Inmate Medical Services Policies & Procedures
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The Inmate Medical Services Polices and Procedure govern the delivery of medical received by patient-inmates. All of the policies and procedures are designed to meet the minimum level of care necessary to provide constitutionally adequate health care to patient-inmates in the State of California. The policies and procedures found here are the most current version available.
All policies and procedures are organized into volumes and chapters.
Volume 1 - Governance and Administration
- Volume 1 – Table of Contents
- Ch. 4, Local Governing Body
- Ch. 8, Implementation and Annual Review
- Ch. 10, Copayment Program Policy
- Ch. 11, Patients’ Rights Policy
- Ch. 12.2, Headquarters Patient Health Care Inquiry Response Policy and Procedure
- Ch. 16.1, Prison Rape Elimination Act Policy
- Ch. 16.2, Prison Rape Elimination Act Procedure
- Ch. 17.1, Advance Directive for Health Care Policy
- Ch. 17.2, Advance Directive for Health Care Procedure
- Ch. 18.1, Physician Orders for Life Sustaining Treatment Policy
- Ch. 18.2, Physician Orders for Life Sustaining Treatment Procedure
- Ch. 20, Health Care Ethics Committee
- Ch. 26.1, Release of Health Information: Family or Friend Access Policy
- Ch. 26.2, Release of Health Information: Family or Friend Access Procedure
- Ch. 27, Aerosol Transmissible Diseases Exposure Control Plan Policy
- Ch. 27, Aerosol Transmissible Diseases Exposure Control Plan Policy LOP Template
- Ch. 28.1, Effective Communication Documentation Policy
- Ch. 28.2, Effective Communication Documentation Procedure
- Ch. 29.1, Death Reporting and Review Program Policy
- Ch. 29.2, Death Reporting and Review Program Procedure
- Ch. 30, Governance and Provider Workforce Definitions
- Ch. 30.1, Governing Body Policy
- Ch. 30.2, Governing Body Procedure
- Ch. 31.1, Health Care Credentialing Policy
- Ch. 31.2, Licensed Medical Provider Credentialing and Privileging Policy
- Ch. 31.3, Licensed Medical Provider Credentialing and Privileging Procedure
- Ch. 32.1, New Medical Provider Onboarding Policy
- Ch. 32.2, New Medical Provider Onboarding Procedure
- Ch. 33.1, Professional Practice Evaluation Policy
- Ch. 33.2, Professional Practice Evaluation Procedure
- Ch. 34.1, For Cause Medical Peer Review Policy
- Ch. 34.2, Medical Peer Review Committee Procedure
- Ch. 34.3, Health Care Executive Committee Procedure
- Ch. 34.4, Medical Peer Review Referral and Intake Procedure
- Ch. 34.5, Safety Assessment, Summary and Automatic Privilege Modification Procedure
- Ch. 34.6, Informal Hearing Procedure
- Ch. 34.7, Peer Review Formal Investigation Procedure
- Ch. 34.8, Formal Appeal Judicial Review Committee Procedure
- Ch. 35.1, Advanced Practice Provider Policy
- Ch. 35.2, Advanced Practice Provider Procedure
- Ch. 40 End of Life Option Act: Exemption Policy
Volume 3 - Quality Management
- Volume 3 – Table of Contents
- Ch. 1.1, Quality Management System Overview
- Ch. 1.2, Quality Management Program, Statewide Governance
- Ch. 1.3, Quality Management Program, Institution
- Ch. 5, Clinical Guidelines Committee Policy and Procedure
- Ch. 7.1, Statewide Patient Safety Program Policy
- Ch. 7.2, Statewide Patient Safety Program Procedure
- Ch. 7.3, Institution Patient Safety Program Procedure
- Ch. 7.7, Patient Safety Program Policy- High Alert Medications
- Ch. 7.8, Patient Safety Program Procedure- High Alert Medications
- Ch. 7.9, Patient Safety Program Policy- Heat Alert Medications
