Minimum standards governing medical records and the conduct of physical examinations in correctional facilities

105 CMR: DEPARTMENT OF PUBLIC HEALTH

105 CMR 205.000: MINIMUM STANDARDS GOVERNING MEDICAL RECORDS AND THE CONDUCT OF PHYSICAL EXAMINATIONS IN CORRECTIONAL FACILITIES

Section

205.001: Purpose 205.010: Scope 205.020: Definitions 205.100: Inmates to be Screened 205.101: Inmates to Have Physical Examination 205.102: Examinations to be Conducted by Licensed Personnel 205.103: Examinations to be Conducted in Privacy 205.104: Results of Examination to be Discussed with Inmate 205.105: Equipment Necessary for Physical Examination 205.200: Content of Physical Examination 205.500: Medical Record to be Maintained 205.501: Record to be Accurate 205.502: Responsibility of Health Services Staff 205.503: Record to be Transferred with Inmates 205.504: Confidentiality 205.505: Inspection of Records 205.600: Contents of Medical Record 205.602: All Visits to be Recorded 205.603: Identification and Filing 205.604: Storage Space 205.700: Severability

205.001: Purpose

The purpose of .000 is to establish minimum standards relative to the conduct of the initial admission physical examinations within correctional facilities and to prescribe the medical record utilized therein.

205.010: Scope

.000 shall apply to all correctional facilities, institutions, jails and houses of correction, as defined by M.G.L. c. 125, § 1, operated by the Commonwealth or any subdivision thereof.

205.020: Definitions

As used in .000, the following words shall have the following meanings, unless the context requires otherwise:

Correctional Facility. Any correctional facility or correctional institution as defined by M.G.L. c. 125, § 1, operated by the Commonwealth or any subdivision thereof, including jails and houses of detention.

Health Services Staff. The staff providing medical care or treatment to inmates within the correctional facility according to recommendations of U.S. Preventive Services Task Force (USPSTF), the Massachusetts Health Quality Partners (MHQP) or other generally recognized evidence-based, consensus practice recommendations.

Inmate. A committed offender or other such person placed in a correctional facility as defined in M.G.L. c. 125, § 1.

Medical Care. All services which are provided for the purpose of securing the prevention, diagnosis and treatment of illness or disability.

(MA REG. # 1346, Dated 8-25-17)

105 CMR: DEPARTMENT OF PUBLIC HEALTH

205.100: Inmates to be Screened

Immediately upon admission to the correctional facility, and prior to being placed in the general inmate population, all inmates shall receive an admission health screening conducted by persons trained in the completion of such a screening. The results of such screening shall be recorded in accordance with .600. Whenever possible such person shall be a member of the health services staff.

205.101: Inmates to Have Physical Examination

Each inmate committed to a correctional facility for a term of 30 days or more shall receive a physical examination no later than 14 days after admission to said facility. However, an inmate entering a correctional facility who is accompanied by a medical record containing a record of a complete physical examination conducted less than 90 days prior to his or her admission need not be given a complete physical examination. Each such inmate not receiving a complete physical examination shall, however, be seen by a physician, or a physician’s assistant or nurse practitioner under the supervision of a physician who shall:

(A) Review the inmate’s medical record;

(B) Examine the inmate for any signs of trauma or disease which may have been incurred by the inmate after his most recent physical examination;

(C) Conduct any examinations and tests which are medically indicated;

(D) Review the findings and any required follow-up services with the inmate.

205.102: Examinations to be Conducted by Licensed Personnel

All physical examinations shall be conducted by a physician licensed to practice medicine in the Commonwealth of Massachusetts or by a properly licensed nurse practitioner or physician assistant under the supervision of said physician.

205.103: Examinations to be Conducted in Privacy

Inmates shall be examined in a room which provides for privacy and dignity to the inmate and examiner. When necessary for security reasons, a correctional officer may be present.

(A) In existing facilities, physical examinations shall be conducted in a room used solely for the purpose of providing medical care. This examination room shall contain a handwash sink with hot and cold running water. The handwash sink shall be equipped with nonhand operated controls such as elbow, knee or foot controls. If, in an existing facility, the required handwash sink cannot be located in the examination room because of preexisting structural obstructions, the sink shall be located in close proximity to the examination room.

(B) In new or renovated facilities, physical examinations shall be conducted in a room used solely for the purpose of providing medical care. This examination room shall contain a handwash sink with hot and cold running water. The handwash sink shall be equipped with nonhand operated controls such as elbow, knee or foot controls.

205.104: Results of Examination to be Discussed with Inmate

Upon completion of the physical examination and all required and ordered laboratory tests a qualified health services staff shall discuss with the inmate the results of said examination, its implication, and suggestions for further diagnosis and/or treatment.

205.105: Equipment Necessary for Physical Examination

The physical examination required by .000 shall be conducted with all appropriate and standard equipment necessary to conduct the examination in its entirety, including an examining table with a disposable covering which shall be replaced after each use, and consistent with standards in 105 CMR 140.210 through 105 CMR 140.211.

