Chapter 5 – Administrative

Policy

• California Correctional Health Care Services (CCHCS) shall utilize a centralized project management process for the development, revision, and approval of all proposed health care Policy Initiatives for publication in the Health Care Department Operations Manual (HCDOM) care guides, regulations, and Policy Memoranda.

Procedure

• Policy Initiative Process Overview

  • The program’s Deputy Director (DD) or delegate shall submit a Policy Initiative proposal to Fiscal Impact Resource and Strategy Team (FIRST) via the Initiative Request Form.

  • Pursuant to the HCDOM, Section 1.2.20, Fiscal Impact Resource and Strategy Team, following FIRST consensus for a Policy Initiative proposal to proceed, the Regulations and Policy Section (RPS) within Policy and Risk Management Services shall:

    • Initiate a Policy Initiative in the project database.

    • Confirm the Interdisciplinary Project Team (IPT) considers all impacted written organizational directives and governance documents during the development process.

    • Track development activities within the project database.

    • Ensure final documents comply with standard style, structure, and guidelines and submit the final documents to each approval group as detailed in the Health Care Regulations and Policy Section Executive Approval List.

    • Develop regulatory text for applicable Policy Initiatives pursuant to Government Code (GC) Section 11342.600.

• Health Care Department Operations Manual

  • Executive sponsors shall review policies to ensure language is accurate and complies with applicable external mandates and Joint Commission standards.

  • The Director, Health Care Policy and Administration, is the primary approval authority for the content of the HCDOM Chapter 5, Administrative.

  • The Plata Receiver and the Undersecretary, Health Care Services, are the primary approval authorities for the content of the HCDOM.

  • Following executive approval, RPS shall:

    • Provide clinical HCDOM sections to the Prison Law Office (PLO), pursuant to the Plata court order.

    • Distribute HCDOM sections to California Department of Corrections and Rehabilitation (CDCR) and CCHCS staff.

      • Any applicable Local Operating Procedures shall be amended to align with the HCDOM as soon as possible but no later than 30 calendar days after distribution.

• Policy Memoranda

  • A Policy Memorandum shall be required when a program needs to provide immediate direction to the field.

    • Programs shall:

      • Draft language on a Policy Memorandum template including the proposed effective date and affected HCDOM sections.

      • Secure approval of the memoranda by those required to sign.

      • Submit unsigned memoranda as noted in Section (b)(3)(B) below.

  • Programs shall submit Policy Memoranda:

    • With a Policy Initiative proposal pursuant to Section (b)(1)(A) above; or
      

    • For an existing Policy Initiative to m_first@cdcr.ca.gov. RPS shall process pursuant to Section (b)(3)(C)1.–3. below.

  • Following FIRST consensus pursuant to the HCDOM, Section 1.2.20, Fiscal Impact Resource and Strategy Team, RPS shall:

    • Review and assign the appropriate alphanumeric designation corresponding to the HCDOM placement.

    • Secure required signatures via DocuSign.

    • Post the signed memorandum on the Health Care Department Operations Manual Resources page of the CCHCS Intranet, submit it to the Memo Repository, and distribute it to CDCR and CCHCS staff.

• Health Care Regulations

  • The Secretary, CDCR, is the approval authority for the content of health care regulations published in the California Code of Regulations (CCR) Title 15.

  • Health care regulations shall be adopted and maintained pursuant to the Administrative Procedure Act (APA) as set forth in GC, Section 11340, et seq and Title 1 of the CCR.

  • Regulatory Administrative Processes – Notice Posting and Distribution

    • Upon publication of a Notice of Proposed Action (NOPA), RPS shall email the Public Information Officer (PIO) at each institution the following:

      • A PDF containing all documents included in the NOPA, including the CDCR 7554, Notice of Change to Health Care Regulations.

      • A blank CDCR 621-HC, Certification of Posting.

    • Within five calendar days of receipt of the NOPA, each institution’s PIO, or designee, shall:

      • Post the CDCR 7554:

        • On staff and incarcerated person bulletin boards.

        • Within incarcerated person housing units, corridors, and other areas easily accessible to incarcerated persons.

