Health Care Department Operations Manual

Cancel

Chapter 3 – Health Care Operations

Article 1 – Complete Care Model

View All Sections >

3.1.14 Laboratory Services

  • Procedure Overview

    • California Correctional Health Care Services (CCHCS) staff shall utilize available processes and resources to ensure patients are provided timely access to laboratory services that are clinically necessary.

  • Responsibility

    • Statewide

      • CCHCS and California Department of Corrections and Rehabilitation (CDCR) 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 patients have timely access to laboratory services that are clinically necessary.

      • A statewide contract shall be maintained with an outside agency (contract laboratory), or multiple agencies, to provide routine laboratory analysis or testing, including a limited 24-hour STAT laboratory testing menu.

      • The Statewide Chief of Laboratory Services is responsible for the implementation and maintenance of a safe and effective Laboratory Services program.  Specifically, they are responsible for:

        • Developing standard operating procedures for institution adoption into Local Operating Procedures (LOPs).

        • Monitoring and assisting institutions with their maintenance of Clinical Laboratory Improvement Amendments (CLIA) certificate of waivers and Clinical and Public Health Laboratory Licenses, and compliance activities and regulatory agency inspections related to Laboratory Services.

        • Initiating and overseeing statewide Laboratory Services contracts, procurements, policies and procedures, workflows, and forms. This includes coordinating Laboratory Services-related Electronic Health Record System (EHRS) issues with Department technical staff to prioritize corrective measures and maintenance activities.

        • Overseeing and providing quality assurance of the Laboratory Services onsite delivery of services in conjunction with the CCHCS contracted outside agency, or agencies.

        • Providing consultation and advice to health care providers and institution staff regarding their institution Laboratory Services departments and the Department’s Laboratory Services test order menu.

        • Monitoring the performance of the contracted outside agency, or agencies, in collaboration with the medical leadership Laboratory Services staff at the institutions and headquarters.

        • Overseeing and coordinating the competency assessment and related remediation efforts of local, regional and headquarters Laboratory Services staff.

    • Regional

      • Regional Health Care Executives are responsible for implementation of this procedure at the subset of institutions within an assigned region.

      • The Regional Health Care Executive is responsible for the oversight of the assigned regional Senior Clinical Laboratory Technologist (SrCLT) staff.

        • The Statewide Chief of Laboratory Services shall provide functional direction to the SrCLT staff.

      • The SrCLT shall:

        • Perform administrative duties at the regional level.

        • Monitor and assist Laboratory Services operations at multiple institutions within their assigned region.

        • Perform institution-based laboratory duties as needed and when appropriate.

        • Monitor institution-based Laboratory Services staff performance within their assigned region through regular onsite compliance auditing, training, competency verification, and any subsequent remediation.

        • Coordinate with the statewide Chief of Laboratory Services, or designee, and the appropriate hiring authority, or their designee, on all competency verification related processes, findings, and remediation.

    • Institutional

      • The Chief Executive Officer (CEO), or designee, is responsible for implementation of this policy at the institution level.

      • The CSE, or designee, is responsible for ensuring the institution has designated specimen collection and processing locations (laboratories) and a clinic administrator responsible for properly functioning lab processing equipment, properly maintained and an adequate amount of lab-related supplies, an adequate number of trained staff, appropriate patient scheduling processes are in place for laboratory services, and established lab processing work flows and lab LOPs are adhered to.

        • A standardized LOP template shall be developed by the statewide Chief of Laboratory Services.

        • At a minimum, an institution shall adopt a standardized LOP template customized for their site containing the following elements https://cdcr.sharepoint.com/sites/cchcs_lifeline_labs:

          • General Lab Policy and Staff Roles and Responsibilities.

          • Laboratory Orders.

          • Specimen Collection and Processing.

          • Paternity Testing.

        • LOP adoption requires the signature of an institution’s Laboratory Director as designated on the CLIA Certificate of Waiver, and the Statewide Chief of Laboratory Services.

        • The LOPs shall be reviewed, updated if required, and resigned at a minimum of every two calendar years or more frequently as required.

        • Laboratory Services and non-Laboratory Services staff shall adhere to LOP requirements.

      • Health care providers are responsible for ordering medically necessary laboratory studies consistent with community standards and department policy and care guidelines.

  • Procedure

    • Routine Laboratory Orders Processing

      • Routine Laboratory Orders typically include the following collection priorities with the indicated collection time defaults within the EHRS:

        • AM Draw: Next morning.

        • ASAP: Next day.

        • Routine: 30 calendar days.

