Health Care Department Operations Manual
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The Health Care Department Operations Manual (HCDOM) outlines the delivery of medical and dental care provided to patients. All of the provisions are designed to meet the minimum community standard of health care and are the most current version available.
Chapter 1 Health Care Governance and Administration
Article 1 Statewide Health Care Governance
Article 2 Health Care Program Governance
- 1.2.1 Complete Care Oversight Team Committee
- 1.2.2 Clinical Documentation and Decision Support Committee
- 1.2.3 Quality Management Program Overview
- 1.2.4 Quality Management Program, Statewide Governance
- 1.2.5 Quality Management Program, Institution
- 1.2.6 Statewide Patient Safety Program
- 1.2.7 Institution Patient Safety Program
- 1.2.9 Patient Safety Program Heat Alert Medications
- 1.2.10 Mortality Review and Reporting
- 1.2.11 CCHCS Systemwide Pharmacy and Therapeutics Committee
- 1.2.12 Disposal of Regulated Waste Generated by Health Care Staff
- 1.2.13 Aerosol Transmissible Diseases and Exposure Control Plan
- 1.2.14 Medical Classification System
- 1.2.15 Utilization Management Program
- 1.2.16 Gender Affirming Surgery Review Committee
- 1.2.17, Continuing Health Care Education Planning Committee
Article 3 Health Care Workforce Governance
- 1.3.1 For Cause Medical Peer Review
- 1.3.2 Medical Peer Review Committee
- 1.3.3 Health Care Ethics Committee
- 1.3.4 Health Care Executive Committee
Article 4 Professional Workforce
- 1.4.1.1 New Medical Provider Onboarding
- 1.4.1.2 Nursing Civil Service Staff Onboarding
- 1.4.1.3 Registry/Contracted Nursing Personnel Onboarding
- 1.4.1.4 Pharmacy Staff Onboarding
- 1.4.1.5 Dietary Services Staff Onboarding and Competency Assessment
- 1.4.1.6 Laboratory Services Staff Onboarding and Competency Assessment
- 1.4.1.7 Medical Imaging Services Staff Onboarding and Competency Assessment
- 1.4.4 Advanced Practice Provider
- 1.4.5 Health Care Credentialing
- 1.4.6 Licensed Medical Provider Credentialing and Privileging
- 1.4.7 Professional Practice Evaluation
- 1.4.8 Medical Peer Review Referral and Intake
- 1.4.9 Safety Assessment, Summary and Automatic Privilege Modification
- 1.4.10 Informal Hearings
- 1.4.11 Peer Review Formal Investigation
- 1.4.12 Formal Appeal Judicial Review Committee
- 1.4.13 Nursing Services Leadership
- 1.4.14 Nursing Professional Practice Model
- 1.4.15 Nursing Professional Practice Program
- 1.4.16 Professional Nursing Standards
- 1.4.18 Nursing Competency Program
- 1.4.19 Nursing Standardized Procedures, Protocols, Order Sets, Clinical Pathways, and Standing Orders
- 1.4.20 Medical Assistant
- 1.4.21 Pharmacy Responsibilities, Scope of Service, and Supervision
- 1.4.22 Medical Provider Documentation Expectations
Chapter 2 Patients' Entitlements and Responsibilities
Article 1 Provision of Health Care Services
- 2.1.1 Patients’ Rights
- 2.1.2 Effective Communication Documentation
- 2.1.3 Over-the-Counter Products
- 2.1.4 Reading Glasses
- 2.1.5 End of Life Option Act Exemption
Article 2 Confidentiality and Privacy
- 2.2.1 General Use and Disclosure of Protected Health Information
- 2.2.2 Use and Disclosure of Protected Health Information Based on Patient Authorization
- 2.2.3 Enforcements, Sanctions, and Penalties for Violations of Individual Privacy
- 2.2.4 Minimum Necessary Use and Disclosure of Protected Health Information
