June 2013 PHOENIX COMPLEX
ALHAMBRA UNIT
MEMORANDUM

DATE: October 24, 2012
TO: Charles L. Ryan, Director
THROUGH: Robert Patton, Division Director
THROUGH: Carson McWilliams, Northern Region Operations Director
THROUGH: Al Ramos, Warden
FROM: Meegan A. Muse, Deputy Warden
Helena Valenzuela, Wexford Health Medical Compliance Monitor
Holly Massey, Interim Wexford Health Complex Site Manager
SUBJECT: COMPLIANCE WITH THE AMERICAN HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY
ACT OF 1996 (HIPAA)
POSITION PAPER
ISSUE
Should the Department of Corrections, Phoenix/Alhambra Complex, address the spatial arrangement of the inmate
intake area to ensure confidentiality of obtaining inmate medical and mental health information in order to comply
with American Health Insurance Portability and Accountability Act of 1996, (HIPAA) and the Standards for Health
Services in Prisons by the National Commission on Correctional Health Care?
BACKROUND
HIPAA, which stands for the American Health Insurance Portability and Accountability Act of 1996, is a set of rules
to be followed by doctors, hospitals and other health care providers. This protects all "individually identifiable health
information" held or transmitted by a covered entity or its business associate, in any form or media, whether
electronic, paper, or oral. The Privacy Rule calls this information "protected health information (PHI)."12 “Individually
identifiable health information” is information, including demographic data, that relates to:
• the individual’s past, present or future physical or mental health or condition,
• the provision of health care to the individual, or
• the past, present, or future payment for the provision of health care to the individual, and that identifies the
individual or for which there is a reasonable basis to believe it can be used to identify the individual.13 Individually
identifiable health information includes many common identifiers (e.g., name, address, birth date, Social Security
Number). www.hhs.gov/ocr/privacy
The Arizona Department of Corrections follows the accreditation program by complying with the requirements in the
manual, Standards for Health Services in Prisons, developed by the National Commission on Correctional Health
Care. The Standard states, “Discussion of patient information and clinical encounters are conducted in private and
carried out in a manner designed to encourage the patient’s subsequent use of health services.” (Standards for
Health Services, p. 15)
The Wexford Health Sources, Inc. Contract states in section 2.10.15.1: Information Confidentiality
”Confidentiality/Exchange of Information: The Contractor shall ensure that inmate health information is handled in
accordance with any applicable procedures established by Federal and State confidentiality of health information
laws and regulations.” Additionally stated, “To ensure compliance with HIPAA regulations, Wexford Health will set
forth protocols that meet or exceed accepted privacy standards of the correctional health care industry.” (section
2.10.15.1, p. 443)
CURRENT PRACTICE
Inmate medical and mental health intake evaluations are conducted in Delta run. The top portion of the Physical
Examination form (#1101-77P) and the Reception Center Screening form (#1101-21P), demographics, is conducted
in the hallway in Delta run by Patient Care Technicians (PCT’s). The nursing portion of the Reception Center
Screening form (#1101-21P) is conducted in one room in Delta run utilizing 2 to 5 nurses. Mental Health
evaluations are conducted in another room in Delta run by two Psych Associates utilizing the Initial Mental Health
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Assessment form (#1103-27) and if needed, additional SOAPE notes are written in the inmate’s medical file to
address additional needs (i.e. – continuous watch, etc.). Mobile partitions (from 5 to 6 feet tall and 5 feet wide) are
being used in both rooms in an attempt to address confidentiality compliance. There is no partition in the hallway
surrounding the PCT desk.
OPTIONS
1) Possibility of any open offices or other areas within the unit to expand into.
Comments: An inspection was conducted by key staff. The current infrastructure does not support additional areas
to be utilized by medical or mental health staff. Other office areas are currently occupied by other staff and there
are no empty rooms.
2) Possibility of introducing additional office spaces (i.e. - mobile trailer, etc.) within the Alhambra yard.
Comments: Cost and utility installation may be prohibitive. As well, an additional security officer would need to be
allocated for additional location.
3) Possibility of expanding the current Nursing and Mental Health staff hours.
