W. Va. Code R. § 95-3-13

Current through Register Vol. XLI, No. 50, December 13, 2024

Section 95-3-13 - Medical and Health Care Services

13.1. Right to Medical Care. All inmates shall have access to necessary medical, dental and psychiatric care provided by licensed personnel.

13.2. Responsibility. Medical, dental and mental health matters involving clinical judgments shall be the sole province of the physician, dentist and psychiatrist or qualified psychologist respectively; however, security regulations applicable to facility personnel also apply to health personnel. The official responsible for the facility provides the administrative support for the accessibility of health services to inmates.

13.3. Responsible Physician. A physician shall be designated to approve health care policies, procedures and agreements which can include use of hospital emergency rooms. Each facility shall have agreements for 24 hour medical coverage. All physicians and dentists examining or treating inmates shall be licensed to practice in the State of West Virginia.

13.4. Medical Autonomy and Facility Administration. Medical decisions shall be made only by the physician or designee(s). It shall be made clear to the health authorities and physicians that security regulations which apply to the non-medical staff also apply to them. They will be provided with a list of these regulations and an orientation to the facility system.

13.5. Decision-making: Special Problem Patients. Before inmates with diagnosed psychiatric or significant medical illnesses are given housing assignments, work assignments or transfers, consultation between the facility administrator and physician or their designees shall take place to decide on any special precautions or preparations. Special diets must be provided when ordered by health personnel and approved by the physician.

13.6. Notification of Next of Kin. Any inmate having any serious illness or injury or who dies while incarcerated shall have his next of kin or legal guardian notified by the facility administrator or the physician.

13.7. Post-mortem Examination. In the event of an inmate death, the state medical examiner shall be notified immediately. If the cause of death is unknown, or the death occurred under suspicious circumstances, or the inmate was unattended from the standpoint of not being under current medical care, a post-mortem examination shall be performed.

13.8. Minimum Staff Training Requirements. Health trained staff is defined as personnel who have certified first-aid and CPR training and also have received information regarding the symptoms of physical and mental illnesses common the the inmate population (including depression and chemical dependence), basic management of seizures, medication administration, health record maintenance, recognition of potential suicides, and procedures for patient transfers to appropriate medical facilities or health care providers. Each shift shall include at least one member who has become health-trained as described above.

13.9. Suicide Prevention. There shall be a written suicide prevention and intervention program that is reviewed and approved by a qualified medical or mental health professional. All staff with responsibility for inmate supervision shall be trained in the implementation of the program. Staff shall make every reasonable effort to prevent suicides through intake screening, identification and supervision of suicide-prone inmates.

13.10. Prohibitions. Inmates shall not be used for the following duties:

13.10.a. Performing direct patient care services;

13.10.b. Scheduling health care appointments;

13.10.c. Determining access of other inmates to health care services;

13.10.d. Handling or having access to surgical instruments, syringes, needles, medications, health records; and

13.10.e. Operating equipment.

They shall be able to perform maintenance and janitorial services under supervision of qualified staff.

13.11. Receiving Medical Screening. A receiving medical screening appraisal to elicit information pertinent to the inmate's health shall be performed on every inmate at the time of admission. The screening shall be recorded on a form which has been approved by the physician. When the inmate has been transferred from another facility and is accompanied by a previously completed screening form, the form shall be reviewed and verified. Receiving screening shall be conducted by a health-trained staff member. Inmates who are in need of immediate medical attention at the time of admission shall be referred immediately for emergency care. The screening process shall include at least an inquiry, observations and disposition.

13.11.1. Inquiry. The screening process shall include, but is not limited to, an inquiry into:

13.11.1.a. Current illness and health problems, including dental problems;

13.11.1.b. Venereal diseases and other infectious disease;

13.11.1.c. Medication taken and special health requirements;

13.11.1.d. Use of alcohol and other drugs which includes types of drugs used, mode of use, amounts used, frequency used, date or time of last use and history of problems which may have occurred after ceasing use (e.g. convulsions);

13.11.1.e. Past and present treatment of hospitalization for mental disturbance or suicide; and

13.11.1.f. Other health problems designated by the responsible physician.

