresistant observation window (e.g., made of Lexan® vs. glass)
that permits easy scanning of the room.
b. Sliding door cannot be easily blocked or tied shut.
c. Interior hinges that are >18 inches above the floor are flushmounted or retractable or have been modified with epoxy (or in
some other fashion) in order to keep the patient from utilizing it
to securely anchor any kind of noose.
d. The door lacks features that are higher than 18 inches from the
floor to which cloth or other material may be securely hung or
tied.
e. Standard cell doors (with bars) are fully shielded from the inside
with Lexan® or wire mesh having holes not larger than 3/16"
The floor and walls are solid, smooth, and high-impact resistant.
They also lack metal or other protrusions. Walls lack features that
are higher than 18 inches above the floor to which cloth or other
material may be securely hung/tied.
Tile and baseboards, when present, are securely attached.
The ceiling is solid and lacks features to which cloth or other material
can be securely tiedlhung or, if present, such features are at least
ten (10) feet above the floor.

Property of Corrections Corporation of America
JUL Y 2006

13-84AA

Yes

Review Item
5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

No

N/A

Comments

Vents are covered with small wire mesh or a metal plate (with holes
not larger than 3/16") in a manner that cloth or other material cannot
be securely tied to or hung from the vents. Space around the vent
frame is sealed with hard epoxy or other suitable substance to
prevent placing of cloth or other material between the vent frame
and the wall or ceiling. Vents have no exposed sharp edges or, if
present, such features are at least ten feet (10') above the floor.
Lighting is recessed and covered with shatter-resistant material or, if
not recessed, is contained in a security-rated fixture that is smooth
and installed in such a manner that cloth or other material cannot be
securely tied to or hung from fixture. No space exists between the
fixture and the ceiling/wall. Hard epoxy or other material that cannot
be easily removed was used to fill space between fixture and ceiling.
The light fixture does not possess features to which cloth or other
material can be securely tied or hung or, if present, the fixture is at
least ten feet (10') above the floor.
Sprinklers are not within reach of the inmate from floor or are
recessed in a cone-shaped housing or other housing to which cloth
or other material cannot be securely tied/hung; nonrecessed
sprinkler is out of the inmate's reach and is connected to a coupling
that would separate under 70 Ibs. of weight No space exists
between the base of the housing and the surface to which it is
attached . Hard epoxy or other material that cannot be easily
removed was used to fill space between fixture and ceiling .
Windows are made of shatter-resistant material or are covered with
security-rated screens or other material (e.g., Lexan®) that prevent
access to the glass. Holes in security-rated screen are not> 3/16"
inch. Window cranks are flush with frame.
Toilet and sink are made of metal. They are also smooth and lack
features to which cloth or other material can be securely tied or
hung. Fixture(s) is (are) mounted against the wall and water shut-off
valve is outside the room.
Smoke detectors, when present, are at least ten (10) feet above the
floor or are recessed in wall/ceiling or are enclosed in small wire
mesh or other suitable housing that prevents access to the smoke
detector. The wire mesh or other enclosure has holes that are not
larger than 3/16" and lacks features to which cloth or other material
can be securely tied/hung.
Electrical outlets are not present Electrical switches, e.g. , to adjust
lighling, are secure to the point that inmate cannot access wiring.
Switches do not protrude so far as to be used to inflict serious injury.
Beds, when present, have solid bottoms and are secured to the floor
or wall so that inmate cannot stand upright All other surfaces are
smooth so that cloth or other material cannot be securely hung or
tied. Beds are not more than 18" above the floor if the beds have
features to which cloth or other material can be securely hung or
tied.
A plastic-covered or other washable mattress (except cloth) with
triple stitching is available for immediate use in each room. The
mattress is intact, with no tears or loose stitching.
Three (3) triple-stitched, heavy canvas (weight #12) or other tearresistant blankets are available for immediate use in each room.
Blankets are intact, with no tears or loose stitching.

