DENVER SHERIFF DEPARTMENT
Office of the Sheriff
 Department Order
1.00.4003
 Previous Revision:
August 2019		  Current Revision:
February 2021		  Reviewed:
September 2019
  Effective Date:
February 22nd, 2021
Related Standards:
ACA 4-ALDF: 1A-08; 2A-15; 4C-03; 4C-04; 4C-05; 4C-06; 4C-07; 4C-08; 4C-09; 4C-13; 4C-14; 4C-15; 4C-16; 4C-17; 4C-19; 4C-20; 4C-22; 4C-23; 4C-24; 4C-25; 4C-26; 4C-28; 4C-29; 4C-30; 4C-31; 4C-34; 4C-35; 4C-36; 4C-38; 4C-39; 4C-40; 4D-01; 4D-02; 4D-03; 4D-05; 4D-08; 4D-09; 4D-10; 4D-11; 4D-13; 4D-14; 4D-15; 4D-16; 4D-17; 4D-18; 4D-19; 4D-27; 7B-09; 7D-25
Health Insurance Portability and Accountability Act (HIPAA) of 1996: 48 C.F.R. §324.70
Related (referenced) Department Orders:
1.00.1019; 1.00.1022; 1.00.4007; 1.00.8001; 1.00.8004; 1.00.10001; 1.00.10006
 Subject:
HEALTH SERVICES
  1. Purpose: This order outlines health services provided to individuals confined in the Denver Sheriff Department ("DSD" or the "Department") detention facilities, as well as clarifies the relationship between health services staff, administrative, and DSD's sworn and non-sworn staff.
  2. Policy: It is the policy of the DSD to deliver cost effective medical, dental, and behavioral healthcare to individuals confined in DSD detention facilities that is consistent with the standard of care provided in the community.
  3. Cancellation: This order supersedes and cancels previous versions of Department Order 1.00.4003.
  4. Definitions:
    1. "Health Information Management or HIM" means the maintenance and securing of inmate health and healthcare information. It is health services' practice to acquire, analyze, and protect digital and traditional medical information to provide inmates with quality patient care in DSD facilities.
    2. "Health Services Administrator or HSA" refers to the person that ensures effective and efficient methods to manage healthcare services within DSD facilities.
    3. "Serious Medical Condition," for the purpose of this policy, refers to an illness, injury, impairment or physical or mental condition that involves inpatient care.
  5. Guidelines:
    1. Structure and Oversight: <ACA-4ALDF: 4D-01> 
      1. General:
        1. DSD’s health services shall be overseen by the Denver Health and Hospital Authority (DHHA). Health services shall be staffed with the following DHHA designees, but not limited to:
          1. A health services administrator (HSA)
          2. A physician
          3. A nurse manager 
          4. A behavioral health director
        2. The HSA, responsible physician, nurse manager, and behavioral health director shall be supervised by the Denver Health Medical Center (DHMC) Correctional Care Medical Facility (CCMF) and be authorized to provide healthcare services to inmates incarcerated by the DSD in accordance with the DSD's contractual agreement with the DHHA.
      2. Physician:
        1. The assigned physician shall be licensed in the State of Colorado and be responsible for the following, but not limited to:
          1. managing the medical opinions and care given to inmates;
          2. reviewing recommended treatments for inmates made by healthcare providers in the community; and 
          3. providing primary care to inmates.
      3. Behavioral Health Director:
        1. Clinical behavioral health services and activities are  the responsibility of the DHHA’s designated behavioral health director. <ACA-4ALDF: 4C-28>
      4. Health Service Administrator:
        1. The HSA shall assist with the coordination of and supervise health services, including, but not limited to:
          1. Medical
          2. Dental
          3. Behavioral health. 
        2. While the HSA arranges for availability of health services, the DSD provides the administrative support for making these services accessible to inmates.
      5. Nurse Manager:
        1. The nurse manager is responsible for the supervision of the nursing and nursing support services personnel.
      6. All medical and dental matters involving medical judgment are the sole responsibility of the assigned physician and dentist.
  6. Administrative Guidelines:
    1. Coordination of Inmate Health Services:
      1. The physician and HSA shall coordinate inmate health services with the Sheriff, division chief, or majors at the respective facilities to assure that all components of the healthcare system are administered without a compromise to safety or security. <ACA-4ALDF: 4D-14>
      2. Problematic health issues and program development shall be discussed at administrative staff meetings or as needed. <ACA-4ALDF: 4D-14>
      3. The HSA and physician shall advise the Sheriff and division chief on environmental health matters pertaining to inmates, including, but not limited to, the management of serious and infectious diseases, as well as precautionary procedures and actions taken by employees. 
