SOP 508.10: Confidentiality of Mental Health Records

|GEORGIA DEPARTMENT OF CORRECTIONS
Standard Operating Procedures|Col2|Col3|
|---|---|---|
|Policy Name:Confidentiality of Mental Health Records|Policy Name:Confidentiality of Mental Health Records|Policy Name:Confidentiality of Mental Health Records|
|Policy Number: 508.10|Effective Date: 4/27/2018|Page Number: 1 of 6|
|Authority:
Commissioner|Originating Division:
Health Services Division|Access Listing:
Level I: Al Access|

I. Introduction and Summary:

All mental health information will be regarded as confidential, available to authorized
users, and disclosed in accordance with federal and state law and Georgia Department of
Corrections (GDC) policy. This procedure is applicable to all GDC facilities with a
mental health mission.

II. Authority:

A. O.C.G.A. §§24-9-40 through 24-9-43, 50-18-72 (2), 24-9-47, and 37-3-162;

B. GDC Standard Operating Procedures (SOPs): 508.04 Credentialing Verification and

Privileging, 508.16 Mental Health Levels of Care, and 507.02.02 Confidentiality of
the Health Record and Release of Information;

C. National Commission on Correctional Health Care Standards: 2014 Adult Standard:

P-H-02 - Confidentiality of Health Records, and 2014 Juvenile Standard: Y-H-02
Confidentiality of Health Records and Information; and

D. ACA Standard: 4-4396.

III. Definitions:

A. Confidentiality - An expressed or implied promise not to divulge or share certain

information except for narrow and defined circumstances. This protection of
information from unauthorized disclosure is a result of a professional relationship
afforded by professional codes of ethics.

B. Disclosure - The act of transmitting or communicating mental health information to

a person who would not otherwise have access thereto.

C. Mental Health Primary Care Provider - Mental Health staff granted any clinical

privileges under SOP 508.04 Credentialing Verification and Privileging.

IV. Statement of Policy and Applicable Procedures:

A. Ownership of Mental Health Records and Mental Health Information:

1. A mental health record will be maintained on every offender receiving mental

health services while in the custody of the GDC;

|GEORGIA DEPARTMENT OF CORRECTIONS
Standard Operating Procedures|Col2|Col3|
|---|---|---|
|Policy Name:Confidentiality of Mental Health Records|Policy Name:Confidentiality of Mental Health Records|Policy Name:Confidentiality of Mental Health Records|
|Policy Number: 508.10|Effective Date: 4/27/2018|Page Number: 2 of 6|
|Authority:
Commissioner|Originating Division:
Health Services Division|Access Listing:
Level I: All Access|

2. The mental health record is the property of the GDC and will be maintained in

accordance with professional standards and practices governing mental health
records administration; and

3. Except as identified in this SOP, information from offenders’ mental Health

records shall not be included in institutional or Central Office files.

B. Access to Mental Health Records:

1. All mental health records will be kept separate from custody records and stored

in a secure area under the control of the mental health unit manager. Mental
health records will not be left unattended in areas accessible to unauthorized
individuals;

2. A sign-out card will be placed in each mental health record. The person signing

out the record will note the date and sign their name. This card will be left in the
file cabinet in place of the record; and

3. Direct Access to the Mental Health Record will be Limited to the Following:

a. Mental health care providers employed by GDC or the contract vendors who

are providing mental health care services to the patient;

b. Any member of the offender's treatment team;

c. Health care providers employed or contracted with by GDC or the contract

vendor;

d. Members of the Office of Health Services, Central Office and contract

vendors’ designated personnel involved in conducting quality improvement
studies, audits, or investigating offender health care concerns;

e. Individuals conducting research approved by the statewide mental health

program supervisor and/or Commissioner of the GDC;

f. The Georgia Attorney General’s Office or other legal agents of involved

parties in the event an offender files a claim or suit relating to the offender's
mental health care, against the state or health care agents, including the
contract vendor, which results in waiver of confidentiality;

