Chapter 4 – Special Circumstances

Policy

• California Department of Corrections and Rehabilitation (CDCR) and California Correctional Health Care Services (CCHCS) staff shall promptly identify, assess, monitor, and treat patients participating in a hunger strike or refusing food. Clinical and custody staff shall collaborate in an attempt to promptly address the issue(s) and obtain a resolution that is satisfactory to the patient and the department.

Purpose

• To ensure that the patient is provided all necessary care and treatment while also working to promptly resolve the hunger strike or food refusal.

Responsibility

• The Chief Executive Officer (CEO), or designee, and Warden, are responsible for the implementation, monitoring, and evaluation of this policy.

Policy

• California Correctional Health Care Services staff shall evaluate patients who are identified, reported, and documented by any staff member as having poor hygiene or whose hygiene compromises the sanitation of their personal and immediate housing area.

Purpose

• To provide patients who display inappropriate hygiene management with indicated medical or mental health care.

Responsibility

• The Chief Executive Officer, or designee, of each institution is responsible for the implementation, monitoring, and evaluation of this policy.

Procedure

• Any staff who observes a patient displaying behavior such as refusing to shower for an extended period of time, fecal smearing, urinating on the floor, food smearing, displaying behavior or displaying their person or property in an unhygienic manner, or other similar inappropriate behavior, shall notify the facility clinic Registered Nurse (RN) or Triage and Treatment Area RN. 

• The RN, or designee, shall conduct an evaluation within one business day of notification and, if indicated, shall refer the patient to a primary care provider or mental health clinician.

• Health care staff shall document requests for evaluations and the evaluation in the health record.

Policy

• California Correctional Health Care Services (CCHCS) health care staff shall review a health record prior to any controlled use of force including, but not limited to, chemical agents such as Oleoresin Capsicum, Chloroacetophenone, and Orthochlorobenzalmalononitrile.  Health care staff shall document the review in the health record and also note any identified medical or psychiatric conditions or known disabilities which may predispose a patient to increased risk of an adverse outcome from the controlled use of force.  Health care staff shall provide necessary medical care including decontamination advice and monitoring of patients who refuse decontamination and/or referrals following controlled use of force, and document their assessment in the health record.  CCHCS health care staff shall perform medical evaluations of all patients involved in an assault, cell extraction, or use of force.

Purpose

• To direct health care staff in the following:

• Steps to take prior to and during controlled use of force.

• Controlled use of force video recording requirements.

• Decontamination and monitoring following controlled use of force.

• Controlled use of force in licensed health care facilities.

• Determining the presence or absence of any injuries incurred by a patient as a result of an assault, cell extraction or use of force.

Responsibility

• The Chief Executive Officer, or designee, of each institution is responsible for the implementation, monitoring, and evaluation of this policy.

Procedure

• Prior to Controlled Use of Force

  • A Primary Care Provider (PCP), Licensed Mental Health Practitioner (LMHP), or Licensed Nursing Staff (LNS) (Registered Nurse [RN], Licensed Vocational Nurse, Licensed Psychiatric Technician) shall be notified by custody staff prior to controlled use of force including, but not limited to, chemical agents such as Oleoresin Capsicum, Chloroacetophenone, and Orthochlorobenzalmalononitrile.

  • The LNS shall review the health record and document the review.  For patients housed in an inpatient setting, the inpatient RN shall conduct the review.  For all other patients, the review shall be conducted by the Triage and Treatment Area (TTA) RN.

    • The LNS shall also note any conditions that may predispose the patient to an adverse outcome from the use of force and any known disabilities that will require accommodation during the controlled use of force.

  • Conditions that may predispose a patient to an adverse outcome from exposure to chemical agents include, but are not limited to, the following:

    • Cardiac insufficiency

    • Acute reactive pulmonary disease (asthma)

    • Chronic obstructive or restrictive lung disease

    • Pregnancy

    • Allergic reaction to the carrier or active ingredient

    • Corneal or ocular injury

  • If the TTA RN identifies any medical or psychiatric condition or disability which may predispose a patient to increased risk of an adverse outcome from exposure to chemical agents, the RN shall immediately contact the Incident Commander and explain in non-technical language the medical risks if chemical agents are used. 

  • The TTA RN shall contact the PCP or psychiatrist if there are serious concerns about the use of chemical agents.

    • The PCP or psychiatrist shall review the health record and document the review.  The documentation shall include any condition that may predispose the patient to an adverse outcome from the use of force.