      4. The HSA shall meet with the Sheriff at least quarterly and submit quarterly reports/minutes. Quarterly reports/minutes shall include, but not be limited to: <ACA-4ALDF: 7D-25>
        1. effectiveness of the healthcare system;
        2. description of any environmental factors that need improvement;
        3. changes effected since the last reporting period; and
        4. recommended corrective action or possible areas for additional training.
      5. The HSA shall immediately report any condition that poses a danger or compromises the safety of staff or inmates to the Sheriff.
      6. All procedures shall follow federal and state laws.
    2. No Restrictions on Health Staff of Providers: <ACA-4ALDF: 4D-02>
      1.  Refer to Procedure Manual 5.00.4014 - Jails: Medical Management for guidance.
    3. Rules, Regulations, for Health Services Personnel:
      1. Security rules and regulations approved by the Sheriff shall apply to health services personnel working in the facilities.
      2. State and/or federal license and certification requirements and restrictions shall apply to health services personnel working in the facilities. <ACA-4ALDF: 4D-05; 4C-09>
      3. Health services staff shall follow informed consent standards and regulations. <ACA-4ALDF: 4D-15>
        1. Informed consent shall be documented in a language understood by the inmate.
      4. Health services' staff duties and responsibilities shall be governed by job descriptions that include qualifications. Such job descriptions shall be on file and approved by the health authority. <ACA-4ALDF: 4D-03>
    4. General Treatment Protocols:
      1. Treatment by health services personnel shall be communicated verbally or via written orders.
      2. Treatment shall be within the limits established by state laws and regulations.
      3. Written processes shall be maintained in the health services policy and the procedure manual kept in the health services unit and/or on the DHHA electronic drive.
      4. When treatment is rendered against the inmate’s will, it shall only be done in accordance with local, state, and federal laws and regulations: <ACA-4ALDF: 4D-15>
        1. An inmate may refuse in writing any medical, dental, or behavioral healthcare.
        2. If an inmate declines to sign the refusal form, such refusal must be indicated on the form and the form must be signed by at least two (2) witnesses to verify the inmate’s refusal to sign.
        3. If there is a concern about the inmate’s decision-making capacity, an evaluation shall be completed by health services. 
        4. Involuntary administration of psychotropic medication(s) to inmates must comply with applicable laws and regulations, and:<ACA-4ALDF: 4D-17>
          1. be authorized by a physician who specifies the duration of therapy;
          2. be used only after less restrictive options have been utilized without success, as determined by the physician or psychiatrist;
          3. include details explaining why, when, where, and how the medication is to be administered;
          4. include regular monitoring of the inmate for adverse reaction and side effects; and
          5. include preparation of treatment plans for less restrictive treatment alternatives as soon as possible.
      5. Any student or intern, or residents assisting in delivering health services shall be under staff supervision consistent with the associated level of training. <ACA-4ALDF: 4D-10>
        1. Prior to student or intern assistance, the responsible physician, behavioral health clinician, or designee shall have written policies and procedures indicating student or intern assistance. These policies and procedures shall include authority and limitations. <ACA-4ALDF: 4D-10>
        2. Students or interns shall agree in writing to abide by all facility policies, including those relating to the security and confidentiality of information. <ACA-4ALDF: 4D-10>
    5. Inmate Health Records Protocols: <ACA-4ALDF: 4D-13>
      1. Health information management (HIM) records shall be maintained separately and apart from all other inmate records and are not considered public.
      2. Access to these records shall follow state and federal laws and regulations.
      3. Non-health services staff are not permitted access to inmate HIM records unless authorized through the Administrative Investigative Unit (AIU).
      4. Access to inmate HIM records is managed by the health services administrator.
      5. Refer to the Health Insurance Portability and Accountability Act (HIPAA) of 1996 (48 C.F.R. §324.70) for additional guidance.
    6. Pharmaceutical Management: 
      1. Pharmaceutical administration and management shall be in accordance with local, state, and federal regulations and be supervised by properly licensed personnel. <ACA-4ALDF: 4C-38>
      2. All nonprescription medications that are available to inmates must be jointly approved by the responsible physician and division chief. <ACA-4ALDF: 4C-39>
      3. A review of such nonprescription medications and access shall be conducted annually by the health authority, physician, and the division chief. <ACA-4ALDF: 4C-39>
    7. Inmate Injuries and Review: <ACA-4ALDF: 1A-08>
      1. Incidents of serious inmate injuries shall be reviewed and analyzed as soon as possible, but at least annually by the DSD for the purpose of identifying, preventing, and correcting problems. 
