ATTACH.FIVE.Policy.pdf

Index # 113.09 Page 1 of 8

Effective Date: May 2, 2024 Distribution: A

Supersedes: 113.09 (4/15/20) PCN 20-17 (6/15/20) Approved by:

Subject: CLINICAL SERVICES CONTINUOUS QUALITY IMPROVEMENT

ADMINISTRATIVE POLICIES

AND PROCEDURES

State of Tennessee

Department of Correction

I. AUTHORITY: TCA 4-3-603, TCA 4-3-606, TCA 63-1-150, TCA 63-6-219 and TCA 68-11-272.

II. PURPOSE: To promote wellness among the inmate population by maintaining a system that continually identifies opportunities for improvement through the measured quality of care outcomes.

III. APPLICATION: All Wardens/Superintendents, all clinical services staff, privately managed institutions, and contract staff.

IV. DEFINITIONS:

A. Clinical Services: Healthcare services that encompass physical health and behavioral health (mental health and substance use treatment) services.

B. Continuous Quality Improvement (CQI): A process of ongoing monitoring and evaluation to systematically and objectively assess the adequacy and appropriateness of the health care provided to inmates and to recommend and execute improvement(s) as needed.

C. CQI Data: Statistics and other protected health information are required to be entered in the TDOC Clinical Services Database. Such data includes Medication Error Log, Inmate Grievance/Inquiry Log, CQI Committee Agenda, Minutes, and Attendance Roster, as well as any other reports required by the Assistant Commissioner of Clinical Services/designee.

D. Institutional CQI Committee: A group of clinical providers (e.g., health administrator, behavioral health administrator, medical director/physician, etc.) and other facility staff (e.g., Wardens/Superintendents, food services, security, etc.) who are responsible for the review of processes, practices, and outcomes of the facility’s clinical services delivery system.

E. Keep on Person (KOP): Medication approved to be kept in an inmate’s possession for the purpose of self-administration.

F. Statewide Continuous Quality Improvement Coordinator (SCQI Coordinator): A designated individual in medical and behavioral health assigned to coordinate all statewide continuous quality improvement activities, which include evaluation, recommendations, implementation, and ongoing monitoring.

G. Statewide CQI Committee (SCQI Committee): A group of clinical providers appointed by the Commissioner or Assistant Commissioner of Clinical Services/designee to identify opportunities for quality improvement, evaluate outcomes through quality indicators, and evaluate risk management processes.

H. TDOC Clinical Services Database: An electronic confidential collection of protected health information stored on a secure, shared drive containing specific inmates’ medical diagnoses and health status. This data may be utilized to report and analyze outcome measures regarding the quality of health care and disease management.

ATTACHMENT FIVE

Effective Date: May 2, 2024 Index # 113.09 Page 2 of 8

Subject: CLINICAL SERVICES CONTINUOUS QUALITY IMPROVEMENT

V. POLICY: The TDOC strives to ensure quality patient care by requiring and supporting the maintenance of an effective system-wide Continuous Quality Improvement (CQI) program.

VI. PROCEDURES:

A. The Statewide Continuous Quality Improvement Committee (SCQI) identifies opportunities for quality improvement, evaluate outcomes through quality indicators, and evaluate risk management processes.

1. The SCQI Committee will be directed by a Charter, which is reviewed and approved at least annually by the Assistant Commissioner of Clinical Services/designee.

2. Members of the committee consist of a variety of clinical professionals, including physicians, nurses, psychiatrists, and administrative staff. Other operational staff will be asked to serve on an “as-needed” basis.

3. The committee meets at least quarterly. Committee members are expected to attend regularly scheduled meetings. In case of scheduling conflicts or emergencies, there is an allowance of no more than two absences from meetings, per year.

4. The Continuous Quality Improvement (CQI) program provides an evaluation of the quality of care through measured outcomes in the health delivery system as follows:

a. The SCQI Committee evaluates and makes recommendations regarding the structure of institutional CQI programs with input from selected institutional staff.

b. The process and outcomes are evaluated primarily by each institutional CQI committee with oversight by the SCQI Committee.

5. The CQI process provides regular feedback to clinical services care providers and the institutional CQI committee through ongoing examination of the care provided.

The process also serves as a mechanism for the improvement of the quality and consistency of the clinical services care delivery system.

6. Sub-committees: The SCQI Committee directs the following sub-committees, which are responsible for reporting findings and recommendations to the SCQI Committee for review and action as appropriate.

a. Infectious Disease Committee: Responsible for developing a comprehensive program of surveillance and implementing protocols to address the control and prevention of communicable diseases within

TDOC.

b. Peer Review Committee: Responsible for developing a written evaluation of the professional competence of all physicians, psychologists, and dentists every two years. As necessary, the committee reviews specific cases and/or patterns of professional activities.

Effective Date: May 2, 2024 Index # 113.09 Page 3 of 8

c. Morbidity and Mortality Review Committee: Responsible for reviewing all data related to inmate death and illness and reporting the findings to the Tennessee Bureau of Investigation (TBI). The committee will also identify risk factors related to inmate morbidity and mortality, as well as recommend and implement strategies to reduce risk factors and improve the health of the inmate.

d. Pharmacy and Therapeutics Committee: Responsible for developing and maintaining a Departmental drug formulary and reviewing the utilization and cost-effectiveness of the pharmacy system. The committee may also review policies and procedures for the management and administration of pharmaceuticals, as well as recommend procedural changes and interventions.

