John R. Justice (JRJ) Grant
Student Loan Repayment Program
Roles and Responsibilities
Updated August 6, 2014

Bureau of Justice Assistance
The Office of Justice Programs (OJP) Bureau of Justice Assistance (BJA) is the federal
grant making agency tasked with oversight of John R. Justice (JRJ) grant funds to
participating states, territories, and the District of Columbia (hereafter collectively referred
to as “states and territories”). As part of this responsibility, BJA ensures that all federal
statutory and regulatory requirements which govern the program are adhered to and/or
being implemented accordingly. In this role, BJA may establish policies, procedures, and
reporting mechanisms to enforce compliance with such requirements. This includes (but
is not limited to) requiring participating states and territories to verify the eligibility (initial
and continuing) and status of JRJ beneficiaries.
In its discretion, BJA has elected to fund this program through JRJ administering agencies
(as designated by the Governor or chief executive-equivalent) for each of the participating
56 states and territories. Awards are made on a formula basis, developed by BJA with the
assistance of the Bureau of Justice Statistics (BJS). This formula is based, in part, on
population size.
OJP/BJA assumes some responsibility in the collection of funds owed by JRJ beneficiaries
who have breached the terms of their service agreements. Upon notice of such a breach
(JRJ administering agency and beneficiary responsibilities herein are more fully described
below), BJA will send a general notice of repayment to the JRJ beneficiary and carbon
copy OJP’s Office of the Chief Financial Officer (OJP OCFO) who may then demand
repayment within 45 days from their first having received notice of a recipient having
entered “repayment status.” If the debtor is non-compliant in repaying the debt, the OJP
OCFO will refer the matter to the U.S. Treasury Department (with notice to the debtor) and
interest and collection fees will be assessed in addition to the principal amount owed.
Finally, BJA is tasked with the review and approval of requests for waivers of repayment
obligations owed by beneficiaries to the Federal Government. (The basis for such a waiver
is found in the Act). As part of this process, the JRJ Program Lead will perform an initial
review of all requests and make a recommendation to the BJA Director or his/her designee
for action. The JRJ Program Lead will provide outreach for any missing information
necessary to properly consider a waiver request.
BJA’s comprehensive list of JRJ beneficiaries (compiled from verification forms provided
from each of the states and territories) will be updated to identify any beneficiaries that
have been issued or denied a waiver. The beneficiary, beneficiary’s state or territory, and
OJP’s OCFO will each be notified of approved or denied waiver requests.

JRJ Administering Agency
BJA will make awards to designated JRJ administering agencies, whose role is to establish
and maintain a statewide JRJ Grant Program that is consistent with the John R. Justice
Prosecutors and Defenders Incentive Act, under 42 U.S.C. §3797cc-21 (the “Act”) and all
applicable federal regulations and other BJA- and/or OJP-promulgated programmatic
guidance.
Once an award is accepted, the designated JRJ administering agency must submit quarterly
financial status reports, quarterly performance metrics reports, and semi-annual progress
reports. JRJ administering agencies must also submit to BJA, on an annual basis, an
assessment report that evaluates the impact of the JRJ Grant Program on the recruitment
and retention of prosecutors and public defenders in the state by engaging with prosecutor
and public defender offices. This may be accomplished qualitatively, through surveys,
leader interviews, a focus group, or in a manner otherwise prescribed by BJA.
Additionally, JRJ administering agencies are required to annually verify the eligibility
(initial and continuing) and status of JRJ beneficiaries and submit to BJA, via the Grants
Management System (GMS), as a “Special Report” (or by a method otherwise prescribed
by BJA) the following documents:
1. All John R. Justice Student Loan Repayment Program (JRJSLRP) Service
Agreements, Secondary Service Agreements (including any addenda and
associated documentation) properly executed by participating beneficiaries for each
fiscal year;
2. All outstanding JRJSLRP Service Agreements and Secondary Service Agreements
(including any addenda and associated documentation) properly executed in prior
fiscal years that have not already been uploaded into GMS;
3. A complete list of recipients of JRJ benefits issued by the JRJ administering agency,
including a reference to the grant award number from which funds were paid on
behalf of each beneficiary;
4. A complete list of individuals (if any) who have had JRJ benefits paid on their
behalf by the JRJ administering agency, but who have left the program prior to
fulfilling their service obligation, including a reference to the grant award number
from which said JRJ benefits were paid.
JRJ administering agencies are required to also keep on record, available for audit and, if
necessary, collection purposes, any record relied upon by the JRJ agency to support its
funding decisions, including:
1. Applications received.
2. Income, debt, and loan data provided as part of each such application.
3. Documentation of outreach efforts implemented to distribute funding amongst a
wide range of employing agencies within the state.
4. Documentation of decisional processes in the evaluation of an individual’s ability
to repay his/her loan obligations.
5. Documentation of decisional processes in the evaluation of an individual’s
meritorious service (including military service) (if applicable).

6. Proof of an individual’s eligibility under the statutory definitions of “prosecutor”
or “public defender.”
7. Proof of an individual’s debt obligations under a “qualifying loan.”
BJA maintains the right to request from the JRJ administering agency any other records
that are reasonably required to determine compliance with statutory obligations, and the
JRJ agency, as a condition on receiving funds, will agree to cooperate to the fullest extent
possible in producing all such records.
Additionally, according to statute, once an eligible applicant is approved for participation
in the JRJ program, that beneficiary should be given priority consideration to receive
funding during the second and third years of the three-year service agreement, pending the
availability of funds. Renewal is not automatic and nothing shall obligate the state to renew
a benefit in the same (or greater) amount as was previously paid on behalf of a beneficiary.
Priority consideration granted in the second and third year of an initial JRJSLRP Service
Agreement obligation will ordinarily satisfy the priority consideration requirement.
Priority consideration beyond the third year is not required.
Upon completion of the original 3-year service obligation, subsequent agreements may be
entered into for additional obligations of service in consideration for future grant awards.
The terms of additional service obligations are addressed in Appendix C of the current
solicitation (JRJSLRP Service Agreement – Secondary Term of Service). The Appendix
C form should be exclusively used by the state JRJ administering agencies in situations
under which the selected beneficiary has: a) fulfilled his/her initial 3-year service
obligation; b) been selected again by the JRJ administering agency to receive additional
JRJ benefits, and c) agreed to commit to an additional one (1) year of service obligation in
exchange for those additional benefits. Through the first 3 years of the program, JRJ
beneficiaries had been subject only to one JRJSLRP Service Agreement, executed at the
time that the JRJ beneficiary first entered into the JRJ program. BJA became aware that,
in certain cases, some JRJ beneficiaries were asked to and subsequently signed additional
JRJSLRP Service Agreements even though the date of such execution occurred within the
original 3-year term of the JRJ beneficiary’s obligation of service. Such subsequent
“agreements” did not extend the original terms of service obligation, but rather served as a
reaffirmation and acknowledgement of the originally signed agreements and the terms and
conditions thereunder. Beginning with fiscal year 2013 and going forward, any JRJ
beneficiary who enters into a JRJSLRP Service Agreement – Secondary Term of Service
agrees to extend the beneficiary’s term of service obligation by the period of time expressed
therein, in exchange for the receipt of additional JRJ benefits. State JRJ agencies have
been warned to immediately cease the practice of having JRJ beneficiaries execute
additional JRJSLRP Agreements during the second and third year of a JRJ beneficiary’s
original Service Agreement, and instead advised to have the beneficiary execute the
JRJSLRP Acknowledgment of Benefit form (see Appendix D) on an annual basis during
the course of the beneficiary’s Service Agreement(s).
In the event of a breach of a service obligation agreement, a principal sum equal to the
amount that the beneficiary is required to repay to the Department of Justice (DOJ) shall
be recoverable by the Federal Government from the beneficiary (or the beneficiary’s estate,
if applicable) by such methods as provided by law for the recovery of amounts owed to the

Federal Government. The foregoing should not be understood to preclude the Federal
Government from recovering any interest that may be owed in the collection of a debt.
Once a JRJ beneficiary has been determined to be in a “repayment status,” it is incumbent
upon the designated JRJ administering agency to promptly notify BJA.
Once the 45-day period has expired and the debtor has not fully repaid the debt owed,
OJP’s OCFO will refer the matter to Treasury. Under standard practice, uncollected debt
is referred to Treasury within 60 days after the first notice (described above) is sent by
OJP’s OCFO.
JRJ Beneficiaries
As a condition precedent to the payment of any benefit under this program, all selected
beneficiaries must sign the “Service Agreement” currently included as part of the
solicitation as Appendix B. JRJ Beneficiaries are required to satisfy all of the terms of the
Service Agreement including but not limited to the following terms:


I will notify the designated JRJSLRP State administrative agency, without delay, in
writing, of any transfer to a new position or employing agency, identifying myself
as a JRJSLRP beneficiary.



I will notify the designated JRJSLRP State administrative agency, without delay, in
writing, of my intention to voluntarily separate, resign, or retire from my position
as an eligible beneficiary before completing my service obligation under paragraph
1 above.



