Skip navigation
× You have 2 more free articles available this month. Subscribe today.

Settlements Reached In Alabama Women Prisoners' Class-Action Suit

by Matthew T. Clarke

On August 23, 2004, U. S. District Judge Myron Thompson signed a settlement order in a class-action civil-rights lawsuit brought by prisoners at three Alabama Department of Corrections women's prisons challenging their conditions of confinement. The suit focused on basic human needs such as adequate living space, ventilation, personal safety, security, medical treatment and mental health care. The order approves two agreements: The Conditions Settlement Agreement and the Medical Settlement Agreement. Together, they require sweeping improvements in the conditions at the three prisons.

Unconstitutional Prison Conditions

In December, 2002, the court declared conditions at Julia Tutwiler Prison for Women, Edwina Mitchell Work Release Center (later renamed Tutwiler Annex) and Birmingham Work Release Center unconstitutional. It described conditions at Tutwiler as a time bomb ready to explode facility-wide at any unexpected moment." Laube v. Haley, 234 F.Supp.2d 1227 (M.D.AL 2002). See: PLN, Sep. 2003 pp. 32, 33; Oct. 2003 p. 1.; June 20011, p. 35.
Indeed, conditions at Tutwiler and the other prisons were gruesome. Tutwiler had been built in 1942 and intended to house about 360 women. By 2002, it held 1,017 prisoners. Violence was rampant, medical treatment virtually nonexistent and mental health care largely unknown. The situation at Tutwiler was reflective of the overall situation within the DOC, in which 26,000 prisoners were being housed in prisons designed to hold 12,500, according to DOC spokesman Brian Corbett.

Shades Of Abu Ghraib

Over the course of the suit, the Tutwiler administration began giving draconian punishment for disciplinary infractions. One such punishment was food restriction in which the prisoner was given a roll for lunch and a roll for supper. Another was forcing prisoners to remain static in uncomfortable positions for long periods of time. The settlement ends this type of abuse.

Reduction In Population

The DOC is to divert as many prisoners as possible into community corrections placement (such as supervised work release). To that end, it is to conduct classification reviews of the prison population at least every six months with the plaintiffs' lawyers and their agents able to review the classification records to check for and correct errors. Two target population values are 700 or less at Tutwiler, 250 or less at the Annex. If those are achieved for the required period, other sections requiring additional laundry capacity, staffing, and administrative segregation cells are suspended (so long as the population remains that low).

The Heat, the Heat, the
Terrible Heat

A persistent complaint involved the lack of ventilation in very hot Tutwiler buildings. The settlement requires the addition of an exhaust fan to dormitories one through eight and two exhaust fans to dormitory nine, and at least one wall-mounted rotating fan for every three segregation cells, the availability of ice for prisoners, and allowing an additional shower when the temperature exceeds 85 degrees F. The DOC agreed to buy five new ice machines, increasing its ice production capacity 50%. It also agreed to monitor temperatures in the dormitories and allow the prisoners to wear shorts after 3:30 p.m. The DOC agreed not to turn off fans for punishment and to modify the windows at Tutwiler so that the upper row of windows can be opened 45 degrees and the lower row of windows fully opened.

Recreation Assured

The DOC agreed to build shaded outdoor enclosures attached to each dormitory at Tutwiler (except Dorms 5 and 10). It agreed to allow at least one hour of outdoor recreation a day, five days a week for general population prisoners and 45 minutes a day, seven days a weeks for segregation prisoners. Recreational equipment (e.g. softball, volleyball and basketball equipment) will be available on the recreation yards. Prisoners will be permitted and encouraged to form exercise classes.


Per the settlement, prisoners are to be allowed two visits per month with family and loved ones.

Bugged By Bugs

Another common complaint was that the prisons were insect infested. In the settlement, the DOC agreed to monthly insect extermination and to make cleaning and disinfection supplies readily available. Bathrooms, bathing areas and living areas will be regularly cleaned and disinfected to control mold and staphylococcus.


The DOC agreed to maintain all critical machinery, including locks, plumbing, electrical systems, roofs, drop ceilings, windows, floors, HVAC systems, laundry systems, dishwashing equipment, cooking equipment, and refrigeration units. This includes establishing a preventative maintenance schedule and making in-house repairs within 24 hours (7-days if DOC has to use out-of-house maintenance personnel).


Tutwiler will have at least one 125-pound-capacity washer and one 125-pound-capacity dryer and one press for every 250 prisoners housed there.
Programs and Treatment

DOC agreed to provide drug treatment programs to prisoners sentenced to attend such programs. It also agreed to provide adequate and appropriate vocational, educational, industrial, therapeutic, or other programming to accommodate at least 60% of the women prisoners.