C. Statewide Continuous Quality Improvement (SCQI) Coordinator responsibilities are as follows:

1. Plan and coordinate health and behavioral health services CQI activities.

2. Continuously monitor and update the TDOC clinical services database.

3. Provide technical assistance to institutions related to CQI procedures.

4. Promote acceptance and understanding of the CQI process.

5. Request evaluation of specific topics as necessary.

6. Review significant CQI findings to identify patterns or trends and recommend improvements to enhance effectiveness. Prepare and submit findings and/or recommendations to the Assistant Commissioner of Clinical Services/designee quarterly during the SCQI meeting or more often if indicated.

7. Conduct site visits bi-annually with institutional staff to provide feedback and recommendations to improve the quality of health and behavioral health care in TDOC institutions and privately managed facilities.

8. The medical and behavioral health SCQI coordinator reviews the TDOC clinical services database by the 15th of each month to ensure all required CQI data, from the previous month, has been entered. A status report is provided to the Assistant Commissioner of Clinical Services/designee by the last day of the month.

D. Institutional CQI Committees: The health services administrator is responsible for maintaining a monthly institutional Clinical Services CQI committee meeting and also serves as the committee advisor for structure and goals.

1. The committee composition minimally includes the health and behavioral health services administrator/designee, Warden/Superintendent/designee, Associate Warden of Treatment/Deputy Superintendent, Director of Nursing (DON), Fiscal Director, institutional physician/medical director, CQI coordinator, representatives from nursing, dental, behavioral health/psychiatry. Substance use treatment, health record management, food services, fire and safety, and additional security staff should be considered ad hoc members as CQI issues indicate.

Effective Date: May 2, 2024 Index # 113.09 Page 4 of 8

2. Each institutional health services administrator designates one registered nurse (RN) whose primary responsibilities include serving as the institutional CQI coordinator and overseeing the institutional infection control/surveillance program. In larger facilities (over 500 inmates), it is necessary for the health services administrator to designate another RN with infectious disease management experience as the Infection Control Coordinator in accordance with Policy #113.42, Communicable Diseases.

3. The health services administrator, in consultation with the institutional CQI coordinator, appoints or reappoints committee members annually. Membership appointment/reappointment is recorded in the committee minutes. An institutional CQI committee membership roster is maintained in the TDOC clinical services database. Appointments to fill committee vacancies are made as soon as possible.

4. All committee members are required to attend at least ten meetings annually. If continual absenteeism of any member occurs, the committee evaluates options for improvement and resolution.

5. The committee meets by the 15th of each month to review and discuss CQI reports and opportunities for quality improvement.

6. When opportunities for improvement are identified that require action beyond the scope of clinical personnel authority, the health services administrator forwards those particular institutional CQI committee findings and recommendations for action to the Associate Warden of Treatment/Deputy Superintendent.

7. The minutes are recorded at each meeting and provide a permanent, factual, historical record. The agenda and minutes for each meeting are maintained in the clinical services database utilizing the templates provided.

8. The medical and behavioral health SCQI Coordinator review institutional CQI meeting minutes and reports findings to the Assistant Commissioner of Clinical Services/designee quarterly, or more often if indicated.

E. Professional Peer Review and Supervision.

1. A documented peer review program for all health care practitioners and a documented external peer review program will be utilized for all physicians, psychologists, and dentists and are completed every two years.

2. The peer review of all physicians, psychologists, and dentists should be routinely completed every two years with an ability to have an immediate review if problems of practice arise. In the event of a patient care complaint or an observation by other health services providers, security, or other nonmedical providers, the responsible physician can call a panel of independent physicians to review the practice and practice patterns of the physician on whom the complaint has been made. The investigation and findings will be kept in the employee’s file and remain confidential.

3. In accordance with Policy #113.11, Clinical and Nursing Protocols, each mid-level provider must have a physician preceptor who is responsible for supervising his or her clinical practice. The physician/mid-level provider relationship must be

Effective Date: May 2, 2024 Index # 113.09 Page 5 of 8 clearly established in writing, with a copy maintained by each party and the health services administrator. At least monthly, the supervising physician reviews a minimum of 20% of health records written by the mid-level provider during the past 30 days.

F. CQI Reporting Requirements.

1. In accordance with Policy #113.54, Clinical Services Statistics Collection and Reporting, the health services administrator/designee maintains all facility medical and behavioral health CQI logs in the TDOC Clinical Services Database utilizing the templates provided by the medical and behavioral health SCQI coordinators.

These templates are used to gather information for reporting on the Monthly Statistical Report, CR-2124. These logs are completed on or before the 8th of each month and include but are not limited to:

a. Medication Error Administration Accuracy Log;

b. Inmate Grievance Log;

c. Monthly Statistical Report, CR-2124;

d. Chronic Care Log;

e. HIV Log;

f. Quarterly Nurse Sick Call Review by the Physician; and

g. Annual studies for hypertension, diabetes, and HIV.

2. Plans of Corrective Action (POCA): After the official report from an audit has been completed, the HSA and BHA will receive an audit summary from the TDOC Office of Inspector General (OIG)/designee regarding the timeframe in which to submit a POCA for each noted deficiency. The facility HSA, BHA, DON, and CQI Coordinator will work together to create a POCA that is measurable and actionable. The HSA or BHA will ensure the audit summary is returned with the appropriate POCA within the time frame determined by the OIG/designee. The HSA and BHA will ensure the electronic POCA form on the Q-drive is complete and includes:

a. Description of the deficiency.

b. Root cause including the 5 Why Analysis (asking “Why” five times).

c. Action that defines changes to the current process; and

d. The individuals responsible for the implementation.

The HSA and BHA or designee will maintain POCA information on the Q drive as directed by the medical and behavioral health statewide CQI coordinators. The OIG/designee will determine if a POCA may be closed based upon review during the next audit.