I will notify the designated JRJSLRP State administrative agency, without delay,
in writing, of my status in default of any loan obligation with respect to a qualifying
“student loan,” as defined in 42 U.S.C. §3797cc-21(b)(3)(A).



In the event I voluntarily leave my position as an eligible beneficiary, or in the event
I am involuntarily separated for misconduct or unacceptable performance before
completing the agreed upon period of service, I will be indebted to the Federal
government and must reimburse the Department of Justice for the full amount of
any student loan repayments made on my behalf under this service agreement. I
further acknowledge that a sum equal to the amount that I am required to repay
shall be recoverable by the Federal government from me (or my estate, if
applicable) by such methods as are provided by law for the recovery of amounts
owed to the Federal government.

Appendix B is an agreement between the eligible beneficiaries (as selected by the JRJ
administering agency) and the DOJ, and as such, may not be modified by the grantee or
anyone else without the express written authorization of the BJA Director, and DOJ
(through BJA) will not accept or consider variances of the terms or form of Appendix B.
Consistent with the terms of the JRJSLRP Service Agreement, JRJ beneficiaries are
required to inform their JRJ state administering agency of their separation from a qualified
position of employment and the status of their repayment. A payment in the total amount

of the JRJ Student Loan Repayment benefits that have been made on behalf of the JRJ
beneficiary must then be sent to the Office of Justice Programs (OJP) Office of the Chief
Financial Officer (OCFO) with a notation of the applicable Grant Number(s) from which
the funds were derived, at the following address:
U.S. Department of Justice, Office of Justice Programs
Office of the Chief Financial Officer (Attn: Accounting Control Branch)
810 Seventh Street, N.W.
Washington, DC 20531
OJP does not provide the option of installment method payment plans for funds owed to
the federal government, though it is possible that debtors may be able to arrange for a
repayment plan through the Treasury Department (a matter that will not involve OJP).
Waiver Requests: JRJ beneficiaries who wish to request waivers to their obligation of
repayment of JRJ benefits must follow the formal process for submitting waivers as
described below:
Submit a formal waiver request via email at the dedicated mailbox: jrjwaiver@usdoj.gov
To be considered by the BJA Director, waiver requests must include the following required
items:
1. A sworn statement, made by the recipient (requestor) under penalty of perjury,
certifying and attesting to the truthfulness and accuracy of the information
provided, in the form of a one (1) page Word document that includes an explanation
for the waiver request;
2. Attached applicable supporting documentation, including any documentation in
support of the waiver request received from the State JRJ Administering Agency.
Formal Process for Waiver Review: Waivers will be reviewed to ensure compliance with
the Act and all applicable terms of the JRJSLRP service agreement to determine “whether
recovery would be against equity and good conscience or against the public interest.”
Requests that are incomplete or do not comply with the above-referenced process for
submitting a waiver request will not be reviewed until and unless such requirements are
fully met. As the issuance of a waiver is made at the sole discretion of the BJA Director,
any actions taken with respect to waiver requests will be considered final with no rights of
appeal.


U.S. Department of Justice

Civill\ights Division
Office ofSpecial Counseljor Immigration-Related
Uri/air Employment Practices - NYA
950 Penmylvania Ave, NW
Washington, DC 20530
Main (202) 616-5594
Fax (202) 616-5509

July 30, 2014
BY EMAIL (Kristen.roy@legrand.us)
Kristen Roy
Legrand
60 Woodlawn Street
West Hartford, CT 06110

Dear Ms. Roy:
Thank you for contacting the Office of Special Counsel for Immigration~Related Unfair
Employment Practices (OSe). This is in response to your e~mail dated June 24, 2014, in which
you request guidance for how to proceed after discovering that your company accepted more
documentation than necessary for Form I~9 purposes "in a few cases." In your email, you
explain that your company made this discovery after an internal review of the company's Forms
I~9. You also state that your company was advised by another agency to inquire with our office
about compliance with the anti~discrimination provision of the Immigration and Nationality Act
(INA), including whether "to retain or destroy excess documentation."
The Office of Special Counsel for Immigration~Related Unfair Employment Practices
(OSC) investigates and resolves charges of national origin and citizenship status discrimination
in hiring, firing or recruiting or referring for a fee; discriminatory documentary practices in the
employment eligibility verification (Form I~9 and E~Verify) process; and retaliation under the
anti~discrimination provision of the INA, 8 U.S.C. § 1324b. OSC cannot provide an advisory
opinion on any specific case or set of facts. However, we can provide general information on the
INA's anti~discrimination provision and the Form I~9 process.
Please note that we are not aware of any publicly available guidance issued by any
agency recommending steps an employer should take if it accepted too many documents during
the Form I~9 process. However, an employer may violate the anti~discrimination provision of
the INA if it requests more or different documents or rejects reasonably genuine~looking
documents on the basis of citizenship or immigration status or on the basis of national origin
during the Form I~9 process. If an employer requests more than one List A or a combination of
one List B document and one List C document, a violation of the anti~discrimination provision of
the INA will depend upon whether the employer made any of those requests because of an
employee's citizenship or immigration status or because of an employee's national origin.
Furthermore, while an employer should correct its practices upon learning that it may have
violated the anti-discrimination provision of the INA, an employee who believes that he or she
was the victim of discriminatory Form I~9 practices, has up to 180 days from the date of the
discriminatory practice to file a timely charge with our office. We encourage you to visit our

website (www.justice.gov/cli/about/osc) or to contact our toll-free employer hotline (1-800-255
8155 or TTY 1-800-237-2515) if you would like to learn about resources available to assist your
human resources staff in complying with the anti-discrimination provision going forward, such
as through free webinar training by our office or distribution of educational materials to your
staff.

Sincerely,

Alberto Ruisanchez
Deputy Special Counsel

2


U.S. Department of Justice
Federal Bureau of Prisons

PROGRAM STATEMENT
OPI
HSD/HSS
NUMBER
6010.05
DATE
June 26, 2014

Health Services Administration

/s/
Approved: Charles E. Samuels, Jr.
Director, Federal Bureau of Prisons

1. PURPOSE AND SCOPE
To deliver medically necessary health care to inmates effectively in accordance with proven
standards of care without compromising public safety concerns inherent to the Bureau’s overall
mission.
a. Summary of Changes
Policy Rescinded
P6010.04

Health Services Administration (6/20/2013)

Section 4.j.: Removes the restriction that consulting physicians and dentists must hold a current
license “in the state where services are provided.” Delivering services on a Federal installation
requires a current and valid professional license from any state.
b. Program Objectives. The expected results of this program are:
■ Staff will be guided in the development and operation of Bureau health care programs.
■ Administrative policies, procedures, and controls will be established, implemented, and
reviewed.
■ Appropriately trained, skilled, and credentialed staff will be employed.

■ Lines of authority and accountability will be established to provide for appropriate personnel
supervision.
■ Inmate medical care will be delivered efficiently and cost effectively within the levels of care
established by Bureau policy.
2. ADMINISTRATION
Providing health care within a correctional environment presents unique challenges not
encountered by practitioners elsewhere. The Health Services Division’s goal is to provide
medically necessary health care services.
On occasion, there may be an incompatibility between medical and correctional guidelines;
conflicts related to medical care should be resolved, as far as practical, in favor of medicine. At
the same time, the medical staff must be part of the institution’s correctional team.
a. Delegation of Authority. The Director’s authority to provide for the care and treatment of
persons charged or convicted of offenses against the United States has been delegated to the
Assistant Director, Health Services Division (HSD). The Assistant Director, HSD, directs and
administers all activities related to the physical and psychiatric care of inmates, the Bureau’s
Safety and Environmental Health Program, and Food and Farm Services.
The Assistant Director, HSD, has delegated the clinical direction and administration of all
activities related to the physical and psychiatric care of inmates to the Medical Director. The
Medical Director is the final health care authority for all clinical issues.
The Director delegates to the Regional Directors and Wardens authority to make
recommendations to the appropriate judge regarding the mental competency of inmates. The
Director retains the authority to audit and review any action taken under these delegations.
b. Core Principles. The following core principles support the Health Services Mission
Statement:
■ Human Value. All inmates have value as human beings and deserve medically necessary
health care.
■ Public Safety. Health care for inmates must be delivered within the constraints of
correctional concerns and responsibilities inherent to the Bureau of Prisons’ overall mission.