Comments: Changes have already been made to the staff hours to better accommodate the needs of the unit.
Variations to the staff hours are limited due to the dependence of the time that the new arrivals come in to the unit
and the daily operational activities of the unit.
4) Possibility of mirroring community standards utilized in regional healthcare facilities, mental health institutions,
and correctional practices.
Comments: At regional healthcare facilities, such as hospital emergency departments, patients are screened,
triaged, evaluated, and treated, often in medical bays separated by cloth material (i.e. – curtains made of paper,
linen, or other thin cloth, etc.) in an attempt to address confidentiality compliance. At regional mental health
institutions (i.e. – walk-in mental health clinics and psychiatric emergency rooms), mental health screenings are
often conducted in much the same manner as hospital emergency departments. At regional correctional facilities
(i.e. – jails and prisons), the medical and mental health screening practices are often conducted in similar situations.
RECOMMENDATION
This committee recommends that the Phoenix / Alhambra Unit mirror the community standards utilized in regional
healthcare facilities, mental health institutions, and correctional practices (Option 4). The committee will review this
issue annually to evaluate and determine new viable options.
Corrective Actions: October Action plan submitted by Corizon1.Process to address access to care, to include but not limited to:
a.Scheduling patients
b.Staffing
2.In-service staff on process expectations per Sick Call 2.20.2.2 contract performance outcome 1
Sick call shall be held five days a week, Monday through Friday (excluding Holidays), for all
inmates (Sick Call Attachment); and site specific process
a.Agenda/sign off sheet to verify, inclusive of all pertinent staff
3.Monitoring (Sick Call Audit Tool)
a.Audit tools developed
b.Weekly site results discussed with RVP
c.Audit results discussed a monthly CQI meeting
d.Minutes and audit reported monthly to Regional office for tracking and trending
Responsible Parties = FHA/DON/RDCQI/RVP
Target Date-11/30/13
Continue to monitor weekly x 3 weeks, monthly until within compliance, then quarterly; monitoring frequency using
audit tool per audit results.
10/11/13 Update – All HNR s to be triaged by nursing, inclusive of MH.
2 Are sick call inmates being triaged within 24 hours(or immediately if inmate is identified with emergent
medical needs)? [P-E-07, DO 1101, HSTM Chapter 5, Sec. 3.1]
Level 1 Red User: Helena Valenzuela Date: 6/27/2013 12:12:17 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: October Action plan submitted by Corizon1.Process to address, to include but not limited to:
a.Daily pick up.
b.Date stamp.
c.Triage within 24 hrs, immediate triage of patient if emergent.
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d.Seen within 48 hrs after date stamp or 72 hrs weekend/holiday.
e.Nurse line sees patient, then to provider line when appropriate.
f. Submit final site process to RVP.
2.In-service staff on policy titled ”Routine Appointments – Request” Chapter 5, Section 3.1 (
(Attachment II.2.) and per Sick Call 2.20.2.2 contract performance outcome 2 (Sick Call
Attachment);
a.Agenda/sign off sheet to verify, inclusive of all pertinent staff.
3.Monitoring (Sick Call Monitoring Tool)
a.Audit tools developed.
b.Weekly site results discussed with RVP.
c.Audit results discussed a monthly CQI meeting.
d.Minutes and audit reported monthly to Regional office for tracking and trending.
Responsible Parties = FHA/DON/RDCQI/RVP
Target Date-11/30/13
Continue to monitor weekly x 3 weeks, monthly until within compliance, then quarterly; monitoring frequency using
audit tool per audit results.
2 Are sick call inmates being triaged within 24 hours(or immediately if inmate is identified with emergent
medical needs)? [P-E-07, DO 1101, HSTM Chapter 5, Sec. 3.1]
Level 1 Red User: Helena Valenzuela Date: 6/27/2013 12:12:17 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: October Action plan submitted by Corizon1.Process to address, to include but not limited to:
a.Daily pick up.
b.Date stamp.
c.Triage within 24 hrs, immediate triage of patient if emergent.
d.Seen within 48 hrs after date stamp or 72 hrs weekend/holiday.
e.Nurse line sees patient, then to provider line when appropriate.
f. Submit final site process to RVP.