      2. The accreditation manager shall:
        1. review data and consult with the HSA as needed to complete an annual review of serious injuries;
        2. present and discuss findings and corrective actions with facility operations majors or their designees and the HSA; and
        3. compile a final report for the Sheriff, including identifying any patterns associated with serious inmate injuries. 
    8. Experimental Procedures and Research:
      1. Inmates may participate in medical or pharmaceutical research. Facilities electing to perform such biomedical research shall be in compliance with all state and federal guidelines. <ACA-4ALDF: 4D-18>
      2. Any request to use patient information for medical research requires prior approval from the Sheriff, even if it is solely for the purpose of collecting and analyzing information. Refer to Department Order 1.00.10006 – Policy Development and Research Practices.
    9. Elective Procedures: <ACA-4ALDF: 4D-16>
      1. Elective procedures shall not be performed in custody unless:
        1. such procedure(s) are needed to correct a substantial functional deficit; or 
        2. in the case where by an existing pathological process threatens the well-being of the inmate while in custody.
      2. Each request shall be considered on a case-by-case basis.
  7. Inmate Guidelines:
    1. Communicating Need for Medical or Behavioral Health Services:
      1. If an inmate is in need of non-urgent medical and/or behavioral health services, they may submit a health services kite. 
      2. If the inmate has an urgent or emergent issue, then the inmate is encouraged to tell deputy and/or hand a kite directly to a nurse when they make rounds.
    2. Inmate Involvement in Healthcare Services: 
      1. Inmates are not to be used to: <AC-4ALDF: 4D-11>
        1. perform direct patient care services;
        2. schedule health care appointments;
        3. determine access of other inmates to healthcare services;
        4. operate diagnostic or therapeutic equipment; or 
        5. handle or have access to surgical instruments, syringes, needles, medications, or health records.
    3. Behavioral Health Referrals: 
      1. Mentally ill or developmentally disabled inmates who do not appear to be able to adapt to jail conditions shall be referred to behavioral health  for evaluation, referral, and care. <ACA-4ALDF: 4C-34> 
      2. Refer to Department Order 1.00.4007 – Mental Health Assessment, Intervention, and Services and Department Order 1.00.1019- Inmates with Disabilities/Americans with Disabilities Act(ADA) for additional information.
    4. Special Needs Inmates: <ACA-4ALDF: 4C-40><Department Order 1.00.1022 – Restrictive Housing>
      1. The physician, behavioral health director, nurse manager, division chief or designee, and, as appropriate, the programs administrator, shall consult prior to taking action regarding chronically ill, physically disabled, geriatric, seriously mentally ill, or developmentally disabled inmates. Such consultation should focus on:
        1. Housing assignments
        2. Program assignments
        3. Disciplinary measures
        4. Transfers to other facilities
    5. Prosthetic and Adaptive Devices: 
      1. Pre-existing prostheses, orthodontic, and adaptive devices may be allowed into the jail facilities if approved by medical personnel. 
      2. In cases where the individuals need for a device occurs after incarceration, procurement of the prosthetic or adaptive device will be accomplished when the health of the inmate would be adversely affected. <ACA-4ALDF: 4C-35>
      3. Refer to Department Order 1.00.1019- Inmates with Disabilities/Americans with Disabilities Act(ADA) and Procedure Manual 5.00.4014 - Jails: Medical Management for additional information.
    6. Detoxification: <ACA-4ALDF: 4C-36> 
      1. Detoxification shall be done only under health services supervision and in accordance with local, state, and federal laws.
      2. Detoxification from alcohol, opiates, hypnotics, stimulants, and sedative drugs shall be performed following guidelines for treatment and observation of individuals manifesting mild or moderate symptoms of intoxication or withdrawal from alcohol or other drugs.
      3. Inmates experiencing severe, life-threatening intoxication (overdose) or withdrawal as determined by health services shall be transferred to an appropriate medical facility for treatment.
    7. Pregnant Inmates: 
      1. Pregnant inmates shall be provided healthcare counseling, regular examinations, treatment, dietary supplements, and postpartum follow-up care. <ACA-4ALDF: 4C-13>
      2. Pregnant inmates shall be examined  by a health trained or qualified health services professionals. 
      3. The health record shall reflect the care provided and the outcome of each pregnancy if carried to term while still in custody.