  • In all situations that may require controlled use of force, mental health shall be consulted.  An LMHP shall evaluate the patient and provide intervention, as appropriate, during a cool down period.  The LMHP shall collaborate with the team during this cool down period.

  • If there is disagreement among the collaborative team members (medical, nursing, mental health, and custody) regarding the strategies to be employed, the issue shall be elevated to the appropriate clinical and custodial managers up to and including the Chief of Mental Health, or designee; Chief Medical Executive, or designee; Chief Nursing Executive, or designee; Chief Executive Officer, or designee; and Warden or Chief Deputy Warden.

  • In the event the disagreement is not resolved at the institution level, the issue shall be elevated to the Regional Health Care Executives and the appropriate Associate Director, Division of Adult Institutions.

• During Controlled Use of Force

  • Controlled use of force shall not be accomplished without the physical presence of the LNS.  The LNS shall be in close proximity to the incident to facilitate an immediate medical response, but not so near as to become involved in the controlled use of force.  The LNS is not required to wear controlled use of force team equipment (e.g., helmet, personal protective equipment kit). 

  • Prior to commencing with the controlled use of force, the LNS shall ensure they are in possession of the appropriate medical supplies and equipment to respond to a medical emergency.

  • The LNS who reviewed the health record and the LNS who is on-site during the controlled use of force are not required to be the same person.

• Controlled Use of Force Video Recording Requirements

  • As per the California Department of Corrections and Rehabilitation Department Operations (CDCR) Manual (DOM), each controlled use of force shall be video recorded.

  • Per the DOM, the onsite LNS and LMHP shall identify themselves on camera and confirm that the health record was reviewed. The LNS shall:

    • Indicate if the patient has any health conditions that put them at increased risk for adverse outcome from the use of chemical agents or other force options.

    • Also indicate any known disabilities the patient has that will require any accommodation before, during, or after the controlled use of force.

    • Not include specific conditions or any other protected health information.

  • Per the DOM, the LNS onsite during the controlled use of force shall also identify themselves on camera as performing that role and having the necessary medical equipment.

• Decontamination and Monitoring Following Controlled Use of Force

  • Incarcerated persons exposed to chemical agents shall be decontaminated by custody staff as soon as practicable after exposure.  The LNS shall document in the health record that decontamination services were provided by custody.

  • Health care staff shall determine whether other patients in the immediate area were exposed and provide necessary medical care. Health care staff shall advise the patient how to self-decontaminate in his/her cell using water from the sink and soap, if available, if the patient refuses decontamination by custody or if there are safety concerns regarding out-of-cell decontamination.

    • Health care staff shall document in the health record that the patient refused decontamination by custody and was provided self-decontamination instructions.

  • Health care staff shall monitor patients exposed to chemical agents and who refuse decontamination by custody at least three times every 15 minutes for no less than 45 minutes, starting from the time the patient was last exposed.

  • Health care staff shall document in the health record the time of each 15-minute monitoring check and document what they observed.

  • If the patient involved in use of force is housed in the general population and requires re-housing in the Administrative Segregation Unit, the LNS shall also complete a review of the patient’s mental health record and, if indicated, refer the patient to mental health staff.

  • If an injury to a patient constitutes an emergency, staff shall implement the Health Care Department Operations Manual, Chapter 3, Article 7, Emergency Medical Response.

• Controlled Use of Force in Licensed Health Care Facilities

  • When circumstances are such that a controlled use of force is considered within a health care facility (e.g., Correctional Treatment Center, Skilled Nursing Facility, Psychiatric Inpatient Program, Hospice), the LNS shall consider the impact on medical conditions and the possible need to relocate uninvolved patients in the immediate vicinity during a controlled use of force.

  • Administration of Involuntary Medication or Medical Treatment (PC 2602/Probate Code 3200): When force is necessary to administer medication or medical treatment within a health care facility, on-duty health care staff shall ensure medical authorization for the involuntary medication or treatment exists.  Health care staff shall also consult with the treating psychiatrist, PCP, or mid-level provider, if available, to verify the current and critical need for involuntary medication or treatment.  If the treating psychiatrist, PCP, or mid-level provider is not available, the physician or psychiatrist on-call shall be consulted.

    • Health care staff shall advise the Incident Commander of such prior to the application of controlled use of force.

  • Application of Four/Five Point Restraints: Only departmentally approved four/five point restraints shall be applied by authorized LNS in health care facilities. Authorization for application of four/five point restraints shall only be given by health care staff in accordance with California regulations and the Mental Health Services Delivery System Program Guide.  On-duty health care staff shall ensure authorization exists and shall advise the Incident Commander of such prior to the controlled use of force under these circumstances.