- Ch. 7.10, Patient Safety Program Procedure- Heat Alert Medications
Volume 4 - Medical Services
- Volume 4 – Table of Contents
- Ch. 1, Complete Care Model Policy
- Ch. 1.1, Scope of Patient Care Services Procedure
- Ch. 1.2, Care Teams and Patient Panels Procedure
- Ch. 1.3, Scheduling and Access to Care Procedure
- Ch. 1.4, Population and Care Management Services Procedure
- Ch. 1.5, Care Management/Care Coordination Procedure
- Ch. 1.6, Complete Care Model Procedure: Complete Care Oversight Team
- Ch. 1.7, Medical Imaging Services Procedure
- Ch. 1.8, Laboratory Services Procedure
- Ch. 2.1, Reception Health Care Policy
- Ch. 2.2, Reception Health Care Procedure
- Ch. 3.1, Health Care Transfer Policy
- Ch. 3.2 Health Care Transfer Procedure
- Ch. 6.1, Patient Health Care Education Policy
- Ch. 8, Outpatient – Specialty Services
- Ch. 11.1, Medication Management Policy
- Ch. 11.2, Medication Orders – Prescribing Procedure
- Ch. 11.3, Medication Storage and Accountability Procedure
- Ch. 11.4, Medication Administration Procedure
- Ch. 11.5, Medication Adherence Procedure
- Ch. 11.6, Medication Continuity with Patient Movement: Transfer-Parole-Release Procedure
- Ch. 12.1, Emergency Medical Response System Policy
- Ch. 12.2, Emergency Medical Response System Procedure
- Ch. 12.3, Emergency Medical Response Training Drill and Nursing Skills Lab Policy
- Ch. 12.4, Emergency Medical Response Training Drill and Nursing Skills Lab Procedure
- Ch. 12.5, Emergency Medical Response Bag Inventory/Audit Policy
- Ch. 12.6, Emergency Medical Response Bag Audit/Checklist Procedure
- Ch. 12.7, Emergency Medical Response: Post-Event Review Policy
- Ch. 12.8, Emergency Medical Response: Post-Event Review Procedure
- Ch. 12.9, Crash Cart Equipment Policy
- Ch. 12.10, Crash Cart Equipment Procedure
- Ch. 14.1, Outpatient Housing Unit Policy
- Ch. 14.2, Outpatient Housing Unit Procedure
- Ch. 15.1, Correctional Treatment Center Policy
- Ch. 15.2, Correctional Treatment Center Procedure
- Ch. 17.1, Medical Evaluation for Assaults, Cell Extractions, and Use of Force Policy
- Ch. 17.2, Medical Evaluation for Assaults, Cell Extractions, and Use of Force Procedure
- Ch. 19, Hygiene Intervention Policy
- Ch. 19.2, Hygiene Intervention Procedure
- Ch. 20.1, Outpatient Dietary Intervention Policy
- Ch. 20.2, Outpatient Dietary Intervention Procedure
- Ch. 21, Palliative Care and Treatment Policy
- Ch. 21.2, Palliative Care and Treatment Procedure
- Ch. 22.1, Individual Hunger Strike Policy
- Ch. 22.2, Individual Hunger Strike Procedure
- Ch. 22.3, Mass Organized Hunger Strike
- Ch. 22.4, Mass Organized Hunger Strike Procedure
- Ch. 23, Comprehensive Accommodation Policy
- Ch. 23.1, Comprehensive Accommodation Procedure
- Ch. 24.1, Access to Contraceptive and Family Planning Services Policy
- Ch. 24.2, Patient Care During Pregnancy and Childbirth Policy
- Ch. 24.3, Patient Care During Pregnancy and Childbirth Procedure
- Ch. 26, Gender Dysphoria Management Policy
- Ch. 29.1 Medical Classification System Policy
- Ch. 29.2 Medical Classification System Procedure
- Ch. 30.12, Foreign Body Examinations Policy
- Ch. 30.13, Foreign Body Examinations Procedure
- Ch. 32, Durable Medical Equipment and Medical Supply Policy
- Ch. 32.1, Durable Medical Equipment and Medical Supply Procedure
- Ch. 33, Contraband Surveillance Watch Policy
- Ch. 34.1, Utilization Management Program Policy
- Ch. 34.2, Utilization Management Medical Services Review Procedure
- Ch. 34.3, Utilization Management Inter-Rater Reliability Procedure