Safety and Security

The DOC agreed to increase staffing to one guard for every 50 prisoners in the dormitories. Guards may not work over 16-hours straight without an 8-hour break. Lines of sight will be cleared. Improved drug testing that doesn't give false positives for approved medications will be implemented. DOC will maintain sufficient segregation cells to house 4% of the female population. DOC will implement a classification scheme with at least three custody levels and audit its implementation. It will also implement a policy for identifying special needs prisoners such as those emotionally disturbed, mentally retarded, mentally ill, or who pose or are at high risk.

Medical Issues

DOC will be required to provide prisoners medically necessary services in a timely manner. This includes prisoners in work release programs (although they may opt out and see a health care provider of their own choosing at their own expense). There will be a daily sick call (excluding medical contractor holidays) and it may not be held between midnight and 6:00 a.m. Prisoners submitting a sick call slip must be seen by a nurse (or higher-level medical personnel) within 48 hours and the slips must be reviewed by a nurse within 24 hours. Any prisoner seen by a nurse two consecutive times for the same symptoms must be referred to a higher-level practitioner.

Medical staff must be notified when a prisoner is placed in a segregation cell and must promptly review the medical appropriateness of such placement. Segregated prisoners must be monitored daily by health care staff. Guards must monitor each segregation cell every thirty minutes and immediately notify medical staff if a medical problem is detected.


All newly-arriving prisoners at Tutwiler will be medically screened within 12 hours of arrival. Prisoners at risk for suicide will be immediately referred to a. mental health care provider. Tuberculin skin tests will be performed and read at intake. An initial physical examination will be performed on the newly arriving prisoner by a physician, PA or NP within seven days of arrival. This will include a pap test, cervical screening for Chlamydia and gonorrhea, testing for syphilis, and screening for pregnancy.

Continuity Of Care

A policy to facilitate continuity of care will be implemented. If a newly-arriving prisoner can identify her medication, she will be given it if the prescription can be verified by a physician or pharmacist. If verification is not obtained within 24 hours of intake, the prisoner must be seen by a physician or physician's assistant within 48 hours of intake so that the medication can be prescribed. Continuity of medication will be maintained when prisoners are transferred between DOC prisons, to local hospitals, or to local detention centers. Upon release, prisoners on prescribed medication will be given a ten-day supply of their medication. Longer supplies may be given under some circumstances (severe mental illness or HIV). DOC will cooperate with the Social Security Administration in securing prisoners federal benefits upon release.

Medical Services

DOC agrees to provide medical services in accordance with NCCHC standards. This includes annual pap smears, periodic mammograms and annual TB skin tests. Emergency medical services will be available 24/7. Prisoners will be provided care for pregnancy, gestational diabetes, osteoporosis, menstrual abnormalities, ovarian and cervical abnormalities and menopause in accordance with American College of Obstetricians and Gynecologists standards. Appropriate care, including pain control, shall be available for terminal and elderly patients. Patient education shall be provided by the medical staff. Medical diets shall be provided as needed.
Dental services will be provided and dentists will have current licenses. Dental services will include effective pain and infection control, restoration of carious teeth, extractions, long-term management of periodontal disease, and provision of bridges and dentures. Prisoners will be given the opportunity to have their teeth cleaned at least once every two years. Dental impressions will be made as soon as possible and prisoners given their dental prosthetics within 60 days of the impression being made.

A program will be instituted for control of airborne and blood-borne pathogens. Prisoners with suspected active TB shall be isolated in negative-pressure rooms. DOC shall implement policies and procedures for the treatment of prisoners with chronic medical conditions in accordance with NCCHC guidelines. This includes regular check ups at least once every three months and an individual treatment plan for chronic-condition prisoners. All HIV-positive prisoners shall be vaccinated for hepatitis B.
Prisoners needing prosthetics shall be fitted with one within 60 days of prescription and shall be given follow-up care. Replacement prosthetics for those that no longer fit shall be made available within 90 days.

Mental Health

Dormitory 2 at Tutwiler shall be renovated for use as a mental health housing unit of 40 beds. A mental health auditor shall make on-site inspections at least three times a year. DOC shall ensure the standard of care for prisoners with serious chronic mental health conditions is consistent with American Psychiatric Association standards. Policies and procedures to ensure treatment of prisoners at risk for suicide, who injure themselves, who suffer from depression or from physical or sexual victimization shall be implemented and crisis intervention and follow-up care provided.