Effective Date: May 2, 2024 Index # 113.09 Page 6 of 8

3. The medical and behavioral health SCQI coordinators will review the TDOC clinical services database on or before the 15th of each month to ensure all required CQI data has been entered and provide a status report to the Assistant Commissioner of Clinical Services/designee. The medical or behavioral health SCQI coordinator will consult with the HSA, BHA, or designee regarding data that is either incomplete or appears to present a discrepancy. The TDOC Assistant Commissioner of Clinical Services/designee notifies the facility’s Warden/ Superintendent and copies the appropriate Correctional Administrator of any delinquent reports.

G. Institutional CQI Studies.

1. Each institutional CQI committee monitors the following CQI indicators as often as deemed necessary:

a. Patient satisfaction (i.e., inmate grievances, correspondence, and information requests);

b. Medication Errors;

c. Risk assessment/accident/injury monitoring;

d. Tuberculosis management;

e. Bloodborne pathogen prevention;

f. Dental treatment;

g. Health maintenance;

h. Suicide prevention;

i. Appropriateness of chronic disease management;

j. Credentialing;

k. Informed consent - psychotropic medications;

l. Mortality review (See Policy #113.05, Deaths and Autopsies.);

m. Inpatient care;

n. Therapeutic diets;

o. Pharmacological therapies, including Keep On Person (KOP);

p. Physician-patient encounter/sick call review;

q. Institutional-specific studies; and

r. Methicillin-Resistant Staphylococcus Aureus (MRSA) and other infectious diseases.

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2. Each month, the institutional CQI committee reviews processes that may require improvement and completion of a CQI study. Results of the study will be reported to the medical or behavioral health SCQI coordinator(s) and recorded in the monthly CQI committee meeting minutes. The minutes must include the following:

a. Data collection and analysis.

b. Corrective actions required, which include educational/training activities, as applicable; and

c. Outcome evaluations to determine action plan effectiveness.

3. Facilities send a request to the medical or behavioral SCQI coordinator in Central Office for approval by Assistant Commissioner of Clinical Services/designee to study CQI processes not included in this policy. Approved CQI processes may be studied in the month following approval.

H. Patient Encounter/Sick Call Review: A quality improvement review of sick call and all other patient encounters is conducted quarterly by the facility physician. The review includes:

1. An examination of all encounter logs.

2. A review of referrals made by the staff members conducting sick call.

3. Oral discussion with staff members.

4. A review of randomly selected health records to include:

a. Adequacy of treatment plans

b. Extent to which orders have been carried out

c. Legibility and completeness

d. Adequacy of pharmaceutical management

e. Appropriateness of implementation and countersigning of clinical or nursing protocols; and

5. A report of the review prepared by the facility physician and submitted to the institutional CQI committee and uploaded to the corresponding folder on the Health Services Clinical Database.

I. Confidentiality and Release of Information.

1. All information or minutes are subject to rules of confidentiality as authorized by Tennessee Code Annotated 63-6-219 and Public Law 99-660. Committee minutes are confidentially compiled and maintained in the institutional CQI committee files. Copies of minutes are to be classified and marked as confidential, protected

Effective Date: May 2, 2024 Index # 113.09 Page 8 of 8 health information and only shared in accordance with Policy #113.52, Release of Protected Health Information.

2. All facilities maintain a copy of the committee minutes with original signatures.

Such copies are secured in a confidential CQI folder for a minimum of five years.

3. No documents maintained by the CQI program are removed from the facility or Central Office unless specifically authorized by the TDOC Assistant Commissioner of Clinical Services.

4. Information (CQI data), analysis findings, recommendations, conclusions, and actions developed by or for clinical services care staff, clinical services, or other individual committees performing CQI assessments or similar functions will not be available to unauthorized persons or organizations or used for other purposes as allowed for under state and federal law.

5. Information covered by this policy includes clinical services staff employee files, credentials, committee considerations, and administration and clinical services staff disciplinary actions.

VII. APPLICABLE FORMS: CR-2124.

VIII. ACA STANDARDS: 5-ACI-1A-17, 5-ACI-6A-12, 5-ACI-6A-13, 5-ACI-6B-015-ACI-6D-02, 5- ACI-6D-03, and5-ACI-6D-09.

IX. DIVISION OF PRIMARY RESPONSIBILITY: Office of Clinical Services.

Index #: 512.01 Page 1 of 9

Effective Date: September 1, 2021

Distribution: B

Supersedes: 512.01 (2/15/20)

PCN 20-21 (8/1/20)

PCN 20-16 (6/1/20)

Approved by: Tony Parker

Subject: MAINTENANCE, SAFEGUARDING, AND ARCHIVING OF TENNESSEE DEPARTMENT OF CORRECTION (TDOC)

RECORDS

ADMINISTRATIVE POLICIES

AND PROCEDURES

State of Tennessee

Department of Correction

I. AUTHORITY: TCA 4-3-603, TCA 4-3-606, TCA 4-6-140, TCA 10-7-504, Title 28, USC, Section 534, and 2008 Public Chapter 1179.

II. PURPOSE: To establish procedures for the maintenance, safeguarding, and archiving of TDOC records and information.

III. APPLICATION: TDOC employees, privately managed facilities, and contract vendors.

IV. DEFINITIONS:

A. Abbreviated Code Definitions:

1. TBI: Tennessee Bureau of Investigation (TBI) forms

2. BOP: Board of Parole (BOP) forms

3. CR: Tennessee Department of Correction (TDOC) forms

4. OMS: Offender Management System

5. FileNet: An electronic document repository.

B. Administrative Records: Any record created that documents Department operations or day to day management functions but does not necessarily relate directly to the programs of the Agency.

C. Community Supervision File: Contains all documents related to an offender’s case management, including supervision plan, program treatment, drug tests, court orders, etc.

