Chapter 3 – Health Care Operations

Policy

• The California Department of Corrections and Rehabilitation (CDCR) shall maintain and utilize a system of priority ducats to provide patients timely access to dental care.

Purpose

• To maintain a process that provides all patients with access to dental care through the successful implementation of a dental ducat delivery process within CDCR.

Procedure

• General Requirements

  • Each institution shall establish procedures for processing, distributing and documenting dental ducats that:

    • Provide patients with timely access to dental care.

    • Provide a system of accountability for the distribution and delivery of dental ducats.

    • Provide a method for documenting and processing a patient’s refusal or failure to report for scheduled dental appointments.

  • These procedures shall include:

    • Provision for the Office Technician (OT), or designated dental staff, under the direction of the dentist, to enter dental appointments in the Electronic Dental Record System (EDRS) Appointment Book no later than one day prior to the scheduled encounter.  The OT, or designated dental staff, shall schedule patients for dental appointments at designated intervals in accordance with EDRS Workflow 2-1 and associated Front Office Job Aid.

    • A written methodology for the distribution of ducats within the institution, which shall include instructions that, upon receipt, the facility or program unit custodial supervisor or designated custodial staff shall be responsible for delivering the ducats to the patients in a timely manner, in accordance with the correctional facility’s local operational procedures.

    • A written methodology for documenting the delivery of the dental ducats to the patients ensuring that they shall receive a ducat prior to their scheduled appointment and shall arrive at the clinic at the specified time on the ducat.

    • A written methodology for re-routing dental ducats to patients who have received intra-facility bed/cell moves, which ensures that patients will receive the ducats with sufficient time to report for scheduled appointments.

    • Provision for Developmental Disability Program (DDP)/Disability Placement Program (DPP) designated patients to be given specific instructions concerning the time and location of their scheduled appointment(s).  Custody staff delivering the ducats to such designated patients shall utilize effective forms of communication to ensure that the patients arrive at the designated appointment location.

    • A notation that Health Care Services ducats shall be treated as priority ducats.  For the purpose of this policy, priority ducats indicate the necessity of dental care.

    • Provision for patients to bear the responsibility of reporting to the dental appointment as indicated on the priority health care ducat. (Reference the California Code of Regulations [CCR], Title 15, Division 3, Chapter 1, Article 1, Section 3014 “Calls and Passes”).

    • A system to provide patients timely access to health care services from any facilities or housing units on modified program or lock down status. (Reference the Health Care Department Operations Manual (HCDOM), Section 3.3.5.13(d)(7))

• Dental Ducat Cancellation or Rescheduling at the Patient’s Request

  • In the event a patient informs the Correctional Officer (CO) delivering the ducat that they wish to refuse, cancel or reschedule their appointment, the CO shall advise the patient that they must report to the ducat in person to refuse, cancel or reschedule.

  • The patient’s cancellation or request for rescheduling an appointment shall be regarded as a refusal and is subject to the provisions outlined in Section (c)(4)(C)3.

• Dental Ducat Cancellation or Rescheduling by Dental Staff

  • If a patient’s scheduled appointment for Dental Priority Classification (DPC) 1A dental care is cancelled or rescheduled by dental staff, then the patient shall be seen by a dentist within one calendar day.  For all other DPC appointments, the dentist shall see the patient within 35 calendar days of the cancelled appointment or consistent with the timeframe associated with the original DPC code assigned at the date of diagnosis, whichever is shorter.

  • If a patient’s face-to-face triage or limited problem focused exam encounter is cancelled or rescheduled by the dental clinic, then the patient shall be seen by a dentist within the following three business days.

• Failure to Report for Dental Ducats

  • If a patient fails to report for an appointment, the CO assigned to the dental clinic area shall attempt to locate the patient and notify the custody supervisor if unable to locate the patient.

  • Unintentional Failure

    • If it is determined that the patient failed to report for reasons beyond their control, the matter shall be referred to the Health Program Manager III, who shall seek to ensure that corrective measures are taken.

    • The dentist or designee shall notify the OT or designated dental staff to reschedule the patient. 

    • If a patient unintentionally fails a dental appointment, then the dentist shall see the patient within one calendar day for a DPC 1A dental need.  For all other DPC needs, the dentist shall see the patient within 35 calendar days following the unintentional failure or consistent with the timeframe associated with the original DPC code assigned at the date of diagnosis, whichever is shorter.

    • If a patient unintentionally fails a face-to-face triage or limited problem focused exam encounter, then the patient shall be seen by a dentist for a face-to-face triage or limited problem focused exam within three business days.

    • Dental staff shall document the reason for the patient’s failure to report to the scheduled appointment and that the patient was rescheduled as appropriate in a clinical note in the EDRS, in accordance with EDRS Workflow 1-2 and associated Back Office Job Aid.

  • Intentional Failure

    • If it is determined that the failure to report was intentional on the part of the patient, then the dentist, or designated DA or OT shall request that the patient be sent or escorted to the dental clinic. 

    • If the patient refuses to go to the dental clinic, then the custody staff shall notify the dentist, or designated DA or OT. 

    • The dentist shall record the intentional failure to report as a refusal in a clinical note in the EDRS, in accordance with EDRS Workflow 1-2 and associated Back Office Job Aid, as well as complete a CDCR 7225-D, Dental Refusal of Examination and/or Treatment. (Reference the HCDOM, Section 3.3.5.6(c)(6) for other requirements concerning a patient refusal).

    • In the event a patient intentionally fails to report for a dental appointment, a dentist shall conduct a face-to-face interview and counseling session with the patient.

      • The dentist shall follow the processes described in the HCDOM, Section 3.3.5.6(c)(1) through (3).

      • Patients who are insistent in their refusing to report shall not be subject to cell extraction or use of force to gain compliance with the priority health care ducat. In these instances, a dentist must respond to the patient’s housing unit, at a time that does not interfere with patient care, to provide the necessary education regarding the refusal. Custody staff cannot accept refusals on behalf of the patient.

      • If the patient refuses the face-to-face interview and counseling session, then the dentist shall record this refusal as outlined in Section (c)(4)(C)3.

    • Patients who intentionally fail to report for a dental appointment shall be required to submit a CDCR 7362, Health Care Services Request Form, in order to access future dental care.

  • Dental staff and/or custodial staff, as appropriate, may initiate progressive incarcerated person disciplinary action, as necessary, based on the factors of the patient’s failure to report. (Reference the CCR, Title 15, Division 3, Chapter 1, Article 1, Section 3000, “Definitions – General Chrono” and/or the CCR, Title 15, Division 3, Subchapter 4, Article 5, Section 3312, “Disciplinary Methods”).

Policy

• All California Department of Corrections and Rehabilitation (CDCR) dental departments shall document and monitor patient requests for dental treatment submitted via the CDCR 7362, Health Care Services Request Form.

Purpose

• To standardize the recording and scheduling of patient dental encounters.

Procedure

• The Electronic Dental Record System (EDRS) is used for documenting and monitoring patient requests for dental treatment and to schedule encounters. Patients are able to request or access dental services as outlined in the Health Care Department Operations Manual (HCDOM), Section 3.3.5.13(c)(4).

  • A dental staff member shall document patient requests for dental treatment (via a CDCR 7362 or otherwise) in the EDRS Treatment Request Manager, in accordance with EDRS Workflow 1-2 and associated Front Office Job Aid.  Requests generated at chairside shall be completed as outlined in Sections (c)(2)(B) and (c)(3)(A) of this chapter.  (Reference the HCDOM, Section 3.3.5.13(d)(2)(B)5. through 7. for CDCR 7362 review requirements).

  • All patients shall be scheduled in advance, on an equal basis, based on the severity of their dental conditions and where applicable, after fulfilling eligibility requirements for Plaque Index score and time remaining on their sentence (Reference the HCDOM, Section 3.3.5.3, Appendix 1, Dental Priority Classification).

  • The Office Technician (OT), or designated dental staff, shall enter dental appointments in the EDRS to facilitate creation of priority ducats which shall be distributed as outlined in the HCDOM, Section 3.3.5.1(c)(1)(B).

  • The California Correctional Health Care Services, Information Technology, Service Now shall be the system used to provide ongoing support for EDRS users to resolve application related issues, grant or modify EDRS access, and make hardware changes.

• Information entered in the EDRS is for the purpose of documenting patient dental encounters and monitoring access to care.

  • The provider or designee shall be responsible for correctly and accurately entering all pertinent information in the EDRS.

  • For patients with a Dental Priority Classification (DPC) 1, 2 or 3, as documented in the EDRS Treatment Plan, the provider or designee shall ask the patient, at the end of the encounter, if they would like to request for further treatment. (Reference the HCDOM, Section 3.3.2.2(c)(2)(C) and (D) for exceptions to this procedure).

• Patient Requests for Further Treatment at the End of a Dental Encounter

  • If a patient has a current EDRS treatment plan or valid outstanding procedures, and requests further treatment at the end of a dental encounter, the provider shall document the request in a clinical note in the EDRS. The OT, or designated dental staff, shall schedule the patient for treatment at the next available encounter relative to the patient’s DPC. (Reference the HCDOM, Section 3.3.5.3(c)(5) for timeframe requirements within which treatment must be initiated).