P6010.05

06/26/2014

2

■ Inmate Rights and Responsibilities. Inmates must understand their right to access health
care as well as their responsibilities to participate in health care in a manner that ensures
maximal benefit from offered services.
■ Evidence-Based Care. Standards of care for inmates will employ proven treatment
strategies, generally supported by outcome data.
■ Public Health. Inmate health interventions that prevent the spread of contagious diseases
and reduce preventable diseases and injuries are important to public health, and are consistent
with the Bureau of Prisons’ overall mission.
■ Fiscal Stewardship. Medical services provided to Federal inmates will be obtained at the
lowest possible cost. Comprehensive contracts for medical services with discounted rates
will be pursued wherever possible.
■ Inmate Function. Medically necessary interventions will aim to improve inmate functioning
to a level that facilitates performance of activities of daily living within the correctional
environment.
■ Compassionate Care. Clinicians treating inmates will appropriately weigh the risks and
benefits of various treatment options, and recognize and address the psychosocial needs of
inmates with terminal illnesses and other serious medical conditions.
3. HEALTH SERVICES DIVISION, ORGANIZATIONAL CHART
a. The Assistant Director, Health Services Division, is responsible for all policy and activities
related to the mission of the Division. This includes:
■
■
■
■

Managing human resources for the Division.
Directing budget planning and fiscal control.
Regularly inspecting institution health care facilities and programs.
Coordinating research activities related to health care.

The Office of the Assistant Director is staffed by the Assistant Director, Medical Director,
Deputy Assistant Director, and an Executive Assistant.
b. The Medical Director, as final health care authority for the Bureau, is responsible for all
health care delivered by Bureau health care practitioners and U.S. Public Health Service (PHS)
officers as well as establishing health care programs. Under 18 U.S.C. § 4005, the Bureau is
authorized to request assignment of PHS officers to assist with the direct delivery of health care.

P6010.05

06/26/2014

3

The Medical Director serves as the focal point for this relationship.
Historically, the Medical Director has been a board- certified physician assigned to the Bureau
under 18 U.S.C. § 4005.
The Assistant Director and Medical Director provide consultation and guidance to the Regional
Directors and Wardens.
Physicians selected as Clinical Specialty Consultants are privileged and supervised by the
Medical Director. Clinical Specialty Consultants are responsible for clinical guidance for
specific regions.
c. The Deputy Assistant Director has oversight authority for non-clinical medical operations as
well as Food Service and Safety.
d. HSD Planning and Goals. HSD will establish measurable goals and objectives for the
Bureau’s medical/mental health programs that are reviewed at least annually and updated, as
needed. The BOP’s strategic planning process will be used to review the goals and objectives
quarterly.
The BOP Governing Body will review the annual report submitted by the Office of Quality
Management, HSD.
The HSD is responsible for policy, planning, and evaluation. These responsibilities include:
■
■
■
■
■
■
■
■
■
■
■
■
■
■
■

Strategic planning.
Quality management.
Information systems.
Informational and statistical reporting.
Special medical population projections.
Facilities planning and design.
Managed care.
Policy planning, development, and analysis.
Budgetary activities.
Human resource issues.
Drug-Free Workplace Program.
Continuing Professional Education.
Tele-health.
Mental health programs.
Dental programs.

P6010.05

06/26/2014

4

■
■
■
■
■
■
■
■
■

Nursing programs.
Laboratory services.
Pharmacy programs.
Radiology services.
Physical therapy services.
Social worker services.
Medical designations and transportation.
Medical contracting.
Commissioned Officer/Public Health Service personnel issues.

e. Regional Office. As managerial staff, Regional Health Systems Administrators (RHSAs)
serve as principal advisors to the Regional Director and Deputy Regional Director in all matters
related to health care delivery. The primary responsibilities of the RHSAs include:
■
■
■
■

Develop suggestions for policy revisions.
Perform management assessments.
Prepare responses to correspondence and Regional Administrative Remedies (BP-10s).
Respond to health care problems at all institutions within the region (including Residential
Reentry Centers).
■ Provide advice to Regional Directors regarding the planning and development of new
institutions and construction at existing institutions.
RHSAs must be knowledgeable regarding:
■
■
■
■

EEO and recruitment.
Joint Commission standards.
American Correctional Association (ACA) standards.
Acceptable standards of medical practice in order to recommend changes and improvements.

f. Health Services Unit (HSU). The primary objective of institutional health services personnel
is the delivery of health care to inmates committed to the care and custody of the Attorney
General. The HSU’s organization will vary among institutions depending upon their security
levels and missions.
Ordinarily, the HSU at each institution will have a Clinical Director (CD) and a Health Services
Administrator (HSA), who report to the Warden (or Associate Warden). Specific functions are
described in subsequent sections.
All HSUs will participate in the BOP’s Program Review process to assess the achievement of
goals and objectives.

P6010.05

06/26/2014

5

The CD and the HSA will review all HSU policies and procedures annually and revise, if
necessary. All policy/procedures and revisions are subject to local negotiations. The reviewers
will sign and date each policy/procedure reviewed or revised.
4. DESCRIPTION OF MAJOR DUTIES/RESPONSIBILITIES
a. Clinical Director (CD). The CD is responsible for oversight of the clinical care provided at
the institution, including:
■
■
■
■
■

Reviews applications and credentials for membership to the medical staff.
Establishes practice agreements.
Implements and monitors in-house Continuing Professional Education (CPE) training.
Maintains the quality of health records.
Evaluates patient care through an ongoing program that identifies problems and their
resolution.

The CD will maintain a close working relationship with local community hospitals and health
care providers contracted by the institution. The CD will make the community hospital aware
that care provided to inmates will be authorized in advance by the institution, not at the inmate
patient’s request.
During outside hospitalization of an inmate, a physician, normally the CD, will document on the
SF-600 contact with the attending physician to ensure that:
■ He/she remains fully informed of the patient’s condition.
■ The care provided relates to the diagnoses on admission and any complications that develop.
■ Every effort is made either to return the inmate to the institution or transfer him/her to a
Medical Referral Center (MRC) as soon as the patient’s condition allows.
The CD will review, initial, and date all outside hospital and operative reports.
The CD is the clinical supervisor for Mid-Level Practitioners (MLPs) and must provide input
into performance evaluations concerning these individuals with the HSA or AHSA. However,
the HSA or AHSA are considered the primary supervisors of the MLPs for administrative issues.
The CD provides clinical supervision for other clinical personnel (nurses, Emergency Medical
Technicians [EMTs], etc.). In institutions without an assigned Bureau physician, the contract CD
will perform clinical supervision. The CD may designate a staff physician to provide all or part
of this clinical oversight, but such delegations must be clearly defined.

P6010.05

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6

Staff physicians providing clinical oversight for MLPs and other clinical personnel will provide
input for quarterly clinical care Performance Log entries.
The CD will ensure new health care providers are properly trained and oriented prior to
assignment to independent duty.
At a minimum, the CD or contract physician will provide the following supervisory functions for
MLPs:
(1) Review at least two health records, per provider, of the patients evaluated by the day shift
clinical staff (normal work week) at the end of each workday. If this review is not practical at
the end of the workday, it should take place the next possible workday.
This review, when necessary, will include a discussion of the case with the treating MLP and a
treatment plan review.
The reviewing physician will initial and date those charts reviewed.
(2) On the next normal workday, review all health records of those cases clinical staff evaluated
on the evening and morning watch, weekend, and holiday shifts. If this review is not practical, it
should take place the next possible workday.
This review, when necessary, will include a discussion of the case with the appropriate clinical
staff and a treatment plan review.
The reviewing physician will initial and date those charts reviewed.
When questions arise during record reviews, the physician responsible for clinical supervision
will arrange a face-to-face discussion with appropriate clinical staff as soon as possible.
(3) Be available to consult on cases requiring urgent attention.
(4) Review unusual and interesting cases with clinical staff individually, at staff meetings, and
other appropriate times.
b. Health Services Administrator (HSA). The HSA plans, implements, and directs all aspects
of the department's administration, including:
■ Supervision of administrative personnel.

P6010.05

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7

■
■
■
■
■
■

Procurement.
Supply.
Drug-free Workplace Program.
Housekeeping.
Sanitation.
Maintenance.

The HSA also provides supervision and direction for ancillary departments, including:
■
■
■
■
■
■

Pharmacy.
Laboratory.
Radiology.
Physical Therapy.
Social Workers.
Health records.

The HSA provides supervision and direction to these Health Services staff, including designation
of shifts and assignment of general and specific duties. Ordinarily, the HSA represents the
department on various committees and in other interdepartmental meetings or negotiations.
The HSA and CD integrate administrative management functions with clinical programs
(laboratory, radiology, physical therapy, pharmacy etc.).
The HSA or AHSA are considered the primary supervisor for MLPs, EMTs, and nurses in nonmedical facilities for administrative issues. Clinical input will be provided by the CD.
At institutions where the CD is a contract physician, the CD and all contract clinical staff are
under the HSA’s administrative oversight.
The HSA and the CD will be the direct avenues of communication between Health Services and
the CEO or designee, Regional Office, and Central Office. This does not exclude program
supervisors from communicating with these individuals and offices; however, the HSA and CD
have the primary responsibilities.
The HSA will prepare quarterly statistical reports to help monitor the health care services
provided. This report will only be used locally. The reporting format will also be determined
locally. The quarterly report will include:
■ Use of healthcare services by category.
■ Referrals to specialty consultants.