DOC will maintain sufficient medical staff and ensure that they are trained in CPR. Medical staff involved in triage and treatment shall be appropriately trained. Guards will receive training for CPR, Basic First Aid, and education on HIV, hepatitis, TB and recognizing mental illness. Guards will not interfere with medical treatment and shall abide by medical restrictions.


DOC shall provide needed medications in a timely manner and keep commonly needed medications in its formulary as well as provide for the timely provision of off-formulary medications. There shall be a general pill call at least three times a day and provision for prisoners to keep appropriate medications on person.

Other Medical Provisions

DOC will keep accurate medical records and implement a medical quality assurance program. An independent review shall be made within 30 days of a prisoner's death. The parties agreed to install Dr. Michael Puissis as Correctional Health Care Monitor to monitor compliance with the agreement and report to the court.

Other Matters

The lawsuit was filed in 2002 with the assistance of the Southern Center for Human Rights (SCHR), a nonprofit Atlanta, Georgia, law firm that advocates for human rights. SCHR Attorneys Lisa Kung, Tamara Serwer Caldas, and Stephen Bright and attorneys Marion D. Chartoff (Montgomery, AL), John A. Russell, III (Aliceville, AL), Gretchen Naomi Rohr (Atlanta, GA), and George E. Schulz, Jr. (Jacksonville, FL) represented the plaintiffs.

The agreements were tentatively approved on July 1, 2004, when DOC was enjoined to abide by them, they expire July 1, 2008. The order was delayed until after a fairness hearing held on July 21, 2004. The court heard testimony from seven prisoners and considered written comments and objections by 81 prisoners on about 350 separate issues. Only 7 of the 81 prisoners opposed the settlement. The court ruled that the settlement was in the best interest of the plaintiff class and that many of the matters objected to were already being addressed by the parties. The court also noted favorably that the population of the prisons had already been drastically reduced and many of the provisions of the agreements were already being implemented.

Upon request of the plaintiffs' attorney, the court will enforce compliance with all aspects of the agreement if, after having the non-compliance brought to its attention, the DOC fails to correct the problem. The parties agreed that the relief granted complies with the PLRA. The court agreed to award plaintiffs unspecified attorney fees. See: Laube v. Campbell, 333 F.Supp.2d 1234 (M.D.AL 2004).

Additional sources: Associated Press, Montgomery Advertiser, Birmingham News.


As a digital subscriber to Prison Legal News, you can access full text and downloads for this and other premium content.

Subscribe today

Already a subscriber? Login

Related legal case

Laube v. Campbell

C. Dental services. All dentists must be currently licensed. Women requiring treatment for relief of acute oral and maxillofacial conditions characterized by trauma, infection, pain, swelling or bleeding which are likely to remain acute or worsen without intervention, must be provided appropriate dental care (including effective infection and pain control) promptly. Women requiring treatment for the control of extensive subacute dental or oral pathology, must be provided dental care within 30 days. This care shall not be limited to extractions or temporary fillings, but also includes restoring carious teeth, extractions, long-term management of peridontal disease, and endontic and prosthodontic procedures needed to retain or restore essential masticatory function. Women requiring ongoing treatment for chronic dental or oral pathology and for the restoration of essential function must be seen within 60 days. For women who are prescribed dental prosthetics such as dentures, impressions for such prosthetics shall be made as soon as it is medically appropriate to make such impressions. The dental prosthetic shall be available within 60 days of impression. All prisoners will have the opportunity to have their teeth cleaned at least once every 24 months. Individuals at risk of peridontal diseases because of age, tobacco use, rate of accumulation of deposits, medication, or medical conditions such as diabetes or HIV infection, may need to be cleaned more often, in accordance with the standard of care for their conditions.

D. Infection control. An infection control program that includes airborne and blood-borne pathogen control plans conforming to Centers for Disease Control ("CDC") regulations, guidelines and recommendations shall be developed and implemented. The program must include appropriate training for correctional and health care staff consistent with these recommendations and guidelines. The airborne and bloodborne pathogen plans must be reviewed and updated every two years or sooner if appropriate.

