Health Care Department Operations Manual

Chapter 3 – Health Care Operations

Article 1 – Complete Care Model

View All Sections >

3.1.10 Specialized Health Care Housing

Procedure Overview
- California Department of Corrections and Rehabilitation (CDCR) shall ensure appropriate specialized health care housing is available to meet the level of care needed for each patient. These services shall include access to both community and institution-based specialized health care housing. CDCR shall ensure that the continuum of services is available statewide, with licensed services provided at a subset of institutions.
- CDCR shall ensure the coordination of planned health care to patients needing services for preventive care to prevent illness and injury, interventions for acute illness and injury, supportive care for patients able to attend to their own activities of daily living, rehabilitation services, short and long-term nursing care, and palliative and end-of-life care under the direction of an interdisciplinary health care team. The scope of services provided to patients shall be interdisciplinary and include at a minimum: medical, mental health, dental, nursing, pharmacy, diagnostic, rehabilitative, and assistive services appropriate to maximize the quality of life and functional status and to reduce morbidity and mortality.
Responsibility
- Statewide
  - CDCR and California Correctional Health Care Services (CCHCS) departmental leadership at all levels of the organization, within the scope of their authority, shall ensure administrative, custodial, and clinical systems are in place, and appropriate tools, training, technical assistance, and levels of resources are available to ensure this procedure is successfully implemented and maintained.
  - The Undersecretary, Health Care Services, CDCR, and the Directors, Health Care Operations and Health Care Policy and Administration, CCHCS, shall designate a statewide committee with responsibility for the management of specialized health care housing facilities and beds statewide. Standing members of the committee shall include at a minimum, the Deputy Directors of Medical, Nursing, Mental Health, and Dental Services, Health Care Placement Oversight Program (HCPOP), Utilization Management (UM), Pharmacy, Ancillary and Allied Health Services, and Regional Health Care Executives (RHCEs). The committee shall be responsible for ensuring appropriate services are available for patients statewide, coordination of care, access to the appropriate level of care, and reducing the risks associated with handoff and transfer of patients between health care teams and specialized health care housing units.
  - Statewide health care leadership from all disciplines shall be responsible for developing and distributing tools to assist institutions in the development of Local Operating Procedures (LOPs) for their specialized health care housing units.
  - HCPOP in coordination with the Specialized Health Care Housing Standing Committee is responsible for the endorsement of patients to specialized health care housing units in the event that the institution does not have any appropriate, non-contract inpatient level of care beds available.
  - UM has the primary responsibility for establishing and maintaining a standardized, auditable system for managing health care resources within CDCR.
- Regional
  - RHCEs are responsible for implementation of this procedure at the subset of institutions within an assigned region. RHCEs shall, at a minimum, monitor timeliness, access, and admission and discharge rates to ensure that patients’ level of care within the specialized health care housing unit is appropriate for their health care needs.
- Institution
  - The Chief Executive Officer (CEO) has overall responsibility for implementation and ongoing oversight of a system to provide management of the scope of specialized health care housing within their institution. The CEO delegates decision making authority to designated health care executives for the daily operations of the specialized health care housing units and ensures adequate resources are deployed to support the system.
  - The CEO and all members of the institutional leadership team are responsible for ensuring:
    - All necessary resources are in place to support the successful implementation of this procedure at all levels including, but not limited to:
      - Institution level
      - Patient panel level
      - Patient level
    - Access to and utilization of equipment, supplies, health information systems, patient registries and summaries, and evidence-based guidelines.
    - Implementation of institution-specific LOPs that fully support and implement this procedure (refer to Section (e), Local Operating Procedure Requirements).
  - Institutional leadership shall review the operation of each element of the specialized health care housing unit ensuring that the patient is at the appropriate level of care; staff resources are available and distributed in order to provide the required patient care services; and that staff have access to the required resources, services, procedures, templates, equipment, supplies, and any other resources necessary to meet patient health care needs.
  - Each CDCR licensed facility (e.g., Correctional Treatment Center (CTC), Mental Health Crisis Bed (MHCB), Psychiatric Inpatient Program (PIP), Hospice) shall designate a Governing Body in accordance with the sections of the California Code of Regulations applicable to their licensure. An institution with multiple licensed facilities shall designate one Governing Body with responsibility for oversight of all licensed care within the institution. The Governing Body shall also communicate with the institution Quality Management Committee (QMC) at a periodic frequency to meet its oversight obligations but not less than quarterly.
