DENVER SHERIFF DEPARTMENT
Office of the Sheriff
 Department Order
1.00.1015
 Previous Revision:
March 2019		  Current Revision:
March 2022		  Reviewed:
August 2021		  Effective Date:
March 8th, 2022
Related Standards:
ACA-4ALDF: 5A-05; 5A-06; 5A-07; 5A-08
Health Insurance Portability and Accountability Act
42 CFR Part 2 
Revised Municipal Code of the City and County of Denver
Colorado Revised Statutes
City of Denver’s General Retention Schedule
Related (referenced) Department Orders:
1.00.1025
 Subject:
INMATE SUBSTANCE ABUSE PROGRAM
 
  1. Purpose: The purpose of this order is to establish the Denver Sheriff Department ("DSD" or "Department") policy for inmate substance abuse programs. 
  2. Policy:
    1. It is the policy of the DSD to offer inmate substance abuse education and treatment services that promote the resolution of substance use related problems, that increase social adjustment, and that can potentially reduce recidivism.
    2. Inmates shall have an opportunity to participate in such programs and services during their incarceration in an effort to facilitate successful reentry into the community. 
    3. Such services shall focus on substance abuse education; treatment and recovery; social, cognitive, and behavioral counseling, life skills training, health-related education, and relapse prevention.
    4. DSD shall support competent and certified addictions counselors to help facilitate substance abuse programs and services, including classes and individualized counseling. 
  3. Cancellation: This order supersedes and cancels previous versions of Department Order 1.00.1015. 
  4. General Guidelines:                          
    1. The inmate programs administrators at each facility, along with the director of inmate programs, operations division chief, and the Sheriff, shall assure that procedures which support this policy and the objectives of inmate substance abuse services are maintained.
    2. Counseling and other program staff shall remain in good standing in their respective profession(s), complying with all standards and honoring professional ethics, as well as the Department’s code of conduct and ethical standards of behavior.
      1. Licensed/certified professionals shall maintain their professional credentials in good standing.
      2. Program staff shall remain abreast of and comply with any changes in federal, state, and local laws regulating their roles and responsibilities as providers of substance abuse services.
      3. Personnel shall maintain confidential records in accordance with best practices and applicable laws. 
        1. Confidential information and other records pertaining to participating inmates shall be stored and maintained in accordance with applicable privacy rules, including, but not limited to, federal, state, and local laws, (i.e., Health Insurance Portability and Accountability Act (HIPAA); Code of Federal Regulations (CFR) Title 42: Chapter 1: Subchapter A: Part 2; the Revised Municipal Code of the City and County of Denver; Colorado Revised Statutes (CRS); and the City of Denver’s General Retention Schedule, policies, and procedures).
    3. The purpose of the substance abuse treatment program is to assist inmates with restoring productive lives and providing motivation and guidance toward ongoing recovery. <ACA-4ALDF: 5A-05> 
      1. Substance abuse services shall be available in the form of group therapy sessions, individual counseling sessions, and substance abuse education.
      2. Services shall be evidence-based or research-based to address substance abuse and criminogenic risks and needs.
      3. The Department shall provide incentives for targeted treatment programs to increase and maintain the inmate’s motivation for treatment. 
        1. Such incentives shall include certificates of completion or other credits consistent with the goals of the facility and program.
      4. The Department shall partner with community agencies to provide opportunities for inmates to continue to engage in treatment services post-release.
  5. Implementation:
    1. Program and Services: <ACA-4ALDF: 5A-06, 5A-07; 5A-08>
      1. A coordinated staff approach shall be used to deliver treatment services for participating inmates with substance abuse problems. 
        1. This service delivery approach shall be documented in minutes from the treatment planning conferences and in individual treatment files.
      2. The range of services for the substance abuse program shall include, but not be limited to, the following:
        1. risk/need screening;
        2. risk/need assessment to identify problem areas;
        3. coordinated development of a transition case plan, including discharge interventions with professional and non-professional community service providers to encourage a continuum of supervision, treatment, and support groups; and
        4. individual treatment objectives, including:
          1. treatment goals;
          2. counseling needs;
          3. substance abuse; 
          4. relapse prevention and management;
          5. culturally-sensitive individual treatment objectives, as appropriate; and
          6. the provision of self-help groups as an adjunct to treatment.