D. Confidential Information:

1. Health and behavioral health treatment.

2. Educational records of inmates receiving special education services.

3. The TDOC shall adhere to the federal Health and Human Services Alcohol and Drug Abuse

Confidentiality regulations. (See Policy #113.52) Disclosure of any information to the BOP or others about inmate’s treatment for alcohol/drug abuse requires written consent from the inmate on Authorization for Release of Health Services Information, CR-1885, and

Authorization for Release of Substance Use Disorder Treatment Information, CR-1974.

4. The TDOC shall adhere to Title 28, United States Code (U.S.C.) Section 534 and restrict access to FBI criminal histories to criminal justice agencies for criminal justice purposes.

5. Social Security numbers.

6. Identifying information (name, address, telephone number) of victims, victim family members, and members of the public who have requested notice regarding changes in inmate status.

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RECORDS

E. Inactive Inmate Institutional Records (IIIR): The IIR, Satellite Folders, and Inmate Unit File for any inmate who has been released from institutional custody of TDOC either by discharge release to parole, probation, community corrections, court order or death.

F. Inmate Health Record: A letter sized, 10-compartment, outpatient, brown file folder with prong fasteners at the top of each inside flap maintained in the institution's medical records area.

G. Inmate Records Office File: A letter sized, four-compartment, light blue folder maintained in the institutional records office.

H. Inmate Institutional Record (IIR): All documents located in designated files related to an inmate's conviction, sentence, and period of incarceration.

I. Inmate Unit File: A letter sized, six-compartment, light green file folder maintained in the unit management office.

J. Satellite Folders: Documents related to inmate property, jobs, visitation, education, and programs.

K. Security Sensitive Information: Any information which, if disclosed to an inmate, could threaten the security of the institution and/or the safety of a confidential source.

L. TDOC Field Offices: Community Supervision Offices, Day Reporting Centers or Community

Resource Centers.

V. POLICY: Institutions shall maintain complete and current files on each inmate and shall safeguard such files from unauthorized or improper disclosure of information. Files shall be maintained as a paper record or as a scanned record in FileNet. Central Office, the Academy, Community Supervision, institutions or other TDOC field offices shall ensure that any information as defined in Section IV.(B) is secured at all times. Records available through OMS conversations shall not be duplicated in the inmate institutional record, unless there is a requirement for signature by inmate or staff. At no time will any inmate have access to another inmate’s record.

VI. PROCEDURES:

A. The Assistant Commissioner of Prisons shall promulgate specifications for institutional file folders. References in this policy to the placement of CR forms, which may be obsolete, are for instructional purposes only as to the proper location of the forms used prior to OMS and are not a duplication of information contained in OMS. Records at the institutions shall be maintained in separate files as follows:

1. Inmate Records Office File: Complete history of inmate’s institutional record.

2. Unit File: Complete history of inmate’s institutional record. Where unit management is not utilized, this file shall be co-located with the Records Office File.

3. Health Record: Complete history of inmate’s health record. All documents placed in an inmate’s health record shall be written legibly in black ink, and attached face up, in chronological order, with the most recent information on top:

a. Section 1 - Assessment data, treatment plan(s), teaching plans

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RECORDS

b. Section 2 - Diagnostic reports

c. Section 3 - Provider’s orders/medications

d. Section 4 - Chronological progress/clinic notes

e. Section 5 - Consultations

f. Section 6 - Dental

g. Section 7 - Infirmary

h. Section 8 - Discharge summaries

i. Section 9 - Miscellaneous

j. Section 10-Mental health

4. Satellite Folders: Documents related to inmate property, jobs, visitation, education, and programs.

B. When inmates are temporarily transferred to another facility, the current volume of the inmate institutional and health record shall be forwarded as appropriate with the inmate to the receiving institution as outlined in Policy #403.01.1. When an inmate is permanently transferred to another facility, the complete institutional and health record will follow the inmate.

C. Initiation of the IIR: Diagnostic Center Wardens shall be responsible for the initiation of the IIR.

(See Policies #401.02 and #401.04)

D. Maintenance and Security of Files:

1. Each Warden/Superintendent shall be responsible for developing a local policy and procedure to ensure the security of these files. The Warden/Superintendent shall designate the employee(s) responsible for the proper development, maintenance, and care of all file components of the IIR and scanning into FileNet.

2. All new information designated for inmate records shall be scanned into FileNet and filed in the paper record within 14 working days.

3. The Records Office file, Unit file, and Health file shall:

a. Be maintained by the TDOC ID number. The offender’s TDOC ID number shall be affixed to the end tab and numerically color-coded for ready reference.

b. Include the Sign In/Sign Out card, CR-1006, to be used anytime a record is removed from a file repository. If the file is removed by one employee for use by another, that information shall be indicated on CR-1006. The individual signing the file out assumes full responsibility for the file, including contents and organization thereof, until the file is returned.

4. Satellite folders shall be maintained in locations and in accordance with procedures established by the Warden/Superintendent.

5. Files not in use at the Central Office, the institutions, Community Supervision, or other

TDOC field offices shall be stored in a secure area or locked repository. Files in use shall be directly supervised and controlled by an authorized employee.

E. Organization of Files:

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RECORDS

1. All documents (new and existing) maintained in inmate institutional records office file(s) will be scanned into FileNet by institutional records office personnel. All scanned documents will be stamped “SCANNED” in red ink in the top right-hand corner prior to filing in the inmate

Records Office File(s). Document scanning should be completed prior to the offender being released.

2. All documents placed in inmate files shall be legible and attached face up, in chronological order, with the most recent information on top.