  - Each institution shall designate a subcommittee in writing that has responsibility for the administration of the specialized health care housing provided at their institution. The designated subcommittee shall report to the Institution QMC. This subcommittee shall address at a minimum the following operational elements within the specialized health care housing units:
    - Emergency Management
    - Infection Control and Prevention
    - Human Resources
    - Environment of Care
    - National Patient Safety Goals
    - Health Information Management (Electronic Health Record System)
    - Leadership
    - Life Safety
    - Medication Management
    - Performance Improvement
    - Provision of Care, Treatment, and Services
    - Clinical Laboratory Improvement Amendments/Waived Testing
  - The designated subcommittee shall be responsible for taking corrective action to resolve and/or elevate concerns identified in the review. The review and action taken shall be documented and forwarded to the Institution QMC.
  - Each institution that provides a licensed service within their specialized health care housing units shall ensure that they comply with all applicable laws, rules, regulations, and policies regarding facility organization, standing committees, and policy and procedure development and implementation.
Specialized Health Care Housing Overview
- Nursing Services
  - Nursing Care shall be available 24 hours per day, 7 days per week under the direction of a Supervising Registered Nurse (RN).
  - Nursing care services are designed to ensure an appropriate level of care is delivered to each patient through timely access to health care services, initial and ongoing assessment, planning, intervention and evaluation in a system designed to promote health maintenance, reduce risk of debilitative injury, improve function, and maximize the patient’s quality of life through application of evidence-based nursing practice.
  - Specialized health care housing units that do not have 24/7 RNs may have the CDCR 7362, Health Care Services Request Form, available for patients who request them and shall utilize the process described in the Health Care Department Operations Manual (HCDOM), Section 3.1.5, Scheduling and Access to Care. The institution LOP shall outline processes specific to each unit’s management of the CDCR 7362s.
  - For specialized health care housing units that do not utilize CDCR 7362s, daily nursing documentation shall include:
    - Patient’s requests for care
    - Patient’s concerns or complaints
    - Nursing interventions provided
  - Nursing care management services shall be provided to patients within the specialized health care housing units. The extent of care management services varies according to the complexity of the patient. Nursing care management services begin at the time of admission and continue through discharge. Nursing care management services shall be provided through a collaborative process of patient evaluation, advocacy, care planning, facilitation, and interdisciplinary coordination.
  - Nursing care management services shall be coordinated and continued across all levels of care (ambulatory, acute, and inpatient), in all physical locations where patients receive care within CDCR, and include the patient’s transition to community-based services upon parole and/or discharge.
- Medical Services
  - Medical services shall be available 24 hours per day, 7 days per week under the direction of the Chief Medical Executive (CME).
    - Services shall be provided in person, telephonically, or through an approved telehealth solution.
    - The institution CME, or designee, shall ensure that a roster is available at all times to specialized health care housing unit staff designating the attending health care provider who is responsible for patient care.
  - The attending health care provider is responsible for initiating admission, determining the anticipated length of stay, identifying treatment goals and discharge planning for patients being admitted to, discharged from, or changing levels of care within the specialized health care housing units.
  - Medical services shall be provided to patients within the specialized health care housing units in accordance with the HCDOM, Chapter 3, Health Care Operations, and any other applicable laws, rules, regulations, and court orders.
- Mental Health Services
  - Mental Health services shall be available 24 hours per day, 7 days per week under the direction of the Chief of Mental Health.
    - Services shall be provided in person, telephonically, or through an approved telehealth solution.
    - The Chief of Mental Health shall ensure that a roster is available at all times to specialized health care housing unit staff designating the mental health care clinician who is responsible for supporting the specialized health care housing units.
  - Mental Health services shall be provided to patients within the specialized health care housing units in accordance with the Mental Health Services Delivery System (MHSDS) Program Guide and associated policies, as well as any other applicable laws, rules, regulations, and court orders.
  - The designated mental health clinician, within his or her scope of practice, is responsible for initiating admission, determining the anticipated length of stay, identifying treatment goals and discharge planning for the mental health care of patients being admitted to, discharged from, or changing levels of care within the specialized health care housing units.
- Dental Services
  - Under the direction of the Health Program Manager III (HPM III) and the Supervising Dentist (SD), Dental Services shall be available at least 8 hours per day, Monday through Friday, excluding holidays. Emergency Dental Services shall be available 24 hours per day, 7 days per week.
    - Services shall be provided in person or telephonically.