P6010.05

06/26/2014

8

■
■
■
■
■

Number of prescriptions written.
Number of laboratory and x-ray tests completed.
Observation room admissions, if applicable.
Onsite or off-site hospital admissions.
Serious injuries or illnesses, deaths, and off-site transports.

The HSA supervises inmates assigned to the HSU and organizes and directs training for inmate
workers.
The HSA is responsible for the orientation and non-clinical training of staff assigned to the HSU,
including correctional officers.
The HSA must be knowledgeable about personnel regulations applicable to both civilian and
PHS staff. The HSA is the local Personnel Officer for Public Health Services (PHS)
Commissioned Corps personnel. He/she assists in recruiting new personnel and keeps staff
informed of training opportunities.
The HSA or designee is responsible for maintaining each PHS Officer’s leave record.
Leave records must be certified and forwarded to the Officer’s duty station when an officer
transfers, or to the Bureau Commissioned Personnel Office when an officer separates or retires.
For institutions with PHS personnel, refer to Supervisor’s Guide to the Commissioned Corps,
available from the Division of Commissioned Personnel’s website.
The HSA will ensure that health care staff are appropriately licensed, registered, or certified.
Evidence of current licensure, certification, or registration must be verified at the primary source
and maintained in the HSU.
A copy of each Physician’s/Dentist’s Comparability Allowance Agreement, including evidence
of Board Certification status, must also be on file.
The HSA is responsible for budget and procurement activities, including controlling purchases,
maintenance, and distribution of equipment, materials, and facilities of the HSU.
The HSA must be knowledgeable about medical supplies, equipment, and their sources of
supply.
The HSA plans HSU budgetary requirements and maintains fiscal control over HSU contracts.

P6010.05

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9

The HSA keeps the CD and other health services staff members informed of the annual and
quarterly budgets.
The HSA certifies vouchers for payment submitted in connection with consultant care or other
“outside” medical services to verify their accuracy. Vouchers will also be reviewed with respect
to:
■ Were the billed services authorized and appropriate and have the services been completed?
■ Were the billed services actually provided?
■ Are the amounts invoiced correct within the terms of the contract; or, if there was no
contract, are they commensurate with customary fees in the community?
■ Is the billing or payment a duplication that must be prevented?
Services rendered by outside vendors will have the advance approval of the Contracting Officer
or the Contracting Officer’s Technical Representative (COTR) except in emergency situations,
which require prior notification.
c. Assistant Health Services Administrator (AHSA). As part of the management team, the
AHSA is responsible for administrative operations of the HSU as assigned by the HSA.
d. Mid-Level Practitioners (MLPs). MLPs are graduate physician assistants (certified or noncertified), nurse practitioners, and unlicensed medical graduates.
Mid-level practitioners must have a “Practice Agreement” with a licensed physician prior to
providing health care in the institution.
Practice Agreements will be granted based on the MLP’s qualifications, knowledge/skills, and
experience, as identified and verified in the credentials portfolio or by demonstration.
Practice agreements will be valid for a period not to exceed two years (see BP-A0823, MidLevel Practitioner (MLP)/Sponsor Physician Practice Agreement).
e. Nursing Department. Nursing departments are located only in MRCs. The institution’s
mission and size determine the complexity, numbers, and categories of nursing staff employed.
The department may include nurse administrators, supervisory personnel, staff nurses, and
licensed practical (vocational) nurses.
(1) Director of Nursing (DON). DONs are only assigned to MRCs. The DON is a Registered
Nurse who promotes accepted standards of care and establishes a means of monitoring and
evaluating nursing care. The DON is responsible for the delivery of nursing services.

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He/she analyzes, plans, implements, and evaluates all of the nursing department’s functions.
The DON participates in policy decisions affecting nursing personnel, patient care, and is a
member of the Governing Body.
The DON ensures staff nurses are trained properly and demonstrates the ability to use any
medical equipment that may facilitate nursing care. The DON maintains training documentation.
He/she organizes the department to provide optimum service to all shifts.
He/she encourages nursing staff to participate in continuing education programs and attend
required meetings.
The DON develops, allocates, and administers the nursing services budget, where appropriate.
(2) Assistant Director of Nursing (ADON). The ADON is a Registered Nurse accountable to
the DON. The ADON has specific duties as delegated by the DON and is authorized to act in the
DON's absence.
He/she supervises, coordinates, and integrates the activities of one or more nursing supervisors.
(3) Supervisory Clinical Nurse (SCN). The SCN is a Registered Nurse usually accountable to
the ADON or the DON. The SCN has responsibility for a specific shift or area, such as a
building or a unit (e.g., medical/surgical or specialty units within an Operating Room and Post
Anesthesia Recovery Room).
The SCN implements policies and procedures of the nursing department for his/her designated
area and coordinates care and services with other supervisors.
(4) Charge Nurse. The Charge Nurse is a Registered Nurse. In some settings, the Charge
Nurse may be called the team leader or patient care coordinator. He/she is usually accountable to
the Supervisory Clinical Nurse and serves a specific group of staff on a nursing organizational
unit.
The Charge Nurse assumes specific responsibility for the daily “hands on” nursing care of
patients and is primarily responsible for coordinating patient care with physicians, other hospital
departments, food service, and consultants.

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(5) Staff Nurse (Registered Nurse) (RN) – Medical Referral Center. The staff nurse, who is
usually accountable to the Charge Nurse, plans, implements, and evaluates the nursing care being
provided to his/her assigned patients.
He/she provides ongoing health education during hospitalization. Prior to discharge, the RN
gives discharge instructions to help the patient understand the need for follow-up care.
He/she maintains and improves clinical competence through continuing education and
progressive experience. After receiving documented training and demonstrating ability, the RN
must be able to operate any specialized equipment that may facilitate nursing care.
(6) Staff Nurse (Registered Nurse) (RN) – Non-Medical Referral Center Institution. The
staff nurse, who is usually accountable to the CD, coordinates, implements, and assesses patient
response to care provided in the out-patient setting.
He/she provides ongoing health education. The RN provides instructions to help the patient
understand the need for follow-up care.
He/she maintains and improves clinical knowledge and skills through continuing education and
progressive experience. After receiving documented training and demonstrating ability, the RN
must be able to operate any specialized equipment used in patient care.
(7) Licensed Practical (Vocational) Nurse (LPN/LVN) – Medical Referral Centers. The
LPN/LVN generally provides technical support and assistance to patients who are relatively
stable or who have chronic illness.
An RN must supervise LPNs/LVNs who provide direct patient care in an inpatient, outpatient, or
long-term care setting.
(8) Licensed Practical (Vocational) Nurse (LPN/LVN) – Non-Medical Referral Centers.
An LPN/LVN in a general population institution provides administrative and healthcare support
to other clinical staff. LPNs/LVNs may collect patient data, including vital signs and the nature
of the complaint, and may assist other clinical staff in providing routine treatment or emergency
care with appropriate supervision.
If LPNs/LVNs are providing nursing care such as the administration of medications and
treatments, an RN or physician must provide supervision on that shift.

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f. Emergency Medical Technicians/Paramedics (EMTs). Institutions may employ EMTs with
the prior approval of the National Health Systems Administrator. Institutions must ensure the
following when employing EMTs:
■ There are practice protocols appropriate to an EMT’s training.
■ EMTs are only assigned duties that are within the scope of their training and demonstrated
knowledge and skills.
g. Chief Pharmacist. The Chief Pharmacist is responsible for the distribution, administration,
and dispensing of all medications in the institution. Additional responsibilities include providing
pharmaceutical care to the inmate population, including medication information.
h. Correctional Officers Assigned to the HSU. Correctional Officers will be oriented
appropriately to the objectives and procedures of the health care team. To the extent feasible,
they will be included in conferences, planning reviews, and other activities related to the HSU.
Correctional Officers will be informed, preferably by the CD and psychiatrist/psychologist, in
managing inmates who are being treated or under observation for a mental health problem, or
inmates with medical conditions requiring special precautions.
At institutions with a mental health unit, staff meetings with Correctional Officers assigned to
that unit are desirable. Cases illustrating specific types of mental disorders should be presented,
and the medical officer or psychiatrist should interpret the patient’s behavior and explain how it
should be managed.
Officers will be given an opportunity to discuss problems encountered during the week with
health services staff.
i. Other Health Services Staff. The duties of other health services staff are described in their
billet description or position description as applicable.
j. Consultant Staff. Consultant medical staff are often needed to complement in-house staff.
The HSA and CD will determine the need for consultant contracts. The HSA will write the
statement of work. (Refer to the Program Statements Bureau of Prisons Acquisitions Policy
and Human Resource Management Manual.)
The HSA/CD will ensure that each consultant staff member is qualified and will maintain
optimal professional performance through:
■ Appointment/reappointment procedures.