- 2.2.5 Administrative, Technical, and Physical Safeguards
- 2.2.6 Use and Disclosure of Protected Health Information: Special Exceptions
- 2.2.7 Patient Privacy Rights
- 2.2.8 De-Identification of Patient Information and Use of Limited Data Sets
- 2.2.9 Business Associate Use and Disclosure of Protected Health Information
- 2.2.10 General Use and Disclosure of Personally Identifiable Information
- 2.2.11 Privacy Incident and Potential Breach Reporting and Case Workflow
- 2.2.12 General Privacy Policies for Staff and Patient Information
- 2.2.13 Handling Protected Health and Personally Identifiable Information
Article 3 Health Information Management
- 2.3.1 Health Information Management Overview
- 2.3.2 Security and Privacy
- 2.3.3 Managing Health Record Access to Protected Health Information
- 2.3.4 Release of Information
- 2.3.5 Health Information Exchange
- 2.3.6 Health Record Content and Organization
- 2.3.7 Health Record Viewing and Scanning
- 2.3.8 Health Record Documentation, Analysis, and Completion
- 2.3.9 Health Record Storage and Retrieval
- 2.3.10 Health Record Exception Process
- 2.3.11 Retention and Destruction
- 2.3.12 Death Records: Administrative Hold
- 2.3.13 Health Record Application/System Downtime Contingency Plan
- 2.3.14 Release of Health Information: Family or Friend Access
- 2.3.15 Headquarters Patient Health Care Inquiry Response
- 2.3.16 Patient’s Right to Amend Health Record
Article 4 Health Care Directives
Chapter 3 Health Care Operations
Article 1 Complete Care Model
- 3.1.1 Complete Care Model
- 3.1.2 Scope of Patient Care Services
- 3.1.3 Care Teams and Patient Panels
- 3.1.4 Patient Education
- 3.1.5 Scheduling and Access to Care
- 3.1.6 Population and Care Management Services
- 3.1.7 Care Management/Care Coordination
- 3.1.8 Reception Center
- 3.1.9 Health Care Transfer
- 3.1.10 Specialized Health Care Housing
- 3.1.11 Outpatient Specialty Services
- 3.1.12 Outpatient Dietary Intervention
- 3.1.13 Medical Imaging Services
- 3.1.14 Laboratory Services
- 3.1.15 Access to Contraceptive and Family Planning Services
- 3.1.16 Patient Care During Pregnancy and Childbirth
- 3.1.17 Palliative Care and Treatment
- 3.1.18 Registered Nurse Pronouncement of Death
- 3.1.19 Next of Kin Notification for Death, Serious Illness, or Serious Injury
- 3.1.20 Clinical Photography/Digital Imaging
- 3.1.21 Care Team Enhanced Conference
Article 2 Pharmacy and Medication Services
Article 3 Dental Care
Preface
- 3.3.1 Dental Care Definitions
- 3.3.1.1 Dental Care Introduction
- 3.3.1.2 The Standard of Medical Autonomy
- 3.3.2.1 Initial Health Screening – Receiving and Release
- 3.3.2.2 Dental Care – Reception Center
- 3.3.2.3 Comprehensive Dental Examinations – Mainline Facility
- 3.3.2.4 Periodontal Disease Program
- 3.3.2.5 Periodontal Disease Program for Pregnant Patients
- 3.3.2.6 Dental Prosthodontic Services
- 3.3.2.7 Dental Restorative Services
- 3.3.2.8 Oral Surgery
- 3.3.2.9 Endodontics
- 3.3.2.10 Fixed Prosthetics (Crown & Bridge)
- 3.3.2.11 Implants
- 3.3.2.12 Orthodontics
- 3.3.2.13 Facility Level Dental Health Orientation/Self-Care
- 3.3.3.1 Infection Control Procedures
- 3.3.3.2 Control of Dental Instruments and Sharps
- 3.3.3.3 Dental Radiation Safety
- 3.3.3.4 Hazardous Material and Waste Management
- 3.3.4.1 Dental Clinic Operations Reporting
- 3.3.4.2 Licensure and Credentialing
- 3.3.4.3 Dental Peer Review