  • Patient Refusal of Admission, Discharge, or Transfer to/from a Health Care Facility: When a clinician with admitting privileges to a CDCR health care facility has determined it is necessary to admit, discharge, or transfer a patient into/from a health care facility, health care staff shall ensure that a written order for the admission, discharge, or transfer exists, and shall advise the Incident Commander of such prior to the controlled use of force.

• Evaluation and Medical Documentation Following an Assault, Cell Extraction, or Application of Use of Force

  • The LNS shall evaluate the patient as soon as practicable after the patient has been involved in an assault, cell extraction or any application of use of force.

  • The LNS shall document the incident with findings on a CDCR 7219, Medical Report of Injury or Unusual Occurrence, and document comprehensive medical information in the health record.

Policy

• California Correctional Health Care Services (CCHCS) medical providers shall order a medical imaging foreign body examination when medically necessary.  Medical imaging staff shall use approved protocols corresponding to the anatomical area where the foreign body is suspected to be located.

Purpose

• To provide guidance to both medical and custody staff regarding how medical imaging examinations are to be ordered and performed in the event of a suspected foreign body.

Responsibility

• The Chief Executive Officer, or designee, is responsible for the implementation, monitoring, and evaluation of this policy.

Procedure

• Prior to Examination

  • The ordering medical provider shall create an order in the health record to request a foreign body examination.  The order shall identify the anatomical area where the foreign body is believed to be located, a brief explanation of the item suspected, and circumstances of its insertion/ingestion.

  • CDCR custody officers shall escort the patient to the local Medical Imaging Services department.

• Performing the Examination

  • All clothing (except shorts) and jewelry shall be removed from the patient.

  • The Radiologic Technologist (RT) shall place the patient onto the x-ray table according to the examination protocol for the suspected anatomical area.

  • The RT shall perform the examination following the examination protocol and mark the examination as a STAT in the Radiology Information System and Picture Archiving Communication System (RIS/PACS).

  • A patient may refuse a medical test (e.g., x-ray for contraband) when ordered or recommended by a medical provider.  The refusal shall be documented in the health record.

  • Custody staff may seek a court order for the patient to comply with the examination if the patient refuses the examination recommended by the medical provider or an examination was not ordered by a medical provider due to the absence of a medical indication for the study.

  • Upon receipt of a copy of the court order for the examination, the CCHCS medical provider will order the requested examination.

  • Refusal to comply with a court-ordered examination will be managed by custody staff.  Medical staff will not perform a radiologic examination without the cooperation of the patient.

• Examination Interpretation

  • Since the examination is marked as a STAT, the Radiologist shall have a final report available in the RIS/PACS within two business hours (between the hours of 7:00 a.m. and 7:00 p.m. Monday through Friday).

  • In the event that the examination is performed outside of the Radiologist’s business hours or an immediate interpretation is needed, the ordering medical provider shall provide a preliminary interpretation and complete a CDCR 7537, Preliminary Interpretation/Discrepancy Report.

  • The ordering medical provider shall give a preliminary interpretation to the requesting custody staff, especially in cases where the patient has been detained (i.e., confined to a cell, placed in restraints), pending the Radiologist’s interpretation.

  • Any questions concerning the interpretation of the examination prior to the Radiologist’s review must be directed to the reviewing medical provider. (No other staff member is authorized to provide an interpretation of the examination).

Policy

• Incarcerated persons undergoing Contraband Surveillance Watch (CSW) pursuant to the California Department of Corrections and Rehabilitation (CDCR) Department Operations Manual, Section 52050.23, shall be provided appropriate clinical observation, assessment, and management.

Purpose

• To ensure incarcerated person safety during CSW.

Applicability

• This policy applies to CSW conducted within CDCR institutions.

Responsibility

• The Chief Executive Officer (CEO), in collaboration with the Warden, is responsible for the implementation of this policy.

Procedure

• Notification

  • When custody staff initiates CSW, custody staff shall escort the incarcerated person to the Triage and Treatment Area (TTA).

  • In order to ensure continuity of care, TTA staff shall notify the following, as applicable:

    • Primary Care Team

    • Mental Health

    • Dental

    • Medication Nurse

• Initial Assessment

  • A CDCR 7219, Medical Report of Injury or Unusual Occurrence, shall be completed in the TTA by licensed health care staff and provided to custody staff for placement in the incarcerated person’s C-file.

