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UNCLASSIFIEDULAW ENFORCEMENT SENSITIVE (When Completed) <br />Are prisoners with mental health issues identified as part of the vulnerable population? <br />C' Yes r No <br />Are prisoners with mental health issues referred to qualified mental health professionals? <br />(' Yes (- No <br />Routine, Chronic, and Emergency Health Services <br />Are all prisoners made aware of the process for requesting health care services? <br />C' Yes No <br />Does the facility document receipt and disposition of health care requests by prisoners? <br />r Yes r No <br />Does the facility document all health care rendered to prisoners? <br />( Yes C No <br />Does the facility document all health care referrals? <br />C' Yes C No <br />Does the facility document all health care refused by prisoners? <br />(- Yes f No <br />Does the facility have a policy or procedures for identifying medical emergencies? <br />f Yes C" No <br />Does the facility provide access to prescription medication? <br />C' Yes C No <br />Does the facility participate in the National Manged Care Contract (NMCC) and Pharmacy Program? <br />r Yes C No <br />Does the facility have an onsite pharmacy? <br />C" Yes C° No <br />Does the facility provide a 7-day supply of prescribed medication upon transfer or release? <br />(Yes C` No <br />Does the facility document responses to prisoner health care grievances? <br />(- Yes (` No <br />When does the facility respond to health care grievances? <br />Days <br />Response to Medical, Mental and Dental Health Needs <br />Are all prisoners who require health care beyond the capacity of the facility transferred to a facility where such care is <br />available? <br />C Yes C No <br />NOTICE: This document is intended FOR OFFICIAL USE ONLY and may contain LAW ENFORCEMENT SENSITIVE OR CONFIDENTIAL information <br />which is for the sole use of the intended recipient(s). Any unauthorized review, use, disclosure, or distribution is prohibited. If you are not the intended <br />recipient, please contact the sender and destroy all copies of this document. Any Protected Health Information contained in this document is to be used <br />only to aid in providing healthcare services to federal prisoners. Any other use is a violation of Federal HIPAA Law and/or the Privacy Act and will be <br />reported as such. <br />UNCLASSIFIEDNLAW ENFORCEMENT SENSITIVE (When Completed) <br />Form USM-218 <br />Page 13 of 27 Rev. 02/25 <br />