  • If a patient requests further treatment and does not have a current EDRS treatment plan and is eligible for a comprehensive exam, or in the provider’s opinion the patient’s dental condition warrants a new comprehensive exam, they shall complete and sign a CDCR 7362 stating “Exam.” The provider, or designee, shall notify the OT, or designated dental staff, to schedule the patient for a comprehensive exam at the next available encounter. (Reference the HCDOM, Section 3.3.2.3(c)(1)(A)(2) and (c)(2)(F) for timeframe requirements within which treatment must be initiated). The OT, or designated dental staff, shall scan the CDCR 7362 into the EDRS Document Center.

  • If a patient refuses to request further dental treatment at the end of a dental encounter, where a current treatment plan or valid outstanding procedures exist, then the provider shall document the refusal in a clinical note in the EDRS, in accordance with EDRS Workflow 1-2 and associated Back Office Job Aid, and complete a CDCR 7225-D, Dental Refusal of Examination and/or Treatment. (Reference the HCDOM, Section 3.3.5.6(c)(6) for other requirements concerning a patient refusal). The patient shall be required to submit a CDCR 7362 to access future dental care.

Policy

• The dental treatment needs of California Department of Corrections and Rehabilitation (CDCR) patients shall be addressed based on the priority of need, time remaining on their sentence (Reference Appendix 1, Dental Priority Classification), and where applicable, the patient’s demonstrated willingness to engage in proper oral hygiene.  A CDCR dentist shall assign an objective Dental Priority Classification (DPC) to each newly admitted patient upon entering the CDCR and after each dental encounter.

Purpose

• To ensure that all patients have equal access to dental services based upon the occurrence of disease, significant malfunction, or injury and medical necessity.

Procedure

• All patients shall be assigned a DPC at the Reception Center Screening, at the time of their comprehensive dental examination at a Mainline Facility and after each face-to-face triage, limited problem focused exam or treatment encounter.  This DPC shall be reviewed and appropriately modified after each dental encounter.

• Dental treatment shall be prioritized as follows:

  • DPC 1A, 1B, 1C:  Urgent Care.

  • DPC 2:  Interceptive Care.

  • DPC 3:  Routine Rehabilitative Care.

  • DPC 4:  No Dental Care Needed.

  • DPC 5:  Special Dental Needs Care

• Emergency dental treatment shall be available on a 24 hour, seven days per week basis.

• In general, dental encounters shall be scheduled based on the patient’s DPC, as determined by a CDCR dentist.

• Once a dentist has diagnosed a dental condition, treatment shall be initiated within the timeframes indicated for each DPC and subject to the limitations listed in Section (c)(7) and (8).

• The DPC timeframe shall be adhered to so long as it is consistent with the community standard of care for general dentistry. Deviation from the DPC timeframe is permitted if complying with the DPC timeframes is not, for whatever reason, in the best interest of the patient. In such instances, the clinician shall document in a clinical note in the Electronic Dental Record System (EDRS), in accordance with EDRS Workflow 1-2 and associated Back Office Job Aid, that they are deviating from the Health Care Department Operations Manual (HCDOM), Chapter 3, Article 3, Dental Care, the reason for the deviation, and that the deviation is consistent with the community standard of care.

• Patient eligibility for DPC 3 care shall be subject to the requirements outlined in the HCDOM, Section 3.3.2.13(c)(2).

• Patients with less than 12 months of verifiable, continuous incarceration time remaining on their sentence in a Mainline Facility shall receive only Emergency and DPC 1 and 2 dental care. Patients with less than six months of verifiable, continuous incarceration time remaining on their sentence in a Mainline Facility shall receive only Emergency and DPC 1 dental care.

• Following each encounter, a dentist shall update the patient’s DPC and document it in a clinical note in the EDRS, in accordance with EDRS Workflow 1-2 and associated Back Office Job Aid. This DPC is reflective of the status of the patient’s oral condition after the encounter.

Policy

• All Mainline Facility patients who receive a comprehensive dental examination by a California Department of Corrections and Rehabilitation (CDCR) dentist shall have an individual treatment plan developed in conjunction with the examination. The dentist shall explain the advantages and disadvantages of the treatment plan to the patient.

Purpose

• To establish guidelines for the development of individual dental treatment plans for Mainline Facility patients in the CDCR.

Procedure

• Prior to receiving routine dental care, all Mainline Facility patients shall have a dental treatment plan documented on the Electronic Dental Record System (EDRS) odontogram and Progress Note panel in accordance with EDRS Workflow 1-3 and associated Back Office Job Aid. (Reference the Health Care Department Operations Manual [HCDOM], Section 3.3.2.6(c)(1)(F) regarding treatment plans that include a dental prosthesis).

• The dentist performing the examination and establishing the treatment plan shall verify that the patient received a Dental Materials Fact Sheet (DMFS) and has signed a CDCR 7441, Patient Acknowledgement of Receipt of DMFS.  If this did not occur then the dentist shall provide one and shall have the patient sign a CDCR 7441.

• Appropriate radiographs shall be available and interpreted by the treating dentist when developing a dental treatment plan.

• During each treatment encounter for procedures associated with an established treatment plan, the provider shall ask the patient and shall verify if:

  • Any new dental conditions have arisen since the patient last received dental treatment.

  • Any existing dental conditions have become more acute since the patient last received dental treatment.

• All dental care provided to patients and pertinent information regarding dental encounters shall be noted as outlined in the HCDOM, Section 3.3.6.1(c)(1)(F) through (H).

• Any additions or corrections to the original dental treatment plan made during the course of treatment shall be entered on the EDRS odontogram and Progress Note panel in accordance with EDRS Workflow 1-3 and associated Back Office Job Aid.

Policy

• The California Department of Corrections and Rehabilitation shall utilize language assistance services when necessary to assist in providing dental health care to patients.

Purpose

• To establish guidelines for the appropriate utilization of interpreter services when providing dental care to patients.

Procedure

• Dental staff shall consult with the individual at their institution who is assigned to ensure effective communication with Limited English Proficient (LEP) patients and shall utilize the LEP coordinator when questions arise regarding LEP services.

• Eligible patients must be provided qualified interpreter services during all phases of health care provision. (Reference the Health Care Department Operations Manual [HCDOM], Section 2.1.2, Effective Communication).

• Available medical translation services for eligible patients shall be utilized in the order of preference as follows:

  • Qualified bilingual health care staff interpreters at the institution.
    

  • Contracted language translation services or certified medical interpretation services as provided for by institutional, regional, or statewide contracts. Dental staff shall obtain the most current contracts from the institution LEP coordinator, contract analyst or Associate Warden (AW) for Health Care Services, or Captain when there is no Health Care Services AW position allocated at the institution.

• A list of qualified bilingual health care staff interpreters is to be made available to the Office Technician or designated dental staff by the Institution LEP Coordinator.

• When urgent/emergent health care must be provided to a patient who requires the assistance of an interpreter to effectively communicate, and a qualified health care staff interpreter is not available in a timely manner, any available interpreter may be utilized. In such situations, a qualified health care staff interpreter must be summoned and upon arrival immediately replace the non-qualified interpreter.

• Use of interpreter services and accommodation(s) made for effective communication shall be noted in the health record as outlined in the HCDOM, Section 3.3.6.1(c)(1)(F) through (H).

Policy

• The California Department of Corrections and Rehabilitation (CDCR), its agents and the Division of Health Care Services, shall adhere to the requirements set forth in the California Code of Regulations, Title 15, Division 3, Chapter 2, Subchapter 2, Article 2, Section 3999.210, “Refusal of Treatment.”

Purpose

• To set forth procedures to ensure and document that a patient’s right to refuse dental treatment is respected.

Procedure

• Refusal of dental care or refusal to provide informed consent for treatment must be documented by completing CDCR 7225-D, Dental Refusal of Examination and/or Treatment.

  • The CDCR 7225-D shall include a description of the examination and/or treatment being refused as well as the risks, benefits and alternatives of the intervention and the consequences of refusing treatment. In addition, the dentist signing the CDCR 7225-D shall inform, or have dental staff inform the patient of the need to submit a CDCR 7362, Health Care Services Request Form, in order to receive treatment for any condition(s) previously refused. The dentist shall document this on the CDCR 7225-D.

  • In the event a patient refuses dental services without an evaluation by a dentist to determine the nature of the problem and establish a possible course of treatment, a notation to this effect shall be made on the description section of the form.

• A dentist shall review and countersign all refusals of dental services prior to the CDCR 7225-D being scanned into the patient’s Electronic Dental Record System (EDRS). In addition, a dentist shall inform or ensure that a dentist has informed a patient who refuses treatment of the risks, benefits, and alternatives of the intervention and the consequences of refusing treatment.

• A complete and thorough documentation of the patient’s refusal is to be documented in a clinical note in the EDRS, in accordance with EDRS Workflow 1-2 and associated Back Office Job Aid, and as outlined in the Health Care Department Operations Manual [HCDOM], Section 3.3.6.1(c)(1)(F) through (H), including:

  • A description of the dental service(s) being refused.

  • The risks and benefits of the proposed service(s).

  • Health consequences of refusing the dental service(s).

  • Alternative treatment options, if any.

• A patient may accept or decline treatment of any diagnosed condition(s) including, but not limited to, any or all portions of a recommended dental treatment plan.

  • A patient’s intentional failure or refusal to report to the dental clinic shall be considered a refusal of all treatment.

  • When a patient reports to the dental clinic for an appointment and indicates that they are too sick to receive dental care, this shall be considered a refusal of all treatment.

  • When a patient refuses treatment, the condition(s) being refused shall no longer be governed by the mandated treatment timeframes outlined in the HCDOM, Section 3.3.5.3, Appendix 1, Dental Priority Classification.