3. Documents pertaining to an individual inmate shall be placed in the designated file as follows:

a. Records Office File shall contain:

(1) Section I: Identification/Classification Data:

(a) CR-1391 - Initial Classification Summary or Face Sheet (shall always remain on top). One copy of each previous photograph may be retained in this section.

(b) Security/sensitive information

(1) Protective Service Routing Sheet, CR-3241

(2) Protective Service Hearing Report, CR-3240

(3) Protective Custody Review Report, CR-3239

(4) Fingerprint card (shall always remain on bottom)

(5) Incompatible Inmate Notice, CR-2109

(2) Section II: Sentence/Legal:

(a) Copy of Judgement Document (mittimus, commitments, and indictments in chronological order)

(b) Detainer placement/removal notice (INFOPAC produced detainer notice BI01D070 can be produced after Detainer (LSTS) is used)

(c) Warrants/court orders/governor's warrants/declaratory orders - any document relating to court appearance/escapes (i.e., CR-1853, and/or

CR-1988) shall remain attached to the warrant/court order. All court orders for future court appearances will be placed on top in the

Records Office file. After court hearing, documentation shall be placed in chronological order.

(d) Notice of court order (legal) name change (original) (NOTE:

Records will not be changed to reflect the new name. An entry shall be made on the Offender Aliases (LCLB) by the records office to reflect legal name change and a written notice forwarded to the required staff)

(e) All other information received concerning inmate's time.

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(3) Section III - Parole/Release Documents:

(a) CR-0122, Extradition Waiver

(b) Agreement on Detainer Request/Waiver Hearing Form I through IX

(c) BP-0015, Parole Certificate or CR-3403, Probation Certificate

(d) Notice to TBI of Sex Offender Release

(e) Victim Witness Coordinator Notification

(f) Facesheet at time of release

(g) CR-1941, Letter of Discharge

(h) CR-1945, Release Notification

(i) CR-1947, Release Authorization

(j) CR-1416, Personal Property Clearance

(k) CR-4088, Reentry Discharge Summary

(l) BI01D082, Offender Community Release Notification

(m) Miscellaneous Release Documents

(4) Section IV- Inmate Information

(a) CR-3694 Request for 60 Day Education Credit

(b) Emergency Notification Form

(c) If an offender has identification documents (birth certificate, social security card, driver’s license, identification card, GED certificate, high school diploma, CR-3723, or application for driver’s license and inmate identification), they will be kept in his/her file for identification purposes or to assist in obtaining identification documentation with the item content typed on the front of the sealed envelope prior to his/her release. A sealed envelope shall be used to maintain this documentation. All identification documentation shall be issued to the inmate upon release from TDOC custody.

(d) Security Threat Group File

(1) CR-3536 Criminal Submission Form (always on top).

(2) Supporting STG Documentation in chronological order

(e) CR-3118 inmate inquiry - Information Request

b. Unit File shall contain:

(1) Section I - Identification/Classification Data:

(a) CR-1391, Initial Classification/Face Sheet, pages 1-4 (always remains on top)

(b) CR-2253, Pre-Sentence Report (if not available on OMS)

(c) CR-2574, Admission Assessment

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RECORDS

(d) FBI Rap Sheet and NCIC 2000 until rap sheet has been received, except in privately managed facilities where such information shall be removed from the file and be maintained by the Commissioner’s designee.

(e) CR-1377, Family Questionnaire (where applicable in older files and if information is not available on OMS)

(f) CR-1378, Parental Questionnaire (where applicable in older files and if not available on OMS)

(g) CR-3619, Contact Visitation with Minor Agreement

(h) CR-2116, Spouse's Questionnaire (where applicable in older files and if not available on OMS)

(i) CR-2547, Structured Interview (where applicable in older files)

(j) CR-3683, Program Recommendation Guide

(2) Section II - Sentence/Legal:

(a) CR-2969, Sentence Reduction Credit Waiver

(b) CR-2816, Additional Sentence Letter (if not available on OMS)

(c) CR-2042, Class IV Prisoner Designation Letter

(d) CR-0016, Actions Involving Good Conduct Credits, if applicable

(e) CR-3298, Sentence Credits

(f) Written Notice of Legal Name Change

(g) CR-3224, Denial of Program Credits.

(3) Section III - Disciplinary/Administrative Segregation/Protective Services:

All documents related to a specific incident shall be maintained together.

(a) Disciplinary Report (OMS screen LIBK), INFOPAC produced

BI01MGL - Disciplinary Report and BI01D028 - Disciplinary

Action Report

(b) CR-1834, Disciplinary Report Hearing Summary

(c) CR-1831, Disciplinary Continuation

(d) CR-1833, Disciplinary Report Appeal

(e) CR-2123, Involuntary Administrative Segregation Placement Report

(f) CR-1600, Administrative Segregation Review.

When this section will not hold additional documents with the use of additional prong fasteners, older material may be transferred to an auxiliary folder of the same color, which shall be marked as "Volume II - A", etc.

Auxiliary folders are a part of the IIR and must accompany the inmate when transferred.

(4) Section IV - Reclassification:

(a) CR-2109, Incompatible Inmate Notice

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RECORDS

(b) CR-1850, Memo to Committing Jurisdiction

(c) CR-0078, Reclassification Summary, pages 1, CAF (BI01MHD), and Summary (BI01D018), INFOPAC produced Classification

Hearing Notice/Waiver (BI01D021), if applicable, and Offender

Classification Notice (BI01D018)

(d) CR-2877, Waiver

(e) CR-3004, Classification Appeal or INFOPAC report Appeal

Decision Notice (BI01D022)

(f) CR-0996 or BI01D089, Assignment of Responsibility.