2.In-service staff on policy titled ”Routine Appointments – Request” Chapter 5, Section 3.1 (
(Attachment II.2.) and per Sick Call 2.20.2.2 contract performance outcome 2 (Sick Call
Attachment);
a.Agenda/sign off sheet to verify, inclusive of all pertinent staff.
3.Monitoring (Sick Call Monitoring Tool)
a.Audit tools developed.
b.Weekly site results discussed with RVP.
c.Audit results discussed a monthly CQI meeting.
d.Minutes and audit reported monthly to Regional office for tracking and trending.
Responsible Parties = FHA/DON/RDCQI/RVP
Target Date-11/30/13
Continue to monitor weekly x 3 weeks, monthly until within compliance, then quarterly; monitoring frequency using
audit tool per audit results.
3 Are vitals signs, to include weight, being checked and documented each time an inmate is seen during
sick call? [P-E-04, HSTM Chapter 5, Section 1.3]
Level 1 Amber User: Helena Valenzuela Date: 6/27/2013 12:16:33 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: October Action plan submitted by Corizon1.In-service nursing staff on per Sick Call 2.20.2.2 contract performance outcome 3 (Sick Call
Attachment);
a.Agenda/sign off sheet to verify
2.Monitoring (Sick Call Monitoring Tool)
a.Audit tools developed
b.Weekly site results discussed with RVP
c.Audit results discussed a monthly CQI meeting
d.Minutes and audit reported monthly to Regional office for tracking and trending
Responsible Parties = FHA/DON/RDCQI/RVP
Target Date- 11/30/13Continue to monitor weekly x 3 weeks, monthly until within compliance, then quarterly;
monitoring frequency using audit tool per audit results.
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10/11/13 Update – VS will include weight when appropriate.
4 Is the SOAPE format being utilized in the inmate medical record for encounters? [DO 1104, HSTM Chapter
5, Section 1.3]
Level 1 Amber User: Helena Valenzuela Date: 6/27/2013 12:27:49 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: October Action plan submitted by Corizon1.In-service all staff including providers on policy titled ”Continuous Progress Note (SOAP)”,
Chapter 5, Section 1.3 (Attachment IV.1.) and per Sick Call 2.20.2.2 contract performance
outcome 4 (Sick Call Attachment); use of Corizon NETs
a.Agenda/sign off sheet to verify
2.Monitoring (Sick Call Monitoring Tool)
a.Audit tools developed
b.Weekly site results discussed with RVP
c.Audit results discussed a monthly CQI meeting
d.Minutes and audit reported monthly to Regional office for tracking and trending
Responsible Parties = FHA/DON/Medical Director/RDCQI/RVP
Target Date- 11/30/13
Continue to monitor weekly x 3 weeks, monthly until within compliance, then quarterly; monitoring frequency using
audit tool per audit results.
10/11/13 Update –NETs to be used for all Nursing sick call.
5 Are referrals to providers from sick call being seen within seven (7) days? [P-E-07]
Level 1 Amber User: Helena Valenzuela Date: 6/27/2013 12:34:27 PM
Corrective Plan: See October action plan as submitted by Corizon.
Corrective Actions: October Action plan submitted by Corizon1.In-service all staff including providers on Sick Call 2.20.2.2 contract performance outcome 5
(Sick Call Attachment); Seen by Physician or Midlevel within 7 days
a.Agenda/sign off sheet to verify
2.Monitoring (Sick Call Monitoring Tool)
a.Audit tools developed
b.Weekly site results discussed with RVP
c.Audit results discussed a monthly CQI meeting
d.Minutes and audit reported monthly to Regional office for tracking and trending
Responsible Parties = FHA/DON/Medical Director/RDCQI/RVP
Target Date- 11/30/13
Continue to monitor weekly x 3 weeks, monthly until within compliance, then quarterly; monitoring frequency using
audit tool per audit results.
6 Are nursing protocols in place and utilized by the nurses for sick call?
Level 1 Amber User: Helena Valenzuela Date: 6/27/2013 12:39:02 PM
Corrective Plan: Problem Identified: Helena Valenzuela reports nursing at Aspen is not using refusal forms as
appropriate.