      4. Pregnant inmates who are determined to be in labor shall immediately be transported to DHMC for care. Under such circumstances, health services staff shall notify DSD sworn staff that transport is immediately required.  
  8. Health Services Staff:
    1. Orientation of Health Services Staff: 
      1. All new full-time health services employees shall complete a formalized forty (40) hour orientation program before undertaking their assignments. <ACA-4ALDF: 7B-09>
    2. Staffing Analysis: <ACA-4ALDF: 2A-15><Department Order  1.00.10001 – Administrative Review and Evaluation>
      1. A staffing analysis shall be used to help determine essential positions needed to perform the health services mission and to provide the defined scope of services.
      2. The health services staffing plan shall be reviewed annually for adequacy by the health authority.
    3. Availability of Services and Continuity of Care: 
      1. Twenty-four (24) hour emergency medical, behavioral health, and dental care shall be available for inmates at all facilities. 
      2. Triage and initial care shall be provided by health services personnel on duty. <ACA-4ALDF: 4C-03>
      3. Routine and emergency dental care shall be provided to each inmate under the direction and supervision of a licensed dentist. <ACA-4ALDF: 4C-20> 
      4. Acute, non-emergent health services shall be managed and prioritized by health services staff using routine scheduled sick calls. These schedules shall conform to standards established by the American Correctional Association (ACA) and the National Commission on Correctional Health Care (NCCHC). <ACA-4ALDF: 4C-03>
      5. Chronic and convalescent care shall be evaluated and treated by health services staff. <ACA-4 ALDF: 4C-07>
        1. Written detailed procedures and treatment plans for chronic and convalescence care shall be maintained by health services staff in the health services policy and procedure manual and in conjunction with health services protocols for disease management. <ACA-4ALDF: 4C-19>
      6. The assigned physician shall maintain a written plan addressing the management of communicable diseases, including but not limited to, tuberculosis; hepatitis A, B, and C; and HIV. <ACA-4ALDF: 4C-14; 4C-15; 4C-16; 4C-17>
      7. Continuity of care shall be maintained from reception to discharge, including the transfer of records to other agencies or facilities. <ACA-4ALDF: 4C-04>
      8. Detailed procedures for health services provisions, protocols, and procedures, including continuity of care, shall be maintained in the health services policy and procedure manual and in conjunction with health services protocols for disease management.
    4. Initial Health Assessments, Screening, and Records: 
      1. Healthcare encounters, including medical; dental; and behavioral health interviews, examinations, and procedures, shall be conducted in a setting that reasonably respects the inmate’s privacy. <ACA-4ALDF: 4D-19>
      2. Intake health services screening and initiation of HIM records shall be initiated at the Denver Detention Center (DDC) using an established format. <ACA-4ALDF: 4C-22> 
        1. During the intake process, behavioral health services staff shall perform an initial behavioral health screening. <ACA-4ALDF: 4C-29>
        2. Inmates who are transferred or booked into the Denver County Jail (COJL) shall be screened by health services staff at the COJL facility prior to housing. <ACA-4ALDF: 4C-23>
        3. These intakes will be performed by health services staff as required by NCCHC and ACA accreditation standards. 
        4. The extent of the health assessment is defined by the responsible physician
      3. All inmates shall receive a comprehensive behavioral and health appraisal within fourteen (14) days of admission to a jail facility. <ACA-4ALDF: 4C-24; 4C-30>
        1. The full extent of the health appraisal is defined by the responsible physician. If the health appraisal is not completed at intake, the screening shall at least include, but not be limited to:
          1. review of the intake screening;
          2. collection of additional data to complete the medical, dental, mental health, and immunization histories;
          3. lab or diagnostic tests to detect communicable disease, including venereal disease and tuberculosis; 
          4. recording of height, weight, pulse, blood pressure, and temperature;
          5. other tests and examination as deemed appropriate by health services staff;
          6. review of the results of the medical examination, tests, and identification of problems by medically qualified health services staff;
          7. initiation of therapy, if appropriate;
          8. development and implementation of treatment plan(s), including recommendations concerning housing, job assignment, and program participation; and
          9. a behavioral health appraisal by qualified behavioral health services. 
      4. Health appraisal records shall, at a minimum: <ACA-4ALDF: 4C-25>
        1. utilize a uniform process as determined by the health authority;
        2. include health history and vital signs collected by qualified health services staff;
        3. include the collection of other health appraisal data performed by qualified health services staff; and
        4. include review(s) of results of medical exams, tests, and identification of problems by a provider, as determined by law.