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■ Specific delineation of clinical privileges.
■ Periodic reappraisal of each.
Only physicians and dentists holding an appropriate current license and offering evidence of
training or experience, current competence, professional ethics, and health status will be
considered. The above also pertains to telehealth services provided by other than a Federal
agency.
The HSA will ensure primary source verification of each applicant's current license, education,
or, if appropriate, certification.
The HSA will maintain a Consultant Log Book reflecting times and dates of all consultant visits
(refer to BP-A0352, Inmate Injury Assessment and Follow-up).
5. INMATE HSU W0RKERS
Inmates will only have assignments of minimal responsibility. Inmates will have close
supervision to prevent them from gaining access to privileged medical information, from having
authority/control over other inmates, and from acquiring contraband.
Inmates with skills as physicians, dentists, nurses, and any other health care areas will not be
assigned to the HSU.
a. Inmates will not be assigned to:
(1) The pharmacy and medical storeroom, or to jobs involving the handling or processing of, or
having potential for access to, pharmaceuticals and medical supplies. (Inmates may perform
janitorial services in these areas under direct supervision.)
(2) Areas where they will have access to health records, including blank copies of records or
records to be shredded, forms, or documents that will become part of the health record. This
includes any assignment where reasonable potential for access to a health record exists, not only
assignments located in the health records section, but also such assignments as clerks to
physicians, laboratory and x-ray clerks, and similar areas.
(3) Functions involving the scheduling of appointments or any other tasks with potential for
determining access to medical care.
(4) Jobs as clinic assistants or other medical assistants involving responsibility for direct
treatment procedures such as administering medication, applying liquids or ointments,

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administering medical soaks, dressing changes, irrigating tubes, removing sutures, venipuncture,
providing inhalation therapy, obtaining vital signs, etc.
(5) Duties as “scrub nurse or assistant,” or any other duties that involve physical presence in the
operating room during surgery.
(6) Carry out clinical tests or measurements, such as audiometric testing, pulmonary function
studies, electrocardiograms, refractions, etc. Inmates may not have access to the reports of such
tests.
Additionally, inmate workers may not be present during any x-ray procedure, including
positioning patients on the x-ray table and setting the dials for exposure. This prohibition
includes inmate workers developing x-rays as well as having access to x-rays and x-ray reports.
(7) Situations involving formal clinical contacts between staff and patients, such as triage/sick
call visits and other medical appointments. Exceptions would include emergency treatment or
testing in which assistance of inmate workers is necessary, or interpretation when no staff
member can speak the inmate’s native language.
(8) Inmates will not assist consultants in any way.
b. Inmates can be assigned to:
(1) Janitorial duties throughout the HSU. Inmates must be directly observed in areas of the HSU
that contain privileged medical information or potential contraband.
(2) The dental clinic, in accordance with the Program Statement Dental Services.
(3) Positions as inmate attendants, as long as they are appropriately trained and their duties and
supervision are detailed in written procedures. Examples of appropriate duties include feeding
patients, assisting in the transportation of patients, changing bed linen, and cleaning patient
rooms.
At no time are inmates permitted to document anything in the medical record.
Inmates may assist staff to a limited extent when no other staff are available, but will not be
involved in independent or direct treatment procedures.
At no time will inmates undergoing mental health treatment be used as inmate attendants.

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(4) Serve as “companions,” in accordance with the Program Statement Suicide Prevention
Program.
(5) At institutions with Hospice Programs, inmates may be employed as hospice workers.
6. BUDGET, PROPERTY, AND SUPPLIES
a. Budget. The HSA is the Cost Center Manager for the health services and continuing
professional education (CPE) budget at the institution level.
The HSA prepares all budgetary submissions and maintains records of all budgetary transactions.
The HSA will hold quarterly meetings with health services staff to familiarize them with the
status of the budget.
The only fund control system authorized is the Bureau’s Budget Execution Fund Control System.
The HSA is responsible for ensuring that obligations are accurately controlled, recorded, and
reported.
The HSA is responsible for assigning YREGDOC (fund control) numbers to all obligation
documents and for certifying that funds are available in their respective cost centers prior to the
creation of obligations (refer to the Program Statement Budget Execution Manual). These
computerized records provide detailed up-to-the-minute funds accountability, which prevents
over-obligation of funds available.
The fund control records must be reconciled monthly with the Consolidated Obligation Report in
the Financial Management Information System. This reconciliation must be presented to the
Controller through the respective Associate Warden by the 10th working day of the following
month.
b. Property. Annually, major equipment needs will be submitted to the Budget and Planning
Committee for inclusion on the institution’s priority list. The preparation of major HSU
equipment priority lists is delegated to the HSA in coordination with the institution’s Controller.
c. Procurement Procedures. All requests for purchase/purchase orders and purchase credit
cards will be prepared in accordance with regulations described in the Federal Acquisition
Regulations (FAR), Federal Property Management Regulations (FPMR), Justice Acquisition
Regulations (JAR), and the BOP Acquisition Policy (BPAP). The following priority list,
pursuant to FAR 8.001, will be used for purchasing all medical and dental supplies:

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■
■
■
■
■
■
■
■

Agency inventories.
Excess from other agencies (VA, GSA, USPHS, and DOD).
Federal Prison Industries.
Committee for the Purchase from People who are Blind or Severely Disabled.
Wholesale supply (GSA, VA, etc.).
Mandatory Federal Supply Schedules.
Optional use Federal Supply Schedules.
Commercial Sources.

d. Major Medical/Dental Equipment. Major medical/dental equipment is defined as
equipment costing more than the capitalized personal property criteria stated in the Program
Statement Property Management Manual. If the equipment being purchased meets the criteria
for major equipment, the following must occur:
■ A Request for Purchase form (BP-A0101) must be prepared which adequately and clearly
describes the required item(s).
■ Personal preference items or brand names will not be requested unless a “brand name or
equal” provision is included.
■ The provision will sufficiently describe all the prominent characteristics of the brand name
item.
■ A Major Equipment Justification form (BP-A0135) must accompany the Request for
Purchase form. Forms may be obtained from the institution Financial Management Office.
■ Both forms will be forwarded by e-mail or fax to the Health Services Division to the attention
of the National Health Systems Administrator.
■ If approved, the National Health Systems Administrator will provide written authorization
and the documentation will be returned for appropriate action.
e. Durable Medical Equipment. Inmates transferring or releasing will be authorized to retain
durable medical equipment that is prescribed as part of the treatment plan (CPAP, non-motorized
wheelchair, crutches, custom shoes, orthotic devices, etc.). Durable medical equipment will be
coded in SENTRY using MDS categories.
7. PREVENTIVE MAINTENANCE SERVICES
The HSU will have a written comprehensive preventive maintenance plan for all HSU equipment
that follows the manufacturers’ recommendations.
The plan will include a procedure for reporting and documenting equipment failure.

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Unless the manufacturer otherwise specifies, preventive maintenance actions will be documented
at least twice a year on the appropriate form.
8. COMMITTEE MEETINGS
Committees will be established and meetings held at least quarterly according to standards
approved by the Medical Director. A union representative will be a member of all HSU
committees. When issues are discussed that may lead to discipline of staff, may prompt an
investigation into staff members, or are similarly sensitive, these discussions will take place
without the union present.
The HSA will maintain documentation of committee meetings. Committee meetings may be
combined. The union will be given a copy of all meeting minutes and be afforded an opportunity
to negotiate any changes prior to implementation.
9. MEDICAL STAFF BY-LAWS – MEDICAL REFERRAL CENTERS
Medical Staff By-Laws will be required for all MRCs. MRC By-Laws will be negotiated locally.
Proper routing for clearance of by-laws is:
■
■
■
■
■

HSA and CD.
Warden.
RHSA.
Regional Director.
Medical Director.

Health Services policies will suffice as written criteria for rules and regulations for all other
HSUs.
10. HEALTH CARE STANDARDS
Health Services Unit Accreditation. MRCs will maintain appropriate accreditations with the
Joint Commission (formerly the Joint Commission on Accreditation of Healthcare Organizations
[JCAHO]).
All other institutions will maintain accreditation with Joint Commission Ambulatory Care
Standards.
All institutions will maintain ACA accreditation in the operation of their HSUs.

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11. DEPARTMENT OPERATING GUIDELINES
a. Medical Referral Centers. The HSA at MRCs will ensure that each medical/mental health
department head prepares detailed written policies and procedures governing his/her department.
JCAHO/ACA standards may be used as a resource for developing individual institution policies
and procedures.
Each MRC will establish a daily health services activity log. The log will contain, at a minimum:
■
■
■
■
■

Inpatient census at the beginning of each shift.
Admissions to community hospitals.
Admissions of seriously ill inmates.
Equipment or physical plant failures.
Admissions with unusual signs and symptoms.

Each MRC will also have an activity log for the Ambulatory Care area, which will include the
information listed below for general population institutions. These activity logs may be
combined.
b. General Population Institutions. The HSA at general population institutions will ensure
that a daily health services activity log is maintained. The log will contain, at a minimum:
■
■
■
■

Any outpatient census (inmates temporarily housed in the HSU).
Admissions to community hospitals.
All injuries (other than minor) requiring care.
Any equipment and physical plant failures.

