Health Care Department Operations Manual

Article 1 Statewide Health Care Governance

• 1.1.1 Governing Body
• 1.1.2 Local Governing Body

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
• 1.2.10 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 Control
• 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
• 1.3.5 Behavioral Health Professional Peer Review 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
• 1.4.6.1 Behavioral Health Professional 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
• 1.4.23 Central Clinical Pharmacy Services

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
• 2.2.14 Incidental Use and Disclosure of Protected Health Information
• 2.2.15 Specialized Government Functions
• 2.2.16 Health Oversight
• 2.2.17 Administrative Requirements for Privacy and Security Officials
• 2.2.18 Accounting of Disclosures for Patients’ Protected Health 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 Protected Health 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
• 2.3.15 Patient Health Care Inquiries
• 2.3.16 Patient’s Right to Amend Health Record
• 2.3.17 Disclosure of Protected Health Information for Public Health Activities

Article 4 Health Care Directives

• 2.4.1 Advance Directive for Health Care
• 2.4.2 Physician Orders for Life Sustaining Treatment (POLST)

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

• 3.2.1 Pharmacy and Medication Services
• 3.2.4 Medication Administration

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

Scope of Services

• 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

Health and Safety

• 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

Dental Clinic Adminstrative Procedures

• 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

Dental Clinic Operations

• 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

Health Services Record Management

• 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

Abbreviations Index

• 3.3.7 Abbreviations Used in Chapter 3, Article 4, Dental Care (In Alphabetical Order)

Article 4 Telehealth

• 3.4.1 Telemedicine Specialty Services and Primary Care

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 System
• 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
• 3.5.43 Heat Alert Medications

Article 6 Durable Medical Equipment/Supplies and Accommodations

• 3.6.1 Durable Medical Equipment and Medical Supply
• 3.6.2 Comprehensive Accommodation

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

• 3.8.1 Public Health Disease Reporting
• 3.8.3 Bloodborne Pathogens and Exposure Control
• 3.8.5 Coccidioidomycosis Waiver
• 3.8.6 Tuberculosis Program
• 3.8.7 Tuberculosis Surveillance Program
• 3.8.8 Communicating Precautions from Health Care Staff to Custody Staff

Article 1 Health Care

• 4.1.1 Hunger Strike
• 4.1.2 Hygiene Intervention
• 4.1.3 Medical Evaluation for Assaults, Cell Extractions, and Use of Force
• 4.1.4 Foreign Body Examination
• 4.1.5 Contraband Surveillance Watch
• 4.1.6 Prison Rape Elimination Act
• 4.1.7 Gender Dysphoria Management