  • A patient shall be required to submit a CDCR 7362 in order to receive treatment for any condition(s) previously refused.

  • The date of diagnosis used to determine the timeframe within which treatment must be initiated shall be the date on which a CDCR dentist examines the patient and determines the degree of urgency of the condition(s) for which treatment was previously refused.

  • If a patient refuses a particular procedure and has other treatment planned procedures, the dentist shall ask the patient if they wish to receive treatment for the next most urgent treatment planned procedure(s) during that day’s appointment. The dentist shall continue asking the patient until the patient has refused all treatment or agrees to receive treatment during that day’s appointment. If the patient agrees to receive treatment for other diagnosed conditions, dental staff shall:

    • Follow the process outlined in the HCDOM, Sections 3.3.5.2(c)(2)(B) and 3.3.5.2(c)(3)(A).

    • Document the encounter in the EDRS as having been completed when the patient consents to and receives treatment during the same encounter.

    • Not provide treatment to which a patient agrees if doing so is not in their best interest (e.g., fabricate a dental prosthetic appliance when the patient refuses to have all prerequisite treatment completed; the patient has an abscessed tooth and refuses extraction but wants less urgent treatment done).

  • If a dentist decides that a patient is too sick to undergo a dental procedure, or if the dentist is concerned that the patient’s presence in the clinic area poses a health risk to others, these circumstances do not constitute a refusal. The dentist should refer the patient to a nurse or physician to expedite proper medical care in accordance with EDRS Workflow 1-7.1 and associated Back Office Job Aid, as well as EDRS Workflow 3-4. If the patient’s primary care team deems it necessary, the consultation with the nurse or attending physician should occur prior to reappointment for dental care.

• A patient’s decision to refuse treatment is reversible at any time and shall not prejudice future treatments.

• For each instance of a patient’s refusal of treatment, CDCR dentists shall place an order in the Electronic Health Record System for a 128-C Dental Refusal.

Policy

• The California Department of Corrections and Rehabilitation (CDCR) shall ensure that emergency medical services are provided in the dental clinic as necessary, that each dental clinic maintains an up to date Emergency Kit containing supplies and equipment to be used in treating patients during medical emergencies, and that all dental personnel receive annual training on the institution’s emergency medical response (EMR) system.

Purpose

• To provide patients prompt access to emergency medical care as needed in the dental clinic, to establish the requirement that all dental clinics have a standardized Emergency Kit that might be used in treating patients during medical emergencies, and to establish training requirements on the institution’s EMR system.

Procedure

• General Requirements

  • All dental staff within the dental clinic shall immediately respond to a medical emergency in the clinic.

  • The dentist shall assume responsibility of the medical emergency, and ensure that a dental staff member immediately notifies the medical department of the emergency.

  • The dentist shall continue to assume responsibility of the medical emergency, pending the arrival of a physician or emergency medical personnel.

  • Dental staff who responds to a medical emergency in the dental clinic shall take immediate action to preserve life and shall follow the institution’s EMR Local Operating Procedures (LOP).

  • The first responder shall document the medical emergency in a clinical note in the Electronic Dental Record System (EDRS), in accordance with EDRS Workflow 1-2 and associated Back Office Job Aid, and as outlined in the Health Care Department Operations Manual (HCDOM), Section 3.3.6.1(c)(1)(F) through (H).

  • The dentist, if not the first responder, shall assist in the documentation and completion of any required clinical notes or incident reports.

  • The first responder or designee shall submit a copy of any incident reports to the Health Program Manager (HPM) III within one calendar day of the incident.

  • If a patient is unable to be resuscitated, the decision to terminate Basic Life Support/CPR shall be made by a physician or community emergency medical services staff. Pronouncement of death shall be made by a physician, according to acceptable medical standards.

  • While preservation of a crime scene is a valuable investigatory tool, this shall not preclude or interfere with the delivery of health care.

  • Custody requirements shall not unreasonably delay medical care in a life-threatening situation.

  • Required emergency equipment, supplies and emergency medications shall be maintained and readily available in the dental clinic.

• Emergency Supplies and Equipment

  • Each dental clinic at each facility shall have:

    • An Emergency Kit kept in close proximity to the operatory for quick and easy access during a medical emergency that contains at least the following drugs and latex free supplies:
      Drugs for Medical Emergencies in the Dental Clinic

      Drug Name	Dosage	Quantity
      Epinephrine	0.3 mg	One pre-dosed syringe (e.g., EpiPen or Twinject)
      Diphenhydramine	50 mg (1 ml)	Two vials each containing 1 ml at 50 mg/ml concentration
      Nitroglycerin tablets	0.4 mg	Twenty-five tablets
      Levalbuterol	One metered dose	One Xopenex HFA® inhaler
      Glucose gel	15 gm	One tube containing 15 gm of glucose
      Chewable aspirin	81 mg	Smallest available package
      Naloxone nasal spray	4 mg	Two boxes containing 2 single-dose nasal spray devices each (4 total doses)

      • Two plastic evacuators (large diameter suction tips).

      • Two sterile, 2 cc disposable syringes with 18 or 21 gauge needles; or two sterile, 3 cc disposable syringes with 22 gauge needles.

    • The following equipment that shall be latex free and kept in close proximity to the operatory for quick and easy access during a medical emergency:

      • Portable oxygen tank that is full, along with tubing and mask.

      • Ambu-bag (Bag-Valve-Mask) with HEPA filter.

      • Blood pressure cuff and stethoscope or blood pressure machine.

      • Automated External Defibrillator (AED) [dental staff shall regularly monitor the battery to verify the unit is functioning properly and the pads to ensure they are not expired].

  • The Supervising Dentist (SD) or Supervising Dentist Assistant (SDA) shall ensure that the Emergency Kit is accessible, well demarcated and properly secured in each dental clinic.

  • On a daily basis, dental staff (as described in the HCDOM, Section 3.3.1, Dental Care Definitions) shall verify the integrity of the seal on the portion of the Emergency Kit containing the medical emergency drugs.

    • If the seal is broken, the dental staff member shall count the sharps and medications contained within the Emergency Kit, at the beginning and end of the work day.

    • Dental staff completing the count shall document and initial the count on the Tool Control Inventory Report form, and follow all policies and procedures as stated in the HCDOM, Section 3.3.3.2, Control of Dental Instruments and Sharps.

    • The dental staff member shall also notify the pharmacy that the Emergency Kit seal is broken.

  • On a monthly basis, a dentist shall review the contents of the Emergency Kit in coordination with the institutional pharmacist or designee.

    • If the Emergency Kit seal is intact, the dentist and the institutional pharmacist, or designee, shall verify that the medication expiration dates on the inventory sheet are still valid.

    • The institution pharmacist or designee shall remove and replace any Emergency Kit medications expiring within the next 30 calendar days. (Reference the HCDOM, Section 3.5.22, Emergency Drug Supplies).

    • The dentist shall also check operation of the oxygen delivery system to verify that it is functioning properly and that it is full.

    • The dentist shall document these reviews along with the review date on an inventory sheet that shall be attached to the outside of the Emergency Kit.

  • The SD or SDA shall keep a copy of the Emergency Kit inventory sheet on file for a period of at least one year.

  • The dentist or dental staff completing either the daily sharps count or monthly Emergency Kit review shall notify the SD or SDA, upon completion of that review, of any Emergency Kit items that are missing, damaged, or broken and require replacement. The SD or SDA shall arrange for immediate replacement of the needed items.

  • Upon discovery that any drugs in the Emergency Kit require replacement, the dentist shall notify the SD or SDA and the institutional pharmacist. The institutional pharmacist shall replace all drugs as needed. Furthermore, the pharmacy shall keep a documented record of the expiration dates of the Emergency Kit drugs and perform inspections of the drugs in the Emergency Kits on a monthly basis, or as needed.

  • The dentist shall immediately notify the SD or SDA, (and the institutional pharmacist in the case of emergency drug use), of any Emergency Kit supplies or drugs that need replacement due to use in a medical emergency. The SD or SDA and the institutional pharmacy, if appropriate, shall arrange for immediate replacement of used supplies or drugs.

• EMR System Training

  • The HPM III shall ensure that all dental personnel (including licensed contract staff), receive training on the EMR system before performing or assisting in patient care.

  • Training shall consist of site specific information on the location and contents of the medical Emergency Kit supplies and drugs, along with the steps and roles in accessing the institutional EMR system.

  • The HPM III shall ensure that all dental personnel are retrained annually on the aforementioned topics and when there is a change in the EMR system or contents of the Emergency Kit.

  • Retraining personnel because of changes in the EMR system or contents of the Emergency Kit, shall occur within a week of the HPM III receiving notification of such approved changes.

  • The HPM III shall document and keep a record of this training on file for a period of three years.

  • The HPM III at each institution shall ensure that an LOP for medical emergencies in the dental clinic is developed and approved. This LOP, at a minimum, shall indicate who is responsible for notifying the medical department, and who is responsible for calling an ambulance, if needed. The HPM III shall be responsible for implementing and annually reviewing this LOP.

  • Each institution dental department shall participate in EMR drills which shall be conducted at a minimum once a year in each CDCR dental clinic.

  • The HPM III and the SD shall:

    • Obtain and review a copy of the EMR Event Checklist and EMR Review completed for each EMR Training Drill conducted in one of the dental clinics at the institution.