E. Tuberculosis prevention and treatment. The ADOC, through its agents or contractors, shall promptly diagnose, and treat any individual with a reasonable suspicion of contagious tuberculosis as directed *1257 by the Alabama Department of Public Health. Any individual who reports or exhibits symptoms of tuberculosis, including HIV-positive persons, shall be isolated immediately in a properly functioning negative pressure room and have a chest x-ray as soon as possible but in no event later than 96 hours from the reporting of the symptoms. Follow-up treatment and testing shall be conducted according to the recommendations and guidelines of the CDC. Persons with a positive tuberculin skin test result shall be provided a chest x-ray as soon as possible but in no event later than 96 hours of identification of the positive skin test result. Prisoners with chest x-rays that show possible active tuberculosis infection will receive prompt follow-up evaluation and treatment and will be placed in respiratory isolation until active tuberculosis has been ruled out. Preventive treatment for tuberculosis shall be offered to any prisoner with a positive PPD skin test whose anticipated length of stay is greater than two months. Prisoners who receive positive skin tests or suspicious chest x-rays will be counseled about the meaning of these test results. In the event that an active case of TB is identified in the facility, an appropriate contact investigation as directed by the Alabama Department of Public Health will be conducted and all potentially exposed individuals will be provided detailed and thorough educational materials about tuberculosis infection. The Alabama Department of Corrections shall maintain appropriate facilities and/or make appropriate referral outside prison facility for respiratory isolation that are consistent with the recommendations of the CDC.

F. Chronic illnesses. The ADOC, through its agents or contractors, shall implement policies and procedures to ensure that the overall standard of care for women with serious chronic medical conditions is consistent with clinical guidelines adopted by the NCCHC as detailed in the Standards for Health Services in Prisons and the current clinical guidelines posted on their web-site. For chronic conditions where NCCHC clinical guidelines are not yet available, the ADOC through its agents and contractors, shall provide treatment consistent with nationally accepted clinical guidelines.
For each individual identified with a chronic illness requiring ongoing medical care, a health care treatment plan shall be developed that includes, at a minimum, the following: a written initial evaluation containing short and long range treatment goals by a licensed physician; regular check-ups at least once every 3 months by the chronic care director or higher level practitioner, unless a different period is ordered by a physician; and baseline and quarterly laboratory work and other diagnostics appropriate for the disease. The treatment plan's short and long range goals must be reviewed and updated at least annually in a face-to-face assessment by the attending physician or more frequently as determined by the physician or chronic care director. For patients requiring chronic care, co-payments shall not be assessed for regularly scheduled chronic care clinics.

G. Hepatitis A, B, and C. The ADOC, through its agents and contractors, shall make best efforts to secure grant money to ensure that women are counseled, evaluated and vaccinated for hepatitis A and B by October 2005. All women prisoners who are HIV-positive will be vaccinated for hepatitis B.

H. Prosthesis. Women requiring a prosthesis will be fitted for such a device within 60 days of prescription. If a prosthesis no longer fits a prisoner, she will be *1258 re-fitted for a revised or new prosthesis within 90 days. Prisoners requiring a prosthesis shall be considered chronic care patients for the period necessary to adjust a new, replacement, or refitted prosthesis, and women will receive follow-up care during this adjustment period as medically ordered.

I. Women's health care. Women prisoners must be provided treatment for osteoporosis, menstrual abnormalities, ovarian and cervical abnormalities and menopause in accordance with the guidelines of the American College of Obstetricians and Gynecologists. Preventive screening shall be provided in accordance with the American Cancer Society.

J. Pregnancy. Pregnant prisoners shall be monitored regularly by a medical doctor or physician assistant with obstetric specialty, in accordance with American College of Obstetrics and Gynecology ("ACOG") guidelines for prenatal care. Pregnant women shall be provided an appropriate diet and supplemental vitamins, and given the opportunity to request and receive educational information regarding pregnancy. Gestational diabetics shall be treated according to ACOG guidelines. All high-risk pregnancies, as well as women near term, shall be closely monitored and treated. Upon return from the hospital post-delivery, women prisoners will be allowed appropriate bed rest and time for recovery.

K. Specialty care. Patients requiring necessary medical services that cannot be provided in the facility in a timely manner shall be provided timely access to an outside specialist for diagnostic services or medical care. Where approval by the state medical director is required for specialty care, such approval or denial shall be documented. The ADOC, through its agents and contractors, shall make best efforts to ensure that the outside specialist's diagnoses and test results in addition to the specialist's orders for further testing, treatment and diagnostic services are documented in the patient's prison medical record. Orders shall be carried out in the manner prescribed by the specialist, unless a deviation or override is ordered by the attending physician at the facility. Such a deviation or override must be affirmatively medically justified and documented in the medical record of the prisoner. Necessary off-site care shall include follow-care and monitoring prescribed by the off-site specialist.

L. End of life care and care for the elderly. Elderly patients and those in the terminal stages of a disease shall be provided appropriate care and treatment, including pain control, adequate nutrition, accommodations for mental and physical deterioration, and other appropriate palliative care.