        • Within institution health care facilities.

      • Provide the full contents of the NOPA to:

        • Law libraries.

        • Advisory committees and councils.

  • Distribution and Adoption

    • RPS shall:

      • Post rulemaking documents on the CCHCS internet pursuant to the APA and distribute the Notice and adopted regulations to CDCR and CCHCS staff, and external stakeholders.

      • Confirm Westlaw accurately reflects adopted regulations.

    • Petitions

      • RPS shall process responses to petitions to adopt, amend, or repeal health care regulations, as well as underground regulations petitions related to health care written policy, pursuant to the APA and in collaboration with the impacted programs, CCHCS Office of Legal Affairs, and CDCR Office of Legal Affairs, as appropriate.

      • Any petitions related to health care regulations received by any CDCR or CCHCS staff shall be immediately forwarded to HCregulationsandpolicy@cdcr.ca.gov.

• Health Care Forms Distribution and Publication

  • Following executive approval, RPS shall:

  • Post clinical forms on the Health Care Department Operations Manual Resources page of the CCHCS Intranet and coordinate with the Regulations & Policy Management Branch to post in the CDCR Forms Library on the CDCR Hub.

    • RPS shall send the form to the California Correctional Training and Rehabilitation Authority if the program determines it should be made available for ordering.

  • Distribute the clinical forms to CDCR and CCHCS staff.

  • Provide dental forms to Dental Services for distribution or incorporation into the Electronic Dental Record System.

• Care Guides

  • Pursuant to the HCDOM, Section 1.2.20, Fiscal Impact Resource and Strategy Team, following FIRST consensus and executive approval, RPS shall post the care guide on the CCHCS Intranet and internet and distribute to CDCR and CCHCS staff and the PLO.

• Pilot Programs

  • Following FIRST consensus, RPS shall review the proposed pilot or test program to determine if it meets the definition of a regulatory pilot program pursuant to Penal Code, Section 5058.1.

  • Following confirmation of a regulatory pilot program, RPS shall develop and process all documents necessary for incorporation of the pilot program into the CCR, pursuant to the APA and in collaboration with the IPT.

Policy

• The California Public Records Act (PRA) requires that government records be released to the public, upon request, unless the records are specifically exempt from disclosure by law.  Under provisions of the PRA, California Correctional Health Care Services (CCHCS) shall ensure timely responses to all health care-related PRA requests.

• Responsive records to a PRA request shall be released unless they disclose personal, medical, or other private information about an individual; confidential financial or trade secret information about a company/vendor; are exempt under the PRA; or the PRA requester chooses not to remit the assessed fee for the records.  All requests for records shall be considered PRA requests with the exception of subpoenas, court orders, search warrants, or legal documents.  It is not necessary for a records request to cite the PRA or any other authority, to state the purpose for the request, or to identify themselves or their affiliation.

Responsibilities

• The Deputy Director, Policy and Risk Management Services, or designee, has the authority to release records requested under the PRA and shall ensure departmental compliance with this policy.

• The Associate Director, Risk Management Branch (AD RMB), shall designate a CCHCS PRA Coordinator, or designee, responsible for releasing all health care-related PRA requests.

• The CCHCS PRA Coordinator, or designee, shall ensure instructions for making a PRA request are posted at CCHCS headquarters and https://cchcs.ca.gov/pra/ at all times. The Chief Executive Officer, or designee, at each institution shall ensure the PRA instructions are posted in the law libraries.

• Health Care Litigation Support Section (LSS) staff are responsible for researching PRA requests; contacting programs for responsive records; calculating costs for compiling, copying, and furnishing records, if produced by LSS; preparing PRA responses; and submitting responses to the CCHCS PRA Coordinator for approval to release which may include responsive records, a denial, notification of extension, or confirmation of records, and instructions on remittance or in-person inspection.

Procedure

• Submittal of Public Records Act Requests

  • PRA requests may be sent via email to CCHCSHealthPRAs@cdcr.ca.gov, or by mail to California Correctional Health Care Services, Attention: PRA Coordinator, Building C, P.O. Box 588500, Elk Grove, CA  95758.

