On certification to the Superior Court, Appellate Division.
(This syllabus is not part of the opinion of the Court. It has been prepared by the Office of the Clerk for the convenience of the reader. It has been neither reviewed nor approved by the Supreme Court. Please note that, in the interests of brevity, portions of any opinion may not have been summarized).
This appeal concerns an incarcerated individual's right to adequate medical care and his right to the maintenance of complete and accurate medical records.
J.D.A. is presently incarcerated at the New Jersey State Prison (NJSP) in Trenton. NJSP is administered by the New Jersey Department of Corrections (DOC) which, in turn, has contracted out the provision of medical services in the prison to a private provider -- Correctional Medical Services (CMS). CMS maintains the medical records of inmates in electronic form.
J.D.A. suffers from Hepatitis C. In January 2003, J.D.A. first learned that a June 4, 2001, medical record pertaining to his condition contained an inaccurate notation that the Hepatitis virus was "not detected." On March 23, 2004, J.D.A. submitted a formal written grievance to the Health Services Administrator at NJSP requesting a correction of his medical records. Receiving no response, J.D.A. filed a "remedy form" with DOC and DOC forwarded the form to CMS. On June 18, 2004, CMS responded, stating that "[d]ocumentation entered into a chart is considered a legal document and no one can change that information."
On June 21, 2004, J.D.A. appealed to the Administrator of NJSP and the Administrator denied relief.
J.D.A. then appealed to the Appellate Division. DOC supplemented the record with a letter certification from Dr. Richard Cevasco, its Medical Records Director, stating that only CMS had the "ability to make changes to an inmate's medical record." DOC and J.D.A. both moved for summary disposition. CMS did not enter an appearance in the case.
On December 22, 2004, the Appellate Division granted DOC's motion based, in part, on Dr. Cevasco's certification. J.D.A. filed a petition for certification. On June 13, 2005, the Supreme Court inquired of DOC whether CMS had ever made the corrections to J.D.A.'s medical records. On June 14, 2005, DOC responded with a letter from Carl Ausfahl, Ombudsman for CMS, agreeing to correct certain errors in J.D.A.'s medical chart and to provide explanations regarding others.
The Supreme Court granted J.D.A.'s petition for certification.
HELD: The Department of Corrections (DOC) has the ultimate responsibility for the medical care of inmates and for the maintenance of complete and accurate medical records. In addition to the medical summaries protocol currently in effect under N.J.A.C. 10A:22-2.7, DOC must expeditiously enact comprehensive rules and regulations codifying its obligations for medical care and record keeping, and the methods by which they will be satisfied.
1. During oral argument, DOC finally acknowledged that it, indeed, has a non-delegable duty to assure adequate medical care to inmates. In a narrow sense, DOC's concessions render the issues presented here moot and obviate the need for us to grapple with J.D.A.'s claims of entitlement under the Federal Constitution. However, in light of the labyrinthine history of this case; DOC's refusal to acknowledge until the eleventh hour its ultimate responsibility for inmate medical care and record keeping; the finger-pointing by DOC and CMS; and the amount of time and effort that was required for J.D.A. to obtain the correction of his records, we are not sanguine over the effectiveness of DOC's present policies and procedures. We therefore order that, in addition to the medical summaries protocol currently in effect under N.J.A.C. 10A:22-2.7, DOC must expeditiously enact comprehensive rules and regulations codifying its obligations for medical care and record keeping, and the methods by which they will be satisfied. Those regulations must include DOC's duty to notify inmates of any serious medical condition requiring treatment; to keep complete and accurate medical records (electronic or paper) including all test results and lab reports and to make those complete medical records available to each inmate; and to provide a procedure pursuant to which an inmate may, within a reasonable time after a request, access medical records and seek correction of them. (Pp. 6-8)
The judgment of the Appellate Division is REVERSED. The case is REMANDED to the DOC for proceedings consistent with its representations to us and with the principles to which we have adverted.
The opinion of the court was delivered by: ...