M. Patient education. Patient education shall include one-on-one counseling by medical staff at the time care is provided. The ADOC medical provider shall inform patients of the results of any medical tests and assessments within 10 days of receipt of these results in a manner that protects the privacy of the patient, and shall provide appropriate post-test counseling. Prisoners shall not be charged a co-pay for receiving this information. The ADOC, through its agents and contractors, shall also implement a program to make available to patients up-to-date written information in the areas of infectious and communicable disease, and chronic illnesses. Clinical staff knowledgeable about HIV/AIDS shall provide HIV education for all new prisoners. Prisoners who are HIV-positive shall be provided on-going education and confidential counseling about HIV. This education and counseling may be provided in a structured peer education and support program. The ADOC *1259 and its medical provider shall cooperate with health organizations, or community organizations working in conjunction with health organizations, to provide prisoners educational materials and services regarding medical conditions, treatment, and related social services.

N. HIV/AIDS. Prisoners who learn they are HIV+ in prison shall be informed of their test results and receive appropriate post-test counseling in a confidential setting. Treatment of HIV/AIDS shall be consistent with Department of Health and Human Services guidelines and recommendations.

O. Staphylococcus aureus. The Alabama Department of Corrections, through its agents and contractors, shall continue to develop and implement a program based on FBOP guidelines to treat and to minimize the spread of staphylococcus aureus, including methicillin-resistant staphylococcus aureus (MRSA), and shall work with the Correctional Healthcare Monitor to continually update and improve this program.

P. Therapeutic medical diets. Diabetics, as well as patients requiring low salt, renal, low cholesterol, high calorie, or other special diet, shall be provided a medically appropriate diet as approved by a registered dietician. Special medical diets may be ordered by mid- or higher-level medical providers.

Q. Mental health care. Defendants' mental health consultant Jane Haddad has conducted on-site audits and reviews of the women's prison facilities to determine mental health housing and treatment space needs, as well as training, programming, reporting, treatment, and staffing needs. Defendants have implemented and shall continue to implement all of Dr. Haddad's recommendations as set forth in her report of her January 15-16, 2004, audit. Within 6 months of final approval of this Agreement, Defendants shall begin renovations of Dormitory 2 at Tutwiler Prison to provide for a group room, dayroom, two offices spaces, and a reduction of beds to no more than forty beds. Defendants further agree to use their best efforts to add a nursing station, and six single cells for crisis intervention and intensive psychiatric stabilization, within 3 years of final approval of this Agreement. Until these renovations are completed, the ADOC, through its agents and contractors, may but shall not be required to provide 24/7 mental health nursing coverage in the mental health unit. Until these renovations are completed, the ADOC, through its agents and contractors, shall work with Dr. Haddad to determine and implement the measures necessary to ensure that individuals needing intensive psychiatric stabilization and residential treatment levels of treatment receive adequate mental health care.

R. Mental health auditor. Dr. Haddad, or another mental health consultant mutually agreed upon by the parties, shall continue in her current capacity as Defendants' mental health consultant, with on-site inspections at least 3 times a year, for the duration of this Agreement or 3 months past the date the Residential Treatment Unit becomes fully operational, whichever period is shorter. The mental health consultant shall be paid by the Defendants and be reimbursed for reasonable expenses for the first 2 years, and by counsel for Plaintiffs for the remainder for her tenure. If Dr. Haddad is no longer able to act as mental health consultant, and parties are unable to agree on a mental health consultant within 30 days of her departure, parties will each submit to the Magistrate Judge the names of three suggested consultants, and the Magistrate Judge will select the mental health consultant.

*1260 S. Chronic Mental Illnesses. The ADOC, through its agents and contractors, shall implement policies and procedures to ensure that the overall standard of care of women with serious chronic mental health conditions is consistent with clinical guidelines adopted by the American Psychiatric Association.

T. Suicide Prevention and Treatment Program. ADOC, its agents, and contractors, shall continue to implement an effective and comprehensive suicide prevention and treatment program.

U. Self-Injurious Behavior. Prisoners who engage in self-injurious behavior must receive appropriate and timely mental health intervention including treatment and counseling. Such a prisoner shall also be evaluated by a qualified mental health professional. Only if that professional determines that the behavior was engaged in solely for the purpose of secondary gain may disciplinary action be considered.