  • Health care-related PRA requests submitted to CCHCS or California Department of Corrections and Rehabilitation (CDCR) employees shall be forwarded to LSS within 24 hours of receipt.

    • Requests for contract records made during a contract’s procurement shall not be considered PRA requests and shall be forwarded immediately to the CCHCS contracting office responsible for that procurement. This shall ensure that vendors are provided timely information prior to the close of the procurement. 

    • Only upon completion of a contract’s procurement, including any applicable protest period, will requests for contract records be processed as PRA requests and forwarded to LSS.

  • LSS shall contact the requester to clarify requests that are overly broad, vague, or not sufficiently descriptive, and assist in focusing the request, if possible.

• Fee Determination and Collection

  • CCHCS shall collect fees for responsive records if:

    • Hardcopy records are requested; or

    • Data compilation, extraction, or programming to produce the record is required.

  • LSS shall contact the appropriate CCHCS program area to determine if there is a fee associated with the PRA request.

  • Prior to performing any tasks to gather responsive documents, LSS shall email to the program area the Public Records Act Staff Salary and Cost Breakdown worksheet to complete which includes:

    • An estimate of the calculated hours needed to complete the request, and

    • The number and classifications of staff that will be utilized.

  • LSS shall:

    • Calculate the hourly rate based on the mid-range salary for the classification performing the data compilation, extraction, or programming to produce the record.

    • Prepare a cost estimate.

    • Provide the estimate to the requester, in writing, with instructions on remittance of payment and due date.

  • If full payment is not received by the due date, which is 30 calendar days, LSS shall close the PRA request.

• Responding to Public Records Act Requests

  • The CCHCS PRA Coordinator, or designee, shall respond to the PRA requests within ten calendar days of receipt by providing to the PRA requester one of the following:

    • Confirmation that responsive records exist, an approximate date the records will be available, and instructions about cost remittance or in-person inspection, if requested.

    • A denial letter indicating no records shall be provided and the reason(s) for the denial.

    • A notification of a 14-calendar day extension pursuant to California Government Code Section 7922.535(b).

    • The requested records.

    • A portion of the requested records with an estimated time for the balance of the records to be provided.

• Processing of Public Records Act Requests

  • Upon receipt of the full payment of fees (refer to Section (c)(2) above), LSS shall request responsive documents from the appropriate CCHCS program area within a specified timeframe.

  • The appropriate CCHCS program area shall:

    • Process the request including redacting all personal or exempt information within the responsive records and notify LSS of any information redacted and the reason(s) for the redaction.

    • Provide responsive records to LSS in their original and redacted formats.

  • The CCHCS’ Office of Legal Affairs (COLA) shall consider the appropriateness of proposed redactions and provide legal guidance as needed.

• Release of Public Records

  • Prior to the CCHCS PRA Coordinator releasing records under the PRA, the AD RMB, and COLA shall provide written approval to LSS (except for records in Section (c)(5)(B)1. and 2. below).

  • Release of the following records does not require AD RMB or COLA approval:

    • Official CDCR medical, mental health, or dental forms.

    • Prior versions of the Health Care Department Operations Manual and CCHCS Care Guides.

  • Responsive records shall be transmitted electronically whenever possible; however, records shall be provided to the requester in the format requested and paid for, if applicable (i.e., hardcopies of public records may also be mailed, if appropriate).

• Physical Inspection of Public Records

  • Physical inspection of responsive records to a PRA request shall be permitted within a CCHCS Headquarters’ office during normal business hours or facilitated through the institution Litigation Coordinator. 

  • There is no fee for inspection of public records.

  • LSS staff shall remain present for the duration of the inspection in order to prevent the PRA requester from destroying, mutilating, defacing, altering, or removing any records from the premises.

  • Upon completion of the inspection or at the request of LSS staff, the PRA requester shall relinquish physical possession of the records.

• Denial of Public Records Request

  • LSS shall deny the release of records which are exempt from disclosure under the PRA.

  • If a request is denied, in whole or in part, LSS shall provide the requester with legal justification for withholding the record. 