  • A comprehensive nursing assessment shall be performed by a Registered Nurse (RN) and documented in the health record.

    • Patients with normal vital signs, no complaints, and no physical findings may be released to CSW housing.

    • All other patients shall be referred to a provider for further assessment and orders.

  • The provider shall determine any health care risks or special accommodations, including possible placement in a medical bed, needed for CSW.

  • All patients placed on CSW shall be provided written and verbal information informing them of the risks of ingesting and/or inserting contraband as well as recommendations for elimination of such item(s).

  • A diagnostic study (e.g., x-ray) may be performed when medically necessary only by order of a provider.

    • The presence or absence of a foreign body on an x-ray shall be shared with custody staff.  To the extent that it can be determined, the nature of the foreign body shall be shared with custody staff.

    • When a contraband evaluation is indicated after hours or on a weekend, the on-call provider must evaluate the patient and review the x-ray and document history, indications, examination, and findings.

    • A patient may refuse a medical test (e.g., x-ray for contraband) when ordered or recommended by a provider (in the absence of a court order for the test).  Documentation of the refusal will be obtained and filed in the health record.

    • Upon refusal of the provider ordered/recommended diagnostic study, custody staff may seek a court order to compel the incarcerated person to submit to the diagnostic study.

    • When obtained, a copy of the court order to compel the incarcerated person to comply with the diagnostic study must be provided to medical staff.  A copy of the court order will be placed in the health record.

• Monitoring

  • During the course of the CSW, if custody staff observes a decline in the incarcerated person’s health, or believes that the incarcerated person’s health is affected by the concealed contraband, medical personnel shall be immediately contacted to reassess the incarcerated person’s condition.

  • A CDCR 7362, Request for Health Care Services, shall be provided upon the incarcerated person’s request as designated by policy.

  • For the duration of the CSW, cell front observation shall be performed on second watch by nursing staff daily.  In CSW housing areas where there is a clinic or exam room (e.g., Receiving and Release, Administrative Segregation), a nursing assessment shall be performed by an RN in the clinic/exam room on second watch every three calendar days subsequent to the initial assessment.

    • In CSW housing areas without a clinic or exam room, vital signs shall be taken in the CSW housing area.  All clinical information shall be documented in the health record. 

    • Patients with physical complaints or abnormal physical findings during the RN assessment shall be referred to a provider for further evaluation and orders.

  • If a provider determines evaluation is required more frequently than once per day, the patient shall be placed in a medical bed.

  • The CEO and Chief Nurse Executive or their respective designee shall be notified by custody when an incarcerated person is retained on CSW for a second three calendar day period.

  • The institutional CEO, or designee, shall initially notify the Deputy Director, Medical Services, or designee, when an incarcerated person is retained on CSW beyond six calendar days and every three calendar days thereafter until the CSW ends.

Policy

• California Correctional Health Care Services (CCHCS) shall provide medically necessary emergency and follow-up treatment; follow-up care plans; and necessary referrals including testing for pregnancy, sexually transmitted infections/diseases (STIs/STDs), Hepatitis C Virus (HCV), Hepatitis B Virus (HBV), and Human Immunodeficiency Virus (HIV), to CCHCS patients who are identified as alleged victims or alleged abusers of sexual abuse or sexual harassment by an incarcerated person or staff. All health care staff shall notify patients of their duty to report allegations of sexual abuse or sexual harassment by an incarcerated person or staff, and the limitations of confidentiality at the initiation of services.

Purpose

• To ensure that medically necessary emergency and follow-up treatment is provided to patients who are alleged victims or alleged abusers of sexual abuse or sexual harassment by an incarcerated person or staff.

Responsibility

• The Chief Executive Officer (CEO), or designee, and the Warden, or designee, of each institution are responsible for the implementation, monitoring, and evaluation of this policy.

• Health Care Staff shall:

  • Provide emergency care until the alleged victim and alleged abuser(s) can be sent to an outside contracted county Sexual Assault Response Team (SART) facility to receive a forensic medical examination and treatment conducted by a Sexual Assault Nurse Examiner (SANE) and/or hospital for medical stabilization;

  • Determine and identify any injuries sustained by the alleged victim and alleged abuser(s); 

  • Ensure follow-up testing for pregnancy, STIs/STDs, HCV, HBV, and HIV as indicated; and

  • Provide follow-up health care as indicated.

Procedure

• This procedure applies to all CCHCS patients, including those whose reported abuse occurred more than 72 hours prior to the time of reporting where a forensic medical examination may not be indicated.  There is no cost to the alleged victim for medically necessary emergency and follow-up treatment services, regardless of whether they name the alleged abuser(s) or cooperate with any investigation arising from the incident.

