Perf-Based Stds, Adult Corr. Inst. 5th ed March 2021

Performance Standard 6C: Offender Treatment

Confidentiality 5-ACI-6C-03 (Ref. 4-4396)

(MANDATORY) The principle of confidentiality applies to offender health records and information about offender health status.

• the active health record is maintained separately from the confinement case record • access to the health record is in accordance with state and federal law • to protect and preserve the integrity of the facility, the health authority shares with the superintendent/warden information regarding an offender’s medical management • the circumstances are specified when correctional staff should be advised of an offender’s health status. Only that information necessary to preserve the health and safety of an offender, other offenders, volunteers/visitors, or the correctional staff is provided • policy determines how information is provided to correctional/classification staff/volunteers/visitors to address the health needs of the offender as it relates to housing, program placement, security, and transport • the release of health information complies with the Health Insurance Portabil - ity andAccountabilityAct (HIPAA), where applicable, in a correctional setting

Comment : The principle of confidentiality protects offender patients from disclosure of confidences entrusted to a health care provider during the course of treatment.

Protocols : Written policy and procedure.

Process Indicators : Observation. Interviews.

Informed Consent 5-ACI-6C-04 (Ref. 4-4397)

(MANDATORY) Informed consent standards in the jurisdiction are observed and documented for offender care in a language understood by the offender. In the case of minors, the informed consent of a parent, guardian, or a legal custodian applies when required by law.When health care is rendered against the patient’s will, it is in accordance with state and federal laws and regula- tions. Otherwise, any offender may refuse (in writing) medical, dental, and mental health care. Comment : If the offender refuses to sign the refusal form, it must be signed by at least two witnesses. The form must then be sent to the medical department and reviewed by a qualified health care professional. If there is a concern about deci- sion-making capacity, an evaluation should be done, especially if the refusal is for critical or acute care.

Protocols : Written policy and procedure. Consent or authorization forms.

Process Indicators : Offender health records. Completed consent forms. Complet- ed refusal forms. Interviews. Observation.

Adult Correctional Institutions, Fifth Edition 203