Chapter 3 – Health Care Operations

Policy

• All California Department of Corrections and Rehabilitation (CDCR) dental departments shall maintain statistical data on dental clinic operations.  This data shall be tabulated every month and submitted to the Division of Health Care Services (DHCS), Adult Correctional Dental Care (ACDC) headquarters staff.

Purpose

• To establish and maintain a standardized system for collecting, recording and reporting statistical data on dental clinic operations.  The data shall be utilized to evaluate direct dental services rendered to patients in the CDCR.

Procedure

• Each institution dental department shall utilize only ACDC approved data collection and tracking methods.

• Each institution dental department shall monitor the following data on dental clinic operations via the Quality Management Dashboard.  Data shall be made available upon request to the appropriate Regional Dental Director (RDD) and to DHCS, ACDC headquarters staff.  Institution dental staff shall also verify the validity of the dashboard measures and report discrepancies to the appropriate RDD and to DHCS, ACDC headquarters staff.

  • Access to care.

  • Dental care provided.

  • Dental clinician time management.

  • Refusal reconciliation trends.

• The Health Program Manager (HPM) III and the Supervising Dentist (SD) are responsible for:

  • Ensuring electronic health records are maintained accurately.

  • Reviewing/monitoring electronic data on a regular basis.

• Submission of Dental Clinic Operations Data Reports

  • The Health Program Specialist (HPS) I or designated dental staff shall prepare monthly reports in a timely manner of the data listed in Section (c)(2), as needed for Facility Dental Program Subcommittee meetings and/or as requested.

  • On a weekly basis, the HPS I or designated dental staff shall compile a workload report for the entire institution.

  • Each HPM III shall:

    • Perform regular analyses of data trends and patterns; develop corrective action plans to address problematic areas; prepare and submit associated reports.

    • Review the workload report with the SD for scheduling of providers as well as timeframe compliance for treatment provided to the patients.

    • Maintain copies of the above mentioned reports on file for a period of three years.

Policy

• The California Department of Corrections and Rehabilitation (CDCR), Division of Health Care Services (DHCS) shall ensure that all dental health care services employees and dental health care contractors whose positions or job descriptions require licensure, certification and/or credentialing are in compliance with all federal and state licensing requirements prior to employment.

Purpose

• To ensure compliance with all federal and state requirements regarding the licensure, certification and/or credentialing of dental health care personnel within the CDCR.

Procedure

• Each applicant, when being interviewed and prior to being hired, must submit a copy of their relevant Dental license, Drug Enforcement Administration (DEA) Controlled Substance Registration Certificate (where applicable) and Basic Life Support (BLS) certification, or a letter of verification from the licensing or certifying agency, to the hiring authority.  Applicants are not eligible for employment without proof of current licensure, certification and/or credentials. 

• The hiring authority shall be responsible for requesting verification of licensure, certification and/or credentials with the appropriate accrediting agency.

• Each employee shall thereafter be responsible for keeping their licensure, certification and/or credentials current and for providing verification of renewal to their supervisor. 

• Employees who do not maintain current licensure, certification and/or credentials or whose licenses are suspended or revoked by the Dental Board of California are ineligible for further employment at the time of the expiration, suspension or revocation of their license, certification and/or credentials.

• Verification of current licensure, certification and/or credentials shall be maintained at the facility of assignment by the local personnel section, and the Health Program Manager III.

• All dental health care staff and contractors shall comply with the Health Care Department Operations Manual [HCDOM], Section 1.4.1.1, Health Care Credentialing.

Credentialing

• Credentialing of CDCR dentists shall be performed by the Credentialing and Privileging Support Unit of the California Correctional Health Care Services – Resource Management and Professional Practice Support Section, Medical Services Branch. (Reference the HCDOM, Section 1.4.1.1, Health Care Credentialing).

• Credentialing shall be based on:

  • Documents generated as the result of the peer review process as outlined in the HCDOM, Section 3.3.4.3(c)(3)(F)6. and/or Section (e)(4)(C) of this chapter.

  • Licensure, certificate, and/or credential verification including any regulatory agency’s action(s) against the clinician’s license, credentials and/or DEA Controlled Substance Registration Certificate (where applicable).

  • Verification that the clinician is not subject to any restriction of privileges at any institution, hospital, or health care facility.

  • Verification that the provider has no adverse action(s) from any government funded program including, but not limited to, suspension from participation or outstanding audits for recovery.

  • National Practitioner Data Bank information on action(s) taken against the provider.

• Under normal circumstances, CDCR dentists shall be credentialed for a period of three years pending review and approval of their credentialing file. At the end of each three year credentialing cycle, CDCR dentists shall be subject to the re-credentialing process.

• Six months prior to the conclusion of each dentist’s three year credentialing cycle they shall be notified that a dentist shall review their standards of practice and clinical skills.

Clinical Skills

• At the time of employment and continuously thereafter, dental practitioners who seek employment with the CDCR, DHCS, Adult Correctional Dental Care must demonstrate to the Supervising Dentist satisfactory clinical skills as well as exhibit professional conduct and ethics.

• In keeping with the expectations of a dentist licensed by the Dental Board of California, at a minimum all CDCR dentists shall be expected to possess the ability to:

  • Clinically supervise dental assistants and dental hygienists.

  • Perform dental chart reviews.

  • Provide dental consultations and referrals.

  • Follow Dental Board of California, Centers for Disease Control and Prevention, Occupational Safety and Health Administration and CDCR policies.

  • Perform all aspects of general dentistry including, but not limited to, the diagnosis or treatment, by surgery or other method, of diseases and lesions of human teeth, alveolar process, gums, jaws, or associated structures. Such diagnosis or treatment may include all necessary related procedures as well as the use of drugs, anesthetic agents, and physical evaluation.