12. POLICY WAIVERS
If an institution is unable to comply with the provisions of a policy due to some unique condition,
the Warden must request a formal waiver to that policy. The Assistant Director and Medical
Director, Health Services Division (HSD), may grant exemptions only for those areas
specifically authorized by health services policy in accordance with the Program Statement
Directives Management Manual. The Director must approve all other exemption requests.
All requests must clearly state the problem and attempted solutions.
Requests must be forwarded to the Assistant Director and Medical Director (HSD) from the
Warden, through the Regional Director.

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If approved, the documentation will be maintained with each copy of the appropriate health
services policy in the institution.
If denied by the Regional Office, the request will be returned with an explanation, but does not
need to be forwarded to the Assistant Director and the Medical Director.
No changes will be made until written approval is received.
13. REDUCTION IN SENTENCE (COMPASSIONATE RELEASE REQUESTS)
Under 18 U.S.C. §§ 3582 (c)(1)(A)(i) & 4205(g), institutions may request an inmate be given
consideration for a reduction in sentence (compassionate release) due to extraordinary and
compelling medical conditions. Information for the request for Reduction in Sentence is
gathered from several departments within the institution. The Health Services Unit must provide
a comprehensive medical summary that will include:
■
■
■
■
■
■

An estimate of life expectancy or a statement that life expectancy is indeterminate.
The level or degree of functionality.
All relevant test results.
All relevant consultations.
Referral reports/opinions from which the medical assessment was made.
The level of self-participation in activities of daily living.

Other information that may be helpful in describing the inmate’s present condition include:
■
■
■
■
■
■
■

Are they in a hospice program?
What type of pain medication is the inmate taking and how frequently is it required?
Weight loss.
Frequency of hospitalization.
Mental status.
Mobility status.
Requirement for supplemental oxygen.

More detailed information on Reduction in Sentence (Compassionate Releases) can be found in
the Program Statement Compassionate Release; Procedures for Implementation of 18 U.S.C.
§§ 3582 (c)(1)(A) & 4205(g).

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14. HOURS OF MEDICAL COVERAGE
Each institution will devise a method to provide medical services 24 hours per day, seven days
per week. In many cases, on-site medical coverage may be provided 16 hours per day at
institutions that meet the following conditions:
■ Suitable arrangements have been made with a local medical facility for coverage when the
Medical Officer of the Day is not available.
■ An emergency transportation system must be available for an inmate requiring emergency
care.
■ A procedure will be in place to have CPR-certified staff in the institution during the hours
medical staff are not available. (Refer to the Program Statement Patient Care)
Minimum security institutions meeting the criteria listed above may provide 12-hour on-site
coverage.
Regardless of the method used, there must be a physician or medical facility with the final
responsibility to provide medical treatment as soon as possible, once it has been determined that
an emergency exists. The method will be approved by the Warden.
A physician Medical Officer of the Day will be designated for 24-hour continuous duty to take
care of any emergencies, either by telephone consultation or by a response to the institution.
The Warden will determine the appropriate duty.
Dental Officers may not be assigned as Medical Officer of the Day.
It is suggested that every institution provide a pager or other remote paging system to permit the
Medical Officer of the Day to respond to institutional calls.
15. EMERGENCY CARE
Each institution will develop and follow a written plan to provide for 24 hour emergency
medical, dental, and mental health care. The plan will address the following:
■
■
■
■
■

On-site emergency first aid and crisis intervention.
Emergency on-call procedures for hours that health care providers are not on-site.
Emergency evacuation of the inmate from the institution.
Use of an emergency medical vehicle.
Use of one or more designated hospital emergency rooms or other appropriate facilities.

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■ Emergency on-call physician, dentist, and mental health professional services when the
emergency health facility is not located in a nearby community.
■ Security procedures providing for the immediate transfer of inmates when appropriate.
The HSU will conduct two emergency disaster drills per year. All drills will be critiqued to
identify deficiencies and opportunities to improve. Documentation will be maintained in the
HSA’s office.
At MRCs, compliance with ACA and Joint Commission standards will be considered sufficient
to meet the above requirements.
16. PERSONAL PROTECTIVE EQUIPMENT
The HSU will provide appropriate personal protective equipment (“lab” coats, etc.) and provide
institution or contract laundering services for staff involved in direct patient care.
Personal protective equipment will not be taken to an employee’s home for laundering.
Personal lab coats may be worn, if purchased and laundered by the employee.
17. PHYSICIANS/DENTISTS COMPARABILITY ALLOWANCE PLAN
The Federal Employees Health Care Protection Act of 1998 amended Title 5 United States Code,
Paragraph (2) of section 5948(a), which authorizes the Bureau’s Physicians/Dentists
Comparability Allowance Program (PCAP) and (DCAP). PHS Officers are not eligible for a
PCAP/DCAP.
a. The Physician Comparability Allowance (PCA) and the Dentist Comparability Allowance
(DCA) are authorized to address physician/dentist position recruitment and retention problems.
Physicians and dentists eligible to receive a PCA/DCA may, under these guidelines, enter into a
contract with the Bureau. BP-A0794, Physicians/Dentists Comparability Allowance Agreement,
is the required form for requesting a PCA/DCA.
The contract provides that, by receiving the PCA/DCA, the physician/dentist assumes the
obligation to serve without interruption throughout the term of the contract.
Entering into such an agreement is strictly voluntary. Failure to enter into an agreement in no
way affects the physician’s/dentist’s rights under a previous agreement and in no way affects
employment status.

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b. The Bureau is granted permanent authority to enter into PCA/DCA agreements with eligible
staff.
Both the Office of Personnel Management (OPM) and the Office of Management and Budget
(OMB) establish regulations under which the Act’s provisions are adopted and administered by
Federal agencies. The Bureau’s PCAP & DCAP conform with those regulations and guidelines.
c. The maximum amounts authorized for a PCA/DCA by statute are outlined in the following
tables:
Maximum Allowance Scale – All Grades of Physicians (1- or 2-Year Contract)

Factors
Base
Maximum
Total

Service of 24
months or less

Service over
24 months

$14,000
$14,000

$30,000
$30,000

Maximum Allowance Scale – All Grades of Dentists (1- or 2-Year Contract)

Factors
Base
Maximum
Total

Service of 24
months or less

Service over
24 months

$14,000
$14,000

$30,000
$30,000

d. Executing a Contract. Wardens initiate a PCA/DCA contract with the institution
physician/dentist.
Applicants eligible for PCAP/DCAP positions will be informed of such eligibility by the
Warden, or his/her designee, at the time of the offer of employment.
Wardens may choose not to initiate a contract based upon 5 U.S.C. § 5948. If a contract is not
initiated, the Warden will provide the rationale in writing to the employee.
All institution-initiated PCAs/DCAs will be forwarded to the Regional Director for approval.

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Contract initiation and evaluation will be made at the local level and reviewed at the regional
level. The Medical Director retains final authority to approve, modify, or disapprove all
allowances.
If the Medical Director modifies or disapproves the allowance, he/she, or his/her designee, will
provide the rationale and final decision in writing to the employee. The decision to deny a
PCA/DCA will be made in accordance with 5 U.S.C. § 5948.
e. Allowance Eligibility. Determination that a physician/ dentist is eligible for his/her position
is to be in accordance with the GS-602/680 classification standards.
An individual is “employed as a physician or dentist” only if he/she is serving in a position the
duties and responsibilities of which could not be performed satisfactorily by an incumbent who is
not a physician or dentist.
Physicians/dentists employed in Bureau positions that do not actually require a physician/dentist
to occupy the position are not eligible for a PCA/DCA.
f. Recruitment Difficulty Criteria. Examples of relevant data measuring recruitment difficulty
may include:
■ Length of position vacancy.
■ Number of unqualified applicants (as a percentage of total applicants received/reviewed for
the vacant position).
■ Number of applicants interviewed and found unacceptable because they were underqualified
(expressed as a percentage of the total interviews conducted for the vacant position).
■ Number of physicians rejecting offers of employment and citing inadequate compensation as
the reason (expressed as a percentage of the total number of employment offers made for the
position).
g. Physicians/dentists may be offered contracts for one or two years if they occupy a position:
■ That is certified to require a physician/dentist.
■ Where there are documented recruitment and retention problems.
■ Is authorized by the Medical Director.
h. PCA/DCA Contract. A contract entered into under the PCAP/DCAP’s provisions must be
specific for an individual, position, and institution.