    • Report unacceptable EMR Drill results to the appropriate Regional Dental Director.

Policy

• All California Department of Corrections and Rehabilitation (CDCR), Division of Health Care Services dental staff shall ensure that patients are provided ongoing, medically necessary dental care in accordance with applicable state laws and commensurate with community standards of care.

Purpose

• To provide guidelines to assist in ensuring that CDCR patients receive continuity of health care.

Procedure

• Patients’ dental health care information shall be documented in a health record or other clinically appropriate media. The health record shall be established during intake and shall be accessible when the patient transfers or moves within the system.

• All health care encounters are to be documented in the health record as outlined in the Health Care Department Operations Manual (HCDOM), Section 3.3.6.1(c)(1)(F) through (H).

• For Mainline Facilities, dental staff shall monitor the:

  • QM Dental Transfers Report on a daily basis to identify patients who recently arrived at the institution to ensure continuity of care for these individuals.

  • QM Dental Scheduling Report and/or Electronic Dental Record System (EDRS) Scheduling Assistant on a daily basis to identify patients with documented, untreated dental conditions and schedule the patients within the mandated DPC timeframes, in accordance with EDRS Workflow 2-1 and associated Front Office Job Aid.

  • EDRS Treatment Request Manager on a daily basis to identify patients with DAR and/or specialty referrals to ensure patients are scheduled for treatment in a timely manner, in accordance with EDRS Workflow 2-1 and associated Front Office Job Aid.

  • QM Exam Notices Report on a regular basis to identify patients who are eligible for a periodic comprehensive dental examination and need to receive an exam eligibility notification, in accordance with EDRS Workflow 1-5 and associated Front Office Job Aid.

  • QM Dental Prosthetics Log Report on a regular basis to monitor and manage patients who have a dental prosthetic case in progress.

• When dental staff becomes aware that a patient has transferred to a Mainline Facility without undergoing a Reception Center (RC) dental screening, dental staff at the receiving assigned institution shall:

  • Schedule the patient for an RC dental screening if the patient qualifies as defined in the HCDOM, Sections 3.3.2.2(c)(1)(A) and (B).

  • Follow the process outlined in the HCDOM, Sections 3.3.2.2(c)(1)(B)1. through 3. if in the professional judgment of a CDCR dentist the patient does not need to receive a new RC dental screening.

  • Follow the process outlined in the HCDOM, Sections 3.3.2.2(c)(1)(C) and (D) if the patient qualifies for and needs an RC dental screening.

  • Verify and ensure that the patient has been sent an examination eligibility notification.

• The treating dentist shall be charged with the duty of ‘case management’ to monitor:

  • Timely scheduling of appointments.

  • Rescheduling of cancelled or failed appointments.

  • Necessary medical lab work or oral pathology specimen analysis.

  • Patient follow-up regarding medical and/or oral pathology lab results that are the outcome of a CDCR or contracted dentist ordering the analysis.

  • Referrals to specialists.

  • Follow-up care ordered by specialists.

  • Intermediate appointments for prosthetic cases.

• Dentist Responsibility Regarding Report/Test Results

  • The treating dentist shall review all internal consultation reports, medical and oral pathology lab reports and reports from outside the facility within seven business days of receipt of the report by the dental clinic. (Reference the HCDOM, Section 3.3.6.1(c)(1)(F) through (H) for documentation requirements).

  • The dentist shall inform the patient of the result(s) of the report(s) within three business days of reviewing the report(s). (Reference the HCDOM, Section 3.3.6.1(c)(1)(F) through (H) for documentation requirements). The dentist shall:

    • Send a written notification in accordance with EDRS Workflow 3-1 and associated Dentist Back Office Job Aid. The notification must:

      • Be generated using the EHRS Patient Notification Letter process.
        

      • Include:

        • The date of the consult or test.

        • The reviewing dentist’s name.

        • Whether the results are within normal limits.

        • Whether a follow-up encounter is required and will be scheduled.

        • Language advising patients to submit a CDCR 7362 if they would like to discuss the results in person when the report/test results are negative for pathology or are within normal limits. (Reference Section (c)(6)(B)2. for patients whose results are positive for pathology or are not within normal limits).

          • If a patient submits a CDCR 7362 indicating a desire to discuss the report/test results with the provider, the dentist performing the paper review shall assign the CDCR 7362 a Paper Review Code of “Other” (or “Routine”).

          • The dentist performing the paper review shall have the patient scheduled within the appropriate timeframe. (Reference the HCDOM, Section 3.3.5.13(d)(2)(B)7.b.).

      • Be sent within the mandated timeframe.

      • Be delivered to the patient through the Institution Interdepartmental Mail or the process used for priority ducat distribution.

      • Not contain the name or type of consult or test the patient underwent.

    • Have the OT, or designated dental staff, schedule patients for an encounter within the mandated timeframe to explain the results when the report/test results are positive for pathology or are not within normal limits.

    • Document in an EDRS clinical note:

      • The consult or test result(s) reviewed.

      • Any action required or taken based on the result(s) (e.g., patient referred to primary care provider due to elevated International Normalized Ratio [INR]).

      • That the patient was notified of the result(s) via the EHRS Patient Notification Letter process.

      • The disposition of follow up care, whether a face-to-face encounter was scheduled or the patient advised to submit a CDCR 7362 to access care.

• The OT, or designated dental staff, under the direction of the treating dentist, shall track all referrals and medical, dental or pathology laboratory procedures to ensure their completion.

• If a patient is transferred to another institution, a dentist shall review the dental treatment plan prior to providing treatment.  A review is not required if the patient is being seen by the new institution’s dental staff for only one appointment, or is being treated on a specific referral basis.

• Health care staff shall prepare a care plan, including provisions for referrals, special diets, medications and other appropriate regimens for patients who have special dental needs and are being released from the CDCR.

Policy

• All California Department of Corrections and Rehabilitation (CDCR) facilities shall ensure the availability of emergency dental care 24-hours a day, seven days a week.

Purpose

• To provide cost-effective, timely and competent emergency dental care to every patient consistent with adopted standards for quality and scope of services within a custodial environment, and to establish procedures and guidelines for managing and responding to dental emergencies in CDCR facilities.

Procedure

• General Requirements

  • Patients requiring treatment for a dental emergency shall be seen immediately.

  • Emergency dental services shall be provided first to those most in need, to attempt stabilization and prevent deterioration of a patient’s condition.

  • Emergency dental services shall be the responsibility of the Health Program Manager (HPM) III and Supervising Dentist (SD) at that institution.  The HPM III’s and SD’s duties shall include, but not be limited to:

    • Developing and maintaining approved written policies and procedures for emergency dental services.  Implementing and annually reviewing approved policies and procedures to ensure they are current with the required state regulations.

    • Ensuring the availability of emergency dental services coverage 24-hours a day, seven days a week.

    • Ensuring that Supervising Registered Nurses (SRN), Registered Nurses (RN), mid-level providers and physicians working in the medical clinic or Triage and Treatment Area (TTA) receive training in Oral Assessments and Dental Emergencies for Medical Staff.

    • Ensuring that the medical department has the Dentist on Call (DOC) and SD’s contact phone numbers on file.

  • The Chief Executive Officer or designee at each institution shall ensure that an RN with current training in Oral Assessments and Dental Emergencies for Medical Staff is available 24-hours a day to assess patients with dental emergencies.

  • All patients shall provide authorization for treatment via informed consent for emergency dental services prior to treatment being rendered.

    • All patients who have life-threatening conditions, as determined by the Physician on Call (POC), or treating dentist, (including the SD), and who are unable to provide informed consent shall be treated regardless of whether or not authorization for treatment is provided. 

    • The effort to obtain authorization for treatment shall continue simultaneously with the treatment.

    • The POC or treating dentist shall document in the patient’s health record the life-threatening condition that requires treatment without authorization.

  • No treatment shall be forced over the objection of the patient, or their legally authorized representative or responsible relative, except in emergencies, where immediate action is imperative to save the life of the patient, or in such cases as are provided for by law as noted in the California Code of Regulations, Title 15, Division 3, Chapter 2, Subchapter 2, Article 2, Section 3999.210.

    • If, after adequate explanation of the necessity for treatment and possible adverse effects that may result as a consequence of refusal, the patient maintains their desire to refuse treatment, the patient shall be required to sign a CDCR 7225-D, Dental Refusal of Examination and/or Treatment.

    • The refusal of emergency dental treatment shall also be documented in a clinical note in the Electronic Dental Record System (EDRS), in accordance with EDRS Workflow 1-2 and associated Back Office Job Aid, and as outlined in the Health Care Department Operations Manual (HCDOM), Section 3.3.6.1(c)(1)(F) through (H). (Reference HCDOM, Section 3.3.5.6(c)(6) of this policy for other requirements concerning a patient refusal).

  • For every patient receiving emergency dental treatment, an appropriate entry shall be documented in a clinical note in the EDRS, in accordance with EDRS Workflow 1-2 and associated Back Office Job Aid, and as outlined in the HCDOM, Section 3.3.6.1(c)(1)(F) through (H) of this policy.

  • Emergency dental services shall be performed only by, or as ordered by, a dentist within the scope of their license.

  • Emergency first aid shall be rendered as necessary.

  • Patients shall be allowed to participate in their dental care whenever possible.  Patients shall receive instruction from the dentist or RN regarding their care, the nature of the illness or injury and any follow up care that is necessary.  The dentist or RN shall document in the patient’s health record, any instructions given to the patient.