• Proctoring and Mentoring (Reference the HCDOM, Sections 3.3.4.3(c)(3)(F)2.a. and 3.3.4.3(c)(3)(F)2.b.)

  • The Dental Peer Review Committee (DPRC) shall use the process of proctoring to monitor and review a dentist’s skills during their initial probationary period to ensure they can adequately perform the minimum expected clinical skills outlined in Section (e)(2).

    • The DPRC shall take into consideration aspects of a dentist’s behavior, professional ethics and clinical performance that directly impact their ability to successfully perform the minimum expected clinical skills.

    • In addition to monitoring the areas outlined in Section (e)(4)(F), the committee shall look for and identify:

      • Desirable qualities and qualifications for CDCR, DHCS Dental Program employment.

      • Demands made or expectations held by a dentist that are beyond the scope of CDCR policies and mandates.

      • Any values or attitudes manifested by a dentist that are in conflict with those of the CDCR and the DHCS.

      • A pattern of resistance to or conflicts with the quality and/or peer review processes.

      • Gross mental or physical disabilities that prevent performance of the minimum expected clinical skills.

  • The mentoring process shall be used to foster continuous professional development and training for dentists if they fail to demonstrate acceptable skills. Additional training and mentoring may be required if a dentist fails to demonstrate acceptable skills.

• Monitoring and Reviewing Clinical Performance

  • The DPRC shall monitor a dentist’s standards of practice and clinical skills on an ongoing basis to ensure compliance with accepted standards of care. The monitoring outcomes may be utilized in the formulation of annual performance appraisals and in the proctoring, mentoring and re-credentialing processes. (Reference the HCDOM, Section 3.3.4.3(c)(3)(F)2. and Section (e)(4)(F).

  • DPRC or other dentists performing ongoing monitoring of a dentist’s standards of practice and clinical skills shall employ the Dental Peer Review Audit Tool for the monitoring process.

  • Program Support Team (PST) or other dentists reviewing a clinician’s standards of practice and clinical skills shall base their decision on institution DPRC records as well as random chart audits. (Reference the HCDOM, Section 3.3.4.3(c)(3)(E)1.

  • In any situation, additional quality or peer review evaluations may be completed as needed.  

  • Special cases or critical clinical issues may be referred to the Headquarters Dental Peer Review Committee (HDPRC) for review. (Reference the HCDOM, Section 3.3.4.3(c)(F)7). Personnel issues that do not impact clinical practice shall be referred to the appropriate supervisor.

  • In addition to the items listed in Section (e)(3)(A)2, the DPRC and PST staff shall consider the following when monitoring or reviewing a dentist’s standards of practice and clinical skills:

    • Adherence to the HCDOM, Chapter 3, Article 3, Dental Care.

    • Evaluations of standards of practice and clinical skills including, but not limited to:

      • Outcomes of procedures performed.

      • Utilization management.

      • Risk management data.

    • Relevant education, training, or experience acquired subsequent to initial credentialing and appointment or having occurred after the most recent re-credentialing cycle.

  • The DPRC may recommend extension of a dentist’s period of proctoring or mentoring or that the dentist’s re-credentialing cycle be modified.

Policy

• The California Department of Corrections and Rehabilitation (CDCR), California Correctional Health Care Services (CCHCS), and the Health Care Executive Committee (HCEC) shall maintain oversight and coordination of the statewide professional peer review processes to achieve the CCHCS’ strategic objectives.  The Division of Health Care Services (DHCS), Adult Correctional Dental Care (ACDC) shall establish the Headquarters Dental Peer Review Committee (HDPRC) to plan, develop, manage, and improve the peer review process for CDCR dentists and assist the institution Dental Peer Review Committee (DPRC) in fostering the continuous professional development and training of the clinical workforce.  The dental peer review process shall adhere to all applicable aspects of the CCHCS/DHCS Health Care Department Operations Manual (HCDOM) on Peer Review.

Purpose

• To achieve and maintain the highest possible standards of professional, ethical, dental health care through continuous quality review and/or peer review of services provided.

Procedure

• Peer review is intended to ensure patient safety and the delivery of an acceptable level of care with the ultimate goal of promoting good dental practice culminating in consistently positive outcomes and continuously improving patient care through the gathering and examination of quality review data. In addition, the dental peer review process provides an appropriate, objective and systematic due process for licensed dental practitioners, in accordance with Title 22 of the California Code of Regulations, the California Business and Professions Code, bargaining unit contracts and applicable California Law governing restriction, suspension or revocation of privileges, termination of employment and reporting to appropriate professional licensing boards.

• Confidentiality

  • The DHCS affirms the confidentiality of peer review information and the need to prevent its inappropriate use. It is essential that the analysis of and conclusions drawn from healthcare peer review data, along with the recommendations and actions developed for use by the DHCS, be kept from unauthorized persons or organizations and be protected from any use other than for internal or quality improvement purposes.  The proceedings and records of peer review bodies are protected by Section 1157 of the California Evidence Code.  All participants in the review processes referenced in this policy shall adhere to the above provisions regarding confidentiality.

• HDPRC

  • HDPRC membership shall consist of:

    • One Supervising Dentist (SD) nominated and selected by Program Support Team (PST) and institution staff dentists to serve for two years. This individual shall not be eligible to serve consecutive terms.

    • Two institution staff dentists selected by the four Regional Dental Directors (RDD) to serve for two years. These individuals shall not be eligible to serve consecutive terms.

    • Two PST dentists selected by the four RDDs to serve for two years. These individuals shall not be eligible to serve consecutive terms. When a PST dentist member of the HDPRC is unable to attend an HDPRC meeting the RDDs may select another PST dentist to serve as the alternate.