    - The HPM III and the SD shall ensure that a roster is available at all times to specialized health care housing unit staff designating a dental provider who is responsible for supporting the specialized health care housing units.
  - Dental services shall be provided to patients within the specialized health care housing units in accordance with the HCDOM, Chapter 3, Article 3, Dental Care and all other applicable laws, rules, and regulations.
  - The designated dental provider is responsible for coordinating patient admission with the attending health care provider as well as determining the anticipated length of stay; identifying treatment goals; and discharge planning for the dental care of patients being admitted to, discharged from, or changing levels of care within the specialized health care housing units.
- Pharmacy Services
  - Pharmacy Services shall be available to ensure timely availability of medication 24 hours per day, 7 days per week under the direction of the institution Pharmacist-in-Charge and the Statewide Chief of Pharmacy Services.
    - The licensed Correctional Pharmacy or Central Fill Pharmacy shall ensure furnishing or dispensing of medications to specialized health care housing unit staff for the treatment of patients.
    - Drugs shall be available through the appropriate use of automated drug delivery systems and approved clinic stock in licensed correctional clinics.
    - Appropriate after-hours services shall be made available through the use of centralized remote pharmacist verification services.
    - Centralized remote after-hours pharmacy services shall ensure offsite pharmacist verification of new medication orders will be utilized when the drug is available in an automated drug delivery system or licensed correctional clinic stock.
    - The use of voluntary call back pharmacist services after hours may be utilized if medications are not available in any medication storage area outside the pharmacy area or during hours when the centralized after hours pharmacy services are unavailable.
  - Pharmacy services shall be provided to patients within the specialized health care housing units in accordance with the HCDOM, Chapter 3, Article 5, Pharmacy, and all other applicable laws, rules, regulations, and court orders.
- Ancillary and Allied Health Services
  - Ancillary and Allied Health Services shall be available to patients within the specialized health care housing units under the administrative direction of the Chief Support Executive. Responsibility for the clinical supervision of ancillary and allied health care staff remains with the CME, or designee.
  - Ancillary and Allied Health Services include, but are not limited to:
    - Diagnostic Services (e.g., Laboratory, Radiology)
    - Nutritional (Dietary) Services
    - Medical Supply
    - Biomedical Maintenance
    - Durable Medical Equipment (DME)
    - Physical Therapy
    - Respiratory Therapy
    - Rehabilitation Services
    - Adaptive and Assistive Services
  - The institutional medical leadership shall ensure that specialized health care housing unit patients have access to the Ancillary and Allied Health Services necessary to comply with their interdisciplinary treatment plan.
  - Services shall be provided, as appropriate for the patient and as determined by the ordering health care provider, through the following methods:
    - In person
    - Telephonically
    - Through an approved telehealth solution
    - Through a contracted provider or facility
  - Services provided to patients within the specialized health care housing units shall be performed in accordance with the HCDOM and any other applicable laws, rules, regulations, and court orders.
Procedure
- Admission
  - Patients shall be admitted to a specialized health care housing unit only upon the order of a health care provider granted privileges for the admitting facility.
    - The admitting health care provider shall be responsible for ensuring that all admission orders are written within 24 hours and documented in the health record.
    - Verbal admission orders shall not be given; however, in exigent circumstances, telephonic admission orders may be provided to the RN. The admitting provider shall counter-sign the telephonic orders and document in the health record.
    - The admitting health care provider is responsible for coordinating with other disciplines to ensure that health care actions specific to that discipline are completed (e.g., an admitting mental health clinician is responsible for coordinating the completion of the admitting history and physical [H&P] with the attending medical health care provider).
    - The admitting health care provider shall identify plans including, but not limited to, PCP rounding and follow-up, and anticipated length of stay if known.
  - Patients admitted to a specialized health care housing unit shall have an admitting H&P performed by a medical provider within 24 hours of admission.
  - Patients admitted to a specialized health care housing unit shall have an initial assessment at the time of admission performed by an RN.
    - Other members of the nursing Care Team may collect data and assist in the development of the patient’s interdisciplinary care plan consistent with their licensure and scope of practice.
    - The RN retains responsibility for the finalization and documentation of the admission assessment and the interdisciplinary care plan. The interdisciplinary care plan shall be completed within 72 hours of the patient’s admission and updated as the patient’s condition changes, treatments change and interventions change.
    - The RN shall provide and document patient education that includes, at a minimum:
      - Frequency of provider visits
      - Frequency of nursing rounds
      - How to use the call light
      - How to request care
    - Patients being admitted to a specialized health care housing unit for urgent mental health treatment shall be evaluated by a mental health clinician within the timeframes specified in the MHSDS Program Guide and associated policies and directives. This evaluation is in addition to any examination or H&P completed by the medical health care provider.