  • Any patient needing emergency dental services at another health care facility shall be transported in a safe, secure and efficient manner.

  • When a dental emergency requires the use of a medical transport vehicle, the clinic RN shall be notified via the institutional telephone system.

• Dental Emergencies During Dental Clinic Operating Hours

  • Patients initiating dental emergency requests during dental clinic operating hours shall contact an available or accessible CDCR staff member, who shall then notify the dental clinic of the emergency.

    • The CDCR staff member notifying the dental clinic of the emergency shall work with the dental clinic staff to arrange for the patient to report to the dental clinic on their own, or be escorted to the dental clinic for evaluation.

    • If a patient is unable to walk, arrangements shall be made to have the patient transported to the dental clinic or TTA as appropriate.

  • The CDCR staff member notifying the dental clinic of the emergency shall contact the SD or designee who shall provide direction in those instances when there is not a dentist in the clinic.

  • The dentist shall see these patients upon their arrival at the dental clinic or TTA to establish the patient’s disposition and if needed provide treatment.  The dentist shall ensure that the patient is scheduled for any needed follow-up care relating to the dental emergency.

  • The dentist shall review and sign a CDCR 237-F, Dental Pain Profile, for each patient with a dental emergency.  If a patient is unable or refuses to complete the CDCR 237-F, the dentist shall complete the form on behalf of the patient, documenting the complaint and the reason the patient did not personally complete the form.

  • Patients with a life threatening illness or injury shall receive immediate medical attention.

• Dental Emergencies Outside Dental Clinic Operating Hours

  • The Medical Department shall manage dental emergencies occurring outside of dental clinic operating hours.

  • RNs, who have received training in Oral Assessments and Dental Emergencies for Medical Staff under the direction of the HPM III and SD, shall be notified of dental emergencies by institutional staff, and shall assess patients to determine the need for emergency dental treatment.

  • If in the opinion of the medical staff the situation does not require the attention of a dentist, the POC shall prescribe the appropriate level and type of care.

  • If in the opinion of the medical staff the situation requires the attention of a dentist, the POC, via the medical clinic’s RN, shall be responsible for contacting the DOC at the earliest opportunity to arrange for definitive treatment.

  • The DOC contacted outside dental clinic operating hours regarding a dental emergency shall notify the SD or designee on the next business day of the dental emergency contact. The notification shall be documented in the DOC Log as well as in a clinical note in the EDRS, in accordance with EDRS Workflow 1-2 and associated Back Office Job Aid, and as outlined in the HCDOM, Section 3.3.6.1(c)(1)(F) through (H) of this policy. This notification shall include, but not be limited to, the following:

    • The time the call was received from the RN recorded in military time (using the 24-hour clock).

    • Patient’s name.

    • Patient’s chief complaint.

    • Diagnosis or provisional diagnosis.

    • Treatment or action provided or ordered.

    • Any scheduled follow-up care.

  • When clinically indicated, a dentist shall see the patient the next business day after medical staff contacts the DOC after hours regarding the patient.

  • The HPM III and/or SD shall maintain completed DOC Logs for a period of three years.

• Emergency Transfers

  • When in the opinion of the DOC, treating dentist, or SD it becomes necessary to transfer a patient to another facility for emergency dental services, the RN shall make a written request on a CDC 7252 Request for Authorization of Temporary Removal for Medical Treatment and notify the Watch Commander.  The RN shall document the following on the CDC 7252:

    • Patient’s name and CDCR number.

    • Name of receiving facility.

    • Description of the condition necessitating transfer.

    • The dental evaluation or treatment recommended by the DOC, treating dentist, or SD.

    • Name of the DOC, treating dentist, or SD.

  • The CDC 7252 shall be submitted prior to the transfer and shall be approved so as to create no undue delays.  In a life or death situation, it shall not be necessary to await completion and return of the form.  The patient shall be transferred immediately.

  • The DOC, treating dentist, or SD shall:

    • Contact or have the sending facility RN contact the receiving physician or dentist at the receiving facility and obtain their acceptance of the patient.

    • Document in a clinical note in the EDRS, in accordance with EDRS Workflow 1-2 and associated Back Office Job Aid, a brief history of the illness or injury, treatment received, reason and permission for the transfer, as well as the name of the accepting physician or dentist.

    • Generate a Transfer to Higher Level of Care order in the Electronic Health Record System or provide verbal orders to the emergency medical services physician for the transfer of the patient. 

    • Document on the CDC 7252 a brief history of the illness or injury, treatment received and reason for transfer.  In the absence of the DOC, treating dentist, or SD, the RN shall complete the CDC 7252.

    • Determine whether an ambulance is necessary, and if so, direct the RN or designee to contact the contract ambulance service.  If an ambulance is unnecessary, the Watch Commander shall provide a state vehicle for transportation.

  • The CDC 7252 shall accompany the patient to the receiving facility.

  • The RN or designee shall notify the receiving facility of the impending transfer.

Policy

• All California Department of Corrections and Rehabilitation (CDCR), Division of Health Care Services (DHCS) personnel shall abide by applicable statutes, standards and administrative policy when issuing and complying with direct medical orders.

Purpose

• To ensure that CDCR, DHCS personnel are in compliance with applicable state law in regard to direct medical orders.

Procedure

• Licensed health care staff who, by virtue of their license, are authorized by law or regulations to issue direct medical orders must:

  • Place orders utilizing the Computerized Provider Order Entry (CPOE) method in the Electronic Health Record System, unless otherwise required by federal or state law, or

  • Communicate such orders to appropriate health care providers and sign or electronically authorize these orders within 48 hours or no later than the next business day following a weekend or holiday. (Reference the Health Care Department Operations Manual, Section 3.5.8, Prescription/Order Requirements and Medication Availability).

• In the absence of the ordering health care provider, verbal orders may be countersigned or electronically authorized via CPOE by a non-ordering dentist or physician.

• Modifications to direct medical orders must be authorized by a licensed practitioner.

Policy

• The California Department of Corrections and Rehabilitation shall provide patients with supplemental nutritional support when warranted by a medical or dental condition.

Purpose

• To establish and maintain a system whereby patients are supplied with supplemental nutritional support when warranted by a medical or dental condition.

Procedure

• A treating clinician shall place an order in the Electronic Health Record System for all nourishments and supplements.

• Nourishments and supplements may be prescribed for patients who are pregnant, diabetic, immunocompromised, malnourished, or those with dental or oropharyngeal conditions causing difficulty eating regular diets.

• Prescribed nourishments and supplements shall be delivered to the patients in accordance with established local operating procedures.

• Consistent with a medical/dental necessity, treating clinicians shall prepare a written order (including a stop date) for nourishments and supplements prescribed for patients.

• Reference the Health Care Department Operations Manual, Section 3.1.12, Outpatient Dietary Intervention.

Policy

• The California Department of Corrections and Rehabilitation (CDCR), Adult Correctional Dental Care shall ensure that dental pharmaceuticals are prescribed in accordance with all applicable state and federal regulations and that CDCR policies and procedures regarding prescribing, dispensing, administering and procuring pharmaceuticals are followed. CDCR dental clinics shall maintain a supply of prescription medication as dental stock medications for situations where the dentist determines an immediate dose is necessary.

Purpose

• To establish procedures for providing medications to dental patients in a safe and timely manner.

Procedure

• General Pharmaceutical Procedures

  • Each practitioner must have their own Drug Enforcement Administration Controlled Substance Registration Certificate to write prescriptions for medication. (Reference the Health Care Department Operations Manual [HCDOM], Section 3.5.8, Prescription/Order Requirements and Medication Availability). 

  • Registered Dental Hygienist, (registered) Dental Assistants and dental laboratory technicians shall not administer nor dispense prescribed dental medications to patients unless expressly permitted by the Dental Board of California. 

  • Dentists shall only prescribe medications listed in the CDCR Drug Formulary, unless otherwise provided for by the non-formulary justification process. (Reference the HCDOM, Section 3.5.5, CCHCS Drug Formulary).

• Requirements for Prescriptions and Orders

  • All dental prescriptions or orders shall:

    • Be placed by a dentist utilizing the Computerized Provider Order Entry (CPOE) method in the Electronic Health Record System (EHRS).

    • Contain all required elements and conditions outlined in the HCDOM, Section 3.5.8, Prescription/Order Requirements and Medication Availability.

    • Be documented in a clinical note in the Electronic Dental Record System (EDRS), in accordance with EDRS Workflow 1-2 and associated Back Office Job Aid, and as outlined in the HCDOM, Section 3.3.6.1(c)(1)(F) through (H) and shall include the fact that applicable education/counseling regarding the medication(s) was given.

    • Be managed in accordance with the HCDOM, Section 3.3.6.1(c)(2)(B).

  • Telephone or verbal orders shall be signed or electronically authorized via CPOE as described in the HCDOM, Section 3.3.5.10(c)(1)(B) and (c)(2). (Reference the HCDOM, Section 3.5.8, Prescription/Order Requirements and Medication Availability).

• Dental Stock Medications

  • Only the following prescription medications may be provided by the pharmacy to the licensed correctional clinics to be stored and used for treatment of dental patients with urgent/emergent conditions:

    • Amoxicillin 500 mg #21     [Seven day supply].

    • Amoxicillin 500 mg #4       [One dose pre-med supply].

    • Azithromycin 250 mg #6    [Five day supply].

    • Azithromycin 250 mg #2    [One dose pre-med supply].