        • Timed Study: Collection defaults to ordering provider’s selected collection date.

      • Health care providers shall place orders for all laboratory services in the EHRS.

      • Scheduling and ducating procedures shall be followed for the specimen collection of the ordered lab test(s). The ducating  and scheduling process may be adjusted to facilitate timely specimen collections on or before the requested collection date.

      • The laboratory specimen shall be obtained from the patient on or before the requested collection date. The specimen shall not be collected prior to the requested collection date if prohibited by policy or the ordering provider.

        • If there are questions regarding an order, staff shall call or message the ordering health care provider for clarification.

        • Laboratory orders shall be collected by Laboratory Services staff during laboratory’s normal business hours.

        • Staff may collect a routine lab test the next business day should the requested collection date fall on a weekend or holiday.

      • Staff are prohibited from canceling or discontinuing Laboratory Services orders unless staff are authorized by the ordering provider or as specified under Section (c)(5)(C) of this policy to perform the cancellation or discontinuation, and there is EHRS documentation of the reason for the cancellation or discontinuation.  The ordering provider, or appropriate clinical staff, shall be consulted prior to canceling or discontinuing an order suspected of being a clinically unnecessary duplicate order, or associated with recurring or multiple future collection appointments such as most Timed Study laboratory orders.

      • Staff shall record the specimen collection date and time and person collecting the specimen in the EHRS and update the status of the specimen to “collected.”

        • Laboratory specimens shall be labeled in the presence of the patient and not labeled prior to collecting the specimen.

      • For specimens not collected by Laboratory Services staff, e.g., an inpatient collection, the designated staff shall arrange for pick-up or delivery, and final processing at the institution laboratory during laboratory’s normal business hours.

        • The specimen shall remain in a secure storage area with appropriate environmental conditions to maintain the specimen in an adequate state until retrieved by staff or dropped off at the laboratory.

        • Un-retrieved specimens, or specimens collected outside of Laboratory Services normal business hours, shall have a designated secure storage area with appropriate environmental conditions to maintain the specimen in an adequate state.

      • Storage of laboratory specimens awaiting collection by couriers shall be secured in a locked container.  Institution health care leadership or a designated health care team member shall coordinate with custody staff to determine the type(s) of locked boxes to be used and their appropriate placement for couriers to readily access and retrieve specimens.

      • The specimen shall be picked up by the contracted outside agency each business day at the contractually agreed upon time.

      • All non-critical results shall be reported to the institution within 24 hours of completion of the contracted laboratory’s analysis or testing in accordance with the Laboratory Services contract or test schedule.

    • STAT Laboratory Orders Processing

      • Health care providers shall place orders for all STAT laboratory services in the EHRS.  The order shall be collected as soon as possible on the same calendar day and the results from the reference lab shall be available within contractual timeframes.

        • Refer to the Health Care Department Operations Manual (HCDOM), Section 3.1.5, Scheduling and Access to Care, under Section (c)(3)(C)(4), if a laboratory appointment originated from the order of a psychiatrist.

        • STAT laboratory order processing requirements and timelines only apply to lab tests designated on the Approved CDCR-CCHCS STAT Testing Menu.  Providers shall only place STAT orders from the approved Testing Menu.

        • Providers seeking STAT results for lab tests not designated on the Approved CDCR-CCHCS STAT Testing Menu or results faster than their institution’s expected STAT processing time have the option of referring for offsite laboratory services.  Providers shall follow the LOPs and policies applicable to offsite care at their facility.

      • If there are questions regarding an order, staff shall call or message the ordering health care provider for clarification.

      • For STAT orders, the patient shall be sent to the appropriate location for collection of the ordered STAT lab test(s).

      • STAT laboratory specimens shall be collected by staff as soon as possible on the same calendar day.

      • Staff shall place the STAT pick-up notification call to the contracted laboratory immediately following the order’s change to an “in-transit” order status.

      • Upon notification of a STAT order for laboratory services, the specimen shall be picked up by the contracted laboratory within two hours for non-rural institutions and three hours for rural institutions, 24 hours per day, seven days per week.

      • Processing of the patient’s specimen shall begin immediately upon arrival at the contracted laboratory.

      • STAT results shall be provided by the contracted laboratory via telephone to the Triage and Treatment Area (TTA), or designated health care team member, within four hours of the telephone request for pick-up for non-rural institutions and five hours for rural institutions.

      • If the STAT results are received after hours or the ordering provider is unavailable, the TTA staff shall notify the on-call provider within 30 minutes and document the notification in the EHRS.