|GEORGIA DEPARTMENT OF CORRECTIONS
Standard Operating Procedures|Col2|Col3|
|---|---|---|
|Policy Name:Confidentiality of Mental Health Records|Policy Name:Confidentiality of Mental Health Records|Policy Name:Confidentiality of Mental Health Records|
|Policy Number: 508.10|Effective Date: 4/27/2018|Page Number: 3 of 6|
|Authority:
Commissioner|Originating Division:
Health Services Division|Access Listing:
Level I: All Access|

g. GDC’s Office of Legal Services for purposes of responding to properly

authorized requests, as determined by Office of Legal Services attorneys, for
disclosure of such records and to assist the Georgia Attorney General’s
Office and other entities in the handling of legal matters;

h. Offenders or any representative designated by the offender pursuant to

Paragraph E of this SOP will have access to their own mental health record
for review upon written request to the responsible mental health authority and
with reasonable notice; and

i. Exceptions to (g) are permitted in certain mentally disordered offenders in

which the treating Psychiatrist/Psychologist believes that disclosure of mental
health information is detrimental to the physical or mental health of the
offender and makes a notation to that effect in the mental health record.

C. Access to Mental Health Information for Non-Mental Health Personnel:

1. Access to mental health information for non-health personnel who adhere to the

same rules of confidentiality as mental health personnel is necessary in certain
circumstances for the purposes of;

a. Appropriate classification of the offender that includes institutional, housing,

programming, and work assignments based on medical limitations and
capabilities;

b. Ensuring that mental health appointments are kept in a timely manner (e.g.,

providing a list to correctional staff of offenders who have mental health
appointments);

c. Appropriately processing disciplinary reports in accordance with SOP

209.01, Offender Discipline; and

d. Ensuring compliance with the “heat plan” per SOP 508.24 Psychotropic

Medication Use Management.

2. Mental health personnel will collaborate with institutional operations and the

Georgia Department of Community Supervision (probation and parole) to ensure
that adequate mental health information is available for the appropriate
classification of offenders. Appropriate security measures will be instituted to
prevent unauthorized access to confidential mental health information (e.g.,
security codes for access in computer systems).

|GEORGIA DEPARTMENT OF CORRECTIONS
Standard Operating Procedures|Col2|Col3|
|---|---|---|
|Policy Name:Confidentiality of Mental Health Records|Policy Name:Confidentiality of Mental Health Records|Policy Name:Confidentiality of Mental Health Records|
|Policy Number: 508.10|Effective Date: 4/27/2018|Page Number: 4 of 6|
|Authority:
Commissioner|Originating Division:
Health Services Division|Access Listing:
Level I: All Access|

3. Basic documentation about the offender and the mental health treatment is

provided in the confidential mental Health record. Some documents are reviewed
and signed by the offender. Documentation can include, but is not limited to,
Consent to Mental Health Treatment (M20-02-01), Mental Health Progress Note
(M20-02-02), Mental Health Progress Note Number 2 (narrative) (M20-02-02B),
Psychiatric Progress Note (M20-02-03) and Refusal of Treatment (M20-02-04).

4. In general, the sharing of mental health information will focus on measures to be

taken to provide needed mental health services. Mental health diagnoses will be
shared only in circumstances where doing so is necessary to ensure the delivery
of services.

5. With the exception of mental health information required for the appropriate

classification and assignment of offenders, confidential information from
offender's mental health files will not be included in the institutional or Central
Office files.

6. Correctional personnel who receive confidential health information, in the course

of their duties, will be responsible for maintaining the confidentiality of such
information. Correctional personnel shall adhere to the same confidentiality
rules as other professionals.