• Initial Encounter

  • When it is reported that a patient is the alleged victim of sexual abuse, California Department of Corrections and Rehabilitation (CDCR) and CCHCS staff shall immediately report the allegation to the local watch commander and Investigative Services Unit (ISU) for investigation.  Incidents may be reported verbally or in writing by the patient, by another incarcerated person or third party, anonymously (e.g., written or telephone message), by a staff member, in a health care grievance or incarcerated person appeal, etc. All reports must be forwarded for investigation and thoroughly reviewed by the ISU.

  • Incidents reported within 72 hours of the event

    • Licensed Health Care Staff shall:

      • Assess and identify any urgent/emergent injuries sustained by the alleged victim and alleged abuser(s).

      • Provide necessary and immediate emergency medical care to the alleged victim and alleged abuser(s).

      • Document any injuries sustained by the alleged victim and alleged abuser(s) on a CDCR 7219, Medical Report of Injury or Unusual Occurrence, in addition to documenting the assessment and care provided in the health record.

      • Provide a copy of the CDCR 7219 to custody staff.

      • Ensure the alleged victim and alleged abuser(s) do not shower, remove clothing, use restroom facilities, or consume any liquids prior to providing emergency treatment.

      • To the extent possible, maintain physical separation (visual and auditory) between the alleged victim and alleged abuser(s).

      • Notify the alleged victim of health care staff’s duty to report all allegations of sexual abuse, and sexual harassment and the limitations of confidentiality at the initiation of services.

      • Notify the Watch Commander of the incident.

      • Notify the ISU staff of the incident.  The ISU shall collect any clothing and relevant evidentiary materials that are discarded in the course of providing emergency treatment.

    • The Chief Medical Executive, or designee, shall review the medical documentation of the incident.

    • The need for a forensic medical examination is determined pursuant to criteria within the Department Operations Manual (DOM), Sections 54040.9, 54040.12.1, and 54040.12.2.  If a forensic medical examination is required, the Triage and Treatment Area (TTA) Registered Nurse (RN) shall complete the CDCR 7252, Request for Authorization of Temporary Removal for Medical Treatment, and deliver it to the Watch Commander.

      • Health care staff shall inform the alleged victim and alleged abuser(s) that custody staff will transport them to an outside contracted county SART facility for a SANE/SAFE forensic medical examination if deemed appropriate. The alleged victim may refuse the forensic medical examination pursuant to DOM Section 54040.12.1, and the refusal shall be documented in the health record. The alleged abuser(s) may refuse the forensic medical examination, unless a court order has been obtained to compel their participation pursuant to DOM 54040.11, and the refusal shall be documented in the health record. The SANE at the outside contracted county SART facility is responsible to offer the following:

        • A forensic medical examination for patients who are alleged victims and alleged abusers of sexual abuse.

        • Tests for STIs/STDs HCV, HVB, and HIV, as indicated.

        • Pregnancy tests for patients who are alleged victims of sexually abusive vaginal penetration.

      • All involved health care staff shall complete a CDCR 837-C, Crime/Incident Report Part C-Staff Report, to include documentation of all statements made by the alleged victim and alleged abuser(s) and provide a copy of the CDCR 837-C to custody staff.

  • Incidents reported after 72 hours of the event

    • The licensed health care provider shall provide medically necessary emergency treatment as outlined in (d)(1)(A)1.

    • Designated custody staff shall consult with the SANE at the outside contracted county SART facility to determine if the alleged victim and alleged abuser(s) should be taken for a forensic medical examination.  If so, the health care provider shall follow steps for alleged victim and/or alleged abuser(s) transportation send-out listed in Section (d)(1)(A)3, a and b.

    • If the SART/SANE determines that a forensic medical examination would not be indicated, a CCHCS health care provider shall offer a medical evaluation to both the alleged victim and alleged abuser(s), separately. The alleged victim may refuse this evaluation pursuant to DOM Sections 54040.12.1 and 54040.12.2, and the refusal shall be documented in the health record. The alleged abuser(s) may refuse the forensic medical examination, unless a court order has been obtained to compel their participation pursuant to DOM 54040.11, and the refusal shall be documented in the health record. 

    • During the medical evaluation, the health care provider shall:

      • Offer a physical examination pertinent to any symptoms or injuries reported by the alleged victim and alleged abuser(s) including a targeted physical examination of skin, mucosa, genitals, and rectum (if involved) as indicated, and provide detailed documentation of findings in the health record.