    • Ibuprofen 400 mg #30        [Ten day supply].

    • Acetaminophen 325 mg #30      [Ten day supply].

  • The SD or dentist designee shall order dental dispensing stock medication specified in Section (c)(3)(A) by placing an order for the medication(s) using the Requisition Tab in PowerChart.

  • Storage, Inspections and Par Levels

    • The SD or designee shall ensure that all medications stored in the dental clinics are in a secure location and under appropriate storage conditions in accordance with the HCDOM, Section 3.5.16, Medication Inventory Management, Labeling, and Storage. The Pharmacist-in-Charge (PIC) shall ensure that medications stored in dental clinics are inspected monthly.

    • The SD and the PIC shall be responsible for determining appropriate par levels of medications issued for use by dentists within the dental clinics.

  • Reporting Medication Issues from Dental Dispensing

    • Medication issues related to the function of dispensing dentists shall be reported to the SD at the institution, the appropriate Regional Dental Director, and the Statewide Chief of Pharmacy Services.

  • EHRS Downtime Process

    • If the EHRS is not available when the dentist needs to order and/or administer a medication, the dentist shall follow the current EHRS downtime process.

• Dental Dispensing Requirements

  • A CDCR dentist may act as a dispensing dentist and when doing so shall assume all the requirements and responsibilities of a dispenser of medications in accordance with California Business and Professions Code, Section 4170. When acting as a dispensing dentist, the dentist shall:

    • Perform a safety assessment including patient allergy, medication history, and contraindications to confirm that the medication they intend to prescribe is appropriate. The assessment shall be completed by reviewing the patient’s health record and current medication profile.

    • Place an order for the medication(s) in PowerChart using only the medication orders that have the DENTAL STOCK MED suffix (e.g., Ibuprofen [DENTAL STOCK MED]).  DENTAL STOCK MED orders within PowerChart are configured to auto-verify and thereby support administration of medication from dental stock.

    • Not select another medication order, besides the DENTAL STOCK MED, or the dentist will not be able to chart administration within PowerChart until the medication is verified by the pharmacy.

    • Ensure that the pharmacy has affixed a label that complies with California Business and Professions Code Section 4076 to the medication package being dispensed to the patient. The dentist or designee shall enter the patient’s name, CDCR number, the date of dispensing, as well as the dentist’s name and clinic designation as the dispensing entity.

    • Personally dispense required medication(s) in an appropriate package and with a legal label as defined in Section (c)(4)(A)4. Dispensing the medication cannot be delegated to any other dental staff.

    • Comply with Section (c)(2)(A)3.

  • When dispensing dental stock medications to a patient, the dentist shall:

    • Chart the administration of the medication within PowerChart via barcode scanning.  In cases of barcode equipment failure, the dentist may chart medication administration within PowerChart via the non-scanning process.

    • Ensure that the medication administered is documented by dental staff on a CDCR 7438, Dental Pharmaceutical Record Log. The SD shall maintain completed Dental Pharmaceutical Record Logs for a period of three years.

• Medication Availability (Reference the HCDOM, Section 3.5.8, Prescription/Order Requirements and Medication Availability).

  • Non-urgent new medication orders received by the pharmacy during normal business hours shall be available to the patient no later than three business days later, unless otherwise ordered by the dentist (e.g., the order specifies the medication is to start today).

  • Dentists shall inform patients that medications ordered today can be picked up at the medication line in three business days unless deemed more urgent by the prescriber. (Reference the HCDOM, Section 3.5.8, Prescription/Order Requirements and Medication Availability).

  • For situations where a patient is housed as an inpatient, is receiving care in the Triage and Treatment Area (TTA), or is in an urgent/emergent treatment area, dentists shall follow the local institution STAT process to obtain single doses of prescription medication for administration in emergency situations. Dentists shall not order STAT medications in the outpatient clinic setting. (Reference the HCDOM, Section 3.5.8, Prescription/Order Requirements and Medication Availability).

  • In situations where the dentist determines an immediate dose is necessary and doses of the medication are not available in the dental clinic, the dentist shall order the medication(s) in PowerChart and immediately alert pharmacy or TTA staff of the urgency of the order to allow:

    • Pharmacy staff to dispense the medication dose during their normal operating hours.

    • The medication to be obtained from the TTA’s after-hours medication supply outside of normal pharmacy operating hours.

Policy

• The California Department of Corrections and Rehabilitation (CDCR) and California Correctional Health Care Services (CCHCS) shall ensure all patients are provided access to dental care by adhering to the requirements set forth in the CCR, Title 15, Division 3, Chapter 2, Subchapter 3, Article 6, Section 3999.367(a)(1), Dental Care. CCHCS, Adult Correctional Dental Care shall be responsible for developing policies and procedures that ensure all patients receive equal access to dental care.

Purpose

• To ensure that CDCR patients have timely and equal access to dental care by utilizing a system that provides guidelines enabling patients to receive dental care based on medical necessity.

Procedure Overview

• For the purpose of this policy, access to care means that a patient can be seen by a clinician in a timely manner, be given a professional clinical judgment and receive medically necessary care. 

• The Dental Health Program Manager (DHPM) III shall ensure access to dental care for all patients by identifying and eliminating any unreasonable barriers that obstruct the availability of dental services.

• All patients shall be informed via the Patient Orientation to Health Care Services Handbook (Reference the Health Care Department Operations Manual [HCDOM], Section 3.3.2.13(c)(1)(A)) of the facility dental services available to them.

• All patients shall have equal access to dental services by:

  • Submitting a CDCR 7362, Health Care Services Request Form, requesting dental care for which ducated face-to-face triage encounters shall be scheduled to have specific complaints addressed.

    • The CDCR 7362 is a confidential health care document used to assess the priority of the request and to access the appropriate discipline or provider;

    • The CDCR 7362 shall be available to patients in the housing units, clinics, Reception Center and from health care staff;

    • Patients shall complete all pertinent information requested in Part I. at the top of the CDCR 7362, sign and date the form, and submit the request as outlined in Section (d)(1)(D); or (d)(2)(A).

  • Receiving unscheduled dental encounters for emergency and urgent Dental Priority Classification (DPC) 1 dental services.

  • Being referred by other health care providers, ancillary, and custodial staff.

  • Receiving a DPC based on clinical findings and radiographs. All patients shall be eligible to receive dental treatment based on their assigned DPC in accordance with the HCDOM, Section 3.3.5.3, Dental Priority Classification.

• Patients requiring special dental needs care shall have treatment initiated or scheduled regardless of time remaining on their sentence after meeting plaque index score eligibility requirements where applicable and pending approval by the Dental Authorization Review Committee.

Procedure

• General Requirements

  • Dental services shall be available at least eight hours per day, Monday through Friday, excluding holidays. Dental clinics shall operate until all authorized emergency, scheduled urgent care DPC 1 and ducated patients have been seen. (Reference Section (d)(4)(B)).

  • Patients shall initiate access to dental services utilizing the CDCR 7362 and may submit a CDCR 7362 at any time to request dental services.

  • If a patient is unable or refuses to complete a CDCR 7362, health care staff shall complete the form on behalf of the patient, documenting the complaint and the reason the patient did not personally complete the form. In this instance, the health care staff member completing the CDCR 7362 shall sign and date the form.

  • Special procedures shall be implemented to ensure that patients who have difficulty communicating (e.g., those with a mental illness, who are non-English proficient, developmentally disabled, low reading level, or hearing impaired) have equal access to dental services.

    • Translation services (including sign language) shall be available for patients, as necessary, via certified bilingual health care staff or by utilizing a certified interpretation service when bilingual health care staff is unavailable.

    • Each institution shall maintain a contract for certified interpretation services. (Reference the HCDOM, Section 3.3.5.5(c)(3)(B)).

  • The DHPM III shall make arrangements with the custody unit supervisor to have patients with emergent or urgent DPC 1 dental conditions, as determined by the dentist or health care provider, report to the clinic on their own or escorted to the dental clinic for evaluation.

    • If a patient is unable to walk, arrangements shall be made to have the patient transported to the dental clinic or Triage and Treatment Area (TTA) as appropriate.

    • The dentist shall see these patients upon their arrival at the clinic and provide necessary treatment.

  • In cases of dental emergencies, patients shall receive dental services without submitting a CDCR 7362. Patients may access emergency care by verbally notifying custody or health care staff. Patients with a life-threatening illness or injury shall receive immediate medical attention.

  • RDHs and (registered) Dental Assistants shall not make dental assessments exceeding their scope of license, training, or departmental policies.

• CDCR 7362 Collection, Review and Distribution

  • Each institution shall have at least one locked box on each yard or facility designated for patients to deposit CDCR 7362s.

  • Mondays through Fridays the following shall occur:

    • A health care staff member shall pick up the CDCR 7362s daily.

    • After returning the CDCR 7362s to the clinic, a Registered Nurse (RN) shall initial and date the request forms.

    • The CDCR 7362s shall be separated, distributed by service requested (e.g., medical, dental, or mental health) and forwarded to their respective areas for processing. 

    • A dental staff member shall record each CDCR 7362 requesting dental services.

      • In the event a patient submits multiple CDCR 7362s within a relatively short time period, the requests may be combined and treated as one for the purpose of the paper review and face-to-face triage processes. During the face-to-face triage encounter, the dentist shall ensure that all of the different dental issues contained on all of the CDCR 7362s are addressed and that the patient receives treatment at that time if indicated or is scheduled appropriately for treatment of all of the different dental issues contained on all of the CDCR 7362s.