(5) Section V - Parole/Release Data:

(a) BP-0007, Application for Compact Services

(b) BP-0008, Agreement to Return

(c) Letters of recommendation and/or any parole related documents

(d) BI0105, DNA Blood Analysis Request

(e) CR-3521, Consent for DNA Analysis

(f) CR-3669, Rules of Employment (See Policy #505.10)

(6) Section VI - Memorandum, Correspondence, Cumulative Education Report, and Miscellaneous: Documents filed in this section may be comprised of, but not limited to, the following:

(a) Emergency Notification Information

(b) CR-2110, Orientation Acknowledgment or INFOPAC report

BI01D015

(c) CR-2161, Instructions to Inmates

(d) CR-2045, Notification of Restitution Obligation

(e) CR-2060, Victim Restitution Contract and Repayment Schedule

(f) CR-1463, Contract/Agreement Parts 1 and 2

(g) CR-2061, Court Cost Contract and Repayment Schedule

(h) CR-2064, Community Service Contract

(i) CR-2069, Restitution Program Participation Contract

(j) CR-2965, Individual Program Plan, includes CR-2169, CR-2963, and CR-2964

(k) CR-1972, Program Pass

(l) CR-1973, Authorized Absences Appointment/Escort Pass

(m) CR-1974, Release of Information Consent Form

(n) CR-3086, Inmate Request to Review Institutional File

(o) CR-1922, Marriage Application Form

(p) BI01D072, Request for Furlough

(q) Form W-9, Request for Taxpayer ID Number and Certification

(r) Equivalency Diploma

(s) Vocational Certificate(s)

(t) RNA, Offender Case Plan/CR-4169 Refusal Form

(u) RNA Interview Guide, CR-4179 (A copy of the RNA needs report shall not be given to inmate)

(v) RNA Needs Report

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c. Inmate Health Record: See Policy #113.50 for file content requirements.

d. Satellite Folders:

(1) Property (CR-1921, CR-1416, CR-1167, CR-1413) (See Policy #504.02)

(2) Inmate Jobs (See Policy #505.07)

(3) Academic/Vocational Education (See Policy #117.02 and 117.03)

(4) Mental Health Program (See Policy #113.81)

(5) Visitation File (See Policy #507.01)

F. Transfer of IIR: The Warden’s/Superintendent’s designee shall ensure that the IIR of an inmate being transferred conforms to the criteria established by Policies #403.01 and #403.01.1 prior to transfer.

G. Confidentiality and accessibility of inmate records shall be the responsibility of each

Warden/Superintendent/designee, Superintendent/designee for the Academy, and

Commissioner/designee for Central Office. He/she shall ensure that inmate records are given only to identified and authorized individuals. He/she shall ensure that only authorized individuals are given access to the Workplace database.

1. Public Access to Files: Individuals shall be allowed access to, or inspection of, inmate institutional files in accordance with the Tennessee Public Records Act (“TPRA”) in TCA

10-7-501, et seq.

a. Confidential information and information the release of which would place the safety of an employee, law enforcement officer or informant, or other inmate in jeopardy shall be redacted prior to being given to or inspected by a citizen per Chapter 0420-1-2, Tennessee Comprehensive Rules and Regulations.

b. Charges for any costs associated with reproducing or providing these files and forms required by 2008 Public Chapter 1179 shall be in accordance with Policy #216.01. If an NCIC 2000 criminal history is maintained in the file, it shall be removed prior to access by the public.

2. Access to Health/Behavioral Health Information: Individuals shall be supplied health/ behavioral health information only in accordance with Policy #113.52.

3. Inmate Access to IIR: An inmate will be allowed, upon request, to review his/her record or relevant OMS conversations annually. If screen prints are made, the inmate must pay per

Policy #501.02. The request should be granted after the record(s) are screened and security sensitive information is removed. OMS conversations containing security sensitive information shall not be made available for inmate review. If there is a question as to what should be removed or reviewed, the decision shall be made by the Warden/Superintendent.

Employee(s) designated by the Warden/Superintendent shall be present at all times when the record is being reviewed by the inmate (NOTE: Inmate Health Record review - See Policy

#113.52.) At no time will an inmate be allowed to remove items from the IIR. CR-3086 is required to complete the review process. A fee shall be charged to inmates for copies made of the IIR. (See Policies #216.01, #208.05, and #509.03)

H. When an inmate escapes, his record shall be handled in accordance with Policy #506.12.

Effective Date: September 1, 2021 Index # 512.01 Page 9 of 9

I. Disposition of Inactive Inmate Institutional and Health Records:

Records for inmates who are released from custody by discharge, parole, probation, death, or court order shall be disposed of as follows:

1. Inmate Health Record and Behavioral Health Program Files are to be retained as indicated in

Policy #113.50.

2. Records Office File, Unit File, Satellite Property Folders, Inmate Job Folders, and Visitation

Folders shall be reviewed to ensure all documents have been scanned. Upon verification of the scanned contents of both files for accuracy and completeness, a certificate of destruction must be completed and submitted to the Director of Records Management/Designee for approval prior to any destruction being scheduled. After the certificate of destruction has been approved, the records can be destroyed after 30 days. For records that have not been scanned, the file will be maintained onsite until scanning has been completed.

3. Academic/Vocational Folders are to be retained for five years in accordance with RDA 11369 and then destroyed. Documents related to program certificates should be scanned into

FileNet.

J. Any employees who possess confidential information in their office as defined in Section IV.(B) of this policy shall lock office doors and/or filing cabinets that contain this information. No confidential information shall be stored in plain view. Employees shall report any suspected tampering of file security to their immediate supervisor.

K. Employee computers shall be affixed at the restart and/or log off position at the end of the workday as well as be password protected during short-term absences to prevent unauthorized access to any confidential information as defined in Section IV.(B).