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Should an individual move to a position or an institution other than that for which the contract is
executed, the contract is to be terminated.
A new contract is then subject to renegotiation under the termination and renewal provisions of
the PCAP/DCAP.
i. Termination. The Bureau may terminate the agreement by written notice when it is in the
Bureau’s best interest, by the employee via written notice, or when any one of the following
occurs:
■ End of employment.
■ Assignment to a position or status excluded from PCA/DCA coverage or not approved for a
PCA/DCA.
■ Completion of the service agreement or enactment of superseding law.
■ Change of tour of duty to less than 40 hours per pay period or to an intermittent tour of duty.
■ Loss or failure to maintain a valid license to practice medicine/dentistry.
Termination of the agreement prior to its scheduled expiration date may require the
physician/dentist to repay all or part of the gross PCA/DCA. Title 5 U.S.C. § 5948(e) provides
that agencies may waive, in whole or in part, PCA/DCA repayment under certain conditions
(involuntary separation without cause, e.g., due to a medical condition; a legislative change;
mandatory retirement; or other circumstances beyond the physician’s or dentist’s control).
The authority to waive repayment is delegated to the Medical Director.
j. Repayment Schedule. When a repayment is required, the repayment must be in a lump sum
according to the following schedule:
■ For a physician/dentist who has executed a one-year agreement and who does not complete
one year of service, the payback amount is 100 percent of the gross PCA/DCA.
■ For a physician/dentist who has executed a two-year agreement and who does not complete
one year of service, the payback amount is 100 percent of the gross PCA/DCA.
■ For a physician/dentist who has executed a two-year agreement and who completes at least
one year of service, the payback amount is 50 percent of the gross PCA/DCA.
k. Special Provisions
(1) The Warden will provide the physician/dentist a written explanation of the intent to suspend,
withhold, or terminate the PCAP/DCAP. The physician/dentist will have 10 working days to
respond in writing to the Warden’s letter. The Warden will have the final decision authority.

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(2) The PCA/DCA is paid biweekly in equal amounts incorporated into the physician’s/dentist’s
regular paycheck throughout the service period. The PCA/DCA is taxable and is considered to
be a portion of the recipient’s base pay for purposes of compensation, lump sum payments,
workers’ compensation, and life insurance benefits. Applicability of the PCA/DCA to retirement
computation is found in section l.(1).
(3) When a physician/dentist has to repay a Federal loan that has an optional provision for
waiver of all or part of the loan in return for service, the physician/dentist will have the amount
deducted from any PCA/DCA.
(4) A PCA/DCA may not be paid to any physician/dentist who:
■ Is employed on less than a half-time or intermittent basis.
■ Occupies an internship or residency training program.
■ Is a re-employed annuitant, or is fulfilling a scholarship obligation (i.e., a National Health
Service Corps scholarship or any other scholarship program that requires repayment by
Government service).
(5) Physicians/dentists granted Leave Without Pay (LWOP) while under a service contract must
have their PCA/DCA payments terminated during the period of absence.
Payments of a prorated amount of the PCA/DCA under the expired portion of the contract will
resume upon return to the same position.
No part of the LWOP may be counted toward meeting the 24-month Federal service requirement.
l. Applicability to Civil Service Retirement System (CSRS) and Federal Employees
Retirement System (FERS)
(1) Computation Rules. No part of a PCA/DCA may be treated as basic pay for any retirement
computation purposes unless, before the date of the separation on which the entitlement to
annuity is based, the separating individual has completed at least 15 years of service as a
government physician or dentist; after this condition has been met, any amounts received as
PCA/DCA are treated as base pay for retirement purposes, but only to the extent the amounts are
attributable to service performed on or after December 28, 2000, and only to the extent of the
percentage as follows:

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Total amount of service performed
on or after 12/28/2000 as a
Government physician or dentist is:
Less than 2 years
At least 2, but less than 4 years
At least 4, but less than 6 years
At least 6, but less than 8 years
At least 8 years

Allowable percentage:

0
25
50
75
100

For purposes of an annuity based upon disability, or a survivor annuity based upon the service of
an individual who dies before separating from service, all amounts received as PCA/DCA are
treated as basic pay.
m. Contract Implementation
(1) Authority. The Medical Director is authorized to determine a physician’s/dentist’s basic
eligibility for inclusion in the PCAP/DCAP and retains authority to approve all PCA/DCA
contracts.
(2) New PCA/DCA Contract. The contract for an allowance is negotiated with the
physician/dentist, then forwarded for final approval to the Medical Director through the
institution’s Human Resource Manager (HRM), the Warden, and the Regional Director. In
addition to the contract, the request must include a cover letter from the Warden containing the
following:
■ Description of the specialty required.
■ Rationale and justification for the PCA/DCA as appropriate (recruitment and retention
problems).
■ An analysis of the applicant’s credentials.
■ The final dollar amount of the PCA/DCA requested. After reviewing the request, the
Medical Director notifies the Warden through the Regional Director of the decision.
n. Renewal of PCAP/DCAP Contract. Each physician/dentist desiring to renew a contract
needs to notify the institution’s HRM of his/her intent to renew. The HRM forwards the request,
cover letter, and contract through the Warden and Regional Director to the Medical Director.
To avoid delays in renewal agreements, applications for the Medical Director’s approval must be
submitted 60 days in advance of the desired effective date. The effective date cannot precede the
date of the Medical Director’s signature.

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The institution HRM contacts the Medical Director’s office requesting approval should the
Medical Director’s approval not be received at least one pay period prior to the proposed
effective date.
Renewal of a PCAP/DCAP contract is not automatic. Any contractual, job performance, or
organizational difficulties must be addressed prior to renewal.
o. Adjustment of PCAP/DCAP Contract After 24 Months/Change in Board Certification.
After a physician/dentist completes 24 months of Federal service as a physician or dentist, or
there is a change in Board Certification, a new PCA/DCA agreement is to be completed.
The institution HRM initiates a new contract indicating the new amounts in accordance with the
new schedule. The Warden and the physician/dentist will date and initial these changes and send
the contract through the Regional Director to the Medical Director for final approval.
The contract’s beginning and ending dates must not change.
p. Contract Effective Date. The PCA/DCA contract is effective the beginning of the first pay
period after the date the Medical Director signs the contract.
The Medical Director may authorize a retroactive PCA/DCA under administrative error
circumstances (i.e., institution/regional/Central Office staff inadvertently caused a delay in
processing the PCA/DCA).
q. Institution’s Human Resource Manager (HRM) Responsibility. The HRM explains to
each physician/dentist the PCA/DCA’s purpose and major aspects, terms, and conditions.
Upon approval of the agreement, the original agreement is forwarded to the HRM, who provides
a copy to the physician/dentist and files the original on the left-hand side of the Official
Personnel Folder.
When a physician/dentist is separated from service while receiving a PCA/DCA, or when the
contract expires without renegotiation or renewal, the HRM must notify the National Finance
Center (NFC) and furnish a copy of the notification to the Medical Director’s office.
r. Assistance. Questions regarding the PCAP/DCAP may be directed to the Medical Director’s
office.

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18. CONTINUING PROFESSIONAL EDUCATION
The mission of the Continuing Professional Education Program (CPE) is to maintain, develop,
and increase the knowledge and skills of health professionals to perform their duties. This
program assists in achieving a fully credentialed health care workforce.
CPE goals in the Bureau are commensurate with quality standards of medical practice in the
community.
a. Institution CPE. The HSA is responsible for the in-house CPE Program. All primary health
care providers will complete a minimum of 24 hours of in-house CPE per year. This can be
accomplished through self-study magazine articles, videos, audio cassettes, etc.
Employees will notify the HSA of self-study materials completed. The method of notification
will be determined locally. The HSA will provide adequate duty time for staff to complete inhouse CPE.
Documentation of training will be placed in the employee’s training record.
All health care practitioners, including HSAs and AHSAs, will maintain CPR and AED
certification using American Red Cross or American Heart Association-established standards.
The minimum level of the course should be the Basic Life Support (BLS) Heartsaver Course.
There will be a written policy and procedure outlining the orientation of new health services
staff, in-house consultants, and other new institution staff. The orientation program will include,
but not be limited to:
■
■
■
■

HSU services.
Emergency procedures.
HSU security procedures.
Levels of care provided to the inmates.

The HSA and the Employee Development Manager (EDM) will coordinate this orientation
training.
b. Central Office CPE. The HSD will maintain an APPROVAL STATUS with the American
Council on Pharmaceutical Education as a provider of continuing pharmaceutical education and
will be an authorized sponsor for the Accrediting Council for Continuing Medical Education for
Physicians.