      5. Inmates who report a behavioral health history shall receive a behavioral health evaluation by a behavioral health professional within fourteen (14) days. <ACA-4ALDF: 4C-31><Department Order 1.00.4007 – Mental Health Assessment, Intervention, and Services>
      6. Health services shall determine the conditions for periodic health examinations for inmates. <ACA-4ALDF: 4C-26>
    5. Transfer of Inmates to Other DSD Jail Facilities: <ACA-4ALDF: 4D-27>
      1. Notification to health services of any inmate transfer between DSD facilities (to or from DDC or COJL) is required. 
      2. Summaries, originals, or copies of the inmate’s health record shall accompany the inmate to the receiving facility. Health conditions, treatments, and allergies shall be included in the record.
        1. Transporting deputies shall maintain the confidentiality of the health record.
      3. Specific precautions, including, but not limited to, universal precautions and the use of a mask and/or gloves, should be taken by transporting deputies and shall be documented.
    6. Transfer of Inmates to Medical Facility: <ACA-4ALDF: 4C-05>
      1. Transfer to DHMC or the DHMC CCMF shall be authorized by the responsible physician or authorized  medical/behavioral health personnel. However, the court may order a mental evaluation on a mittimus that will be forwarded to the behavioral health staff. The evaluation is to be completed as soon as possible per the terms of the court order.
      2. Transportation arrangements to healthcare facilities shall be made by the deputy supervisor on duty. Refer to Department Order 1.00.8004 – Transportation of Inmates, Department Order 1.00.8001 - Medical or Special Transportation of Inmates, and Procedure Manual 5.00.8016 - Transportation Management.
        1. Security and transportation procedures shall ensure immediate transportation of inmates in an emergency, including, but not limited to, the use of an emergency medical vehicle. <ACA-4ALDF:  4C-08(b)(c)(f)>
        2. Transportation shall be timely, considering the urgency and prioritization of the inmate’s healthcare need as determined by health services. <ACA-4ALDF:  4C-06(a)(b)>
        3. Health services shall ensure adequate transfer of health information when an inmate is transferred to a healthcare facility. <ACA-4ALDF: 4C-06(c)>
  9. Other Considerations:
    1. First Aid and Emergency Medical Services at Jail Facility: <ACA-4ALDF: 4C-08> 
      1. The COJL and DDC Health Services Units operate as twenty-four (24) hours/day, seven (7) days/week facilities. The health services staff shall respond to emergencies and assist in providing crisis intervention. <ACA-4ALDF:  4C-08(a) >
      2. Security and health services personnel are trained to respond to emergent health-related situations within a four (4) minute response time. <ACA-4ALDF: 4D-08> 
      3. Such training includes instruction on:
        1. recognition of signs and symptoms and knowledge of action that is required in potential emergency situations;
        2. administration of basic first aid to include recognizing the need for emergency care and intervention in life-threatening situation;
        3. certification in cardiopulmonary resuscitation (CPR); 
        4. methods of obtaining assistance;
        5. signs and symptoms of mental illness, violent behavior, and acute chemical intoxication and withdrawal;
        6. procedures for patient transfer to appropriate medical facilities or referral to healthcare providers;
        7. suicide prevention and intervention;
        8. recognizing acute manifestations of certain chronic illnesses such as asthma, seizures and adverse reactions to medications; and 
        9. precautions and procedures with respect to infectious and communicable diseases. 
      4. Emergency bags shall be stationed in designated areas throughout the jail for emergency and mass casualty situations and are to be utilized by health services staff. <ACA-4ALDF: 4D-09> 
      5. An Automatic External Defibrillator (AED) is available for use at each facility. <ACA-4ALDF: 4D-09>
  10. Responsibility: 
    1. Medical: 
      1. The responsible physician, nurse manager, behavioral health director, and HSA shall ensure the provisions of this policy are being followed.
    2. Training: 
      1. The Training Academy shall ensure that the curriculum of all currently existing classes and any newly developed classes are compliant with this order.
      2. The responsible physician and nurse manager or designee(s) shall assist the DSD Training Academy in establishing a training program consistent with ACA and NCCHC standards. 
      3. The Training Academy shall maintain a copy of the training curriculum.
    3. Management: 
      1. 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.
    4. Supervisors: 
      1. All supervisors shall ensure that the provisions of this policy are being followed. 
    5. Staff: 
      1. All deputies and employees shall comply with the provisions of this policy.
  11. Effective Date: This order will become effective on February 22nd, 2021.
  12. Approval: This document has been reviewed, approved, and electronically signed by the Sheriff of the City and County of Denver prior to its publication.