V. Crisis Intervention and Follow-Up Care. Together with the mental health auditor, Defendants will write and implement policies and procedures to ensure that mental health crises and urgent requests for mental health intervention are addressed by qualified mental health staff immediately. Following a mental health crisis such as a psychotic episode or suicide attempt, prisoners shall receive appropriate treatment, counseling, and observation as ordered by the treating psychiatrist.

W. Depression and Abuse. Counseling must be available to women prisoners to address depression and to resolve issues associated with victimization from sexual and physical abuse.

X. Vulnerable Populations. The ADOC, working with its mental health provider, shall develop and implement a policy to protect vulnerable prisoners (particularly mentally ill and/or mentally retarded women) from intimidation, harassment, and abuse.

A. General. ADOC, through its agents and contractors, shall create and fill a sufficient number of qualified permanent medical, nursing, and ancillary health care staff positions (i.e. medical records clerks, lab tech, etc.) to carry out all aspects of this Medical Settlement Agreement.

B. Licensure and credentials. ADOC, through its agents and contractors, shall make best efforts to hire primary care physicians who hold a current valid, unrestricted license to practice medicine in Alabama. In the event Defendants cannot find a primary care physician with an unrestricted license, Defendants will seek approval of a Magistrate Judge to hire a physician with a restricted license in order to avoid a lapse in medical coverage. Such a hire shall be temporary, though Defendants may seek re-approval of a Magistrate Judge in extraordinary circumstances. Parties consent to the jurisdiction of a Magistrate Judge, and Plaintiffs will not seek fees, for disposition of this issue.
Nurses must hold current applicable licenses. All other ancillary personnel must meet applicable state regulatory requirements and training standards. Personnel working under a license or certification who are subject to restrictions or conditions imposed by the licensing agency, or who have formal complaints filed against them, must immediately report such restrictions, conditions, or complaints to the Medical Director. Nurses shall not make nursing assessments or decisions outside the scope of their license and training.

C. Orientation and training. Medical and nursing staff must be currently certified *1261 in cardiopulmonary resuscitation ("CPR"). All medical and nursing staff who provide sick call shall receive regular training to maintain competence in current methods for diagnosing and treating medical complications associated with acute and chronic illness, including the ability to recognize when referral to a physician, mental health provider, or specialist is necessary. Medical and nursing staff shall also be trained to recognize the signs and symptoms of mental illness, including potential suicide risk and how to react appropriately to such symptoms and risks. All medical and nursing staff shall be provided a copy of this Agreement.

D. Security staff. All correctional security staff shall receive regular training regarding HIV, hepatitis and tuberculosis infection, including modes of transmission and universal precautions. All security staff shall have current training in CPR and in Basic First Aid. Security staff shall also be trained to recognize the signs and symptoms of mental illness, including potential suicide risk and how to react appropriately to such symptoms and risks. Security staff will not interfere with the provision of necessary medical care. Security staff shall follow medically ordered restrictions on inmate activity such as bedrest, lifting or work restrictions, bunk profiles and needs for special shoes or clothing.

A. Formulary. The drug formulary must contain modern pharmaceuticals for diagnoses prevalent in the correctional setting, updated at least every 6 months by a team of providers that includes a primary care physician and psychiatrist. The formulary must include drugs in the following classes, among others: (1) atypical anti-psychotics, (2) proton pump inhibitors, (3) angiotensin receptor blockers, (4) selective serotonin reuptake inhibitors, (5) statins, and (6) antiretrovirals.

B. Off-formulary medications. A formulary waiver process that does not inhibit the timely delivery of medications prescribed for medically necessary conditions shall be implemented.

C. Administration. The ADOC, through its agents and contractors, shall develop and implement a system to provide medications in a timely manner and to track and correct problems with the dispensing and administration of medications. Medication normally stocked in the pharmacy must be made available for the administration of the first dose within 24 hours of intake, and within 24 hours of prescription by the physician. Other medications must be available within 48 hours of prescription. Medication shall be administered at times and in a manner (with food, for example) consistent with prescribing guidelines defined by the Food and Drug Administration or as prescribed by a physician. Prisoners refusing medication must be provided counseling regarding the consequences of incomplete adherence; both the refusal and the counseling must be documented and in-person. Nothing in this paragraph precludes the forced administration of medication, so long as such forced medication is administered according to current written policy. If medication is not administered to a prisoner, the reason must be documented and signed by the health care staff responsible for medication administration. Correctional staff shall not administer dose by dose medication to prisoners, except at Birmingham Work Release.
There must be general pill call at least three times a day. Management of pharmaceuticals must be in accordance with state and federal law.

D. Keep on person medications. The ADOC, through its agents and contractors, *1262 shall develop and implement reasonable criteria, policies, and procedures for prisoners to be issued appropriate medications to keep on their persons.