Discussion: Nursing staff at Aspen, in Flamenco and on Baker Ward have been counseled/redirected to comply with
use of refusal forms. Nursing Staff has been reinstructed to complete med pass, noting on back of MARs any
refused doses and complete refusal forms, as directed, to be signed by inmate.
Action Plan: This will be reinforced by training by the DON and nursing supervisors the week of July 8, 2013.
Responsible Person: DON will work in cooperation with unit nursing supervisors to complete and document training.
Status: Initial conversations/redirection done by FHA on July 4, 2013. Formal training by DON, upcoming.
Anticipated Completion Date: Reports will be kept with the DON and available to Monitor on July 17, 2013.
Date Completed ______.
Corrective Actions: Approved per Helena Valenzuela.
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c. Audit results discussed a monthly CQI meeting.
d. Minutes and audit reported monthly to Regional office for tracking and trending.
Responsible Parties = FHA/DON//Medical Director/RDCQI/RVP
Target Date - 11/30/13
Continue to monitor weekly x 3 weeks, monthly until within compliance, then quarterly; monitoring frequency using
audit tool per audit results.

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a.Expired Medications (Appendix I.1.a.)
b.Re-order medications
c.Invalid chart orders (Appendix I.1.c.)
i.Therapeutic dose ranges
ii.Dose changes must have supporting documentation
d.Non-formulary process (Appendix I.1.d.)
i.Reviewed for approval within 24-48 hrs
ii.Providers notified decision within 24-48 hrs
e.Manifest Reconciliation
f.Inventory control
g.Stock Medications
h.Practitioner Cards (Appendis I.1.h.)
i.Controlled Medications (Appendix I.1.i.)
2.In-service staff
a.Using information from 8/19 - 11/13 Regional office mandatory in-service and PharmaCorr
policy
b.Agenda/sign off sheet to verify, inclusive of all pertinent staff (Appendix I.2.b.)
3.Monitoring (Appendix I. - IV Monitoring Tools)
a.Audit tools developed
b.Weekly site results discussed with RVP
c.Audit results discussed a monthly CQI meeting
d.Minutes and audit reported monthly to Regional office for tracking and trending
Responsible Parties = FHA/DON/IC/RDCQI/RVP
Target Date-11/30/13
Continue to monitor weekly x 3 weeks, monthly until within compliance, then quarterly; monitoring frequency using
audit tool per audit results.
10/11/13 Update – Statewide in Sept Redbook and MAR audit, results reviewed; to audit pharmacy in October
related to Controlled Substances and Expired meds.

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Corrective Actions: See above.
6 Are there any unreasonable delays in inmate receiving prescribed medications?
Level 2 Amber User: Kathy Campbell Date: 6/26/2013 7:30:08 PM
Corrective Plan: There is a committee meeting to discuss problem solving for this process. The first meeting is
Friday, August 2, 2013. This is a statewide Corizon/Pharmacorr issue and not at the site level.
See Below.
Corrective Actions: October Action plan submitted by CorizonIntakes1.Standardized process for meds to be available to inmate upon transfer (Pharmacy Appendix 1 & 2)
a.Intake Orders
b.Private Prisons
2.In-service staff on process per PharmaCorr policy,
a.Agenda/sign off sheet to verify, inclusive of all pertinent staff
3.Custody educated regarding contract requirements regarding inmate transfer with meds.
4.Monitoring (Appendix I. - IV Monitoring Tools)
a.Audit tools developed
b.Weekly site results discussed with RVP
c.Audit results discussed a monthly CQI meeting
d.Minutes and audit reported monthly to Regional office for tracking and trending
Responsibile Parties = FHA/DON/Custody/RDCQI/RVP
Continue to monitor weekly x 3 weeks, monthly until within compliance, then quarterly; monitoring frequency using
audit tool per audit results
1.Monitoring (Appendix I. - IV Monitoring Tools)
a.Audit tools developed
b.Weekly site results discussed with RVP
c.Audit results discussed a monthly CQI meeting
d.Minutes and audit reported monthly to Regional office for tracking and trending
2.Standardized process statewide to include, but not limited to (Appendix III.1.):
a.Internal
b.External
2.In-service staff on process and ADC policy titled “Continuity of Care Upon Transfer” Chapter
5, Section 5.0 (Appendices III.2.);
a.Agenda/sign off sheet to verify, inclusive of all pertinent staff.