Property of Corrections Corporation of America
JUL Y 2006

13·84AA

Yes

Review Item

No

NJA

Comments

15. At least three (3) privacy wraps are available for immediate use in
each room at institutions where male inmates are housed. Wraps
are at least 30 inches wide and made of triple-stitched, heavy
canvas, or other tear-resistant material. Wraps are intact, with no
tears or loose stitching. At least ten (10) paper gowns or three (3)
gowns made of canvas or other tear-resistant material are available
per room for immediate use at institutions where female inmates are
housed.
16. The institution has a written procedure ensuring that blankets and
privacy garments are cleaned and treated for fire retardation after
each episode of use or after three (3) consecutive days of use.
Application of fire retarding chemicals is not required on
blankets/garments made of fire-resistant materials (as reported by
the manufacturer).

2.0

FACILITY HISTORY
2.1 Number of suicides at our facility

2002
2003
2004
2005
2006 YTD
TOTAL
2.2 Number of suicide attempts at our facility requiring transport to an emergency room

2002
2003
2004
2005
2006 YTD
TOTAL

2.3 Location of prior year suicides and attempts requiring transport to an emergency room
in medical observation
in segregation
in GP
in other _ _ _ _ _ _ _ (specify)

2.4 Major findings from the past year in the "after action" and Mortality and Morbidity Reviews
a) _________________________________
b) _ _ _ _ _ _ _ _ _ _ _ _ _ _ ___

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JULY 2006

13-84AA

c).
d) ________________________________

2.5 Corrective Actions (List)
Actions

3.0

ComQleted
Yes

No

a) _________________________________

0

0

b) ________________________________

0

c)

0

0
0

d) ______________________________

0

0

STAFFING

3.1 Total Staff by category
Correctional

Non-correctional

Correctional

Non-correctional

Budgeted Hrs.

Filled Hrs.

# of FTE's - Budgeted
# of FTE's - Filled
Variance

3.2 Turnover Rate

3.3 Mental Health Staff
Variance

Psychiatrist
Psychologist
Mental Health Coordinator
Mental Health Counselor
3.4 Mental Health Coverage

o
o

a)

At our facility, we have mental health coverage 7 days/week

DYes

b)

At our facility, we have mental health coverage 5 days/week

DYes

c)

If A & B are no, describe the mental health coverage _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

No
No

Property of Corrections Corporation of America
JULY 2006

13-84AA

3.5 Do you have Unit Management at your facility?

DYes

D

No

If yes, describe _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

4.0

FACILITY GENERAL INFORMATION
4 .1 Capacity and count
Category

# of Beds

Jail
Prison
Detention Center

4.2 Intake turnover
a) At our facility we have ____ intakes and ____ releases per month
b) At our facility inmates intake to the facility:
D On regularly scheduled days (Specify) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

D 24/7
D During the week but not holidays and weekends
4.3 Transportation
a) We average _ _ _ _ _ _ _ _ _ _ court runs/week . Averaging _____ inmates per run

5.0

MEDICAL
5.1 All intra-system transfers have completed transfer information
including an assessment of mental health status.

DYes

D

No

DYes

D

No

DYes

D

No

DYes

D

No

5.2 Pre-seg evaluation includes a documented review of mental
health history and mental health history.
5.3 a) There is a call-out system for mental health
b)

Mental health call-out is completed and/or inmate counseled

5.4 Psychotropic medication use
a)

% of inmates on psychotropic meds

b)

% compliant
Property of Corrections Corporation of America
JULY 2 006

13-8488

Arresting/Transporting Officer Questionnaire
Facility: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Inmate/Resident Name:

o
o

New Inmate

-----------o

Return from Medical Consult

o

Inmate/Resident Number: _ _ _ _ _ __
Return from Court
Return from Special Appointment

1.

Does the inmate appear to be under the influence of alcohol or drugs?

DYes

DNo

2.