      3. Inmates participating in the substance abuse program shall become aware of:
        1. their substance abuse issues;
        2. recommendations for addressing/recovering from substance abuse;
        3. treatment resources available in the jail; and
        4. treatment resources within the community (refer to Department Order 1.00.1025 - Use of Volunteers and Community Resources for Inmate Programs).
      4. Depending on the length of sentence, the substance abuse program also attempts to increase the inmate’s understanding of: 
        1. emotional triggers which contribute to the compulsion to abuse substances;
        2. strategies to identify and make changes in detrimental thought processes; and
        3. current evidence-based treatment techniques for substance abuse.
    2. Substance Abuse Program Assessment                              
      1. The director of inmate programs shall maintain the following records:
        1. types of substance abuse programs;
        2. number of sessions;
        3. number of inmate participants in all programs offered; and
        4. success rates of each program, measuring against program objectives and treatment plans.
      2. The director of inmate programs shall provide an assessment report to the Sheriff annually.
  6. Disclosure:
    1. The DSD shall comply with state and federal regulations, including HIPAA and 42 CFR Part 2.
    2. Where applicable, permission to share health information shall be obtained by using individual consent forms or court orders authorizing the sharing between the DSD and outside organizations (e.g., community treatment providers). 
      1. Contractual agreements shall be entered into between the DSD and outside organizations that perform certain functions or provide services to or on behalf of the DSD to ensure compliance with state and federal regulations related to patient records.
      2. In addition to applying to the DSD, disclosure restrictions apply to:
        1. third-party payers who receive substance use disorder (SUD) records from the DSD;
        2. entities having direct administrative control over the DSD; and
        3. individuals or entities requesting or receiving records from the DSD.
      3. If, upon inmate intake and booking (or as soon thereafter as the individual is capable of rational communication) or otherwise during custody or incarceration, it is determined that an individual has been or will be tested, diagnosed, or treated for substance use or an individual will participate in specific substance abuse programs, the DSD shall communicate to the individual that federal law and regulations protect the confidentiality of SUD patient records.
    3. Upon agreeing to participate in a substance abuse program, inmates shall sign an agreement form provided by programs administrator.
    4. The DSD shall not disclose any SUD information without an individual’s consent unless done in compliance with applicable law, including, but not limited to, a court order authorizing disclosure and use. 
      1. Any disclosure of SUD information must be limited to that information which is necessary to carry out the purpose of the disclosure.
      2. The DSD shall not disclose, facilitate the use, or use any SUD information in any noncriminal proceedings unless a court order authorizing disclosure has been issued for good cause. 
      3. The restrictions on use and disclosure apply whether or not the DSD SUD program (or another lawful holder of the individual’s identifying information) believes that:
        1. the person or entity seeking the information already has it or has other means of obtaining it;
        2. the person or entity is a law enforcement agency or another government official; 
        3. the person or entity has obtained a subpoena; or 
        4. asserts any other justification for a use or disclosure which is not expressly permitted.
      4. DSD programs identified publicly as a place were only SUD diagnosis, treatment, or referral for treatment is provided may not respond to a request inquiring about the presence of an individual in the program unless the individual’s written consent to do so is obtained or if authorized by court order. 
        1. Otherwise, an answer to a request to identify an individual must be done in a way that does not affirmatively reveal that an identified individual has been, or is being, diagnosed or treated for an SUD.
        2. An inquiring party may be provided a copy of 42 CFR Part 2 and advised that they restrict the disclosure of the SUD records but may not be told that the regulations restrict the disclosure of the identified patient’s records.
      5. Prior to the disclosure or re-disclosure of applicable SUD information, the DSD shall have individuals (or their duly appointed representative) provide written authorization to release information unless the disclosure is compelled by court order. 
        1. Disclosure of records in accordance with the consent form shall only be made to any person or entity identified in the consent form.
    5. Individuals who have consented to their patient identifying information being disclosed using a general designation (e.g., to “my past and present treating providers”), upon request, must be provided a list of entities to which their information has been disclosed (list of disclosures). Such requests must be written and are limited to disclosures within the prior two (2) years.
