BOP Program Statement 6010.06 § 4

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 of the medical staff.

 Establishes practice agreements.

 Implements and monitors in-house Continuing Professional Education (CPE) training.

 Maintains the quality of health records.

 Evaluates inmate 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, ensuring good communication and appropriate continuity

of care. The CD will make the community hospital aware that care provided to inmates will be

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authorized in advance by the institution, not at the inmate’s request.

During the hospitalization of an inmate, a physician, normally the CD, will document in the

Electronic Health Record (EHR) contact with the attending physician daily to ensure:

 The CD or their designee remains fully informed of the inmate’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 them to a

Medical Referral Center (MRC) as soon as the inmate’s condition allows.

The CD will review, initial, and date all outside hospital and operative reports.

The CD is the clinical supervisor responsible for overseeing the professional development and

clinical care provided by Advanced Practice Providers (APP) and pharmacists with collaborative

practice agreements. The CD must provide input into performance evaluations concerning these

individuals with the HSA or AHSA. However, the HSA or AHSA is considered the primary

supervisor of the APPs for administrative issues, overseeing daily operations, ensuring efficient

delivery of services, and compliance with regulations. The CD may designate a staff physician to

provide all or part of this non-personal clinical oversight, but such delegations must be clearly

defined. The CD will be the primary supervisor for the Chief Dental Officer and all other

Licensed Independent Medical Officers at the institution. Either the CD or HSA will supervise

the Chief Pharmacist and Director of Nursing.

The CD also provides clinical supervision for other clinical personnel (nurses, paramedics, etc.).

Institutions without a CD or assigned Bureau physician will rely on Temporary Duty (TDY),

Telehealth, or contract help with collaboration from the RMD, who may be Acting CD for all

clinical supervision until appropriate staffing levels are restored. The RMD may designate

another physician as an Acting CD to provide all or part of this clinical oversight, but such

delegations must be clearly defined.

Staff physicians providing clinical oversight for APPs 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 before

assignment to independent duty.

At a minimum, the CD, staff physician, or contract physician will provide the following clinical

oversite functions for APPs:

 Review at least two health records, per provider, of the inmates evaluated by the day shift

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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 on the next possible workday.

 This review, when necessary, will include a discussion of the case with the treating

APP, treatment plan review, and documented as a function in the EHR.

 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 on the next scheduled workday.

 This review, when necessary, will include a discussion of the case with the

appropriate clinical staff, treatment plan review, and documented as a function in the

EHR.

 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.

 Be available to consult on cases requiring urgent attention.

 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.

 Comprehensive Medical Services contract. Refer to Department of Justice (DOJ) Policy

Instruction Acquisition Career Management Program Federal Acquisition

Certification for Contracting Officer’s Representatives and the Program Statement

Human Resource Management Manual.

 Procurement.

 Supply.

 Drug-free Workplace Program.

 Housekeeping.

 Sanitation.

 Maintenance.

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

 Pharmacy (can alternatively be under Clinical Director).

 Laboratory.

 Radiology.

 Therapy Services.

 Social Workers.

 Health records.

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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.

The HSA and CD integrate administrative management functions within clinical programs

(laboratory, radiology, physical therapy, pharmacy, etc.).

The HSA or AHSA is the primary supervisor for APPs, paramedics, and nurses in non-medical

facilities for administrative issues. Clinical input will be provided by the CD or designee.

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 Warden 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 review the Health Services dashboard weekly to help monitor the health care

services provided. Review will include, but not be limited to:

 Use of healthcare services by category (e.g. Health Promotion, Disease Prevention,

Diagnosis and Treatment, and Rehabilitation).

 Referrals to specialty consultants.

 Number of prescriptions written.

 Number of laboratory and x-ray tests completed.

 Observation room admissions.

 On-site 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 PHS Commissioned Corps personnel.

The HSA or designee is responsible for maintaining each PHS Officer’s leave record through

eCORPS following the Supervisor’s Guide to the Commissioned Corps Personnel System,

available from the Commissioned Corps of the U.S. Public Health Service’s website.

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The HSA will ensure 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.

For further guidance, see Program Statement Health Care Credential and Privileging

Program.

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. Advanced Practice Practitioners (APPs). APPs are physician assistants and nurse

practitioners.

Advanced Practice Providers must have a Practice Agreement with a licensed physician prior to

providing health care in the institution.

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.