E. Continuity of medication. The ADOC, through its agents and contractors, shall develop and implement written protocols designed to ensure that there are no lapses in medication.

A. Prisoner health care records. Medical care, including dental and mental health treatment, provided to prisoners shall be accurately documented in each prisoner's medical record. Medical records and health record policies and procedures shall comply with current NCCHC Standards. The records must include all reports received from outside hospitals and emergency rooms, current treatment plans, requests for medical attention, and responses by medical staff. Individual medical records shall be maintained on a current basis, with no more than a 7-day lag for filing new paperwork (except for current MAR's, which must be promptly filed at the end of each month). Patients' health care records shall be available to and used by all healthcare workers in each clinical encounter with the patient.

B. Prison health care logs. The ADOC, through its agents and contractors, shall maintain current and ongoing logs tracking health care requests, all clinical encounters, complaints, grievances, and chronic care clinics, conforming with NCCHC Standards.

A. Infirmary. The quality improvement committee (see below) shall review the capacity of the Tutwiler infirmary (including the "green rooms" or "psychiatric stabilization units") and provide written guidelines as to types of services appropriate for infirmary care. The infirmary unit shall conform with NCCHC standards including the requirement that all infirmary patients must be within sight or sound of nursing or medical staff at all times. Physician rounds shall be conducted 5 days a week, and an RN or higher level medical provider shall be present at the infirmary each day.

B. Medical isolation. Negative pressure in the medical isolation unit shall be documented daily when in use and monthly when not in use. If there is not a working room or not enough rooms at the prison facility, the ADOC shall make appropriate referral outside prison facility for respiratory isolation.

C. Heat and shade. Defendants shall develop and implement a heat plan that includes policies and procedures ensuring sufficient means of cooling and hydration for heat-sensitive individuals to prevent dehydration, heat exhaustion, heat stroke, and other adverse consequences of heat.

D. Sanitation. All areas housing or temporarily holding prisoners with illnesses, or where prisoners receive medical care or testing, shall be thoroughly cleaned on at least a daily basis or more often if necessary, shall be disinfected between placements, and shall be kept in good physical condition.

E. Medical examination rooms. An adequate number of clinical examination rooms shall be provided, containing an examination table and hand washing facilities to ensure private examinations.

F. Equipment. The ADOC shall provide at Tutwiler prison appropriate and operative equipment, such as automatic defibrillators, to respond to medical emergencies. Staff shall be properly trained to use such equipment. If dialysis is conducted on-site, staff shall be trained in proper methods, and appropriate equipment *1263 and space shall be available to perform dialysis. Prisoners who enter prison with respiratory or other medical equipment that is necessary to enable their functioning shall be allowed to use their own equipment or shall be provided appropriate equipment. The ADOC shall ensure that any such equipment receives necessary and timely servicing and replacement. Each facility shall also have a sufficient number of wheelchairs and handicap-accessible bathroom facilities (including toilets, sinks and showers).

A. Ongoing quality management. A quality management program consistent with nationally accepted standards shall be implemented. A monthly administrative committee shall meet to review audits designed to improve quality of health care. A quality improvement committee that includes a representative of the correctional staff will perform at least quarterly reviews of major components of healthcare at each women's facility, including at least the following: access to healthcare, medication management, nursing services, physician services, access to specialty care, mental health services, pharmacy services, dental services, subcontractor services, infection control procedures, healthcare records, sick call services, intake screening and evaluations, chronic disease services, infirmary care, diagnostic services, discharge planning, and adverse patient occurrences including all deaths. The quality management program must review each of these areas, identify any deficiencies in services to prisoners as well as any staff training needs, and produce corrective plans to address the deficiencies and recommend improvements.
Performance in these areas shall be quantified on a quarterly basis, trended, and analyzed for opportunities for improvement. Remedies shall be implemented expeditiously, followed by re-measurement to assess the results of the interventions. The quality management program shall include ongoing assessment of the effectiveness of corrective plans and actions. The staffing of the women's facilities shall be reviewed by Defendants at least every six months and adjustments made to ensure adequate staffing at all times.

B. Mortality reviews. A mortality review of all deaths must be completed within 30 days of each death. The review is to be conducted by a team that includes an independent physician (one who is not the primary care provider at the institution where the death occurred). This review shall consider any and all aspects of custody and health care that may have contributed to the death. The results of this review shall be documented and used to develop interventions to prevent future adverse consequences.

