Health Care Department Operations Manual

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Chapter 1 – Health Care Governance and Administration

Article 4.6 – Professional Workforce: Nursing Services

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1.4.6.2 Contracted Registry Nursing Personnel Onboarding

  • Policy

    • California Correctional Health Care Services shall provide a comprehensive and standardized onboarding process for all contracted registry nursing personnel who provide clinical or support services in California Department of Corrections and Rehabilitation (CDCR) institutions with orientation and training relevant to the job duties for each contracted registry nursing personnel.

  • Procedure Overview

    • Contracted registry nursing personnel shall adhere to all applicable CDCR policies, institutional procedures, and professional scope of practice requirements while performing assigned duties.

    • Nothing in this policy and procedure shall be construed as altering existing laws and regulations governing nursing personnel scope of practice or the provisions of any registry agency contract. Contracted registry nursing personnel are not civil service employees of CDCR.

    • The institutional Chief Nurse Executive (CNE) shall ensure the onboarding plan is implemented in accordance with this policy and procedure.

    • The Supervising Registered Nurse (SRN) III, SRN II, or the Unit Supervisor (US), as appropriate, and the Nurse Instructor (NI) shall individualize the Contracted Registry Nursing Personnel Onboarding Plan, located on the Nursing Services Lifeline page under Resources, to ensure each contracted registry nursing personnel completes, no more than, five days/watches of formal onboarding (Refer to the Sample Contracted Registry Nursing Personnel Onboarding Plan, located on the Nursing Services Lifeline page under Resources).

    • The SRN III, SRN II, or US, as appropriate, in coordination with the NI, is responsible for validating successful completion of the Contracted Registry Nursing Personnel Onboarding and Competency Checklist, located on the Nursing Services Lifeline page under Resources.

    • All contracted registry nursing personnel are required to actively participate in and complete a standardized onboarding process including classroom orientation, on-the-job training and support, and completion of the competency checklist.

  • Procedure

    • Orientation and On-the-Job Support

      • The SRN III, SRN II, US, or NI and appropriate subject matter expert shall use the Contracted Registry Nursing Personnel Onboarding and Competency Checklist, and implement the Contracted Registry Nursing Personnel Onboarding Plan, to ensure each contracted registry nursing personnel completes seven days/watches of formal onboarding.  The plan, at a minimum, shall include the following:

        • Initial introduction to the institution staff, overview of the institution’s missions, physical layout, and issuance of an identification card, work space, computer, and other essential work items.

        • Orientation and shadowing of nursing staff in the institution’s relevant patient care settings within which the contracted registry nursing personnel will work prior to performing patient care duties.  If the contracted registry nursing personnel services are engaged to work in more than one area of the institution, they shall be provided orientation to each specific area in order to achieve competency in providing patient care in that area of the institution.

        • Training and demonstrated competency for the contracted registry nursing personnel in the Electronic Health Record System prior to documenting patient care duties or scheduling in the system.

        • Transition to performing independent, direct patient care duties shall begin no earlier than six working days or equivalent watches after the engagement of services date.

          • Contracted registry nursing personnel shall be assigned where they can easily access other nursing staff familiar with their job duties for questions and assistance during the initial 14 days/watches of providing independent, direct patient care.

          • For the first 14 days/watches after the contracted registry nursing personnel begins independent, direct patient care duties, a CNE designated nursing staff shall be available to meet with the contracted registry nursing personnel during the shift to debrief and answer questions.

        • The SRN III, SRN II, or US, or designee(s), in coordination with the institutional CNE or NI, shall ensure completion of the Contracted Registry Nursing Personnel Onboarding and Competency Checklist.  The completed form shall be maintained in the contracted registry nursing personnel’s proof of practice file.

    • Clinical Competency and Professional Practice/Performance Evaluations

      • The SRN III, SRN II, or US, in coordination with the institutional CNE, shall meet prior to each contracted registry nursing personnel’s professional performance and clinical competency review to evaluate the clinical competency, professional performance and clinical observations in order to determine the continued engagement of services of the contracted registry nursing personnel with CDCR. The performance of all contracted registry personnel shall be evaluated as follows:

      • The SRN III, SRN II, or US:

        • Shall ensure each contracted registry nursing personnel’s professional performance and clinical competency is evaluated at least every two months after the engagement of services date for the first six consecutive months and annually thereafter.

        • May complete additional professional performance and clinical competency-based validation evaluations of contracted registry nursing personnel more frequently as needed to ensure the continued professional performance and clinical competence.

      • Professional performance evaluations shall be documented on the Contracted Registry Nursing Personnel Professional Performance Evaluation, located on the Nursing Services Lifeline page under Resources.