    • One staff dentist from ACDC, Headquarters selected by the three Chief Dentists (CD) to serve for two years. This individual shall not be eligible to serve consecutive terms. Another staff dentist from Dental Program Headquarters may serve as the alternate.

    • At least one CD and/or one RDD shall attend HDPRC meetings and serve as non-voting advisors. Any CD or RDD may serve as the alternate.

    • No Region may have more than one PST or institution staff dentist serving at the same time.

    • HDPRC members shall select a chairperson and vice-chairperson from amongst themselves to serve for two years.

  • Meetings

    • HDPRC meetings shall be held at a minimum once a quarter to review routine institution peer review cases or as needed regarding routine Clinical Performance Appraisals (CPA) or to consider requests for Patterns of Practice (POP) stemming from ‘for cause’ cases sent forward by the institution SD, the RDD, or at the direction of the Deputy Statewide Dental Director (DSDD), or Statewide Dental Director (SDD).

    • A quorum consists of four HDPRC members, one of which must be the chairperson or vice-chairperson.

    • Any member of the HDPRC shall recuse themselves from an upcoming review for reasons of a potential conflict of interest.

      • Such recusals shall only be allowed prior to the beginning of the proceedings or when the member discovers the potential conflict. In either case, whichever is the earlier event.

      • The HDPRC member shall be replaced by another dentist from either Dental Program Headquarters or PST region selected by the HDPRC chairperson.

  • Responsibilities

    • The HDPRC shall evaluate patient care using generic screening criteria and methodologies such as health record reviews and patient outcome data as well as other logs and reports.  During the evaluation process a review of each procedure and service shall be performed to determine:

      • Appropriateness – Were timely dental evaluations and diagnostic tests including radiographs performed per the HCDOM, Chapter 3, Article 3, Dental Care?  Were the correct diagnoses and conclusions drawn?  Was the appropriate treatment provided consistent with the HCDOM, Chapter 3, Article 3, Dental Care? Was the documentation accurate, legible and properly organized as required by the HCDOM, Chapter 3, Article 3, Dental Care?

      • Competence – Was the care delivered in a professional, competent manner and within the guidelines of the HCDOM, Chapter 3, Article 3, Dental Care and the Standard of Care in Dentistry?  Were any changes to the diagnoses or treatment plans correctly perceived and supported by clinical data? Was appropriate documentation noted in the health record?

      • Outcome – Did the patient receive satisfactory access to care and was the treatment appropriate for the diagnosis and were unexpected outcomes documented in the health record?

    • Based on the duties assigned to a dentist by management, the HDPRC shall decide whether to conduct a Clinical Performance Appraisal, a Pattern of Practice, or to make a danger determination possibly leading to restriction or summary suspension of privileges when failure to do so may result in an imminent danger to the health of any patient, prospective patient, or other person.

    • The standard for taking action affecting a practitioner’s ability to provide health care services shall be when the practitioner’s clinical care falls below the required standard of care in that they have failed to deliver care that is consistent with the degree of care, skill and learning expected of a reasonable and prudent practitioner acting in the same or similar circumstances.

• DPRC

  • Only licensed dentists that are employees in good standing of the CDCR DHCS Dental Department are eligible to serve on the DPRC.

  • PST dentists shall provide oversight and validation of the DPRC under the guidance of the RDD.

  • Each CDCR facility shall establish a DPRC composed of:

    • The facility SD who shall chair the DPRC.

    • A staff dentist elected for a one year period as vice-chairperson of the DPRC by the other staff dentists at the facility. This individual shall chair the committee when the SD is unavailable to preside over the committee and shall not be eligible to serve consecutive terms as vice-chairperson.

    • Two staff dentists selected as general members by the facility SD with the approval of the RDD to each serve a six month term. These members shall be replaced with other dentists from the institution on a rotating basis.

    • The Health Program Manager (HPM) III in a supporting, non-voting capacity.

  • Service term requirements

    • A dentist may serve on the DPRC as vice-chairperson, or a general member, or a combination thereof for a maximum of two consecutive terms that do not exceed 18 months. Exceptions to this rule may be granted by either the DSDD or SDD.

    • After serving up to a maximum of 18 months, a dentist shall be eligible to once again serve after a period of six months during which they do not serve on the DPRC.

    • In order to allow for stability and continuity in DPRC function, the service term requirements outlined in Section (c)(3)(D) 1. and 2. shall be waived during the period in which the DPRC is established for the first time at a facility.

    • Any member of the DPRC shall recuse themselves from an upcoming review for reasons of a potential conflict of interest.

      • Such recusals shall only be allowed prior to the beginning of the proceedings or when the member discovers the potential conflict. In either case, whichever occurs first.

      • The DPRC member shall be replaced by a staff dentist at the facility or from another facility within the same region, selected by the RDD from the region in which the review is being conducted.

      • If the replacement dentist is from a different region from the one in which the peer review is being conducted, the selection made by the RDD shall be approved by the DSDD or SDD.

    • An exception process shall be implemented when a dentist has been the subject of repeat “for cause” reviews within an 18 month period.

      • Any subsequent peer reviews of the dentist in question shall be conducted by a DPRC, at their institution, composed of two different staff dentists in the position of general members who did not participate in any of the reviews during the previous 18 month period.

      • The DPRC chairperson and vice-chairperson can be the same individuals as in the previous committee.

  • Meetings

    • DPRC meetings shall be held regularly, and with sufficient frequency, to ensure that each dentist providing treatment at the institution is the subject of a routine peer review at a minimum once every six months and shall normally consist of a minimum of ten health record review cases for each dentist being reviewed.

      • Cases reviewed shall be selected in compliance with the guidelines set forth in the Peer Review Case Selection Tool.

      • Each DPRC member shall review all of the health record review cases selected for a dentist undergoing routine peer review.