13.11.2. Observations. The screening process shall include, but not be limited to, observations including:

13.11.2.a. Behavior, which includes state of consciousness, mental status, appearance, conduct, tremor and sweating;

13.11.2.b. Body deformities, trauma markings, bruises, lesions, jaundice, ease of movement, etc.; and

13.11.2.c. Indications of recent or chronic substance abuse, i.e., needle marks.

13.11.3. Disposition. The screening process shall include the following disposition to:

13.11.3.a. General population;

13.11.3.b. General population and referral to appropriate health care services;

13.11.3.c. Referral to appropriate health care services on an emergency basis; or,

13.11.3.d. Medical isolation for special observation.

13.12. Care for Persons Under the Influence of Drugs. The physician shall approve policies and procedures for the identification of alcohol and drug dependence as well as subsequent management and/or transfer for the care of persons under a drug influence. Unless the facility has special facilities and constant medical supervision to perform detoxification, the process shall not be performed on site; the inmate shall be transferred to a hospital or community detoxification center designated by the physician. Procedures for adequate care of persons under the influence of drugs include policies and training of staff relating to medical screening, observation, referral evaluation, and safety protections.

13.13. Mentally Ill. Post admission screening and referral for care of mentally ill or retarded inmates whose adaptation to the correctional environment is significantly impaired shall be provided. Psychiatric problems identified either at receiving screening or after admission shall be followed up by medical staff. The urgency of the problems determines the responses. Suicidal and psychotic patients may be emergencies and require prompt attention. Inmates awaiting emergency evaluation shall be housed in a specially designated area with constant supervision by trained staff. Inmates shall be held for only the minimum time necessary, before emergency care is rendered. All sources of assistance for mentally ill and retarded inmates shall be identified in advance of need, and referrals should be made on all such cases. No person shall be housed solely on account of involuntary commitment proceedings pursuant to Chapter 27, Article 5 of West Virginia Code.

13.14. Psychiatric Illness. There shall be consultation between the facility administrator and the physician or their designees prior to the following actions being taken regarding patients who are diagnosed as having a psychiatric illness:

13.14.a. Housing assignments;

13.14.b. Program assignments; and,

13.14.c. Transfers in and out of the institution.

13.15. Access to Treatment. It shall be required that each inmate, at time of admission be provided information concerning the right to medical treatment. The information sheet shall be approved by the physician, and shall include procedures for registering complaints and the facility's sick call schedule.

13.16. Sick Call. Sick call is the system through which each inmate reports for and receives appropriate medical services for non-emergency illness or injury. Inmates will have daily access to sick call forms which will be reviewed that day by the health authority or other person designated by the physician. All complaint forms shall become part of the inmate's health record. Sick call shall be performed by a licensed physician, physician's assistant, registered nurse, or other person designated by the physician. If an inmate's custody status precludes attendance at sick call, arrangements shall be made to provide sick call services in the place of the inmate's detention.

13.17. Emergency Services. There shall be twenty-four hour emergency medical care available. By definition, a medical emergency is an acute illness or unexpected health need that must be attended to immediately and cannot be delayed until the next scheduled sick call. The responsible physician shall approve a plan providing for the use of emergency transportation, use of a local hospital emergency department or appropriate health facility with emergency on-call physician services, procedures for the transfer of inmates to other medical facilities and security procedures.

13.18. Use of Restraints or Isolation For Out of Control Inmates. The physician shall approve a plan guiding the use of restraints, or isolation and providing for mental health personnel to evaluate inmates who are repeatedly out of control or remain out of control for more than a short period of time. Use of physical restraints in controlling inmates inside the facility may be used only for the protection of the individual or others. The use of restraints shall be recorded in the inmate's file. Any time an inmate remains out of control for more than a short period of time mental health personnel shall be consulted.

13.19. Disease Prevention. Holding facilities shall establish an area for use by inmates having medical problems which require separation or close observation.