    • Specimens Requiring Special Handling or Processing

      • Staff collecting specimens that require special handling shall follow the specimen requirements provided by the outside agency contracted to provide laboratory analysis and testing.

      • CCHCS laboratory tests requiring special handling or processing include the following:

        • Clinical Urine Drug Screening for Substance Use Disorder treatment (refer to Appendix 1).

        • Reception Center Clinical Urine Drug Screening (refer to Appendix 2).

        • Offsite Pathology Orders (refer to Appendix 3).

    • Review and Notification of Laboratory Test Results

      • Laboratory test results shall be electronically interfaced from the contracted laboratory’s system to the EHRS. 

      • Test results that cannot be electronically interfaced shall be faxed or printed and provided to the designated location within the institution and scanned into the EHRS by Health Information Management.

      • A notification will appear in the ordering health care provider’s Message Center informing them of the return of the results.

        • Results or reports that are routed incorrectly to a provider’s Message Center may be refused by the reviewing provider within the EHRS and shall be forwarded to the appropriate health care provider.

        • If the result of a laboratory test is “Test Not Performed,” the designated staff may submit a replicate order on behalf of the health care provider unless otherwise directed by the health care provider.

        • If there are questions regarding an order, the ordering health care provider shall be contacted for clarification.

      • The health care provider shall electronically review and endorse each laboratory result within five calendar days of the date of receipt.

      • The health care provider shall create a patient notification letter in the EHRS at the time of review and endorsement of each laboratory result.  The patient letters shall include the following:

        • Date of the laboratory test/screening.

        • Name of the health care provider who reviewed and endorsed the lab result.

        • The clinical significance or meaning of the lab results such as, but not limited to, whether the results are unchanged, or within normal limits, or as expected, or whether additional testing is required.

        • Whether a follow-up appointment with a provider is required, and if so, that it will be scheduled.

      • Patient notification letters shall be printed for collection by the designated staff member to be distributed to the patients.

      • Patients may request to view their detailed laboratory test results by submitting a completed CDCR 7385, Authorization for Release of Protected Health Information, through Nursing Services.  There is no fee for the patient to request and view their results.

      • Any critical laboratory values shall be immediately reported by the contracted laboratory via telephone to the TTA or designated health care team member and requires a read back to be communicated for clarification.

      • If critical laboratory values are received after hours or the ordering provider is unavailable, the TTA staff shall notify the on-call provider within 30 minutes and document the notification in the EHRS.

    • Patient Refusals or Failures to Report for Laboratory Services

      • If the patient does not arrive for a laboratory appointment, the designated staff member scheduled to collect the specimen shall notify custody staff of the patient’s failure to report to the clinical appointment.

      • If the patient arrives in the laboratory services area and permits specimen collection, the collection shall be performed.

      • The staff responsible for the specimen collection shall cancel the laboratory order if the patient refuses specimen collection at the laboratory services area. If the patient fails to report (“no-show”) not due to a stated refusal, the staff responsible for the specimen collection shall attempt to reschedule the patient one-time for a second specimen collection attempt. The laboratory order shall be canceled by staff if the patient refuses or fails to report for the second scheduled appointment.

        • The staff responsible for specimen collection shall document the reason for the order cancellation in the EHRS.  The EHRS will automatically notify the ordering provider of the cancellation.

        • The staff responsible for the specimen collection shall not be responsible for leaving the designated laboratory services area to document a patient refusal or failure to report. 

        • Staff shall require authorization from the ordering provider for the cancellation of laboratory orders not associated with a patient refusal, or second specimen collection attempt associated with a failure to report for laboratory service.

        • The cancellation and rescheduling process(es) outlined in Appendix 1 of the HCDOM, Section 3.1.14 for the special handling circumstances and cancellation process for Clinical Urine Drug Screening supersedes this section.

        • The documentation (CDCR 7225, Refusal of Examination and/or Treatment) and counseling procedure for the failure to report for a medical appointment outlined in the HCDOM, Section 3.1.5, Scheduling and Access to Care, does not apply in cases of patient refusals or failures to report related to laboratory orders.

      • The ordering provider and the patient’s care team shall inform the patient of the health care consequences, and the determination of the appropriate next clinical steps because of a patient refusal or failure to report for Laboratory Services.  Appropriate next clinical steps could include, but are not limited to, ordering clinically necessary laboratory services.