 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. The DON:

 participates in policy decisions affecting nursing personnel, inmate care, and is a

member of the local Governing Body.

 ensures nurses are trained properly and demonstrates the ability to use any medical

equipment that may facilitate nursing care.

 maintains training documentation.

 organizes the department to provide optimum nursing services on all shifts.

 encourages nursing staff to participate in continuing education programs and

attend required meetings.

 develops, allocates, and administers the nursing services budget aligning with

organizational goals, objectives, and priorities.

 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 DON’s absence. They supervise, coordinate, and integrate the activities of one or

more nursing supervisors.

 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

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and Post Anesthesia Recovery Room).

 The SCN implements policies and procedures of the nursing department for their

designated area and coordinates care and services with other supervisors.

 Charge Nurse. The Charge Nurse is a Registered Nurse. In some settings, the Charge

Nurse may be called the team leader or inmate care coordinator. They are usually

accountable to the Supervisory Clinical Nurse and serve a specific group of staff on a

nursing organizational unit.

 The Charge Nurse assumes specific responsibility for the daily “hands on” nursing

care of inmates and is primarily responsible for coordinating inmate care with

physicians, other hospital departments, food service, and consultants.

 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 their assigned inmates.

 They provide ongoing health education during hospitalization. Prior to discharge, the

RN gives discharge instructions to help the inmate understand the need for follow-up

care.

 They maintain and improve 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.

 Licensed Practical (Vocational) Nurse (LPN/LVN) – Medical Referral Centers. The

LPN/LVN generally provides technical support and assistance to inmates who are

relatively stable or who have chronic illnesses.

 An RN must supervise LPNs/LVNs who provide direct inmate care in an inpatient,

outpatient, or long-term care setting.

f. Staff Nurse (Registered Nurse [RN]) – Non-Medical Referral Center Institution. The staff

nurse, who is usually accountable to the CD, coordinates, implements, and assesses inmate

response to care provided in the outpatient setting.

They provide ongoing health education. The RN provides instructions to help the inmate

understand the need for follow-up care.

They maintain and improve 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 inmate care.

g. 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 inmate 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.

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If LPNs/LVNs provide nursing care such as the administration of medications and treatments, an

RN or physician must provide supervision on that shift.

h. Emergency Medical Technicians (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.

i. Paramedic. The Paramedic, who is usually accountable to the CD, assesses situations to

determine the nature, extent, and seriousness of an emergency.

They provide treatment prescribed in protocols, standing orders, or current guidelines making

modifications to the protocol or guideline within prescribed limits.

They prioritize treatments, employ a variety of established medical emergency procedures,

techniques, methods, and equipment, including emergency triage.

j. Chief Pharmacist. The Chief Pharmacist is responsible for the supervisory management of

pharmacy operations to include the dispensing of all medications within the institution.

Additional responsibilities include ensuring the facility complies with all Drug Enforcement

Administration (DEA) laws and regulations, procuring medications, and providing pharmaceutical

care to the inmate population, including medication therapy and disease state management.

k. Medication Technicians. The medication technician, who is ordinarily accountable to the

Chief Pharmacist, is responsible for the administration and distribution of medication to inmates.

They assist the pharmacist(s) or other appropriate staff members in a variety of pharmacy related

activities, including, but not limited to, entry of medication orders into a computerized pharmacy

information system, preparation of medications for pharmacist review, automated dispensing

cabinet stocking and maintenance, and procurement and inventory of medications and pharmacy

supplies, etc.

l. Correctional Officers Assigned to 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.

Assigning Correctional Officer posts to health services is highly encouraged. Appropriate use

can ensure health care providers’ time is wisely and efficiently utilized, by the Correctional

Officer managing inmate movement, locating inmates who do not show for appointments,

ensuring expensive specialty contract providers see all assigned patients, and helping coordinate

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inmates being seen during institution lockdowns.

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 inmate’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.

m. Other Health Services Staff. The duties of other health services staff are described in

their billet description or position description as applicable.

n. 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/CD will ensure each consultant staff member is qualified and will maintain optimal

professional performance through:

 Appointment/reappointment procedures.

 Specific delineation of clinical privileges.

 Periodic reappraisal of each.

Only consultant medical staff 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 outside telehealth services not provided by a federal

agency. Refer to the Program Statement Health Care Credential and Privileging Program for

credentialing requirements.

The HSA will ensure primary source verification of each applicant's current license, education,

or, if appropriate, certification.

The HSA will ensure the consultant’s Session-based Invoice Verification (SBIV) reflects the

times and dates of all consultant services provided to inmates.