C. Correctional Healthcare Monitor. Parties have agreed on Dr. Michael Puissis as the Correctional Healthcare Monitor ("Monitor") to monitor compliance with this Medical Settlement Agreement. The Healthcare Monitor shall be a neutral monitor responsible to the Court. The Monitor shall be paid by the Defendants and be reimbursed for reasonable expenses to a maximum amount agreed to by counsel for parties. The Monitor shall have access to women prisoners and their medical records, to members of the medical and security staff, and to any other information or documents he or she deems necessary to determine compliance with this Medical Settlement Agreement. The Monitor shall conduct an initial assessment within 60 days of the Court's approval of this Medical Settlement Agreement and make written recommendations regarding deficiencies that prevent compliance with *1264 this Agreement. The Monitor shall make quarterly on-site inspections of Tutwiler and BWR per year. If the ADOC, its contractors and agents are determined to be in substantial compliance of the Agreement for three consecutive inspections in the second year, the Monitor shall make only two on-site inspections per year for the remainder of the Agreement. The Monitor may bring additional medical experts as needed to properly evaluate the health services provided to Plaintiffs. The Monitor shall prepare audit reports following each inspection, and items for improvement shall be addressed in a subsequent corrective plan by the institution's quality improvement committee. The Monitor shall provide copies of his or her reports to the Court, Defendants', and Plaintiffs' counsel.

A. Notice. The Commissioner of the ADOC and his representatives shall provide a copy of or explain the terms of this Medical Settlement Agreement to all of their agents, representatives, and employees in any way connected with medical care of class members, in order to ensure their understanding of the scope and substance of this Agreement. Women entering Tutwiler shall be provided an information sheet, mutually approved by all parties, informing them of the existence and material terms of this Medical Settlement Agreement. In addition, at least 3 copies of this entire Medical Settlement Agreement shall be maintained in the Tutwiler library.

B. Enforcement. If the ADOC, its agents or contractors, fail to comply with the terms and conditions of this Medical Settlement Agreement, Plaintiffs' counsel may apply to the Court for a finding of contempt or other appropriate relief. Prior to approaching the Court for such relief, Plaintiffs' counsel will bring, in writing, any deficiencies to the attention of the Defendants and the Healthcare Monitor or Mental Health Auditor, as appropriate, and will make reasonable attempts to resolve the issues informally. Issues that cannot be resolved informally between the parties shall be brought to the attention of the Magistrate Judge, who will attempt to mediate a resolution, before Plaintiffs' counsel will move the Court for an Order for Defendants to show cause why they should not be held in contempt.

C. PLRA findings. The parties agree, and the Court hereby finds at this time, and an after independent review, that the prospective relief set forth in this Medical Settlement Agreement is narrowly drawn, extends no further than necessary to correct the violations of federal rights set forth in paragraphs 101-162, 168-171, and 180 in Plaintiffs' Second Amended Complaint, and is the least intrusive means necessary to correct these violations. The parties agree, and the Court after an independent review hereby finds after an independent review of the Medical Settlement Agreement, that this Agreement will not have an adverse impact on public safety or the operation of the criminal justice system. Accordingly, the parties agree, and the Court hereby finds, that this Medical Settlement Agreement complies in all respects with the provisions of 18 U.S.C. § 3626(a). This Medical Settlement Agreement is not intended to have any preclusive effect except as between the parties in this action. Should the issue of the preclusive effect of this Medical Settlement Agreement be raised in any proceeding other than this action, the parties agree to certify that this Medical Settlement Agreement was intended to have no such preclusive effect. This Medical Settlement Agreement does not resolve, adjudicate, *1265 or bar the damages claims of any former, present, or future class members.

E. Attorneys fees. In the event the parties are unable to hereafter resolve by agreement issues relating to Plaintiff's claim for attorneys' fees, Plaintiffs may petition the Court within thirty days of the date on which the Court enters its Order granting the parties' Joint Motion to Adopt Settlement Agreement, for a resolution thereof.

F. Class members. Parties stipulate to the certification of the class of all women who are now or will in the future be incarcerated in an Alabama Department of Corrections facility.

G. Modification. Any party may seek modification of any part of this Medical Settlement Agreement for good cause shown. The ADOC, through its agents and contractors, shall continue to implement in a timely manner all parts of this Agreement pending the decision of the Court on any motion for modification.

H. Term of Agreement. This Medical Settlement Agreement shall be in effect for four years from the date the Agreement is approved by the Court. Nothing in this Agreement is intended to preclude Defendants from moving to terminate the Order in the manner permitted by the Prison Litigation Reform Act.

333 F.Supp.2d 1234