- Ch. 35.1 Over-the-Counter Products Policy
- Ch. 35.2 Over-the-Counter Products Procedure
- Ch. 35.3 Over-the-Counter Products List
Volume 5 - Nursing Services
- Volume 5 – Table of Contents
- Ch. 1.1, Nursing Services Leadership Policy
- Ch. 1.2, Nursing Professional Practice Model Policy
- Ch. 1.3, Professional Nursing Standards Policy
- Ch. 3.1, Nursing Standardized Procedures, Protocols, Order Sets, Clinical Pathways, and Standing Orders Policy
- Ch. 3.2, Nursing Standardized Procedures, Protocols, Order Sets, Clinical Pathways, and Standing Orders Procedure
- Ch. 4.1, Nursing Competency Program Policy
- Ch. 4.2, Nursing Competency Program Procedure
- Ch. 17.1, Nursing Professional Practice Program Policy
- Ch. 17.2, Nursing Professional Practice Program Procedure
- Ch. 19.1, Nursing Civil Service Staff Onboarding Policy
- Ch. 19.2, Nursing Civil Service Staff Onboarding Procedure
- Ch. 19.3, Registry-Contracted Nursing Personnel Onboarding Policy
- Ch. 19.4, Registry-Contracted Nursing Personnel Onboarding Procedure
- Attachments
- Ch. 20.1, Nursing Scope of Service Policy
- Ch. 20.2, Nursing Scope of Service Procedure
Volume 6 - Health Information Management
- Volume 6 – Table of Contents
- CCHCS Abbreviations List
- Ch. 1, Health Information Management Overview Policy
- Ch. 2.1, Security and Privacy Policy
- Ch. 2.2, Security and Privacy Procedure
- Ch. 3.1, Managing Health Record Access to Protected Health Information Policy
- Ch. 3.2, Managing Health Record Access to Protected Health Information Procedure
- Ch. 4.1, Release of Information Policy
- Ch. 4.2, Release of Information Procedure
- Ch. 5.1, Secured Electronic Transmittal of Protected Health Information Policy
- Ch. 5.2, Secured Electronic Transmittal of Protected Health Information Procedure
- Ch. 6.1, Health Record Content and Organization Policy
- Ch. 6.2, Health Record Content and Organization Procedure
- Ch. 7.1, Health Record Viewing and Scanning Policy
- Ch. 7.2, Health Record Viewing and Scanning Procedure
- Ch. 8.1, Health Record Documentation Analysis and Completion Policy
- Ch. 8.2, Health Record Documentation Analysis and Completion Procedure
- Ch. 9.1, Health Record Storage and Retrieval Policy
- Ch. 9.2, Health Record Storage and Retrieval Procedure
- Ch. 10.1, Health Record Exception Process Policy
- Ch. 10.2, Health Record Exception Process Procedure
- Ch. 11, Retention and Destruction Policy
- Ch. 12.1, Death Records-Administrative Hold Policy
- Ch. 12.2, Death Records-Administrative Hold Procedure
- Ch. 13.1, Health Record Application or System Downtime Contingency Plan Policy
- Ch. 13.2, Health Record Application or System Downtime Contingency Plan Procedure
Volume 9 - Pharmacy Services
- Volume 9 – Table of Contents
- Ch. 1, 9.1 Pharmacy Services Policy
- Ch. 2, 9.2 Pharmacy Licensing Requirements Procedure
- Ch. 3, 9.3 Pharmacy Responsibilities, Scope of Service and Supervision
- Ch. 4, 9.4 CCHCS Systemwide Pharmacy and Therapeutics Committee Procedure
- Ch. 5, 9.5 Emergency Drug Supplies Procedure
- Ch. 6, 9.6 After-Hours Medication Supply Procedure
- Ch. 7, 9.7 After-Hours Pharmacy Services
- Ch. 8, 9.8 CCHCS Drug Formulary
- Ch. 9, 9.9 Prescription-Order Requirements Procedure
- Ch. 10, 9.10 Additional Requirements Pertaining to Licensed Inpatient Facilities Procedure
- Ch. 11, 9.11 Dental Urgent/Emergent Medication Process
- Ch. 12, 9.12 Labeling and Storage of Medications Procedure
- Ch. 13, 9.13 Use of Physician’s Orders Forms
- Ch. 14, 9.14 Rescue Medications Procedure
- Ch. 15, 9.15 Handling of Confiscated Medications Procedure