- 3.3.4.4 Dental Program Subcommittee
- 3.3.4.5 Dental Authorization Review Committee
- 3.3.4.6 Dental Radiography
- 3.3.4.7 Clinic Space, Equipment and Supplies
- 3.3.4.8 Inmate Dental Workers
- 3.3.5.1 Priority Health Care Services Ducat Utilization
- 3.3.5.2 Recording and Scheduling Dental Encounters
- 3.3.5.3 Dental Priority Classification
- 3.3.5.4 Dental Treatment Plan
- 3.3.5.5 Interpreter Services
- 3.3.5.6 Patient’s Right to Refuse Treatment
- 3.3.5.7 Medical Emergencies in the Dental Clinic
- 3.3.5.8 Continuity of Care
- 3.3.5.9 Dental Emergencies
- 3.3.5.10 Direct Orders (Medical/Dental)
- 3.3.5.11 Supplemental Nutritional Support
- 3.3.5.12 Pharmaceuticals
- 3.3.5.13 Access to Care
- 3.3.5.14 Dental Care
- 3.3.6.1 Health Records Organization and Maintenance
- 3.3.6.2 Informed Consent
- 3.3.6.3 Privacy of Care
- 3.3.6.4 Dental Chronos
- 3.3.6.5 Medical/Dental Lay-Ins
- 3.3.6.6 Dental Holds and Patient Transport/Transfer
- 3.3.7 Abbreviations Used in Chapter 3, Article 4, Dental Care (In Alphabetical Order)
Scope of Services
Health and Safety
Dental Clinic Adminstrative Procedures
Dental Clinic Operations
Health Services Record Management
Abbreviations Index
Article 4 Telehealth
Article 5 Pharmacy
- 3.5.3 Pharmacy Licensing Requirements
- 3.5.4 CCHCS Drug Formulary
- 3.5.5 Prescription/Order Requirements and Medication Availability
- 3.5.6 Emergency Drug Supplies
- 3.5.7 Automated Drug Delivery Systems
- 3.5.8 After-Hours Pharmacy Services
- 3.5.9 Additional Requirements Pertaining to Licensed Inpatient Facilities
- 3.5.11 Medication Inventory Management, Labeling, and Storage
- 3.5.13 Rescue Medications
- 3.5.14 Handling of Confiscated Medications
- 3.5.15 Procuring, Receiving, and Stocking of Medications
- 3.5.16 DEA Schedule II-V Controlled Substances
- 3.5.18 Medication Shortages or Backorders
- 3.5.19 Medications Brought from a Non-CDCR Facility
- 3.5.21 Break-In, Theft/Loss From Pharmacy or Medication Storage Areas
- 3.5.23 Repackaging and Compounding of Non-Sterile Medications
- 3.5.24 Handling of National Institute for Occupational Safety and Health (NIOSH) Hazardous Drugs
- 3.5.25 Inspecting Medication Storage Areas
- 3.5.26 Investigational Medications
- 3.5.27 Pharmacy Quality Assurance Program
- 3.5.28 Medication Continuity with Patient Movement: Transfer/Parole/Discharge/Re-entry
- 3.5.31 Therapeutic Interchange and Automatic Substitution
- 3.5.33 Temporary Absence of the Pharmacist
- 3.5.35 Impaired Pharmacy Personnel
- 3.5.36 CCHCS Pharmacy Policy and Procedure Manual Review, Revisions, and Additions
- 3.5.38 Pharmacy Services Business Continuity Plan
- 3.5.39 Furnishing or Dispensing Medication to Legally Authorized Persons or Entities: Licensed Correctional Clinics
- 3.5.40 340B Program
- 3.5.41 Medication Adherence
- 3.5.42 High Alert Medications
Article 6 Durable Medical Equipment/Supplies and Accommodations
Article 7 Emergency Medical Response
- 3.7.1 Emergency Medical Response System
- 3.7.1-1 Emergency Medical Response System (applies only to specified institutions)
- 3.7.2 Emergency Medical Response Training Drill Nursing Skills Lab
- 3.7.3 Emergency Medical Response Bag Inventory/Audit
- 3.7.4 Emergency Medical Response: Post-Event Review
- 3.7.5 Crash Cart Equipment
Article 8 Public Health
Chapter 4 Special Circumstances
Chapter 5 Administrative
Article 1 General Administration
- 5.1.1 Implementation and Review of Health Care Regulations, HCDOM, and Health Care Forms