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(1) The CPE Capitation Program is for health care providers, including physicians, mid-level
practitioners, nurses, laboratory staff, HSAs, EMTs, etc. Capitation allocations may also be used
to provide funding for external continuing education.
This program is authorized for civilian/military/college continuing medical educational units.
CPE Capitation funds may be used for home study/ correspondence/on-line courses from
accredited providers.
CPE capitation funds will not be distributed at the institution level.
This program may not be used to obtain a degree (5 U.S.C. § 4107(d)(1)).
Funds may not be used for professional journals or magazines.
CPE capitation funds will not be used for expenses related to obtaining professional licensure or
certification (e.g. application fees, exam registration fees, etc.)
All funding for travel must meet Federal travel regulations.
(2) CPE Residential Program. The National Continuing Professional Education Office
annually sponsors CPE specialty education programs. These programs are based upon needs
assessments submitted by the designated health care professionals.
CPE residential programs are designed to study factors influencing the frequency and distribution
of diseases, injuries, and other health-related events pertinent to health care in a correctional
environment.
All educational offerings will be based upon defined needs and explicit objectives, educational
content, and methods.
As required by the Accreditation Council for Continuing Medical Education (ACCME), the
Central Office CME/CPE Governing Board will review the Residential Program at least
biannually. These reviews are to evaluate the continuing need for the program and the sponsored
activities in relationship to the Health Services mission. The CME/CPE Governing Board will
review issues such as:
■ Whether to add and/or delete professional disciplines.
■ Whether to consider increasing and/or decreasing the discipline’s funding level.
■ To review and evaluate the effectiveness of the overall CME Program.

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■ To plan for the future.
c. CPE Funding Levels and Approval Process
(1) CPE Capitation Funding. CPE capitation funding is approved on an institution need and
available funding basis for all health care personnel.
(2) CPE Capitation Approval Process. Any health care professional who desires to attend
CPE will request CPE approval from the HSA via a memorandum justifying attendance or
participation in the educational activity. A completed Training Authorization (SF-182) and
course brochure or literature must accompany the memorandum to begin the approval process.
The HSA and EDM will review the requested CPE and forward the request via an SF-182 to the
Warden for final approval.
CPE may be a recruitment and retention tool that is used to maintain medical skill proficiency.
Therefore, HSAs are encouraged to approve CPE requests contingent upon the following:
■ Applicability to the profession.
■ Institution HSU needs.
■ Availability of CPE funds.
HSAs maintain the authority to approve or deny CPE training requests. If the HSA approves the
CPE training request, the request will be forwarded to the EDM for review and to the Warden for
final approval.
The required approval processing time will be established at the institution.
The program/educational activity must be provided by an accredited sponsor or provider,
(ACCME, AMA, ANA, etc.), and be approved for continuing education credit. Programs should
be based on required or demonstrated educational need.
d. Funding Allocation
(1) CPE Capitation Funding is based upon Central Office determinations of CPE capitation
needs, proper use in prior fiscal years, and the availability of funds.
CPE capitation funding varies each year and notification will be sent to each institution with the
approved funding level.

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Funds beyond the approval level may be requested via a memorandum, which includes the
appropriate justifications, to the Assistant Director and Medical Director, HSD.
The following professional personnel positions are authorized to receive annual CPE capitation
funds. The total amount of funding will be determined on an annual basis. Minimum amounts
are listed below:
Physician
Mid-level Practitioner
Dentist
Nurse
Pharmacist
Pharmacy Technician
Dental Hygienist
Dental Technician
Dietician
Physical Therapist
Occupational Therapist
Registered Record Administrator
Accredited Record Technician
Laboratory Technologist
X-Ray Technician
Health Services Administrator
Assistant Health Services Administrator
Social Worker
EMT/Paramedic/Health Tech

$1,500
1,100
1,100
800
800
500
800
500
800
800
800
600
600
800
500
800
800
800
500

Mid-Level Practitioners (MLPs) are graduate physician assistants (certified or non-certified),
nurse practitioners, and unlicensed medical graduates.
CPE capitation funding for HSA/AHSAs will not exceed the position amount indicated. No
HSA/AHSA will receive dual capitation funding (i.e., as an HSA/AHSA and again for his/her
discipline). Further, HSA/AHSAs are not authorized to choose between medical capitation
disciplines to receive the higher amount; e.g., an MLP serving as an HSA/AHSA requesting
funding at the $1,100 level instead of the $800 level.
All expenses exceeding the capitation allotment pertaining to the position will be the
responsibility of the employee unless the institution training committee agrees to fund the cost
above the limitation.
Funds allotted to the institution for inmate medical care will not be used to fund additional costs.
Participant Responsibilities. Staff have the following responsibilities when attending CPE
capitation programs:

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■ Follow all Federal Travel Regulations, including the maintenance of accurate financial
records.
■ Share clinical information with all colleagues upon return from training.
■ Pay for any cost exceeding the authorized allocation.
■ Upon completing the training, provide the EDM proper documentation to include in the
employee’s training record.
(2) CPE Residential Funding. All CPE residential training programs are funded at the Central
Office level. Once a CPE residential training program has been developed, requests for
attendance are submitted to the institution Warden.
The Warden nominates participants for the residential programs.
The nominees’ names are submitted to the Medical Director via the National CPE Coordinator
(NCPEC) in Central Office.
The NCPEC will transmit an SF-182 to the institution participant, HSA, and EDM for approved
participants.
Upon notification of a scheduled residential CPE program, the HSA will disseminate this
information to the appropriate health care staff in a timely manner. Any health care professional
who desires to attend a residential CPE program should contact the HSA.
19. PRECEPTORSHIP PROGRAM FOR HEALTH PROFESSIONALS
Correctional institutions may enter into agreements with educational institutions (colleges or
universities) to provide students. When students and postgraduate students are present, their
status will be defined in the organization’s human resources policies. When students and postgraduate students are present and involved in patient evaluation, they are required to identify
themselves as students, and the patient must concur with examination, evaluation, or treatment
by a student.
To meet legal requirements, there are required procedures to establish a preceptorship program.
The basic requirement will be an agreement on the scope of work and funding arrangements, if
applicable, between the correctional and educational institutions.

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HSAs are strongly encouraged to establish preceptorship programs for health care professionals
where feasible, and will contact their contracting officer for details on the procurement
regulations.
At institutions with physician assistant/nurse practitioner (PA/NP) and other health professional
preceptorship programs, the CD will monitor the student’s progress and verify, in conjunction
with the HSA, acceptable performance to support payment of the contract charges, if applicable.
BP-A0793, Physician Assistant/Nurse Practitioner Preceptorship Agreement, is a procedural
guide and provides examples of required documents that can help establish a preceptorship
program. The examples are specific to a PA/NP program, but can be modified for other health
professionals.
20. AGENCY ACA ACCREDITATION PROVISIONS
th

a. American Correctional Association 4 Edition Standards for Adult Correctional Institutions:
4-4348, 4-4349, 4-4351(M), 4-4380(M), 4-4382(M), 4-4385, 4-4393, 4-4408, 4-4409, 4-4412, 44422, 4-4423, 4-4424, 4-4426, and 4-4427
rd

b. American Correctional Association 3 Edition Standards for Adult Local Detention Facilities:
3-ALDF-4E-01, 3-ALDF-4E-03, 3-ALDF-4E-04, 3-ALDF-4E-07, 3-ALDF-4E-08, 3-ALDF-4E16, and 3-ALDF-4E-30
nd

c. American Correctional Association, 2 Edition Standards for Administration of Correctional
Agencies: 2-CO-4E-01
REFERENCES
Program Statements
P1221.66
Directives Management Manual (7/21/98)
P2100.04
Budget Execution Manual (3/18/14)
P3000.03
Human Resource Management Manual (12/19/07)
P3735.04
Drug Free Workplace (6/30/97)
P4100.04
Bureau of Prisons Acquisition Policy (5/19/04)
P4400.05
Property Management Manual (5/26/04)
P4500.10
Trust Fund/Deposit Fund Manual (5/29/14)
P4700.06
Food Service Manual (9/3/11)
P5050.49
Compassionate Release/Reduction in Sentence: Procedures for Implementation of
18 U.S.C. 3582 (c)(1)(A) & 4205(g) (8/12/13)
P5324.08
Suicide Prevention Program (4/5/07)

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P6027.01
P6031.04
P6270.01
P6340.04
P6360.01
P6370.01
P6400.02

Health Care Provider Credential Verification, Privileges, and Practice Agreement
Program (1/15/05)
Patient Care (6/3/14)
Medical Designations and Referral Services for Federal Prisoners (1/15/05)
Psychiatric Services (1/15/05)
Pharmacy Services (1/15/05)
Laboratory Services (1/15/05)
Dental Services (1/15/05)

FAR 8.001. Federal Acquisition Regulation
Title 18 U.S.C., 3582(c)(1)(A) & 4205(g). Reduction in Sentence, Compassionate Release
Requests
Title 5 U.S.C., Section 5948. Physician/Dentist Comparability Allowance Plan
5 CFR, Chapter 1, §551.431. Time Spent on Standby Duty or in an On-Call Status
BOP Forms
BP-A0101
BP-A0135
BP-A0352
BP-A0793
BP-A0794
BP-A0823

Request for Purchase
Major Equipment Justification
Inmate Injury Assessment and Follow-up
Physician Assistant/Nurse Practitioner Preceptorship Agreement
Physicians/Dentists Comparability Allowance Agreement
Mid-Level Practitioner (MLP)/Sponsor Physician Practice Agreement

Records Retention Requirements
Requirements and retention guidance for records and information applicable to this program are
available in the Records and Information Disposition Schedule (RIDS) on Sallyport.

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