Florida Administrative Code › 33 - DEPARTMENT OF CORRECTIONS › 33 - Departmental › Chapter 33-401 - HEALTH SERVICES ADMINISTRATION › Section 33-401.701 - Medical and Substance Abuse Clinical Files

Current through Reg. 50, No. 138; July 16, 2024
(1) The Department of Corrections Office of
				Health Services shall maintain a comprehensive medical file (including medical,
				dental and mental health components) on every person committed to the custody
				and care of the Department. Information included in the inmate's medical file
				is protected health information and shall be used or disclosed in accordance
				with the Health Insurance Portability and Accountability Act Privacy Rule of
				1996, (HIPAA) and Florida law. The Department of Corrections shall also
				maintain a comprehensive substance abuse file on every person inmate who
				receives substance abuse program services. Information included in the inmate's
				substance abuse file is confidential in accordance with 42 C.F.R. Part II, the
				Health Insurance Portability and Accountability Act Privacy Rule of 1996
				(HIPAA), and Florida law. The Department of Corrections' Reception and Medical
				Center Hospital shall maintain an inpatient hospital medical file on every
				inmate admitted for care and treatment at Reception Medical Center
				Hospital.
(2) Definitions.
(a) Business Associate - refers to a person
				or entity who is not a member of the Department of Corrections' workforce and
				who, on behalf of the department, performs a function or activity involving the
				use or disclosure of individually identifiable health information. A business
				associate agreement or contract requiring a business associate to appropriately
				safeguard protected health information is required from business
				associates.
(b) Designated Records
				Set - refers to an inmate's medical, mental health, and dental files, Reception
				Medical Center Hospital's inpatient hospital file, and substance abuse clinical
				files that are maintained by the Department.
(c) Department workforce - includes
				employees, volunteers, interns, trainees and other persons whose conduct, in
				the performance of work for the Department, is under the direct control of the
				Department, whether or not they are paid by the Department.
(d) Disclose - refers to the release,
				transfer, provision of access to, or divulging in any other manner of
				information outside the Department.
(e) Health Services Administrator - refers to
				designated Department employees responsible for working with the privacy
				officer to ensure that all Department privacy procedures are
				implemented.
(f) Hospital file - as
				used in this rule refers to an inmate's inpatient hospital patient records
				created and maintained by Reception Medical Center Hospital.
(g) Medical file - as used in this rule
				refers to the inmate's medical, mental health, and dental files maintained by
				the department.
(h) Personal
				Representative - as used in this rule, means, with respect to a deceased
				inmate, a person appointed by a court to act as the personal representative,
				executor, administrator, curator, or temporary administrator of the deceased
				inmate's estate, or if a court has not made such a judicial appointment, a
				person designated by the inmate to act as his or her personal representative in
				a last will that is self-proved under section
				 732.503, F.S. In addition, if a
				court has not made a judicial appointment as described herein and the inmate
				has not designated a person in a self-proved last will, a personal
				representative also means one of the following individuals:
1. A surviving spouse.
2. If there is no surviving spouse, a
				surviving adult child of the inmate.
3. If there is not surviving spouse or adult
				child, a parent of the inmate.
With respect to a living inmate, a personal representative
				  means a health care surrogate, proxy, guardian, or other person with authority
				  under Florida law to make decisions related to the inmate's health
				  care.
(i) Privacy
				Officer - as used in this rule, refers to a designated employee in the Office
				of Health Services who is responsible for the development and implementation of
				the policies and procedures related to the HIPAA Privacy Rule. The privacy
				officer is the Department's contact person for HIPAA.
(j) Protected health information (PHI) -
				where used herein, refers to inmate or offender information that is created or
				received by the Department of Corrections, whether oral, recorded, transmitted,
				or maintained in any form or medium, that relates to the past, present, or
				future physical or mental health or condition of an inmate or offender, the
				provision of health care to an inmate or offender, or the past, present, or
				future payment for the provision of health care to an inmate or offender and
				identifies an inmate or offender or there is a reasonable basis to believe the
				information can be used to identify an inmate or offender.
(k) Psychotherapy notes - refers to notes
				recorded by a mental health professional documenting or analyzing the contents
				of conversation during a private or group session. The term does not include
				medication prescription and monitoring, session start and stop times, the
				modalities and frequencies of treatment furnished, results of clinical tests,
				and any summary of the following: diagnosis, functional status, treatment plan,
				symptoms, prognosis, and progress to date.
(l) Substance abuse clinical file - refers to
				the department's inmate file containing all written documents, records and
				forms compiled to detail an inmate's substance abuse history, substance abuse
				screening, assessment, intervention, and other substance abuse services,
				including the results of urinalysis testing done for treatment, program
				participation, and admission and discharge summaries.
(m) Substance abuse progress notes - refers
				to notes recorded by a substance abuse health care professional documenting or
				analyzing the contents of conversation during a private or group session. The
				term does not include session start and stop times, the modalities and
				frequencies of treatment furnished, results of clinical tests, and any summary
				of the following: diagnosis, functional status, treatment plan, symptoms,
				prognosis, and progress to date.
(n) Use - refers to, with respect to
				protected health information, the sharing, employment, application,
				utilization, examination, or analysis of such information within the
				Department.