- 5.1.2 California Public Records Act Requests
- 5.1.3 Medical Bed Management
- 5.1.4 Reporting of Actual or Suspected Incidents of Fraud, Errors, and Improper Governmental Activities
- 5.1.5 Disability Placement Program and Developmental Disability Program Staff Accountability
- 5.1.6 Non-Paragraph 7 Process
- 5.1.7 Health Care Grievance
- 5.1.8 Compliance and Support Team
- 5.1.9 Protecting Employees from Retaliation
- 5.1.10 External Audits
Article 2 Human Resources
- 5.2.1 On-Call/Standby and Callback
- 5.2.2 Nepotism and Fraternization Exception Request
- 5.2.3 Live Scan Fingerprinting
- 5.2.4 Administrative Time Off
- 5.2.5 Educational Rotation Program
- 5.2.6 Leave of Absence
- 5.2.7 Duty Statement and Organization Charts
- 5.2.8 Bilingual Services
- 5.2.9 Exit Survey and Exit Interview
- 5.2.10 Merit Issue Complaints
- 5.2.11 Institutional Worker Supervision Pay
- 5.2.12 Lapse in Certification
- 5.2.13 Expired License, Certification, or Registration
- 5.2.14 Family Medical Leave Act, California Family Rights Act, and Pregnancy Disability Leave
Article 3 Information Technology
- 5.3.1 Lost and Stolen Assets
- 5.3.4 Digital Signature Security
- 5.3.5 Electronic Mail Retention
- 5.3.6 Information Security Policy Development and Maintenance
- 5.3.10 Change and Configuration Management
- 5.3.11 Endpoint Security
- 5.3.12 Security Analysis and Continuous Monitoring
- 5.3.13 Server Configuration
- 5.3.14 Access Control
- 5.3.15 Acceptable Use
- 5.3.16 Firewall Configuration
- 5.3.17 Physical and Environmental Protection
- 5.3.18 Security Assessment and Authorization
- 5.3.19 Audit and Accountability
- 5.3.20 Data Retention and Destruction
- 5.3.21 Data Security
- 5.3.22 eDiscovery and Litigation Hold
- 5.3.23 Identification and Authentication
- 5.3.24 Incident Response
- 5.3.25 Security and Privacy Awareness Training
- 5.3.26 Software Management and Licensing
Article 4 Labor Relations
Article 5 Business Services
- 5.5.1 Access to Leased Space
- 5.5.2 Building Security and Access
- 5.5.3 Staff Setup and Office Move Requests
- 5.5.4 Individual Workspace Reconfiguration
- 5.5.5 Requesting Standard Office Supplies
- 5.5.6 Conference and Quiet Rooms
- 5.5.7 Emergency Notification System Registration
- 5.5.8 Automated External Defibrillator
- 5.5.9 Cleaning and Disinfecting
- 5.5.10 Building Evacuation
- 5.5.11 Mail Center
- 5.5.12 Safe Mail Handling
- 5.5.13 Confidential Information Destruction
- 5.5.14 Digital Reprographics Services
- 5.5.15 Supplier Communication
- 5.5.16 Records Management Program
- 5.5.17 Prohibition on the Purchase of Promotional Items
- 5.5.18 Fleet Asset Acquisitions
- 5.5.19 Pooled Vehicle Reservations
- 5.5.20 Use of Privately Owned Vehicles and Rental Vehicles in the Conduct of State Business
- 5.5.21 Warehouse Operations
Article 6 Contracts and Procurement
- 5.6.1 Use of Federal Court Contracting Waiver
- 5.6.2 Prison Health Care Provider Network Web Portal Access and Provider Directory Usage
- 5.6.3 Registry Workforce Management System and Timekeeping
- 5.6.4 Working with Temporary-Relief Registry Providers
- 5.6.5 Pharmaceutical Acquisitions
- 5.6.6 Direct Health Care Service Contractor and- or Provider Performance Issue Reporting
Article 7 Fiscal Services
Article 8 Nursing Services
- 5.8.1 Seniority Watch Preference for Supervising Registered Nurse II
- 5.8.2 Supervising Registered Nurse II Vacation-Annual Leave Requests