      • Patients who submit multiple requests for the same condition or complaint within a relatively short time period should be educated by dental staff on the counterproductive results of doing so.

        • This information can also be disseminated to the patient population via the Incarcerated Persons Advisory Council.

    • With the exception of CDCR 7362s requesting a comprehensive dental examination, a dentist shall review, initial, date and indicate the Paper Review Code (PRC) on each CDCR 7362 within one business day of the dental clinic’s receipt of the CDCR 7362. In those instances when there is not a dentist in the clinic, the Supervising Dentist (SD) shall be notified to provide direction.

    • Dental staff shall not make entries in the Subjective, Objective, Assessment, Plan, Education format on the CDCR 7362.

    • Upon completing the paper review, the dentist shall notify the Office Technician (OT), or designated dental staff, to schedule the patient for an encounter based on the urgency of the request or as outlined in Section (d)(2)(B)8.c. through e.

      • Patients who indicate emergent or urgent dental needs (terms of distress such as pain, swelling, bleeding, infection, etc.) shall be assigned a PRC of 1 (or “Urgent”) and shall be seen for a face-to-face triage encounter within three business days of the dental clinic staff receiving the CDCR 7362.

      • All other patients shall be assigned a PRC of “Other” (or “Routine”) and shall be seen for a face-to-face triage encounter within 10 business days, after the receipt of the CDCR 7362 in the dental clinic.

    • Institutions shall also use the following process to manage patient requests via the CDCR 7362 that are assigned a PRC of “Other” (or “Routine”).

      • For patients who describe or indicate routine conditions on the CDCR 7362, (DPC 3 conditions as defined in the HCDOM, Section 3.3.5.3, Dental Priority Classification), the dentist may choose not to schedule the patient for a face-to-face triage.

      • The dentist or designee may choose to respond in writing (without performing a face-to-face triage) to patients who use the CDCR 7362 process to:

        • Ask when they will receive their fillings/cleaning/denture or to see if they are on a list for treatment.

        • Request an examination or provision of treatment for DPC 3 conditions from an established treatment plan.

      • Patients requesting to be seen for routine conditions (DPC 3 conditions as defined in the HCDOM, Section 3.3.5.3, Dental Priority Classification) and who do not have a treatment plan shall be scheduled for a comprehensive dental examination within 90 calendar days of the dental clinic receiving the CDCR 7362. When this timeframe is not achieved, the treating clinician shall document the reason in a clinical note in the Electronic Dental Record System (EDRS), in accordance with EDRS Workflow 1-2 and associated Back Office Job Aid.

      • Patients requesting to be seen for routine conditions (DPC 3 conditions as defined in the HCDOM, Section 3.3.5.3, Dental Priority Classification) and who have an established treatment plan but have not been scheduled for treatment (other than for procedures for which the patient has refused treatment) shall be scheduled for treatment accordingly.

      • If the patient is not to be scheduled for a face-to-face triage pursuant to the PRC timeframes as outlined in Section (d)(2)(B)7.a. and b., the dentist shall:

        • Perform a review of the patient’s health record to determine if there are any conditions diagnosed that have not been treated.

        • Have the OT, or designated dental staff, generate a written notification to inform the patient as follows:

          • The dental department received the request they submitted.

          • Where applicable, they have been or will be scheduled for an appointment.

          • Of the dentist’s understanding of the nature of the patient’s request.

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

          • They reviewed the health record subsequent to receiving a CDCR 7362.

          • The date and results of the health record review, including the patient’s current DPC.

          • No face-to-face triage was necessary therefore a written response was sent.

          • The rationale or justification for sending a written response.

      • The written notification shall be sent to the patient within ten business days of the dental clinic receiving the CDCR 7362 and distribution shall be accomplished as outlined in the HCDOM, Section 3.3.2.3(c)(1)(A)3.

    • Patients with dental emergencies during dental clinic operating hours shall be managed as outlined in the HCDOM, Section 3.3.5.9(c)(2).  Patients with dental emergencies outside dental clinic operating hours shall be managed as outlined in the HCDOM, Section 3.3.5.9(c)(3).

  • On weekends and holidays the following shall occur:

    • The TTA RN shall:

      • Review each CDCR 7362 for medical, dental and mental health services.

      • Establish medical priorities on an emergent and non-emergent basis.

      • Refer accordingly to the appropriate health care staff.

    • If a dentist is not available, then the TTA RN shall contact the Dentist on Call.

  • Processing CDCR 7362s

    • CDCR 7362s that require a face-to-face triage encounter

      • When a patient submits a CDCR 7362 on their own, or a staff member submits one on behalf of the patient, dental staff shall follow the procedures outlined in Section (d)(2)(B)5. through 7. and shall process the CDCR 7362 in accordance with EDRS Workflow 1-2 and associated Front Office Job Aid.

      • If treatment is provided at the subsequent face-to-face triage encounter, or if treatment is not provided during the subsequent face-to-face triage encounter and the patient needs to be brought back for treatment, dental staff shall follow the procedures described in the HCDOM, Section 3.3.5.2(c)(2)(B) and (c)(3)(A).

        • Close out the CDCR 7362 ensuring that the form is signed and dated by the dental provider. If there are multiple requests for the same chief complaint, all of the CDCR 7362s need to be signed and dated before being scanned. Documenting the time of signature on the form is not required.

        • Ensure that the patient is given a copy or copies, as needed.

        • Scan the completed CDCR 7362(s) into the EDRS Document Center.

    • CDCR 7362s requesting a comprehensive dental examination

      • When a patient submits a CDCR 7362 requesting a comprehensive dental examination, the OT, or designated dental staff, shall process the CDCR 7362 in accordance with EDRS Workflow 1-2 and associated Front Office Job Aid.

    • For CDCR 7362s to which the dentist chooses to respond in writing

      • When a patient submits a CDCR 7362 and the dentist chooses to respond in writing without performing a face-to-face triage encounter, the dentist shall:

      • Follow the procedures described in Section (d)(2)(B)8.e. through f.

      • Complete the CDCR 7362 by writing an appropriate comment on the form (e.g., “No face-to-face triage”), entering their name, title and institution at the bottom of the form then signing and dating it.

      • Notify the OT, or designated dental staff, to process the CDCR 7362 in accordance with EDRS Workflow 1-2 and associated Front Office Job Aid.

• Face-to-Face Triage and Limited Problem Focused Exam Encounters

  • Face-to-face triage and limited problem focused exam encounters shall be performed in order to assess and diagnose a patient’s chief complaint and to provide treatment if necessary.

    • If a patient is being seen for a face-to-face triage or limited problem focused exam encounter, the dentist shall address the patient’s chief complaint. During the encounter, the dentist shall document the condition(s) diagnosed for treatment as well as the proposed treatment on the Dentrix odontogram and the Progress Note panel, in accordance with EDRS Workflow 1-3 and associated Back Office Job Aid, regardless of whether treatment is provided that day or at a subsequent appointment.

    • If the dentist identifies other dental conditions about which the patient is not complaining but which need to be addressed in the future and the patient has not undergone a comprehensive dental examination, the dentist shall inform the patient of the dental conditions and advise them to submit a CDCR 7362 to request an examination. The dentist shall also document in a clinical note in the EDRS, in accordance with EDRS Workflow 1-2 and associated Back Office Job Aid, that the patient has undiagnosed dental conditions about which they have been informed and the patient was advised to submit a request for an examination.

  • A face-to-face triage encounter:

    • Shall be provided for patients who have submitted a CDCR 7362.

    • Is a planned encounter for which dental staff has issued a ducat to the patient.

  • A limited problem focused exam encounter:

    • Shall be provided for patients with a dental emergency:

      • That arrive unannounced to the dental clinic and there is no record of a recently submitted CDCR 7362 addressing the emergent condition.

      • Referred by health care or custody staff and there is no record of a recently submitted CDCR 7362 addressing the emergent condition.

    • Is an unplanned encounter for which dental staff has not issued a ducat to the patient.

  • Each patient presenting to the dental clinic for a face-to-face triage or limited problem focused exam for a stated dental emergency shall complete a CDCR 237-F, Dental Pain Profile, before the face-to-face triage or limited problem focused exam is performed.

    • The dentist shall review and sign the CDCR 237-F before completing the face-to-face triage or limited problem focused exam.

    • If a patient is unable or refuses to complete the CDCR 237-F, the dentist shall complete the form on behalf of the patient, documenting the complaint and the reason the patient did not personally complete the form.

  • For each patient seen for a face-to-face triage or limited problem focused exam encounter, the dentist or designee shall at minimum document the following information in a clinical note in the EDRS, in accordance with EDRS Workflow 1-2 and associated Back Office Job Aid:

    • Vital signs.

    • Health history review. (Reference the HCDOM, Section 3.3.6.1(c)(2)(E) of this policy).

    • Nature and history of the complaint or dental condition that triggered the face-to-face triage or limited problem focused exam encounter.

    • Physical findings.

    • Proposed treatment.

  • Once a dentist has completed the face-to-face triage or limited problem focused exam, every effort shall be made to provide dental treatment at the same encounter. Only if it is not appropriate or possible to provide treatment at the same encounter may a patient be scheduled for care within the timeframes indicated for their DPC. (Reference the HCDOM, Section 3.3.5.3(c)(5) and (6) as well as the HCDOM, Section 3.3.5.3, Appendix 1, Dental Priority Classification).