- Ch. 16, 9.16 Expiration Dates, Beyond-Use Dates and Disposition of Outdated, Contaminated, Mislabeled, or Overstocked and Recalled Medications
- Ch. 17, 9.17 Ordering, Receiving, and Stocking of Medications
- Ch. 18, 9.18 Ordering, Securing, and Disposing of DEA Schedule II, III, IV, and V Controlled Substances Procedure
- Ch. 19, 9.19 Medication Brought into a CDCR Facility by Patient-Inmates
- Ch. 20, 9.20 Floor Stock Orders
- Ch. 21, 9.21 Break-In, Theft/Loss From Pharmacy or Medication Storage Areas
- Ch. 22, 9.22 Medication Information Services Procedure
- Ch. 23, 9.23 Repackaging and Compounding of Non-Sterile Medications
- Ch. 24, 9.24 Handling of Hazardous Drugs Procedure
- Ch. 25, 9.25 Inspecting Medication Storage Areas Procedure
- Ch. 26, 9.26 Investigational Medications
- Ch. 27, 9.27 Pharmacy Quality Assurance Program Procedure
- Ch. 28, 9.28 Parole and Discharge Medications Procedure
- Ch. 29, 9.29 Impaired Pharmacy Personnel Procedure
- Ch. 30, 9.30 Pharmacy Technicians and Ancillary Staff Procedure
- Ch. 32, 9.32 Temporary Absence of the Pharmacist
- Ch. 33, 9.33 Off-Label Use of Prescription Medications
- Ch. 35, 9.35 Therapeutic Interchange and Automatic Substitution
- Ch. 37, 9.37 Pharmacy Staff Scheduling Procedure
- Ch. 39, 9.39 Transfer Medications
- Ch. 40, 9.40 Medication Shortages or Back Orders
- Ch. 41, 9.41 High-Cost Medication Procurement
- Ch. 42, 9.42 CCHCS Pharmacy Policy and Procedure Manual Review, Revisions and Additions
- Ch. 43, 9.43 Prescription Quantity Standards (Solid Oral Dosage Forms)
- Ch. 45, 9.45 Pharmacy Services Business Continuity Plan
- Ch. 46, 9.46 Furnishing or Dispensing Medication to Legally Authorized Persons or Entities- Licensed Correctional Clinics Procedure
Volume 10 - Public Health / Infection Control
- Volume 10 – Table of Contents
- Ch. 1, Bloodborne Pathogens and Exposure Control
- Ch.2.1, Public Health Disease Reporting Policy
- Ch.2.2, Public Health Disease Reporting Procedure
- Ch. 3, Tuberculosis Program Policy
- Ch. 3.2, Tuberculosis Surveillance Program Procedure
- Ch. 7, Inmate Peer Education Program
- Ch. 8.1, HIV Antibody Testing Policy
- Ch. 8.2, HIV Antibody Testing Procedure
- Ch.9.1, Communicating Precautions From Health Care Staff to Custody Staff Policy
- Ch.9.2, Communicating Precautions From Health Care Staff to Custody Staff Procedure
- Ch.10.1 Coccidioidomycosis Skin Test Policy
- Ch.10.2 Coccidioidomycosis Skin Test Procedure
- Ch.11.1 Coccidioidomycosis Waiver Policy
- Ch.11.2 Coccidioidomycosis Waiver Procedure
Volume 11 - Telemedicine Services
Volume 13 - Privacy
Chapter 1: Privacy
- 13.1, General Use and Disclosure of Protected Health Information Policy
- 13.2, Use and Disclosure of Protected Health Information Based on Patient-Inmate Authorization Policy
- 13.3, Enforcement, Sanctions, and Penalties for Violations of Individual Privacy Policy
- 13.4, Minimum Necessary Use and Disclosure of Protected Health Information Policy
- 13.5, Administrative, Technical, and Physical Safeguards Policy Policy
- 13.6, Use and Disclosure of Protected Health Information: Special Exceptions Policy
- 13.7, Patient Privacy Rights Policy
- 13.8, De-Identification of Patient Information and Use of Limited Data Sets Policy
- 13.9, Business Associate Use and Disclosure of Protected Health Information Policy
- 13.10, General Use and Disclosure of Personally Identifiable Information Policy
- 13.11, Privacy Breach Policy
- 13.12, General Privacy Policies for Staff and Patient Information Policy