    - Patients being admitted to a specialized health care housing unit for dental treatment shall be examined by a dental provider within the timeframes specified in the HCDOM, Section 3.3.5.4, Dental Priority Classifications. This examination is in addition to any examination or H&P completed by the medical health care provider.
    - Each specialized health care housing patient shall be informed of his/her rights and responsibilities during the admission process as specified in the LOP.
- Patient Stay
  - The Patient Stay process includes minimum expectations for rounding (type, frequency and composition), communication, and documentation requirements.
  - The frequency of rounds and the composition of the team conducting the rounds are determined by the patient’s condition and the patient’s care setting.
  - Rounds shall include, but are not limited to, nursing rounds, grand rounds, team rounds, safety checks, supervisory rounds, and environment of care rounds.
  - Patients admitted to a specialized health care housing unit shall be assessed by a member of his/her Care Team through rounds at least daily. The purpose of the assessment is to:
    - Determine the patient’s ongoing health care needs.
    - Determine the appropriate level of care.
    - Determine the response to treatment.
    - Analyze progress towards identified goals.
    - Identify unmet health care needs.
    - Adjust the interdisciplinary plan of care to meet the current and anticipated health care requirements.
  - Care Team members shall document their patient care interactions in the health record.
  - Each member of the Care Team is responsible for communicating with other Care Team members regarding any change in the patient’s condition or any abnormal findings.
    - Communication shall be in a manner appropriate for the abnormal finding or change in condition consistent with the Care Team member’s level of licensure and scope of practice.
    - Communication shall be documented in the health record.
- Transfers
  - Patients shall only be transferred between specialized health care housing units upon the written order of a privileged health care provider.
    - The health care provider initiating the transfer shall be responsible for ensuring that all transfer orders are completed prior to the patient’s transfer.
    - Transfer orders shall be documented in the health record.
    - Verbal transfer orders shall not be given except in emergencies as defined in the HCDOM, Section 3.7.1, Emergency Medical Response System.
    - In non-emergent exigent circumstances, telephonic transfer orders may be provided to the RN. The provider initiating the transfer shall counter-sign the telephonic orders and document in the health record.
  - The health care provider initiating the transfer is responsible for coordinating the patient’s level of care change with the receiving specialized health care housing unit’s admitting health care provider.
  - Transfers shall be completed in accordance with the requirements of the HCDOM, Section 3.1.9, Health Care Transfer; MHSDS Program Guide; HCDOM, Chapter 3, Article 3, Dental Care; and/or applicable court orders.
- Discharge
  - Discharge planning shall begin upon admission to the specialized health care housing unit.
  - The goal of the discharge planning process is to maximize the patient’s level of self-care, maximize and preserve functioning, improve quality of life, and to determine the appropriate level of housing post discharge.
    - The patient’s discharge plan shall be interdisciplinary.
    - Discharge planning shall include post-parole/post-CDCR release self-care needs when appropriate for the patient.
  - Patients shall only be discharged from a specialized health care housing unit upon the written order of a privileged health care provider.
    - The health care provider initiating the discharge shall be responsible for ensuring that all discharge orders are completed prior to the patient’s discharge.
    - Discharge orders shall be documented in the health record.
    - Verbal discharge orders shall not be given.
    - In non-emergent exigent circumstances, telephonic discharge orders may be provided to the RN. The provider initiating the discharge shall counter-sign the telephonic orders and document in the health record.
  - The health care provider initiating the discharge is responsible for coordinating the patient’s discharge with the receiving Primary Care Team (PCT). While verbal provider-to-provider communication is the preferred method of transfer handoff communication, the discharge summary shall include, at a minimum:
    - Reason for admission.
    - Current diagnoses in the active problem list.
    - Description of major events during the stay and treatments rendered.
    - Pertinent diagnostic studies.
    - Current medications.
    - Future appointments, diagnostic studies, and treatments.
    - Supplies, assistive devices, and DME including items that are to be in the possession of the patient upon discharge.
    - Assistance with one or more activities of daily living.
    - Disposition.
  - The Patient Summary Sheet may be utilized as a supplement to the primary discharge summary documents. However, the specialized health care housing unit staff are responsible for ensuring compliance with discharge documentation requirements.