      • Peer review cases shall be selected and made available to DPRC members sufficiently in advance to allow them to access and review the health record(s) as well as all other necessary documents prior to the DPRC meeting.

      • A quorum consists of three DPRC voting members, one of which must be the chairperson or the vice-chairperson.

      • In order to establish a quorum, a DPRC member who is absent from the institution can be temporarily replaced by a staff dentist at the facility, or from another facility within the same region, selected by the RDD from the region in which the review is being conducted.

      • A Regional or Headquarters dentist may attend and participate in DPRC meetings at any time but shall not count towards the required quorum.

    • Meeting minutes shall be recorded by the HPM III or designee. The SD shall maintain DPRC minutes on file for a period of three years.

  • Responsibilities

    • In performing routine peer reviews at a facility, the DPRC shall act under the auspices and as an agent of the HDPRC in protecting the health and welfare of patients, in preserving standards of health care delivery, and in evaluating practitioner competency as outlined in Section (c)(2)(C)1.a. through c.

    • The DPRC shall implement a quality review process to exercise concurrent and direct observation through:

      • Proctoring to monitor and review a dentist’s skills during their initial probationary period to ensure they can adequately perform the minimum expected clinical skills. (Reference the HCDOM, Section 3.3.4.2(e)(2). The proctoring process shall be performed by the SD or designee with concurrence from the RDD, and shall include:

        • A review of the dentist’s clinical and patient management skills.

        • Cases sufficient in complexity and in number to demonstrate the dentist’s competency in all aspects of dental care delivered within CDCR.

        • Procedures which ensure that the proctor shall function as an observer in the case and not a consultant or assistant and that the proctor shall perform pre- and post-treatment examinations of the patients being treated.

        • Provision for dentists from outside the local facility but employed by CDCR to be utilized as proctors when needed.

        • A minimum of five health record review cases and three clinical review cases during the proctoring period. Each of the clinical review cases shall be performed by a different proctoring clinician.

        • The use of the Dental Peer Review Audit Tool during the health record case review process.

        • Provision for proctors to generate a brief narrative report of clinical review cases, to include, at a minimum:

          • Pre-clinical – Did the dentist review and complete appropriate forms records as required by the HCDOM, Chapter 3, Article 3, Dental Care?

          • Clinical-Dental Practice – Was there proficiency in using the dental equipment and materials during the procedure as well as in applying infection control procedures?

          • Clinical-Patient Care – Did the dentist effectively deliver dental care so that patient discomfort was minimized whenever possible? Was the care provided within the guidelines set forth by the HCDOM, Chapter 3, Article 3, Dental Care and the Standard of Care in Dentistry?

          • Clinical Interaction With Auxiliary Staff – Was the auxiliary dental staff effectively utilized to their level of licensure and was auxiliary staff given clinical direction in an adequate manner?

      • Mentoring to foster continuous professional development and training for dentists if they fail to demonstrate acceptable skills. Additional training may be required if this occurs. The mentoring process shall be performed by the SD.

        • In determining the level of mentoring required, consideration shall be given to the dentist’s judgment, skills, recognition and management of complications and treatment outcomes.

        • The mentoring process shall last for a minimum of six months and may include:

          • Items outlined in Section (c)(3)(F)2.a.

          • Provision for mentoring to be extended in 30 day increments up to a total of 12 months.

      • The SD who shall place reports of cases used for proctoring or mentoring in the appropriate dentist’s supervisory file for a period of one year or until the dentist in question receives their next annual performance appraisal.

    • Reference the HCDOM, Section 3.3.4.2(e)(3) and (4) for further DPRC responsibilities.

    • The DPRC may choose to utilize a non-CDCR employed, outside consultant for an independent evaluation of a case, only with the approval of the DSDD or SDD.

    • When performing peer reviews, DPRC members shall collaborate to reach a consensus and shall assign one agreed upon rating to each of the ten categories on the Dental Peer Review Audit Tool. In the event the DPRC members are unable to agree on the rating for a particular category, the chairperson or vice-chairperson shall decide the appropriate rating to be assigned.

    • The DPRC shall generate and submit the following peer review documents to the appropriate RDD for validation by PST dentists and to the HDPRC. The originals shall be kept on file by the DPRC for a period of three years and copies sent to the appropriate RDD and to the HDPRC. The RDD and PST dentists shall maintain peer review documents used for DPRC validation for a period of three years.

      • A Dental Peer Review Audit Tool Summary for each dentist who is the subject of a review.

      • A Review Summary Report consisting of a compilation of the results of each Dental Peer Review Audit Tool Summary produced subsequent to a health record case review.

    • When proctoring, mentoring, or other routine peer review results suggest questionable treatment or identify a pattern of substandard practice, the SD shall refer the findings to the RDD and/or HDPRC.

    • Any institutional dentist receiving an unacceptable score on the Dental Peer Review Audit Tool may be directed to receive one or all of the following by the DPRC under the guidance of the RDD and/or the HDPRC:

      • Appropriate counseling.

      • Appropriate remedial training or continuing education.

      • Continued mentoring and review of their work until satisfactory scores are obtained or it becomes apparent that remediation is not a viable option.

  • ‘For Cause’ Review Process

    • The ‘for cause’ review process may be initiated as a result of credible information provided by any person to institution, regional, or headquarters dental or administrative staff about the conduct, performance, or competence of dental practitioners. Anonymous referrals shall not be considered.

    • Sources of information may include, but are not limited to:

      • Staff.

      • Patients.

      • The public.

      • The credentialing process.

      • The privileging process.

      • The peer review process.

      • The death review process.

      • The quality review process.

  • Review Accountability

    • Reviews performed by HDPRC/DPRC members, PST staff, or outside consultants on clinicians employed by CDCR are to be forthright and objective in nature.