      • Assess the physical injuries and the likelihood of transmission of STIs/STDs.

      • Review STI/STD history of the alleged abuser(s) and order appropriate tests for STIs/STDs if indicated and order appropriate tests for the alleged victim for STIs/STDs, if indicated.

      • Provide indicated treatment for symptoms and injuries based on the history and physical examination.

      • Record any injuries noted during the examination of the alleged victim and alleged abuser(s) on a CDCR 7219 and provide a copy to custody staff.

    • All involved health care staff shall complete a CDCR 837-C, Crime/Incident Report Part C-Staff Report, to include documentation of all statements made by the alleged victim and alleged abuser(s) and provide a copy of the CDCR 837-C to custody staff.

    • The ISU shall proceed with the investigation pursuant to DOM, Section 54040.12.2.

• Follow-up Care

  • Return to the TTA from the outside contracted county SART Facility

    • Upon the return from the forensic medical examination, the alleged victim shall be assessed pursuant to the Health Care Department Operations Manual (HCDOM), Section 3.1.11, Outpatient Specialty Services.

    • The TTA RN shall refer the alleged victim for an emergent Mental Health (MH) contact to include a Suicide Risk Assessment and Self-Harm Evaluation (SRASHE).

    • If not completed at the initial encounter (i.e., SART facility), the health care provider shall offer a medical examination to both the alleged victim and alleged abuser(s), separately which the alleged victim may refuse. The alleged abuser(s) may also refuse the examination unless a court order has been obtained to compel the alleged abuser’s participation pursuant to DOM Section 54040.11, and the refusal shall be documented in the health record. During the evaluation, the health care provider shall complete the following:

      • Document a comprehensive history to include STI/STD history, description of the incident, type of sexual contact, type of physical injuries (to include genital or mucosal injuries), occurrence of bleeding, and initial treatment provided by the forensic medical examiner (to include pregnancy test, HIV prophylaxis, etc.).

      • If the alleged victim declined the forensic medical examination at the outside contracted county SART facility, and they agree to participate in the TTA, offer and conduct a targeted physical examination of skin, mucosa, genitals, and rectum (if involved) as indicated, and provide detailed documentation of the findings in the health record. The alleged victim may also refuse this examination which shall be documented in the health record.

      • Assess physical injuries and the likelihood of transmission of STIs/STDs based on the history and physical examination.

      • In addition to treating physical injuries, offer and obtain consent for evaluation and treatment of STIs/STDs and other tests as indicated (refer to Appendix 1), to include:

        • Empiric treatment for Gonorrhea and Chlamydia or test and treat based on laboratory confirmation. All exposed anatomic sites (rectal, throat, urethral) should be tested.

          • Test for HIV. Consider Post-Exposure Prophylaxis (PEP) as indicated.

          • Test for HCV and HBV.

          • Offer Hepatitis B vaccine series (give initially, one month later, and six months after first dose unless the alleged victim is known to have Hepatitis B immunity) Consider post-exposure Hepatitis B Immunoglobulin (HBIG) as indicated.

          • Test for Syphilis

        • Offer Human Papillomavirus vaccine as indicated.  For female patients, obtain appropriately timed tests as indicated:

          • Pregnancy test.

          • Empiric treatment for trichomonas infection.

          • Offer emergency contraception if necessary.

      • A copy of the forensic medical examination shall be provided to ISU by the licensed outside contracted SART facility. The relevant medical findings shall be provided to the appropriate medical and/or nursing staff for follow-up treatment and placed in the health record.

  • Pregnancy Services

    • If a pregnancy results from sexual abuse, victims shall receive comprehensive information, without unreasonable delay and timely access to all lawful pregnancy-related services.

  • Mental Health Referrals

    • All alleged victims of sexual abuse shall be referred for mental health services.

    • Post-Forensic Medical Examination – Mental Health Emergent Referral:

      • Health care staff shall enter an order for an MH Prison Rape Elimination Act (PREA) consult emergent referral in the health record for any patient who was the alleged victim of sexual abuse and referred to an outside contracted county SART facility, even if the alleged victim refused the transport or the examination at the SART facility, as well as for those who received a forensic medical examination conducted by a non-designated SANE provider.  If mental health staff are not onsite, the on-call mental health provider shall be contacted for service provision in all forensic medical examination based referrals, whether the alleged victim received or refused the examination.  Within four hours of the alleged victim’s return to the institution following the forensic medical examination or refusal, a mental health staff shall complete a face-to-face emergency mental health consult in a confidential setting.