13.20. Management of Pharmaceuticals. Procedures for prescribing, dispensing and administering drugs shall be in compliance with applicable state and federal laws and regulations. The physician shall approve written procedures for distribution, administration, accounting and disposal of medications. The physician shall approve a written medication log and maintain one for each inmate receiving medication to include the date, time, name of drug and dosage. Any inmate refusing medication must sign a statement to that effect, which is also signed by a staff member and filed in the health record. Medications will be administered only by a physician or nurse, or, after written approval by the physician, by the health authority or health-trained staff members; exception to this requirement may be made in that insulin injections may be self-administered by the inmate with supervision by the health authority or health-trained staff member. The physician shall inform facility personnel of possible side effects of medication on inmates. When medications are taken orally, the person administering the drug shall observe the inmate swallow the drug and have him/her speak after swallowing to ensure the ingestion of the medication. The facility shall provide a locked storage area for medications and maintain a list of medications stocked by the facility. Medications shall be refrigerated, if necessary.

13.21. Administration of Medication. Persons administering medications shall do so under the authority of the physician and shall have received training appropriate to their assignment. They are accountable for the administration of medication according to orders, and recording of the administration of medications in a manner and on a form approved by the physician. Training, from the physician, encompasses the medical aspects of the administration or distribution of medication; training, from the facility administrator, encompasses security matters inherent in the administration or distribution of medications in a correctional facility. The concept of administration or distribution of medication according to orders includes performance in a timely manner.

13.22. Health Records. A separate health file shall be established on every inmate at the time of his/her receiving screening. The health record shall be sufficiently detailed to enable any practitioner to give continuing care and enable them to determine what the inmate's condition was at a specific time and what procedures were done and to enable consultants to give an opinion after examination of the inmate. Entries must be written in ink and be legible, signed and dated. Records shall be maintained for a minimum of seven years after the inmate's last incarceration. The file shall contain the following:

13.22.a. The completed receiving screening form;

13.22.b. All findings, diagnoses, orders and treatments;

13.22.c. Medication log sheet;

13.22.d. Results of any laboratory, x-ray and diagnostic studies;

13.22.e. Completed medical complaint forms;

13.22.f. Place, date and time of health encounters;

13.22.g. Dental, psychiatric or other consultation reports;

13.22.h. Consent and refusal forms; and

13.22.i. Release of information forms.

13.23. Transfer of Records. In the case of off-site examination, treatment, transfer to another facility, or hospital admission, the inmate's health record or a copy of summary shall accompany them. Documentation of any off-site examination or treatment shall be made in the health record by the physician or other health professional involved. Health records shall be returned to the facility with the inmate, or, in the event of transfer or hospital admission, as soon as possible thereafter. Written authorization by the inmate is required for transfer of health record information, except in an emergency situation where the inmate is unable to authorize.

13.24. Confidentiality. The inmate's medical information, records and confidences entrusted to a physician or other medical care professional in the course of screening, examination or treatment are confidential and shall not be disclosed to anyone except:

13.24.a. With the inmate's informed consent; or

13.24.b. Where the law requires disclosure, e.g., reporting of communicable diseases; or

13.24.c. When the security of the institution or the safety of the individual requires disclosure and then only to the extent necessary for the protection of the inmate and the security of the facility; or

13.24.d. The chief administrative officer can review medical records but must maintain their confidentiality except as provided above.

13.25. First Aid Kits. Each facility shall have one or more first aid kits. The physician shall designate the number, location and contents of first aid kits. The health authority must periodically inspect all equipment and first aid kits.

13.26. Informed Consent. Informed consent of inmates is necessary for all medical examinations, treatment and procedures except for those which are required by law, e.g., treatment of infectious diseases where public health law requires such treatment. Exceptions to obtaining informed consent are allowable if they are in accordance with state law (such as emergency situations or public health matters).

13.27. Notification of Serious Illness or Injury. A process shall be developed whereby individuals so designated by the inmate are notified in case of serious illness or injury of the inmate. Permission for notification shall be obtained from the inmate prior to need, if possible. There may be situations in which the inmate does not want their next of kin notified of their illness or injury; therefore, their consent shall be obtained whenever possible. The next of kin, or other individuals identified by the inmate to be notified in emergencies shall be included in the facility admission form.

W. Va. Code R. § 95-3-13