Has the inmate made any comments (e.g. , ''I'm going to kill myself," "I want
to die ," "I have nothing to live for," "Everyone would be better off without me
around") or engaged in any behavior that would be cause for concern?

DYes

DNo

Has another individual with knowledge of inmate informed you and/or made
comments that suggest that inmate is potentially suicidal and/or has a history
of suicidal behavior, has a history of mental illness, has medical problems,
or is under the influence of alcohol and/or drugs?

DYes

DNo

Does the inmate appear to be overly ashamed, embarrassed , scared,
depressed, or exhibiting bizarre behavior?

DYes

DNo

DYes

DNo

DYes

DNo

DYes

DNo

3.

4.

5. Are there any facts or circumstances surrounding the arrest and/or
alleged crime that may suggest the inmate is potentially suicidal?

6. Was inmate sentenced?
If yes, sentence_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

7.

8.

Do you have any other information that would be helpful to us while
the inmate is confined in this facility?

Comments :

Completed by

---------------------------------

Date

If answer is yes to any of the above,
please notify the Health Services department immediately.
Property of Corrections Corporation of America

JULY 2006

13-508

Intake Mental Health Screening
Inmate/Resident Name: _ _ _ _ _ _ _ _ _ __

Inmate/Resident # _ _ _ _ _ _ _ _ _ _ __

Facility: _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Date of Birth: _ _ _ _ _ _ _ _ _ _ _ _ __

Instructions:
• Explain to the inmate/resident that you need to ask questions regarding their mental health history.
• All items must be read to the inmate/resident. Do not allow inmate/resident to self-administer.
• For questions 3 through 8, ask about both past and current symptoms.
• Circle the appropriate answer.
•

If the inmate/resident gives a "YES" response to ANY of questions 2-12, you MUST refer the inmate/resident to
mental health staff for assessment. There are no exceptions to this procedure.
If the inmate/resident gives a "YES" response to question 10 or 11, make an immediate referral to mental health staff
and make sure continuous observation (suicide) watch is provided until seen by the mental health staff.

•

1.

2.

I Orientation (person, place, time) - if disoriented, please refer immediately.
Have you ever been admitted to a state or private mental hospital by a psychiatrist
or other mental health professional for emotional problems/ nerves?
when and where?
Have you ever taken medication for emotional problems, head trauma or seizures,
for mental illness, or for "nerves"? If yes, when and where?

Oriented

Disoriented

PAST
No
Yes

CURRENT

No

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

Yes

note this in the COMMENT section.

g yourself?

Comments/Observations (e.g., emotional response to incarceration): _________________
This is a screening inventory and IS NOT your only guide for referral to mental health services. You may still refer the
inmate/resident in the following circumstances:
• if you suspect that, in spite of the answers, this inmate/resident is experiencing some emotional difficulties;
• if you need additional mental health information on an inmate/resident prior to classification;
• or for reasons not listed here that you feel are important.

I Referred to Mental Health?

I No I Yes

Interviewer: ____________

I Placed on suicide precaution?

I No I Yes

Title - - - - - - - - Date/Time - - - - - - - - -

Property of Corrections Corporation of America

MAR 2006

13·61 B

Referral for Mental Health or
Chemical Dependency Services
Date:

-----------------------

Inmate/Resident Name:
Inmate/Resident No .:
Briefly describe reason for referral: ___________________________________________

Prior mental health treatment or chemical dependency (if known): _ _ _ _ _ _ _ _ _ _ _ __

Current medication (if referred by Health Services staff):

Drug :

Dose:

Compliant

0 Yes 0 No

Priority:

Emergency
ASAP
As time permits

0
0
0

Referred by:

Property of Corrections Corporation of America

JULY 2006

13·63A

Observation Monitoring Form
Date: _ _ _ _ _ _ _ __
Inmate/Resident Name: _ _ _ _ _ _ _ _ _ Inmate/Resident #

Cell Location _ _ _ _ __

Reason for Observation/Seclusion:

Ordered by: ____________

Time and Date Placed on Observation/Seclusion:

Date Renewed :___________

On Medications?
Yes
No
Frequency of checks: 0 15 minutes 0 30 minutes 0 other_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Items Allowed (Check Appropriate Line)
YES

NO

-

-

Suicide Garment
Undergarments
Suicidal Blanket
Mattress
Pillow
One Book

-

-

Smoking Materials

Notify Health Services Staff For:
1. _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ __ _ _ ___
2. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

3. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

4.________________________
5. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

6. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
7
TIME

CODE

INT'S

TIME

CODE

INT'S

TIME

CODE

INT'S

CODE EXPLANATION
1. Beating on door/wall
2. Yelling or screaming
3. Crying
4. Cursing
5. Laughing
6. Singing
7. Mumbling incoherently
8. Standing still
9. Walking
10. Lying or sitting
11. Quiet
12. Sleeping
13. Meals served/eaten
14. Fluids served/taken
15. Bath/shower
16. Toilet
17. Smoking
18.
19.

Staff Signatures

Initials

Primary Therapist
Psychiatrist/Physician

Code and signature are required on the above time lines.

INT's = Initials

Property of Corrections Corporation of America
MAR 2006

13-86A

Transfer In/Transfer Out Screening
Inmate/Resident Last Name:

DOB:

2.

3.

Inmate/Resident First Name: _ _ _ _ _ _ _ __

------

Inmate/Resident Number:

------

Diabetic:

1.

Primary Language: _ _ _ _ _ _ _ _ _ _ _ __

Time: _ _ _ __

Date:

DYes

DNa

BS:

----------------

------------------------------------

Does inmate/resident have any conditions that would prevent him/her from travel at this
time?
If yes, describe:

DYes

Will inmate/resident require any medications or treatment during transport?
If yes, describe:

DYes

Are there any special needs or instructions for transport personnel?
If yes, describe:

DYes

D No

D N/A
(Transfer In)

D No

D N/A
(T ransfer In)

DNo

D N/A
(Transfer In)

'NOTE: Complete the 13-868

4.

Have all records pertinent to the transfer of medical care accompanied the inmate/resident?
If yes, list documents:

DYes

D No

5.

Does the inmate/resident have a medical condition that could or does pose a health/ safety
threat to him/herself or others?
If yes, describe:

DYes

D No

6.

Current medications and dosage:
(Write "none" or list below)

DYes

D No

Medications sent with instructions:

1.
2.

3.
7.

Does the inmate/resident require immediate medical attention?

DYes

D No

8.

Is the inmate/resident allergic to any medications?
If yes, list:

DYes

D No

9.

Date of last TB skin test:
Action taken :

DYes

D No

Results

10.

Are there any identified nutritional risks?

11.

Current medical conditions: check all that apply
__ allergies
asthma
ulcers
HIV
diabetes
heart condition
__ weight loss
__ high blood pressure
tuberculosis

mm

__ hepatitis
_epilepsy
___ gynecological problems
mental illness or treatment

12.

Current plan of care instituted by transferring facility:

13.

Pending medical appointments and/or surgery: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Disposition:

D Cleared for transport
(Transfer Out)

D Cleared for general population
(Transfer In)

D Hold for medical

Examiner'S Signature: _ _ _ _ _ _ _ _ _ _ _ _ _ _ Title: _ _ _ _ _ _ _ _ Date: _ _ __
Property of Corrections Corporation of America

MAR 2006

13-868

Special Instructions for Transporting Officers
Date: _ _ _ __

-----

Primary Language: _ _ _ _ _ _ _ _ __

-----

Inmate/Resident First Name: _ _- - - - -

Time:

Inmate/Resident Last Name:

Inmate/Resident Number: _ _ _ _ _ _ __

DOB: - - - - -

Special Instructions to Transporting Officer: _ _ _ _ _ _ _ _ _ _ _ _ _ __

Original:

Transporting Officer

Copy:.

Medical Department

Property of Corrections Corporation of America

MAR 2006