L. The TDOC Records Handbook accompanying this policy shall be utilized as the reference guide by staff for the maintenance, safekeeping, and retention of all TDOC records. In addition to inmate institutional records, the content of this handbook will also include but not be limited to records pertaining to Community Supervision, Central Office, Day Reporting Centers, health records, and administrative records.

VII. ACA STANDARDS: 1-ACI-1E-01, 1-ACI-1E-02, 1-ACI-1E-04, 1-ACI-1E-05.

VIII. EXPIRATION DATE: September 1, 2024

CR-3086 (Rev. 7-20) RDA 1167

TENNESSEE DEPARTMENT OF CORRECTION

INMATE REQUEST TO REVIEW INSTITUTIONAL FILE

INSTITUTION

INMATE NAME: TDOC ID:

APPROVED:

WARDEN/SUPERINTENDENT

In accordance with Policy #512.01, I have had the opportunity to review my institutional file in the presence of a counselor/record clerk on this date.

INMATE SIGNATURE TDOC ID DATE

STAFF SIGNATURE TITLE

CR-3086 (Rev. 7-20) RDA 1167

TENNESSEE DEPARTMENT OF CORRECTION

INMATE REQUEST TO REVIEW INSTITUTIONAL FILE

INSTITUTION

INMATE NAME: TDOC ID:

APPROVED:

WARDEN/SUPERINTENDENT

In accordance with Policy #512.01, I have had the opportunity to review my institutional file in the presence of a counselor/record clerk on this date.

INMATE SIGNATURE TDOC ID DATE

STAFF SIGNATURE TITLE

CR-0392(Rev. 07-23) Duplicate as Needed RDA 11368

Index #: 512.01 Page 1 of 1

Effective Date: August 30, 2023 Distribution: B

Supersedes: N/A

Approved by:

Subject: MAINTENANCE, SAFEGUARDING, AND ARCHIVING OF TENNESSEE DEPARTMENT OF CORRECTION (TDOC)

RECORDS.

POLICY CHANGE NOTICE 23-06

PURPOSE: This PCN requires using the new RMD IIIR Destruction Checklist, CR-4316, when requesting a certificate of destruction for inactive inmate institutional records.

INSTRUCTIONS: Print this PCN and attach it to the front of all hardcopy versions of Policy #512.01, Maintenance, Safeguarding, and Archiving of Tennessee Department of Correction (TDOC) Records.

CHANGES TO POLICY:

SECTION VI.I.2. is revised as follows (added text; deleted text):

2. Records Office File, Unit File, Satellite Property Folders, Inmate Job Folders, and Visitation Folders shall be reviewed and certified by Records Office staff to ensure all documents have been scanned, using the RMD IIIR Destruction Checklist, CR-4316. Upon verification of the scanned contents of both all files for accuracy and completeness by the Records Office Supervisor, a certificate of destruction must be completed and submitted to the Director of Records Management/designee for approval prior to any destruction being scheduled. The completed CR-4316 is submitted with the certificate of destruction. After the certificate of destruction has been approved, the records can be destroyed after 30 days. For records that have not been scanned, the file will be maintained onsite until scanning has been completed.

ADMINISTRATIVE POLICIES

AND PROCEDURES

State of Tennessee

Department of Correction

MANAGEMENT

HANDBOOK

February 2023

February 2023 Records Management Handbook 2

RECORDS MANAGEMENT CONTACT LISTING

Mailing Address:

Records Management Division 320 6th Avenue North Rachel Jackson Bldg., 2nd Floor Nashville, Tennessee 37243 615-253-8079 (P) 615-532-1497 (F)

NAME TITLE EMAIL PHONE

Julian Davis Correctional Program

Administrator Julian.Davis@tn.gov 615-253-8287

Lori Priest Director Lori.B.Priest@tn.gov 615-253-8012 (P) 629-395-4706 (C)

Aletha Jefferson Assistant Director Aletha.D.Jefferson@tn.gov 615-253-8005 (P) 629-401-7087 (C)

Mia Cook

Records Analyst Manager/

Expungement Coordinator

Mia.Cook@tn.gov TDOC.ExpungementCoordinator@tn.gov

615-253-8008

Michael Frederick Archive

Warehouse Manager

Michael.Frederick@tn.gov 615-253-8002 (P) 629-867-1322 (C)

Camille Turner Forms, Printing and

Publications Camille.Turner@tn.gov

615-253-8118 (P)

Dedicated Phone Line/Email

General Information and Requests

BI.tdocrmdrequests-archive@tn.gov

615-253-8079 (P) mailto:Julian.Davis@tn.gov mailto:Lori.B.Priest@tn.gov mailto:Aletha.D.Jefferson@tn.gov mailto:.Jefferson@tn.gov mailto:Mia.Cook@tn.gov mailto:TDOC.ExpungementCoordinator@tn.gov mailto:Michael.Frederick@tn.gov mailto:Camille.Turner@tn.gov mailto:BI.tdocrmdrequests-archive@tn.gov mailto:BI.tdocrmdrequests-archive@tn.gov

February 2023 Records Management Handbook 3

TABLE OF CONTENTS

CONTACT LISTING 3

GLOSSARY 4

INTRODUCTION 8

PUBLIC RECORDS 8

RESPONDING TO PUBLIC RECORDS REQUESTS 9

LEGAL AUTHORITY 11

RECORDS BASICS 11

RECORDS STORAGE 12

PROPER STORAGE ENVIRONMENT 13

RECORDS DISPOSITION AUTHORIZATIONS 13

TDOC RECORDS DISPOSITION AUTHORIZATIONS 14

STATEWIDE RECORDS DISPOSITION AUTHORIZATIONS 15

RECORDS DESTRUCTION 15

DETERMINING DATE OF DESTRUCTION 16

METHODS OF DESTRUCTION 16

RECORDS HOLDING REPORT AND GUIDELINES 17

TDOC DISASTER PLAN 18

PROTECTING ESSENTIAL RECORDS 18

ARCHIVING AND CO ARCHIVES TRANSFER PROCEDURES 19

APPENDICES:

A. TDOC POLICY 216.01- TN PUBLIC RECORDS ACT AND REPRODUCTION OF PUBLIC RECORDS 20

B. TDOC POLICY 109.03- RETENTION AND DISPOSITION OF TN DEPARTMENT OF CORRECTION RECORDS 29

C. TDOC POLICY 512.01- MAINTENANCE, SAFEGUARDING, AND ARCHIVING OF TDOC RECORDS 33

D. GOVQA INSTRUCTIONS 42

E. TDOC RDA LISTING 53

F. STATEWIDE RDA LISTING 57

G. CERTIFICATE OF RECORDS DESTRUCTION 63

H. ARCHIVE LABEL TEMPLATE 64

I. OFFENDER HEALTH RECORDS ARCHIVING 65

J. SAMPLE RECORDS HOLDING REPORT 71

K. RECORDS MEASUREMENT GUIDE 72

L. TDOC DISASTER PLAN 73

February 2023 Records Management Handbook 4

GLOSSARY

Active Record Current records created and used during the course of routine daily operations conducted by the Department and are referenced on a frequent basis.

Agency Of or pertaining to the Department of Correction.

Alpha Format Arranging records or files by order of the alphabet, regardless of the file content.

Archive Label Form (CR#4185) used on storage boxes identify the contents, date range, and date of destruction for inactive/archive records.

Archive Record Records accumulated by the Department over a period of time that provide a representation of the functions carried out during the course of normal business practices.

Archiving The process of transferring inactive records to a centralized location for maintenance, safekeeping and retention.

Banker’s Box Standard storage container specifically designed to house letter or legal size files in a standard shelving unit or filing cabinet. The carton is one cubic foot in volume or

15’’L x 13’’W x 10.5’’H

Central Office Archives Central location for records containing health history of an offender.

Certificate of Destruction Form used to document when public records are properly destroyed in accordance with the Department’s

Records Disposition Authorizations

November 2022 Records Management Handbook 5

Confidential Record Any record designated confidential by statute that includes information considered to be privileged and for which access by the public would be generally denied.

Cubic Foot Standard measure of volume equaling 15’L x 13’W x

10.5’H.

Date Range Period of time covered by records.

Destruction Hold Preserving records or relevant information when litigation, investigation, audit or a TN Public Records Act request preempts the time frame for destruction.

Disaster Handbook Department handbook outlining procedures and information necessary to recover records during an unexpected interruption of business caused by a disaster

Essential Records Any records essential for the continuation of operations for the Department

Historical Records Any record deemed to have historical value by nature of the information contained in the record or the requirement by statute that all records in a series be kept for historical reference

Inactive Record A record that has exceeded its active lifespan, but must be retained for a defined period based on the Department

RDA

Measurement Guide Formula used to determine measurement in cubic feet for all record types

Numeric Format Filing system that relies on the use of coded numbers as an index

February 2023 Records Management Handbook 6

Permanent Retention Records having permanent administrative, fiscal, historical, or legal value

Public Record Documents, papers, letters, maps, books, photos, microfilm, electronic data, film, sound recordings, or other material, created or received during the course of official business by any government Agency

RDA A Records Disposition Authorization is and official

Department record approved by the Public Records

Commission containing authority that specifies the length of time a record series must be kept and the required method of destruction.

RDA Cut Off Date The date which a record should be closed in accordance with the guidelines of the Department RDA to begin preparation for final disposal or transfer

Records Custodian Individual(s) responsible for maintaining Department records during the ordinary course of business and producing records for copying or inspection in accordance with state and federal statute.

Records Officer Individual designated by an Agency to assume the responsibility for implementation of the records management program and to facilitate the creation, use, storage, transfer, and destruction of Department records as defined in T.C. A § 10-7-301(11). For TDOC, the

Director of Records Management.

Records Series Group of related records filed together to document a particular function, transaction or activity

Records Holding Report Annual report submitted by the Department to the Office of the Secretary of state providing an accounting of all records held in all Agency offices statewide

Records Coordinator Staff member at a prison facility, field office, central office or other division designated to assist the

Department’s Records Officer with required records management functions

Retention Schedule The length of time a record must be kept in accordance

February 2023 Records Management Handbook 7 with an RDA

Scanning Process by which a digital signal of a document can be stored, transmitted and reconstructed for display as an electronic image

Shredding Process of destroying paper records by mechanical cutting

Statewide RDAs General retention schedules that apply to common functions of all state Agencies such as human resources and fiscal records

Temporary Record Documents which can be disposed of in a short period of time.

TN Public Records Act Statute found under T.C.A. § 10-7-501, providing all state records be made available to any citizen of the State of TN, unless otherwise held to be confidential by state law.

Transfer Physical relocation of records

February 2023 Records Management Handbook 8

INTRODUCTION

The Records Management Division serves as the central location for records retention and storage of offender health records. Our Division is composed of units specializing in records requests processing, electronic scanning, expungement coordination, and warehouse storage. Our goal is to be a leader in records management efficiency through utilizing the latest technology and enhancing the systematic processes used to deliver records information; ensure efficient maintenance and safekeeping for the disposition of offender and administrative records statewide; provide excellent service to our internal and external customers; provide training and information to all staff who handle TDOC public records; and adhere to policies & procedures implemented by

TDOC and…