      • The mental health emergency consult shall include:

        • An emergent SRASHE and determination of the alleged victim’s need for mental health treatment, monitoring and arrangements for follow-up services as necessary. 

        • As therapeutically appropriate, the alleged victim shall be given educational materials related to mental health issues which may develop secondary to sexual abuse.

    • Post-Alleged Sexual Abuse Incidents Without Referral for Forensic Medical Examination – Mental Health Consult Urgent Referral:

      • Health care staff shall enter an order for an MH PREA consult urgent referral in the health record for any patient who was the alleged victim of sexual abuse and not referred to an outside contracted county SART facility for receipt of a forensic medical examination. This MH urgent consult shall occur within 24 hours of MH’s receipt of a completed CDCR 128-MH5 Urgent Referral from ISU related to a sexual abuse incident without referral for a forensic medical examination. A mental health clinician shall complete a face-to-face mental health consult in a confidential setting.

      • The mental health urgent consult evaluation shall include a SRASHE, with the additional components as outlined in Section (d)(2)(C)2.b.1) and 2).

    • Initial Intake or Subsequent Screening Information Regarding Prior Sexual Victimization and/or Prior Perpetration of Sexual Abuse – Mental Health Routine Referrals:

      • If the patient reports to staff during the initial custodial intake screening or at any other time during their confinement within the CDCR that they have experienced prior sexual victimization or previously perpetrated sexual abuse, whether it occurred in an institutional setting or in the community, staff shall ensure that the patient is offered a follow-up meeting with mental health and medical staff. 

      • If the patient declines a mental health and/or medical follow-up meeting, staff shall document this declination in the health record or custodial record, as appropriate based upon the staff classification.

      • If the patient agrees to a mental health consult, staff shall enter an order for a PREA routine mental health consult in the Electronic Health Record System (EHRS) to be completed within 14calendar days of the referral.

      • Within 14 calendar days of the referral, the assigned mental health staff shall review the CDCRMH-7448, Informed Consent for Mental Health Care with the patient and obtain the patient’s consent for mental health treatment. If the patient consents to treatment, the clinician shall complete a PREA routine mental health consult to discuss the reason for referral, administer a SRASHE if clinically indicated, and determine if any level of additional follow-up care is necessary. If the patient declines consent, the clinician shall complete the PREA routine mental health consult and SRASHE (if clinically indicated) based upon EHRS review.

      • Mental health treatment services for victims of sexual abuse shall be provided consistent with the community level of care including, but not limited to:

        • Identification of sexual abuse related mental health issues and treatment.

        • Consideration related to need for monitoring.

        • Arrangements for mental health follow-up services when necessary.

        • Continuity of care referrals as patients are transferred or released from custody.

      • Incarcerated person-on-Incarcerated person Sexual Abusers: Mental health shall conduct a mental health evaluation of all known incarcerated person-on-incarcerated person abusers within 60 calendar days of learning of such abuse history. Treatment shall be offered as deemed appropriate by mental health practitioners.  Mental health staff shall enter an order for a Mental Health PREA Perpetrator consult routine (as completed within 60 calendar days of the facility learning of abuse history) in the health record.

      • Mental health staff shall document all PREA consults and evaluations on a PREA note (Note Type: PREA; Note Template: MH PC3002/Valdivia/Z-Case/PREA Note).  Under no circumstances shall the name of the alleged abuser(s) or alleged victim be included in documentation of the other incarcerated person’s health record.

• Reporting Requirements

  • When a patient who is 18 years of age or over reports to health care staff that they were a victim of sexual abuse that occurred outside of an institutional setting, for the purpose of reporting the incident to the appropriate law enforcement agency, health care staff shall:

    • Provide the patient with the CDCR 7552, Prison Rape Elimination Act Authorization for Release of Information to complete for their authorization to release information.

    • Report alleged abuse to the appropriate law enforcement agency once the signature is obtained on the CDCR 7552. If the patient refuses to sign the CDCR 7552, no notifications shall be made except where required by state law.

    • Send the CDCR 7552 to the ISU with documentation that the appropriate law enforcement agency has been notified.

    • Document any reports made or the patient’s refusal in the health record.  Mental health staff shall document using the PREA note (Note Type: PREA; Note Template: MH PC3002/Valdivia/Z-Case/PREA Note).