D. Disclosure of Mental Health Records:

1. The disclosure of health information complies with the Health Insurance

Portability and Accountability Act (HIPAA), where applicable, in a correctional
setting. Requests to disclose mental health records to third parties (e.g., attorneys,
outside medical facilities, etc.) will be honored upon receipt of a valid written
authorization from the offender to release such information. Such authorization
will include at a minimum:

a. Name of the institution from which the disclosure of information is

authorized;

b. Name of the individual or institution to receive the information;

c. A specific description of the records to be disclosed;

d. A date or event on which the authorization shall expire;

|GEORGIA DEPARTMENT OF CORRECTIONS
Standard Operating Procedures|Col2|Col3|
|---|---|---|
|Policy Name:Confidentiality of Mental Health Records|Policy Name:Confidentiality of Mental Health Records|Policy Name:Confidentiality of Mental Health Records|
|Policy Number: 508.10|Effective Date: 4/27/2018|Page Number: 5 of 6|
|Authority:
Commissioner|Originating Division:
Health Services Division|Access Listing:
Level I: All Access|

e. Offender's full name, state ID number, and date of birth;

f. Date of authorization;

g. Signature of the offender or his/her legal guardian;

h. A statement that the offender may revoke the authorization in writing and

instructions for submitting such written revocation;

i. A statement that treatment, payment, enrollment, or eligibility for benefits

may not be conditioned on obtaining the authorization if such conditioning is
prohibited by HIPAA;

j. A statement regarding the potential for the PHI to be redisclosed by the

recipient and no longer protected by HIPAA.

2. The Disclosure of Information Form will be placed in Section 5 of the mental

health record with a notation of:

a. Description of the specific information that was released;

b. Date information was released; and

c. Signature of the individual handling the release of information.

E. Requests for Access to an Offender's Own Mental Health Record and for

Photocopying of Records:

1. Offenders who wish to have access to their own mental health record will submit

a request in writing to the mental health unit manager or designee who will make
arrangements for the offender to inspect the record under the supervision of a
staff member. The mental health unit manager or designee will designate a
reasonable time for the inspection, with additional time to be scheduled as
needed;

2. Offenders who wish to receive copies of specific information in the record will

identify the information desired in writing using the Release of Information form.
Arrangements will be made to make a photocopy of the specified information
within 30 days. A notation will be made on the form as to what specific
information was disclosed to the offender;

|GEORGIA DEPARTMENT OF CORRECTIONS
Standard Operating Procedures|Col2|Col3|
|---|---|---|
|Policy Name:Confidentiality of Mental Health Records|Policy Name:Confidentiality of Mental Health Records|Policy Name:Confidentiality of Mental Health Records|
|Policy Number: 508.10|Effective Date: 4/27/2018|Page Number: 6 of 6|
|Authority:
Commissioner|Originating Division:
Health Services Division|Access Listing:
Level I: All Access|

3. Offender's requesting a photocopy of mental health records will be responsible

for the reasonable costs of copying and mailing the requested records. The costs
to be charged for such copies shall be in accordance with the Medical Records
Retrieval Rates fee schedule published by the Georgia Department of
Community Health pursuant to O.C.G.A. §31-33-3;

4. Offenders may maintain these copies of records in their possession; however, the

GDC will not assume responsibility for the confidentiality or protection of any
mental health information disclosed to the offender. Offenders will be advised
that correctional officers may inspect envelopes containing mental health records
during shakedowns;

5. If the Psychiatrist/Psychologist reasonably determines that disclosure of the

record to the patient will be detrimental to the mental health of the patient, the
provider may refuse to furnish the record; however, upon such refusal, the
patient’s record will, upon written request by the patient, be furnished to any
other mental health provider designated by the patient. The provider will
document reasons for refusal to furnish the record to the patient in the mental
health record; and

6. Offenders who wish to have photocopies of mental health records sent to a health

care provider, legal representative, or other person designated by the offender
(Side 4 of the mental health record), may sign a release of information to have
the records disclosed. Payment may be required prior to furnishing the record to
a designee other than a health care provider who will be providing treatment.

F. Certified Copies of Mental Health Records:

1. Certified copies of the offender's mental health record will be provided upon

request and receipt of the proper authorization for disclosure;

2. After the record has been reviewed, but prior to copying, all pages/documents

will be clearly numbered in the upper left corner; and

3. A notarized Statement of Authenticity will accompany the copy upon disclosure.

V. Attachments: None.

VI. Record Retention of Forms Relevant to this Policy: None.