• Dental Encounters

  • Priority ducat lists for dental encounters shall be prepared and ducats generated and distributed as outlined in the HCDOM, Section 3.3.5.1(c)(1)(B).

  • Each patient requesting dental services shall be seen if they are ducated and arrive in a timely manner at the clinic for their scheduled encounter, unless the SD or designee cancels the encounter. (Reference the HCDOM, Section 3.3.5.1(c)(3) regarding encounters cancelled by dental staff).

  • If a patient fails to show for any dental encounter, then the dentist or designee shall follow the policy as outlined in the HCDOM, Section 3.3.5.1(c)(4).

  • In the event a dentist is unexpectedly absent and other dentists at the institution are unable to provide treatment for the patients scheduled in the clinic covered by the absent dentist, the scheduled encounters may be cancelled only with the approval of the SD or designee.

  • An inability to access the Electronic Health Record System or EDRS or any other clinical system (e.g., MiPACS) shall not preclude access to or the provision of dental care for patients. Dental staff shall implement downtime procedures when clinical documentation systems are not available.

• Required Staff Members for Patient Dental Encounters

  • For reasons of safety and security:

  • Patients in the dental clinic shall always be directly observed by at least one staff member at all times.

  • A minimum of two staff members (two dental staff or one dental staff and one Correctional Officer) shall be present in or have direct line of sight of the dental operatory when a patient is receiving treatment. Each staff member shall be present in or have direct line of sight of the dental operatory for the duration of the encounter.

• Patient Dental Encounters with Opposite Gender Dental Staff

  • Whenever possible, a staff member of the same gender as the patient shall be present in the dental operatory for the duration of the dental encounter and shall be identified by name and documented in a clinical note in the EDRS, in accordance with EDRS Workflow 1-2 and associated Back Office Job Aid.

• Lockdown or Modified Program

  • During a facility lockdown or modified program, dental staff shall coordinate with the clinic RN, patient appointment schedulers and custody staff to facilitate continuity of care.

  • A lockdown or modified program shall not prevent the completion of scheduled dental encounters, and custody personnel shall escort the patient to the dental clinic, subject to security concerns.

  • In facilities or housing units on modified program or lock down status, a system shall be maintained to provide patients access to health care services.

    • Access to health care services shall be accomplished via daily collection of CDCR 7362s and referral from other health care providers, ancillary staff, and custodial staff.

    • The health care staff shall refer all patients requiring emergent or urgent dental treatment to the dental clinic for evaluation and treatment.

  • Patients in Restricted Housing Units (RHU) (e.g., General Population RHU, Correctional Case Management System RHU, Enhanced Outpatient Program), shall have access to CDCR 7362s.

    • The patients shall be provided a method for depositing the CDCR 7362 in the locked box for daily pick up by health care staff in the RHU.

    • The RN shall refer all patients requiring emergent or urgent dental treatment to the dental clinic for evaluation and treatment.

  • Dental staff shall document occurrences of a lockdown or modified program preventing patient access to care. Dental staff shall report these occurrences to the DHPM III who shall inform the AW for Health Care Services, or Captain when there is no Health Care Services AW position allocated at the institution.

• Specialized Health Care Housing

  • When dental staff become aware that a patient has been admitted to a specialized health care housing unit, for dental related conditions, dental staff shall:

    • Provide a dental clinical evaluation within 24 hours during dental clinic operating hours.

      • Outside dental clinic operating hours, a dental consult may be initiated by the specialized health care housing unit admitting health care provider by contacting the Dentist on Call.

    • Participate in interdisciplinary grand rounds and assessments with frequency determined by the patient’s condition and setting.

  • Emergency, urgent, interceptive, routine, and special dental care shall be provided, determined by the patient’s condition, and consultation with relevant medical and mental health staff.

Policy

• The California Department of Corrections and Rehabilitation (CDCR) shall provide medically necessary dental care for all patients in a timely manner, under the direction and supervision of dentists licensed by the Dental Board of California.  Such care shall be based on medical necessity and supported by outcome data as effective dental care.

Purpose

• To determine and define the scope of CDCR dental services and to establish procedures and guidelines for the delivery of dental care to patients incarcerated in CDCR facilities.

Procedure

• Dental screenings at Reception Centers (RC) and/or comprehensive dental examinations and treatment plan formulations at RCs or Mainline Facilities shall be performed only by a licensed CDCR or contract dentist.

• Only CDCR employed dental staff, contractors paid to perform health care services for CDCR patients, or persons employed as health care consultants shall be permitted, within the scope of their licensure and professional practice, to diagnose the dental needs of or prescribe medication and/or provide dental treatment for patients.

• Within 60 calendar days of assignment to an RC, all patients shall receive:

  • A dental screening as part of their initial health assessment. (Reference the Health Care Department Operations Manual [HCDOM], Section 3.3.2.2(c)(1)(B) for exceptions).

    • The dental screening results shall be documented as described in the HCDOM, Section 3.3.2.2(c)(1)(C).

    • The screening dentist shall review the results with the patient.

  • Education on oral hygiene as outlined in the HCDOM, Section 3.3.2.2(c)(1)(A)2.

• All patients assigned to a Mainline Facility shall be eligible to receive:

  • An initial comprehensive dental examination in the manner and within the timeframes outlined in the HCDOM, Section 3.3.2.3, Comprehensive Dental Examinations – Mainline Facility.

  • Oral hygiene instruction by a dental assistant or other properly trained health care personnel in the manner and within the timeframes outlined in the HCDOM, Section 3.3.2.13, Facility Level Dental Health Orientation/Self-Care.

  • Dental care as medically indicated and documented in the EDRS dental treatment plan. (Reference the eligibility requirements for care outlined in the HCDOM, Section 3.3.5.3, Appendix 1, Dental Priority Classification.

• In the provision of dental treatment, CDCR dentists shall:

  • Monitor patients with the following conditions and shall adhere to the appropriate protocols. [Reference the University of the Pacific, School of Dentistry, Protocols for the Dental Management of Medically Complex Patients (MCV)].

    • Hypertension.

    • Anticoagulant therapy.

    • Infective endocarditis (IE) Risk.

    • Prosthetic cardiac valve.

    • Total joint replacement.

    • HIV/AIDS.

    • Bisphosphonate therapy.

    • Diabetes.

    • Pregnancy.

  • Follow the practice of providing comprehensive care wherever possible, rather than episodic care, and utilizing the principles of quadrant dentistry by performing multiple procedures during an encounter. This includes treating conditions with different Dental Priority Classifications and/or located in different quadrants during the same encounter regardless of eligibility requirements outlined in the HCDOM, Section 3.3.5.3, Appendix 1, Dental Priority Classification.

• CDCR dentists shall refer for follow-up with the facility clinic Registered Nurse or appropriate Mental Health Clinician, any patient who displays inappropriate hygiene management or manifests behavior such as refusing to shower for an extended period of time, fecal smearing, urinating on the floor, food smearing, or similar inappropriate actions. (Reference the HCDOM, Section 4.1.2, Hygiene Intervention).

• The Health Program Manager III of each institution shall be responsible for tracking the scheduling and provision of screenings, examinations and dental care for patients.

• Excluded Services

  • Excluded dental services refer to attempted curative treatments and do not preclude palliative therapies to alleviate serious debilitating conditions such as pain management and nutritional support.

  • Dental services or treatment shall not be routinely provided for the following conditions:

    • Conditions that improve on their own such as:

      • Benign oral lesions.

      • Traumatic oral ulcers.

      • Recurrent aphthous ulcer.

    • Conditions that are not readily amenable to treatment, including, but not limited to:

      • Shrinkage and atrophy of the bony ridges of the jaws.

      • Benign root fragments whose removal would cause greater damage or trauma than if retained for observation.

      • Temporomandibular Joint dysfunction.

    • Cosmetic procedures, which may include, but are not limited to:

      • Removal of existing body-piercing metal or plastic rings or similar devices within the oral cavity, except for security reasons.

      • Restoration or replacement of teeth for esthetic reasons.

      • Restoration of any natural or artificial teeth with unauthorized biomaterials.

    • Surgery that is not medically necessary, which may include, but is not limited to:

      • Extractions of asymptomatic teeth or root fragments unless required for a dental prosthesis, or for the general health of the patient’s mouth.

      • Removal of a benign bony enlargement (torus) unless required for a dental prosthesis.

      • Surgical extraction of asymptomatic un-erupted teeth.

    • Services that have no established outcome on morbidity or improved mortality for health conditions.

    • Root canals on posterior teeth (bicuspids and molars).

    • Implants.

    • Fixed prosthodontics (dental bridges).

    • Laboratory processed crowns.

    • Orthodontics.

• Exceptions to Excluded Dental Services

  • Treatment for conditions that are excluded within these regulations may be provided in cases where all of the following criteria are met:

  • The patient’s attending dentist prescribes the treatment.

  • The treatment is medically necessary.

  • The service is approved by the facility’s Dental Authorization Review Committee as well as the Dental Program Health Care Review Committee. (Reference the HCDOM, Section 3.3.4.5(c)(3) and (4)). The decision to approve an otherwise excluded service shall be based on:

    • Medical necessity.

    • Approved health care outcome data supporting the effectiveness of the services as clinical treatment.

    • Co-existing medical problems.

    • Acuity.

    • Length of incarcerated person’s sentence.

    • Availability of service.

    • Cost.

    • Other factors.