105 CMR: DEPARTMENT OF PUBLIC HEALTH

205.200: Content of Physical Examination

(A) The physical examination shall include inquiry concerning: (1) signs and symptoms of disease or injury; (2) chronic health problems; (3) use of prescribed or non-prescribed medicines or drugs, including alcohol; (4) allergies; (5) prior significant illness and hospitalization; (6) family history; and (7) immunization status.

(B) The physical examination shall also include observation concerning: (1) Behavior, which includes state of consciousness, with screening for mental status and active mental health issues, as well as appearance, conduct, tremor and sweating; (2) Signs of trauma and communicable disease; (3) Dental decay, filled and missing teeth.

(C) The physical inspection and examination shall be consistent with community standards, with targeted attention to risk factors common among incarcerated individuals, and include prompts for reporting such risk factors, including administration of a substance use disorder and mental health screening tool, such as the U.S. Substance Abuse and Mental Health Services Administration Screening, Brief Intervention, and Referral to Treatment (SBIRT), as well as measurement of vital signs, height, weight and oxygen saturation.

(D) Diagnostic Tests. The following diagnostic tests shall be performed on each inmate consistent with the current recommendations of the USPSTF, MHQP or other generally recognized evidence-based, consensus practice recommendations, and as medically appropriate in accordance with the provisions of .101: (1) Complete blood count (CBC); (2) Purified protein derivative (PPD) skin test for tuberculosis infection by the Mantoux technique and/or chest film as appropriate; (3) Urine for the detection of glucose, ketones, protein and white blood cells. In males, if the results of the white blood cell test is positive, a test for Chlamydia trachomatis shall be conducted. (4) Female - test for gonorrhea and Chlamydia trachomatis infection; (5) Female - Papanicolaou smear of the uterine cervix; (6) Female - pregnancy test; (7) Mammogram - for all females who have been committed for a term of at least 90 days consistent with current recommendations of the USPSTF; (8) HIV counseling and voluntary HIV testing; (9) Counseling about hepatitis C and voluntary testing for hepatitis C virus infection according to risk assessment and age-based recommendations of the USPSTF and the Centers for Disease Control and Prevention; (10) Other age and gender appropriate laboratory and imaging screening tests consistent with current recommendations of the USPSTF.

205.500: Medical Record to be Maintained

Each inmate shall have an individual medical record which shall be kept separate from any other administrative records.

205.501: Record to be Accurate

An accurate and complete medical record shall be maintained for each inmate from the time of admission to the time of discharge.

205.502: Responsibility of Health Services Staff

Orders for treatment and all reports shall be legibly entered into the medical record either in ink, type, or electronic digital media and signed by appropriate health services staff submitting such orders or reports.

105 CMR: DEPARTMENT OF PUBLIC HEALTH

205.503: Record to be Transferred with Inmates

At any time an inmate is transferred to another correctional or health care facility, a copy of the medical record or a summary sheet shall accompany the inmate. Any portion of the record, which is not reasonably completed at the time of the transfer, shall be completed and a copy delivered to such facility within 72 hours of said transfer. The medical record or any portion thereof which accompanies the inmate shall be sealed and given into the custody of the transportation officer responsible for the transfer of the inmate and shall be delivered to the person responsible for the maintenance of the medical records at the receiving facility.

205.504: Confidentiality

The medical staff shall maintain and use medical records in a manner which ensures the confidentiality of the information contained therein. Only those persons who need access to the record in order to provide medical services to the inmate or fulfill statutory obligations, and those persons specifically authorized by the inmate to see the record, shall have access to the records and information in them. The Department of Public Health staff shall have access to the records and information in them for the purpose of determining compliance with .000 and shall maintain the confidentiality of records relating to individual inmates.

205.505: Inspection of Records

Medical records may be inspected by, or furnished to, the inmate to whom they relate, his or her attorney or by any other person upon written authorization from the inmate. The inmate's signature on the written authorization shall be witnessed by a correctional facility's staff person. Copies of such records shall be furnished within 72 hours of request. Fees for such copies shall not exceed the fees required for copying public documents.

205.600: Contents of Medical Record

Every medical record used in a correctional facility shall be maintained in accordance with the standards governing medical recordkeeping for clinics as set forth in 105 CMR 140.000: Licensure of Clinics.

205.602: All Visits to be Recorded

All contacts for the purpose of receiving medical care that the inmate has with a health care staff person shall be recorded in the appropriate place in the medical record.

205.603: Identification and Filing

The correctional facility shall maintain a system of identification and filing to ensure rapid access to each patient's medical record, regardless of the physical form or method of storage of records. Each patient shall have a single integrated record, except that records concerning mental health, dental and substance use disorder may be filed separately on the premises, provided there is an effective cross-referencing system.

205.604: Storage Space

The correctional facility shall provide adequate equipment and space for the storage of active and inactive medical records. The records shall be maintained so as to be safe from fire and water damage and from unauthorized use. Medical records shall be retained for the time period set forth in M.G.L. c. 111, § 70.

105 CMR: DEPARTMENT OF PUBLIC HEALTH

205.700: Severability

The provisions of .000 are severable. If any provision shall be declared invalid by any court, such provision shall be null and void and such determination shall not affect or impair any of the remaining provisions.

REGULATORY AUTHORITY

.000: M.G.L., c. 111, §§ 2, 3, 5, 6 and c. 127, § 17.