- Release from CDCR Custody
  - For patients being released from a specialized health care housing unit:
  - The institution UM nurse, Classification & Parole Representative, and clinical team shall coordinate with headquarters UM, Division of Adult Parole Operations (DAPO), Post Release Community Supervision and community based health care providers to identify appropriate placement for the patient.
  - The specialized health care housing unit clinical team, the institution UM RN, and the Receiving and Release (R&R) nurse shall ensure documentation about the patient’s health history, current status, medications, treatments and pending follow-up is obtained, along with required releases of information, and provided to the community based providers.
  - Whenever possible, conferencing with the receiving clinical team is recommended to ensure timely and seamless transition of care.
- Coordination of Services
  - Each specialized health care housing unit shall ensure that their LOP includes instructions on the coordination of services between each level of care within the specialized health care housing units including:
    - The current institution and between its specialized health care housing units.
    - Other CDCR specialized health care housing units.
    - CDCR institutions.
    - Contract facilities.
    - DAPO managed facilities.
    - Other community resources as appropriate to the patient’s health care needs and CDCR status.
  - The patient’s PCT shall ensure the patient’s health care needs are coordinated between all disciplines involved in the patient’s current and future care. The Care Team may be assisted by UM and HCPOP:
    - The Institution’s UM representative serves as the primary resource for the patient’s PCT in determining the appropriate level of care, coordinating services between CDCR facilities, contract facilities, and community resources.
      - The specialized health care housing unit LOP shall refer to the current HCDOM, Section 1.2.15, Utilization Management Program, for guidance on the utilization of health care resources at all levels of care.
    - HCPOP serves as the specialized health care housing unit’s primary resource for endorsing patients to other levels of care when it is determined that the patient’s current location does not meet their health care needs.
      - HCPOP serves as the primary liaison between the CDCR Division of Adult Institutions, DAPO, and Division of Juvenile Justice, ensuring that all custodial requirements for patient movement have been met.
      - The specialized health care housing unit’s LOP shall refer to the current HCDOM, Section 5.1.3, Medical Bed Management, for guidance on the utilization of HCPOP services at all levels of care.
      - Whenever possible, the institution’s Primary Care Provider or UM nurse shall collaborate with HCPOP to initiate a bed hold for patients who are anticipated to be released from a community hospital within three days.
Local Operating Procedure Requirements
- Each CDCR institution shall develop an LOP that outlines the policies and procedures for each level of care provided by each specialized health care housing unit within their institution to fully implement the requirements in this procedure.
- LOPs for areas licensed and/or accredited by a local, county, federal, or state licensing agency and/or accrediting body shall comply with all laws, rules, regulations, and requirements pertaining to the license and/or accreditation held by the licensed/accredited service.
- Admissions process.
- Patient rounding regarding type, frequency, and composition.
- Patient stay process.
- Availability of CDCR 7362s.
- Transfer process.
- Discharge planning process.
- Coordination of services process.
- Patient release or parole process.
- Transfer to county facilities or other outside facilities process.
- Health record documentation frequency requirements for all patient care interactions.
- Provisions for the implementation, structure, and operation of a quality assurance process.
- Patient rights and responsibilities
References
- California Code of Regulations, Title 22, Division 5, Chapter 12, Article 5, Correctional Treatment Centers
- Health Care Department Operations Manual, Chapter 1, Health Care Governance and Administration
- Health Care Department Operations Manual, Chapter 2, Article 2, Confidentiality and Privacy
- Health Care Department Operations Manual, Chapter 2, Article 3, Section 2.3.1, Health Information Management Overview
- Health Care Department Operations Manual, Chapter 3, Article 1, Complete Care Model
- Health Care Department Operations Manual, Chapter 3, Article 2, Medication Management
- Health Care Department Operations Manual, Chapter 3, Article 3, Dental Care
- Health Care Department Operations Manual, Chapter 3, Article 5, Pharmacy
- Health Care Department Operations Manual, Chapter 3, Article 6, Durable Medical Equipment/Supplies and Accommodations
- Health Care Department Operations Manual, Chapter 3, Article 7, Emergency Medical Response
- Health Care Department Operations Manual, Chapter 3, Article 8, Public Health
- Health Care Department Operations Manual, Chapter 4, Special Circumstances
- Health Care Department Operations Manual, Chapter 5, Article 1, Section 5.1.3, Medical Bed Management
- California Department of Corrections and Rehabilitation, Mental Health Services Delivery System Program Guide, 2009 Revision, and associated policies and directives
Revision History
- Effective: 04/2019