  • When a patient who is under the age of 18 reports to health care staff that they were a victim of sexual abuse that occurred outside of an institutional setting, for the purpose of reporting the incident to the appropriate law enforcement agency, health care staff shall:

    • Immediately report alleged abuse to their supervisor and the ISU’s designated investigators.

    • Comply with mandatory child abuse reporting laws and report alleged abuse to the appropriate state agencies.

    • Report the allegation to the victim’s parents or legal guardians except when any of the following apply:

      • The ISU has official documentation showing the parents or legal guardians should not be notified.

      • The victim is under the guardianship of the child welfare system, in which case the report shall be made to the victims’ caseworker instead of the parents or legal guardian.

    • Report the allegation to the victim’s juvenile attorney or other legal representative or record within 14-days of receiving the allegation. Health care staff shall document any reports made in the health record.

    • Document any reports made in the health record. Mental health staff shall document using the PREA note (Note Type: PREA; Note Template: MH PC3002/Valdivia/Z-Case/PREA Note).

  • When a patient alleges that they have been the victim of sexual abuse or sexual harassment by a health care provider, a report shall be filed pursuant to the Business and Professions Code, Section 805.8.

    • All terminations for violations of agency sexual abuse or harassment policies, or resignations by employees that would have been terminated if not for their resignation, shall be reported to any relevant licensing body by the hiring authority or designee.

• Institutional PREA Review Committee

  • Institution leadership shall designate a standing committee, the Institutional PREA Review Committee (IPRC), comprised of multidisciplinary team members including upper-level management officials, with input from line supervisors, investigators, and medical or mental health practitioners.  The team is tasked with reviewing all PREA incidents (except those determined to be unfounded or sexual harassment in nature) and reporting findings to the hiring authority for final review.  The IPRC shall meet to review these PREA incidents on at least a monthly basis, or on a schedule set by institutional custody leadership.

  • The IPRC shall:

    • Consider whether the allegation or investigation indicated a need to change policy or practice to better prevent, detect, or respond to sexual abuse.

    • Evaluate whether the incident or allegation was motivated by race; ethnicity; gender identity; lesbian, gay, bisexual, transgender, or intersex identification status or perceived status; gang affiliation; or otherwise caused by other group dynamics at the facility.

    • Examine the area in the facility where the incident allegedly occurred to assess whether physical barriers in the area may enable abuse.

    • Assess the adequacy of staffing levels in the area where the alleged incident occurred during the different shifts.

    • Assess whether monitoring technology should be deployed or augmented to supplement supervision by staff.

    • Prepare a report of findings including, but not limited to, determinations made pursuant to (d)(4)(B)1 through 5, and document any recommendations for improvement.

    • Determine a corrective action plan(s) for any recommendation(s), implement the recommendations for improvement, or document the reasons for not doing so.

• Training

  • Institution leadership shall ensure that all institution health care staff are provided with training regarding their responsibilities as outlined in the Federal PREA Standards and this procedure, and medical and mental health providers are provided specialized medical and mental health training in their responsibilities as outlined in the Federal PREA Standards and this procedure. A system for the orientation, mentoring, and cross-training of all critical positions in the response to sexual abuse shall be developed and maintained.

Policy

• California Correctional Health Care Services (CCHCS) and the California Department of Corrections and Rehabilitation (CDCR) shall provide medically necessary gender affirming care for transgender and gender diverse (TGD) patients who are diagnosed with Gender Dysphoria (GD). The Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association, provides the diagnostic criteria for GD.

• The CCHCS Transgender Care Guide shall be used to aid medical and mental health staff in the evaluation and management of TGD patients. The Transgender Care Guide is a tool to assist medical and mental health staff in caring for TGD patients.

Purpose

• To provide guidance to CCHCS medical and mental health care staff in the management of TGD patients with GD.

Record and Information Requests related to Gender Affirming Care or Services

• Any court order, administrative order, or subpoena requesting medical records related to gender affirming health care shall be processed by Health Information Management in accordance with HCDOM, Section 2.3.4, Release of Protected Health Information.

• CCHCS and CDCR are not prohibited from disclosing medical information of an individual upon request to a health care facility that is run by an agency or department from another state, or to a federal law enforcement agency, for treatment purposes and direct medical care for the specified individual if the information disclosed is narrowly limited to the request.

• CCHCS and CDCR shall not cooperate with any inquiry or investigation by, or provide medical information to, any individual, agency, or department from another state or, to the extent permitted by federal law, to a federal law enforcement agency that would identify an individual and that is related to an individual seeking or obtaining gender affirming health care or gender affirming mental health care that is lawful under the laws of this state.