  • Appendices

    • Appendix 1, Clinical Urine Drug Screen for Substance Use Disorder Treatment

    • Appendix 2, Reception Center Urine Drug Screening

    • Appendix 3, Offsite Pathology Orders

  • References

    • Health Care Department Operations Manual, Chapter 3, Article 1, Section 3.1.5, Scheduling and Access to Care

  • Revision History

    • Effective: 01/2006
      Revised: 11/12/2025

  • Appendix 1: Clinical Urine Drug Screening

  • Urine Drug Screening (UDS) is a urine toxicology study used for therapeutic monitoring purposes, but may be ordered when a patient presents with an altered level of consciousness.

  • Clinical UDS results, a patient’s decision to decline a Clinical UDS, and/or a patient’s inability to provide a sample due to paruresis or other reason shall only be available to clinical staff on a need to know basis in order to manage a patient’s health care needs, and these results shall not be shared with custody.

  • CLINICAL UDS ORDERING

    • Health care providers shall place orders for the initial UTOX Screen lab test with an “ASAP” collection priority in the Electronic Health Record System (EHRS).

      • The requested collection date for the UTOX Screen lab test will default within the EHRS to one calendar day from the date of the order.

      • Staff may collect the initial UTOX Screen lab test on the next business day should the requested collection date fall on a weekend or holiday.

    • Health care providers shall place orders for follow-up UDS testing (UTOX Monitoring or UTOX Panel tests) as a “Timed Study” collection priority in the EHRS.

      • The UTOX Monitoring and UTOX Panel lab tests may be ordered with requested collection dates within one week of one another and should not be considered duplicate orders.

      • Health care providers should alert Laboratory Services staff of follow-up UDS orders with requested collection dates within one week of another by placing an order comment in the EHRS.

      • The specimen collection for the follow-up clinical UDS test shall occur within the timeframe defined by the laboratory order’s requested collection date.  Staff may not collect the UDS specimen more than one calendar day prior to the requested collection date.

  • CLINICAL UDS COLLECTION & HANDLING

  • Clinical UDS requires special collection and handling to ensure the specimen is free from adulteration.

    • Taking into consideration facility physical limitation characteristics, arrangements shall be made to provide patient privacy during UDS specimen collection. This could consist of an enclosed stall in a multi-stall restroom; a single person restroom; a partitioned area allowing for individual privacy; a commode within a single-occupancy inpatient setting; or other acceptable location.

    • Staff shall review the following UDS collection instructions with the patient:

      • The patient should remove any unnecessary garments, such as a jacket with pockets, or personal property and leave the items outside the collection site.

      • Following the completion of collection, the patient should hand the closed container to the staff when instructed to do so.

      • The patient should not flush the commode unless instructed to do so by the staff.

      • The patient should not wash their hands until instructed to do so by the staff.

    • Staff do not directly observe the patient collecting the UDS sample, but shall actively proctor the process and perform the following actions subject to the limitations of custody, institution infrastructure, and physical layout:

      • Inspect the collection site before the patient enters the area to identify and remove potential specimen adulterants prior to patient entry.

      • Listen for unauthorized commode flushing or handwashing by the patient during the collection process.

      • Verify the patient provided the necessary sample volume as defined by the UDS requirements.  If the sample volume is not adequate, discard the sample and reschedule the patient for a recollection within one calendar day.        

      • Instruct the patient to wash their hands after the urine specimen collection is complete.

      • Inspect the commode bowl and collection site for unusual paraphernalia that could have been used to alter or substitute a specimen.

      • Flush the commode bowl or instruct the patient to do so following the completion of the specimen collection and inspection of the commode.

    • Staff shall observe the sample container for adulteration or substitution by observing the physical characteristics of the specimen such as:

      • Unusual color.

      • Temperature – the urine cup temperature strip should change from black to green signifying the sample is within the expected temperature range.

      • Presence of foreign objects or material

    • Staff shall document any observations in the EHRS indicating possible issues with specimen integrity.

      • Unless directed by the ordering provider or institution leadership, the corresponding UDS order shall be cancelled or discontinued by staff, and the ordering provider shall be notified of the circumstances leading to the cancellation or discontinuation.

    • Staff shall document the following circumstances in the EHRS indicating inability to collect adequate specimen:

      • The patient is unable to void, or an adequate sample volume was not collected by the patient, or both.

      • The patient fails to report (“no show”) for their scheduled UDS collection appointment, and the failure to report was not associated with a specimen collection refusal.

      • For laboratory orders exhibiting either of these two circumstances, staff shall attempt to reschedule the patient one-time within one subsequent calendar day for a second specimen collection attempt.  Unless directed by the ordering provider or institution leadership, the corresponding laboratory order shall be cancelled or discontinued by staff if there was a failure to obtain an adequate specimen with no suspicion of adulteration within this one calendar day period. The ordering provider shall be notified of the circumstances leading to the cancellation or discontinuation of the order.