    • Performing a review that does not present an accurate assessment of a clinician’s standards of practice and clinical skills is unacceptable.

Policy

• The Division of Health Care Services (DHCS), Adult Correctional Dental Care (ACDC) shall maintain a Dental Program Subcommittee (DPS) to provide oversight and overall direction of the dental program. The DHCS, DPS shall plan, develop and manage timely access to effective and appropriate dental services consistent with the standards of the California Department of Corrections and Rehabilitation (CDCR). In addition, each CDCR institution shall establish a Facility Dental Program Subcommittee (FDPS).

Purpose

• To ensure that CDCR patients are provided with quality dental services that are cost effective and in compliance with all applicable laws, regulations, policies and procedures.

Responsibilities

• The DHCS, DPS shall report to the California Correction Health Care Services Executive Quality Management Committee (QMC) and its duties, as they relate to the performance of CDCR dental clinical programs, may include, but are not limited to:

  • Providing oversight of the program’s strategic goals and objectives.

  • Reviewing and monitoring FDPS Quality Management/Quality Assurance initiatives.

  • Reviewing and taking appropriate action on program management reports.

  • Recommending measures for improvement of services.

  • Ensuring compliance with legal and regulatory agencies.

  • Reviewing training curricula, plans and clinical guidelines.

• The FDPS shall:

  • Report to the Institution QMC.

  • Be responsible for the overall planning and management of the institutional dental program by:

    • Evaluating the timeliness, appropriateness and quality of patient dental services.

    • Developing, implementing and reviewing current local operating procedures for the dental program.

    • Monitoring and analyzing relevant data trends and patterns related to the institution dental program presented by the Health Program Manager (HPM) III.

    • Chartering Quality Improvement Teams (QITs)  to review, study and/or audit specific program performance issues, provide findings and make recommendations for improvement of dental services.

    • Developing, implementing and reviewing an ongoing program of orientation and in-service training for relevant staff related to dental policies and protocols.

    • Identifying additional local resource needs related to dental services.

    • Reviewing and recommending development or modification of statewide dental policies, protocols, training and data management.

Membership

• DHCS, DPS

  • The members of the DHCS, DPS shall be selected so as to represent the program for the appropriate and coordinated delivery of dental services.

  • The Statewide Dental Director or designee shall serve as chairperson of the DHCS, DPS.

  • The DHCS, DPS may include the following members:

    • DHCS, ACDC headquarters staff.

    • DHCS, ACDC regional staff.

• FDPS

  • The members of the FDPS shall be selected so as to represent the program and functional areas of the institution that are necessary for the appropriate and coordinated delivery of dental services.

  • The HPM III or Supervising Dentist (SD) shall serve as chairperson of the FDPS.

  • The FDPS shall include the following members:

    • HPM III and/or SD.

    • Dentist Correctional Facility (CF).

    • Supervising Dental Assistant CF.

    • Dental Assistant CF.

    • Dental Analytical/Clerical Support (Health Program Specialist, Staff Services Analyst, Office Technician (OT), etc.)

    • Dental Hygienist CF.

    • Dental Laboratory Technician CF.

    • Representatives from other institution services or divisions (Custody, Plant Operations, Procurement, Contract Analyst, Associate Warden [AW] for Health Care Services, or Captain when there is no Health Care Services AW position allocated at the institution, etc.) shall be invited to committee meetings as non-voting guests when appropriate.

Meeting Schedule and Quorum

• DHCS, DPS

  • The DHCS, DPS shall meet at least annually and there is no required quorum.

  • Meeting minutes shall be recorded and maintained for a period of at least three years by designated DHCS, ACDC headquarters staff.

• FDPS

  • The FDPS shall meet on a monthly basis, but may meet more often if deemed necessary by the HPM III or SD.

  • A quorum consists of the HPM III or SD and one each of the dental staff in Section (d)(2)(C)2. Through 5. (6. and 7.  where applicable).

  • A written agenda shall be formulated under the direction of the chairperson or designee and distributed by the OT to all attendees prior to each meeting.  Requests for items to be placed on the agenda must arrive to the chairperson ten business days prior to the regularly scheduled committee meeting.

  • Each recommendation shall be reviewed as part of old business at subsequent meetings and shall be monitored until resolved.

  • The chairperson or designee shall provide regular reporting of the FDPS meetings to the Institution QMC.

  • The OT shall record written minutes of all committee meetings which shall contain specific recommendations for action when appropriate.  A draft of the minutes shall be distributed to all attendees as promptly as possible by the OT for review and revision. The HPM III shall maintain minutes of the FDPS meetings for a period of at least three years.

Policy

• All California Department of Corrections and Rehabilitation (CDCR) institutions shall maintain a Dental Authorization Review (DAR) Committee and Adult Correctional Dental Care (ACDC) headquarters shall maintain a Dental Program Health Care Review Committee (DPHCRC).

Purpose

• To maintain a process for evaluating and approving or disapproving a clinician’s request(s) for deviations from treatment policy, otherwise excluded dental services, or medically necessary treatment that can only be provided by a contracted specialist.

Procedure

• Membership

  • DAR Committee

    • The DAR Committee shall consist of:

      • A staff dentist elected for a one-year period as chairperson by the other staff dentists at the institution. This individual shall be eligible to serve no more than two consecutive terms before being replaced as chairperson and must wait one year before becoming eligible for re-election to the position of chairperson. Exceptions to this rule may be granted by either the Deputy Statewide Dental Director (DSDD) or Statewide Dental Director (SDD).

      • A staff dentist elected for a one-year period as vice-chairperson by the other staff dentists at the facility. This individual shall fulfill the responsibilities of the chairperson in their absence. The vice-chairperson shall be eligible to serve no more than two consecutive terms before being replaced and must wait one year before becoming eligible for re-election to the position of vice-chairperson. Exceptions to this rule may be granted by either the DSDD or SDD.