9 Are non-formulary requests being reviewed for approval or disapproval within 24 to 48 hours?
Level 2 Amber User: Kathy Campbell Date: 6/26/2013 7:30:32 PM
Corrective Plan: This process is in committee, as is a statewide Corizon/Pharmacorr issue. First committee meeting
is Friday, August 2, 2013.
See Below.
Corrective Actions: October Action plan submitted by Corizon1.Standardized process statewide, to include but not limited to (Pharmacy Appendix 1 & 2):
a.Non-formulary process (Appendix I.1.d.)
i.Reviewed for approval within 24-48 hrs
ii.Providers notified decision within 24-48 hrs
e.Manifest Reconciliation
f.Inventory control
g.Stock Medications
h.Practitioner Cards (Appendis I.1.h.)
i.Controlled Medications (Appendix I.1.i.)
2.In-service staff
a.Using information from 8/19 - 11/13 Regional office mandatory in-service and PharmaCorr
policy
b.Agenda/sign off sheet to verify, inclusive of all pertinent staff (Appendix I.2.b.)
3.Monitoring (Appendix I. - IV Monitoring Tools)
a.Audit tools developed
b.Weekly site results discussed with RVP
c.Audit results discussed a monthly CQI meeting
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d.Minutes and audit reported monthly to Regional office for tracking and trending
Responsible Parties = FHA/DON/IC/RDCQI/RVP
Target Date-11/30/13
Continue to monitor weekly x 3 weeks, monthly until within compliance, then quarterly; monitoring frequency using
audit tool per audit results.
10/11/13 Update – Statewide in Sept Redbook and MAR audit, results reviewed; to audit pharmacy in October
related to Controlled Substances and Expired meds.
10 Are providers being notified of non-formulary decisions within 24 to 48 hours?
Level 2 Amber User: Kathy Campbell Date: 6/26/2013 7:30:40 PM
Corrective Plan: This process is in committee, as is a statewide Corizon/Pharmacorr issue. First committee meeting
is Friday, August 2, 2013.
See below.
Corrective Actions: October Action plan submitted by Corizon1.Standardized process statewide, to include but not limited to (Pharmacy Appendix 1 & 2):
a.Non-formulary process (Appendix I.1.d.)
i.Reviewed for approval within 24-48 hrs
ii.Providers notified decision within 24-48 hrs
e.Manifest Reconciliation
f.Inventory control
g.Stock Medications
h.Practitioner Cards (Appendis I.1.h.)
i.Controlled Medications (Appendix I.1.i.)
2.In-service staff
a.Using information from 8/19 - 11/13 Regional office mandatory in-service and PharmaCorr
policy
b.Agenda/sign off sheet to verify, inclusive of all pertinent staff (Appendix I.2.b.)
3.Monitoring (Appendix I. - IV Monitoring Tools)
a.Audit tools developed
b.Weekly site results discussed with RVP
c.Audit results discussed a monthly CQI meeting
d.Minutes and audit reported monthly to Regional office for tracking and trending
Responsible Parties = FHA/DON/IC/RDCQI/RVP
Target Date-11/30/13
Continue to monitor weekly x 3 weeks, monthly until within compliance, then quarterly; monitoring frequency using
audit tool per audit results.
10/11/13 Update – Statewide in Sept Redbook and MAR audit, results reviewed; to audit pharmacy in October
related to Controlled Substances and Expired meds.

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Corrective Plan: Problem: Scheduling
Discussion: Schedules are shared (posted) on the K-drive of the 15th of each month as requested by monitor
discussed at leadership.
Action: AFHA is concert with DON is leadership in counsel by FHA, who is responsible for recruitment.
Status: We our currently reviewing applications to improve our staffing levels.
Action: We have new hires in backgrounds, as well as continual recruitment and pending offers. Pool/prn staff and
Locums are used to cover vacancies.
Corrective Actions: See above.

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