    • Specimens with an adequate volume and no reasonable suspicion of adulteration shall have a completed label. Ensure the collection cup is closed tightly and secure the lid with parafilm to prevent leakage in transit. If parafilm is used, lid tape is not required.

  • Appendix 2: Reception Center Clinical Urine Drug Screening

  • A Reception Center Clinical Urine Drug Screening (UDS) will be offered to all newly arriving individuals committed to CDCR custody.  The UDS will be part of the Diagnostic Screening Tests and Assessments contained within the Reception Center Initial Health Screening and Triage as outlined in the Health Care Department Operations Manual, Section 3.1.8, Reception Center.  The Reception Center Clinical UDS will be used for screening purposes only.

  • Reception Center Clinical UDS results, a patient’s decision to decline a Reception Center Clinical UDS, and/or a patient’s inability to provide a sample due to paruresis or other reason shall only be available to clinical staff on a need to know basis in order to manage a patient’s health care needs, and these results shall not be shared with custody.

  • RECEPTION CENTER CLINICAL UDS ORDERING

    • The order for Reception Center Clinical UDS testing will be available as part of the R&R New Arrival PowerPlan.

    • Reception Center Clinical UDS testing will consist of a CCHCS UTOX Screen test.

    • The Reception Center Clinical UDS testing will be ordered as a Routine collection priority.

    • RECEPTION CENTER CLINICAL UDS COLLECTION AND HANDLING

    • The Reception Center Clinical UDS screening does not require any special collection and handling requirements to safeguard the specimen from tampering due to the screening nature of the assessment.

    • Specimen can be collected following the process as other urine samples, and should follow the collection requirements particular to this test.

      • One UDS specimen container shall be given to the patient to collect the UDS and Chlamydia and Gonorrhea tests, if ordered.

      • Per the collection requirements, ensure the patient provided an adequate specimen volume to complete the Chlamydia and Gonorrhea and UDS testing.

      • If Chlamydia and Gonorrhea are ordered, transfer 2 mL of urine to the Aptima Transport tube, ensure urine volume is within the fill window on the Aptima tube.  Label Aptima tube appropriately.

      • Process the UDS specimen per the Local Operating Procedure.

      • All urine specimen containers should be labeled appropriately.  Staff shall record the specimen collection date and time and person collecting the specimen in the Electronic Health Record System and update the status of the specimen to “collected”.

        • Laboratory specimens shall not be labeled prior to collecting the specimen.

  • Appendix 3: Offsite Pathology Orders

  • A laboratory order for Offsite Pathology shall be placed in the electronic health record system (EHRS) when a patient has a pathology specimen collected from an offsite procedure.

  • This process does not apply to pathology specimens collected onsite at institutions and sent to a contracted laboratory for analysis.

  • OFFSITE PATHOLOGY NURSE AND PROVIDER MONITORING

    • The TTA, specialty, or designated nurse responsible for the intake of offsite specialty records shall receive the patient’s offsite records and forward them to their institution Health Information Management (HIM) unit for processing.

      • HIM shall follow-up with the offsite provider if no patient records accompany a patient returning from an offsite procedure.

    • HIM shall receive, prepare, scan, and upload the offsite records into the EHRS.  An EHRS Message Center notification to the provider to review the records will be generated.

    • The provider shall review offsite procedure notes to verify the collection of a pathology specimen and its pending status from an offsite procedure.

  • OFFSITE PATHOLOGY WORKFLOW

    • The provider shall place an order for Offsite Pathology in EHRS if records indicate the collection of a pathology specimen during an offsite procedure.

      • Offsite Pathology shall be ordered as a Routine collection priority.

    • Institution laboratory staff shall monitor their Pending Log for any Offsite Pathology orders and notify HIM of any pending orders on a weekly basis.  The Patient Care Team shall monitor the daily Huddle Report and EHRS Care Team Hub for pending Offsite Pathology orders and notify HIM of any pending orders on an as needed basis.

    • HIM shall scan and upload the report of the offsite pathology specimen results into EHRS once it is received.

    • HIM shall then forward the offsite pathology specimen report to the provider through a Message Center notification.

    • The provider shall review, endorse, and create the patient notification letter for the results within five calendar days of the date of receipt.

      • The patient notification letter created by the provider shall include the same elements listed in (c)(4)(E) of the procedure.

    • The regional or headquarters Senior Clinical Laboratory Technologist shall enter “See Scanned Report” in EHRS (PathNet) to close out the Offsite Pathology order.