      • Any institutional dentist(s) providing dental services to patients at the institution.

      • Representatives from other institution services or divisions as non-voting invitees, when needed.

    • A dentist who has served the maximum allowable period of time as chairperson shall be eligible for election as vice-chairperson for a one-year period and shall be eligible to serve no more than two consecutive terms as vice-chairperson, after having served the maximum allowable period of time as chairperson, before being replaced. This individual must wait one year before becoming eligible for re-election to the position of chairperson or vice-chairperson. Exceptions to this rule may be granted by either the DSDD or SDD.

    • A dentist who has served the maximum allowable period of time as vice-chairperson shall be eligible for election as chairperson for a one-year period and shall be eligible to serve no more than two consecutive terms as chairperson, after having served the maximum allowable period of time as vice-chairperson, before being replaced. This individual must wait one year before becoming eligible for re-election to the position of chairperson or vice-chairperson. Exceptions to this rule may be granted by either the DSDD or SDD.

    • The quorum necessary to determine cases shall be the chairperson or vice-chairperson and two staff dentists.  The treating dentist will not be included to meet the quorum.

    • Decisions to approve or disapprove requests for dental services which have been referred to the DAR Committee shall be based upon the decision adopted by a majority of the DAR Committee members present.

  • DPHCRC

    • The DPHCRC shall consist of, but not be limited to, the following:

      • Chief Dentist (CD), Quality Management/Utilization Review, ACDC, DHCS.

      • CD, Policy and Risk Management, ACDC, DHCS.

      • CD, Training, ACDC, DHCS.

      • A minimum of two dentists, ACDC, DHCS.

    • Decisions to approve or disapprove requests for dental services which have been referred by the DAR Committee shall:

      • Require the attendance of a minimum of three dentists, ACDC, DHCS, at least one of which must be a CD or their designee.

      • Be based upon the decision adopted by a majority of the DPHCRC members present.

• Meetings

  • DAR Committee

    • The DAR Committee shall meet monthly or as often as necessary to deliberate on and approve or disapprove dental clinician requests as outlined in Section (b).  

    • The DAR Committee does not have to meet when there are no cases to deliberate. However, institutions must indicate on the DAR Committee meeting minutes that no meeting was held for the particular month.

    • Committee decisions concerning requests for special dental services shall be based on criteria established in the California Code of Regulations (CCR), Title 15, Division 3, Chapter 2, Subchapter 2, Article 1, Section 3999.200(c).

    • The Health Program Manager (HPM) III shall maintain written minutes recorded by the Office Technician (OT) or designated dental staff of all committee meetings which shall contain date, time and location of the meeting; committee members present; cases discussed; treating dentists; and the decision on the requests.  The minutes shall be maintained by the HPM III for a period of three years.

    • The DAR Committee shall review each clinician’s request as part of old business at subsequent meetings and shall continue to monitor until resolved.

    • The HPM III, or designee, shall post a copy of the DAR minutes in the institution’s DAR folder on the Dental Program headquarters ShareDrive on a monthly basis. If the DAR Committee does not meet during a particular month, the HPM III, or designee, shall post a notice in the institution’s DAR folder on the Dental Program headquarters ShareDrive indicating that no DAR Committee meeting was held.

    • DAR Committee requests at the institution level shall be reviewed and either approved or disapproved within 15 business days of receipt by the DAR Committee.

  • DPHCRC

    • The DPHRC shall meet monthly or as often as necessary to deliberate on and approve or disapprove dental clinician requests as outlined in Section (b).  

    • Committee decisions concerning requests for special dental services shall be based on criteria established in the CCR, Title 15, Division 3, Chapter 2, Subchapter 2, Article 1, Section 3999.200(c).

    • A designated DPHCRC member shall maintain written minutes of all committee meetings which shall contain the date; committee members present; cases discussed; and the decision on the requests.

    • The CD, Quality Management/Utilization Review, shall maintain meeting minutes and all documents submitted with each case, including models, for a period of three years.

    • Cases requiring DPHCRC action shall be evaluated and approved or disapproved within 15 business days of receipt by the DPHCRC.

    • The DPHCRC’s decision shall be communicated to the Supervising Dentist (SD).

    • Cases denied by the DAR Committee do not require DPHCRC action; however they shall be forwarded to the DPHCRC who shall keep a record of all cases denied by the DAR Committee for quality control purposes.

• Requests or Referrals for Treatment by a Specialist

  • Any dental care that a treating dentist wishes to refer to a specialist for treatment shall be submitted for approval by the DAR Committee prior to initiating the procedure(s) being referred. (Reference Section (4)(E)).

• Operational Steps for Requests or Referrals Requiring DAR Committee Action

  • The treating dentist shall base the request on a documented oral condition. At a minimum, each request submitted for treatment to be performed on grounds by a CDCR dentist or a contracted provider shall include the following:

    • Patient study models that are properly trimmed and labeled with the date and the patient’s name and CDCR number.

    • Any other relevant documents or information.

  • Each request submitted for treatment by an off-site provider shall include:

    • Section (c)(4)(A)1. and 2.

    • Copy of patient dental record pertinent to the case.

    • Copy of current radiographs (i.e., Panoramic, peri-apical, full mouth series) as necessary.

  • The treating dentist shall:

    • Complete a CDC 7243, Health Care Services Physicians Request for Services, and a DAR Request if the patient is being referred for treatment by an off-site provider.

    • Complete only a DAR Request if treatment will be performed on grounds by a CDCR dentist or a contract provider.

    • Enter the request in the Electronic Dental Record System (EDRS) Treatment Request Manager in accordance with EDRS Workflow 1-7.1 and associated Back Office Job Aid. The treating dentist shall also document the request in a clinical note in the EDRS, in accordance with EDRS Workflow 1-2 and associated Back Office Job Aid.