      • Clinical competencies shall be documented on the Contracted Registry Nursing Personnel Onboarding and Competency Checklist, and kept in a proof of practice file for that contracted registry nursing personnel.

    • Re-orientation of Contracted Registry Nursing Personnel

      • For contracted registry nursing personnel who have not provided service for six months or less, the following is required:

        • A record of previous completion of the Contracted Registry Nursing Personnel Onboarding and Competency Checklist.

        • Contracted registry nursing personnel shall complete all missed classes, updates, and mandatory training.

      • For contracted registry nursing personnel who have not provided service for greater than six months to one year the following is required:

        • A record of previous completion of the Contracted Registry Nursing Personnel Onboarding and Competency Checklist.

        • Contracted registry nursing personnel shall complete all missed classes, updates, and mandatory training.

        • Skills competency validations shall be completed for all areas in which contracted registry nursing personnel will be working.

      • Contracted registry nursing personnel who have not provided service for more than one year shall complete the onboarding process in its entirety.

    • Transferring Between Institutions Without A Break In Service or Performing Patient Care Duties At More Than One Institution

      • Each CDCR institutional CNE is responsible for ensuring that each contracted registry nursing personnel working at that institution is competent to perform all the duties of the position for which the contracted registry nursing personnel’s services have been engaged.

      • The SRN III, SRN II, or US, in coordination with the institutional CNE or the regional CNE may develop an abbreviated onboarding plan for contracted registry nursing personnel covered in this section on a case-by-case basis that takes into account the onboarding, professional performance, and clinical competency evaluations conducted and training provided to the contracted registry nursing personnel at another CDCR institution.

        • A record of completion of the onboarding process, clinical competencies, and professional performance evaluations shall be maintained at each institution.

    • Contracted Registry Nursing Personnel Converting to Permanent Civil Service Status

      • Contracted registry nursing personnel who convert to permanent civil service status shall receive an assessment by the SRN III, SRN II, or US, in coordination with the institutional CNE or the regional CNE of the training, experience, and competencies already achieved and demonstrated by the contracted registry nursing personnel prior to converting to permanent civil service status.

        • Proof of completion of the Contracted Registry Nursing Personnel Onboarding and Competency Checklist, and competency skills validations shall be maintained with the Nursing Staff Onboarding and Competency Checklists in the proof of practice file.

        • If verification of completion of all required courses cannot be obtained, contracted registry nursing personnel shall complete required courses.

      • Contracted registry nursing personnel who convert to permanent civil service status shall complete any outstanding requirements of the nursing civil service onboarding process including, but not limited to:

        • Professional performance and competency evaluations.

        • Probationary period per civil service rules and requirements.

        • Training records of all components, including the competency checklist in the onboarding process are completed with proof maintained in the proof of practice file.

    • Maintenance of Onboarding Documents

      • The following documents shall be maintained in the contracted registry nursing personnel’s proof of practice file as active until the contracted registry nursing personnel’s contract ends.  Inactive records shall be saved for three years including, but not limited to:

      • Contracted Registry Nursing Personnel Onboarding Plan, showing the onboarding activities for each day of the onboarding period.

      • Contracted Registry Nursing Personnel Onboarding and Competency Checklist.

      • Contracted Registry Professional Performance Evaluations.

  • References

    • California Code of Regulations, Title 22, Division 5, Licensing and Certification of Health Facilities, Home Health Agencies, Clinics, and Referral Agencies

    • California Department of Corrections and Rehabilitation, Department Operations Manual, Chapter 3, Article 18, General Training

    • Health Care Department Operations Manual, Chapter 1, Article 4, Section 1.4.6.3, Nursing Services Leadership

    • Health Care Department Operations Manual, Chapter 1, Article 4, Section 1.4.6.7, Nursing Competency Program

    • Health Care Department Operations Manual, Chapter 5, Article 9, Section 5.9.1, General Training Requirements

    • California Correctional Health Care Services, Health Care On-Site Contractor’s Orientation Handbook; https://cchcs.ca.gov/wp-content/uploads/sites/60/DCCS/HC-OSCO-Handbook.pdf

    • American Nurses Association, Standards of Nursing Practice in Correctional Facilities, Kansas City, Mo., 1985

    • American Nurses Association, Correctional Nursing: Scope and Standards of Practice, 2nd ed. Silver Spring, MD, 2013

  • Policy Control
    Executive Sponsor: Deputy Director, Nursing Services
    Effective: 02/2019
    Reviewed: 05/24/2023
    Revised: 07/22/2026