      1. After such request, the DSD must provide a list of disclosures:
        1. in thirty (30) days or less; and 
        2. provide for each disclosure:
          1. the name of the entity(-ies) to which the disclosure was made;
          2. the date of the disclosure; and
          3. a brief description of the patient identifying information disclosed.
      2. Certain entities serving as an intermediary (e.g., an accountable care organization or health information exchange), and not the DSD, may be responsible for compliance with the list of disclosures requirement, if applicable.
      3. When requesting information from an SUD program that is subject to 42 CFR Part 2, the DSD shall ensure that the individual to whom the SUD information pertains has signed a valid consent authorization prior to receipt of the information.
        1. If, prior to entering incarceration, an individual’s SUD diagnosis, treatment, or referral for treatment was not provided by a program which is (either directly or indirectly) federally conducted, regulated or supported, that individual’s records are not subject to 42 CFR Part 2 and the DSD does not have to obtain a 42 CFR Part 2 compliant consent form prior to receiving SUD information. However, an authorization under HIPAA may be required.
      4. Each disclosure made with an individual’s written consent must contain the following written statement:
        1. This information has been disclosed to you from records protected by federal confidentiality rules (42 CFR Part 2). The federal rules prohibit you from making any further disclosure of information in this record that identifies a patient as having or having had a substance use disorder either directly, by reference to publicly available information, or through verification of such identification by another person unless further disclosure is expressly permitted by the written consent of the individual whose information is being disclosed or as otherwise permitted 42 CFR Part 2. A general authorization for the release of medical or other information is not sufficient for this purpose (see §2.31). The federal rules restrict any use of the information to investigate or prosecute with regard to a crime any patient with a substance use disorder, except as provided at §§ 2.12(c)(5) and 2.65.
    6. SUD identifying information may be disclosed to health services personnel to the extent necessary to meet a health services emergency in which the individual’s prior informed consent cannot be obtained. Immediately following disclosure, DSD shall document, in writing, the nature of the disclosure in the individual’s patient records that includes:
      1. the name of the medical personnel to whom disclosure was made and their affiliation with any health care facility;
      2. the name of the individual making the disclosure;
      3. the date and time of the disclosure; 
      4. the nature of the health services emergency; and 
      5. the physician or other treating medical staff who authorized the disclosure of the records by declaring that a health services emergency existed. 
    7. When disclosing SUD information within the criminal justice system, the DSD shall ensure that the following:
      1. Participation in the DSD's substance use program is required for:
        1. the disposition of criminal proceedings against the individual (e.g., as part of a drug court program or another treatment-based alternative to incarceration); or
        2. the individual’s parole or other release from custody.
      2. The disclosure must only be made to those individuals within the criminal justice system who have a need for the information in connection with their duties to monitor the individual’s progress (e.g., a prosecuting attorney who is withholding charges against the individual, a court granting pre-trial or post-trial release, probation or parole officers responsible for supervision of the individual).
      3. An individual within the criminal justice system who receives an individual’s substance use information in accordance with this policy (such as a probation officer) must sign a written acknowledgement that the information being provided may only be disclosed to others to carry out that individual’s official duties regarding the individual’s conditional release or other action for which consent by the individual was given.
  7. Accountability:
    1. Professionals providing inmate substance abuse program services shall maintain professional licenses, certifications, and other required credentials and observe appropriate professional protocols and standards.
    2. Division chiefs shall ensure all related procedures are in compliance with this Order.
  8. Responsibility:                          
    1. Training: The Training Academy shall ensure that the curriculum of all currently existing classes and any newly developed classes are compliant with this Order.
    2. Management: The division chief/unit commander or unit manager of any division or unit affected by this policy shall:
      1. ensure that existing procedures and all newly developed orders are in compliance with this order;
      2. ensure that all affected personnel are made aware of this policy; and
      3. ensure this policy is reviewed annually for compliance with all federal, state, and local laws and standards.
    3. Supervisors: All supervisors shall ensure that the provisions of this policy are being followed.
    4. Staff: All employees shall comply with the provisions of this policy.
  9. Effective Date: This order will become effective on March 8th, 2022.
  10. Approval: This document has been reviewed, approved, and electronically signed by the Sheriff of the City and County of Denver prior to its publication.