    • Assign a DPC 5 to treatment in the EDRS that is planned for referral to the DAR Committee, in accordance with EDRS Workflow 1-3 and associated Back Office Job Aid. (Reference the Health Care Department Operations Manual [HCDOM], Section 3.3.6.6(c)(2) for requirements concerning placing a dental hold).

    • Discuss the request with the patient.

    • Obtain the patient’s verbal consent for the referral and specific treatment to be done and document this in a clinical note in the EDRS, in accordance with EDRS Workflow 1-2 and associated Back Office Job Aid. The patient and the provider performing the procedure shall sign the appropriate written consent form on the day treatment is provided.

    • Provide the OT or designated dental staff with a copy of the CDC 7243.

  • The treating dentist shall submit the request to the SD for review and approval or disapproval. Approved requests shall be forwarded to the HPM III who shall ensure timely scheduling of the request for consideration by the committee.

  • The DAR/DPHCRC approval process may be bypassed if the SD determines that the specialty services or consultation are required because of Emergency or Dental Priority Classification (DPC) 1A conditions.

  • For requests not identified as an Emergency or DPC 1A condition, the HPM III shall forward the request to the chairperson to be placed on the agenda for the next DAR Committee meeting by the OT or designated dental staff. 

  • The agenda shall be formulated under the direction of the chairperson and distributed by the OT or designated dental staff to all attendees prior to each meeting. Requests must be received by the chairperson prior to the scheduled committee meeting.

  • Pre-authorization by the SD is required prior to beginning any requested treatment beyond that necessary to relieve symptoms. 

  • The treating dentist is allowed to present the case and answer any questions the committee members may have but shall not participate in deliberations during the decision process.

  • The committee decision shall be based on available dental care outcome data supporting the effectiveness of the service as dental treatment, coexisting medical or dental problems, acuity of the condition, time remaining on the patient’s sentence (Reference the HCDOM, Section 3.3.5.3, Appendix 1, Dental Priority Classification), availability of the service(s), and cost.

  • Requests Submitted for DAR Committee Deliberation

    • Requests for extractions and treatment of fractures and/or oral pathology shall be submitted to the DAR Committee for deliberation.

    • Requests for medically necessary pre-prosthetic surgery that cannot be accomplished by CDCR dentists at the local institution (Reference the HCDOM, Section 3.3.2.6(c)(1)(E)) shall be submitted to the DAR Committee for deliberation.

    • The above requests do not require submission to the DPHCRC for evaluation and final approval.

  • Requests submitted to the DAR Committee for services other than those listed in Section (c)(4)(K) shall be forwarded to the DPHCRC.

  • The HPM III shall:

    • Ensure that institution DAR Committee decisions requiring DPHCRC involvement are forwarded to the DPHCRC along with all supporting documentation.

    • Monitor the DAR/DPHCRC approval process and ensure scheduling of any approved specialty appointment(s) in conjunction with the UM nurse if necessary.

    • Request timely notification by the UM nurse of completed specialty care appointments.

    • Ensure that the required DAR Committee reviews, decisions, notification of treating dentists and referrals to DPHCRC meet the stipulated time limits.

  • The SD shall share the DAR Committee’s or DPHCRC’s approval or denial of a request with the attending dentist. The attending dentist shall document DAR Committee and DPHCRC final decisions in a clinical note in the EDRS, in accordance with EDRS Workflow 1-2 and associated Back Office Job Aid. Only when a request is denied and treatment will not be provided shall the attending dentist promptly inform the patient of the denial and shall document the notification in a clinical note in the EDRS, in accordance with EDRS Workflow 1-2 and associated Back Office Job Aid.

• Operational Steps for Requests or Referrals Not Requiring DAR Committee Action

  • For requests or referrals for consultation with institution health care providers, the treating dentist shall enter a Dental Consultation Treatment Request in the EDRS Treatment Request Manager and place the appropriate order in the Electronic Health Record System in accordance with EDRS Workflow 1-7.1 and associated Back Office Job Aid.

  • In addition, the treating dentist shall:

    • Document the request in a clinical note in the EDRS, in accordance with EDRS Workflow 1-2 and associated Back Office Job Aid.

    • Discuss the request or referral with the patient.

• The OT or designated dental staff, under the direction of the treating dentist, shall monitor requests or referrals for consultation as outlined in the HCDOM, Section 3.3.5.8(c)(7).

Policy

• All California Department of Corrections and Rehabilitation (CDCR) dental staff shall take clinically diagnostic radiographs and shall comply with all applicable safety and regulatory standards when capturing and processing dental radiographic images.

Purpose

• To establish procedures and guidelines that assist CDCR dental staff to produce dental radiographs of high diagnostic quality.

Procedure

• The Supervising Dentist and/or Supervising Dentist Assistant at each institution shall be responsible for coordinating preventive maintenance for dental radiographic units as well as digital radiographic image capturing, viewing, and storage equipment by qualified service technicians.

• Digital Radiographs

  • Dental staff shall follow the manufacturer’s recommended procedures for operating and maintaining digital radiographic image capturing, viewing, and storage equipment. This includes, but is not limited to, the proper use, handling and maintenance of digital radiographic sensors.

  • Dental staff shall preserve the integrity, diagnostic reliability and privacy of digital radiographs.

  • Dental staff shall ensure the storage of digitally captured radiographs for inclusion in the patient’s Medicor Imaging Picture Archive Communication System (MiPACS) record.

• The California Correctional Health Care Services, Information Technology, Solution Center shall be the system used to provide ongoing support for MiPACS users to resolve application related issues, grant or modify MiPACS access, submit image record corrections to the MiPACS Administrator, and make hardware changes. (Reference the MiPACS User Guide for further details).

Policy

• All California Department of Corrections and Rehabilitation (CDCR) dental departments shall be provided with sufficient suitable space, equipment and supplies to provide and maintain an adequate dental health care delivery system in each institution.

Purpose

• To establish guidelines and basic requirements for adequate space, equipment and supplies in order to deliver dental services in CDCR facilities.

Procedure

• Major and minor dental equipment (e.g., dental operatory chair and delivery systems, handpieces, X-ray units, sterilizers, vacuums and compressors) shall be standardized statewide in all dental clinics to ensure safety and allow for a consistent level of care, facilitate in the training of all staff and increase efficiency in the delivery of dental care.

• All clinical dental staff shall receive training on the proper operation and maintenance of major and minor dental equipment. The Health Program Manager III shall maintain training records on the proper operation and maintenance of major and minor dental equipment for a period of three years.

• Examination and treatment rooms for dental care shall be large enough to accommodate the equipment and fixtures needed to deliver adequate dental services.

• Institution dental department management shall establish and maintain a process to manage dental supply inventory which shall include, but not be limited to:

  • Assigning responsibility for inventory oversight.

  • Centralizing supply storage.

  • Limiting access to supply inventory.

  • Rotating stock kept in storage.

  • Monitoring supply usage in the clinics to prevent materials from expiring.

  • Purchasing supplies in the most economical manner available which shall include, but is not limited to, use of the Statewide Dental Supply Formulary.

  • Adjusting purchasing practices to minimize waste.

• Each dental clinic shall have pharmaceuticals, medical supplies, and mobile emergency equipment, (i.e., oxygen, Automated External Defibrillator [AED]) available for management of medical emergencies in the dental clinic.

• If laboratory, radiological, inpatient, or specialty services are provided on-site, the area(s) devoted to any of these services shall be appropriately constructed in accordance with state and federal guidelines for health and safety and be of sufficient size to accommodate all necessary equipment, records, supplies, tools, etc.

• The following major and minor dental equipment may be replaced according to the indicated replacement cycle date or, if applicable, according to the manufacturer’s instructions, whichever is sooner:

  • Dental Operatory System: every 10 years.

  • Panoramic Unit: every 15 years.

  • Intraoral Radiographic Unit: every 15 years.

  • Vacuum/Compressors: every 5-7 years.

  • Autoclave: every 5 years.

• Major and minor dental equipment that becomes inoperable and is irreparable as determined by a certified service technician shall be replaced regardless of the number of years the equipment has been in service.

• The evaluation and selection of major and minor dental equipment shall be determined by the CDCR, Division of Health Care Services (DHCS), Adult Correctional Dental Care (ACDC).

• The research and evaluation process shall include, but is not limited to:

  • Product evaluation reports from the United States Armed Forces, and the American Dental Association.

  • Evaluation and analysis of the quality and performance factors of existing dental equipment in CDCR and other agencies (e.g., Veterans Administration, Dental Schools, United States Armed Forces) by DHCS, ACDCAdministrators.

• After a period of five years or longer, depending on the replacement cycle of the equipment, a re-evaluation, analysis, and selection of major and minor dental equipment shall be conducted by CDCR, DHCS, ACDC Administrators.

Policy

• Dental departments within the California Department of Corrections and Rehabilitation (CDCR) may utilize incarcerated persons as dental laboratory technician trainees and dental porters.  The utilization of incarcerated dental workers shall require the prior approval of the institution’s Associate Warden (AW) for Health Care Services, or Captain when there is no Health Care Services AW position allocated at the institution.

Purpose

• To establish guidelines for the utilization of incarcerated workers in CDCR dental departments.

Procedure

• Incarcerated persons shall be prohibited from performing the following duties in all CDCR dental departments:

  • Providing direct patient care services.

  • Scheduling health care appointments.

  • Determining patients’ access to dental services.

  • Handling or having access to dental instruments, syringes, or needles.

  • Operating medical/dental equipment with the exception of dental laboratory technician trainees.

  • Handling or having access to medications or health records.

  • Cleaning or disinfecting dental operatory equipment between patient appointments.

  • Cleaning and changing dental vacuum traps or chairside suction filters.

  • Cleaning and changing amalgam collectors/separators.

• CDCR dental departments may utilize incarcerated workers as dental laboratory technician trainees and porters only after the incarcerated workers have:

  • Successfully completed training in Bloodborne Pathogens Regulations and the Senate Bill (SB) 198 Injury and Illness Prevention Program.  Minutes of all training sessions for incarcerated workers and a statement of completion of the training, signed by the incarcerated person, shall be documented and kept on file by the incarcerated supervisor prior to the incarcerated person performing any work assignments.

  • Been offered a Hepatitis B vaccination series.

• All incarcerated workers shall have signed duty statements listing the job performance requirements and health and safety regulations. 

• Incarcerated workers shall adhere to all safety, security and custodial regulations while working in the dental department.

• All incarcerated workers shall be assigned to the dental department by the facility’s Inmate Work Incentive Program (IWIP) Coordinator. 

• All supervisors of incarcerated workers shall adhere to and enforce the rules and regulations of the IWIP in the supervision of incarcerated workers and shall be responsible daily for accurately maintaining incarcerated workers’ time sheets.

• All incarcerated workers in the dental clinic shall be under the direct supervision of a CDCR staff member at all times excluding the office technician.

• Incarcerated dental laboratory technician trainees in the dental laboratory shall be allowed to handle dental equipment, instruments, or tools only under the direct supervision of a CDCR Dental Laboratory Technician.

• All incarcerated workers shall receive annual training in Bloodborne Pathogens Regulations and the SB 198 Injury and Illness Prevention Program.  Training may be provided more frequently if necessary.