  • If LSS denies a PRA request with knowledge that the records may be available within CDCR, CCHCS shall provide contact information for CDCR’s PRA Coordinator to the PRA requester.

• Public Records Act Request Tracking and Reporting Requirements

  • LSS shall utilize a tracking system for each PRA request.

  • The AD RMB, or designee, shall issue a weekly PRA report to designated CCHCS executive staff providing the status of PRA requests, as well as compile an annual report at the conclusion of each fiscal year.

• Document Retention

  • Copies of PRA records shall be maintained within LSS at CCHCS headquarters for a minimum of five years following closure of the request.  PRA records shall be purged after the five-year period, unless there is duty to preserve the documentation pursuant to litigation.

Policy

• The California Department of Corrections and Rehabilitation (CDCR)/California Correctional Health Care Services (CCHCS) adopted a Medical Classification System (MCS) to serve as the process for considering medical factors in making patient placement decisions.

Purpose

• The Health Care Placement Oversight Program (HCPOP), in conjunction with CCHCS headquarters Utilization Management (UM), is responsible for providing management and oversight of institutional Specialized Medical Beds and for making patient placement decisions to ensure maximum and efficient bed utilization and to facilitate timely access to the continuity of care.  Specialized Medical beds are defined as Outpatient Housing Unit, Hospice, Correctional Treatment Center, Skilled Nursing Facility, and General Acute Care Hospital Beds.

Local Level Placements and Discharges

• Admissions and discharges can be made at the local level and shall be reported as they occur unless HCPOP/UM has placed a hold on the medical bed.  HCPOP/UM staff will review all admissions for appropriate level of care placement.

Health Care Placement Oversight Program

• Once HCPOP has placed a hold on a medical bed for an identified placement, the bed shall not be used without authorization from HCPOP. 

• If an institution holding a bed requests to utilize a medical bed on which HCPOP has placed a hold, the institution shall provide the appropriate  documents (CDCR Form 128-C3, Medical Classification Chrono), CDCR Form 7410, Comprehensive Accommodation Chrono, and CDCR Form 1845, Disability Placement Program Verification) to HCPOP for review by UM to determine appropriate bed utilization.

• As the availability of beds, programs, and other capacities change, the HCPOP staff will ensure the Medical Classification Matrix and the Medical Classification Matrix Database are updated as needed.  All updated information shall be disseminated to the field through the CDCR Division of Adult Institutions Population Management Unit.

Medical Bed Placement/Weekends and Holidays

• When institutional medical staff determines the need for an in-patient medical bed within their institution and one is not available, medical staff shall contact HCPOP to determine if the needed type of specialized medical bed is available at an alternate institution prior to placing/retaining a patient in a community hospital.

• The need for a specialized medical bed may be for a medical admission, to clear a swing bed (a bed that can be used for either medical or mental health) for mental health, or to return a patient from a community hospital.

• All transfers made during weekends/holidays are medical and return for short duration to avoid a hospital admission or delay in a community discharge.  The transferred patient shall be returned to the sending institution upon bed availability.

Contact

• For questions or clarification, please contact the Chief, Health Care Placement Oversight Program.

Forms

• CDCR Form 128-C3, Medical Classification Chrono

• CDCR Form 1845, Disability Placement Program Verification

• CDCR Form 7410, Comprehensive Accommodation Chrono

Policy

• California Correctional Health Care Services (CCHCS) shall maintain the highest standards of conduct in the fulfillment of its mission.  CCHCS employees entrusted with state resources must, at a minimum, exercise reasonable care for safekeeping.

• Management is required to ensure that state assets are protected, laws and regulations are followed, financial and management information is reliable, and the organization and programs are operating effectively and efficiently.

• The State of California has adopted the Standards for Internal Control in the Federal Government by the Comptroller General of the United States (Green Book) that provides an overall framework for establishing and maintaining effective policies, procedures, and practices for an effective work place environment.

• CCHCS management shall create an effective work environment in their areas of responsibility and have established policies, procedures, and practices to mitigate, prevent, and detect actual or suspected incidents of fraud, misuse/theft of assets, inappropriate contract/procurement activities, employee misconduct, errors in financial reporting, errors that impact the state fund, and other fiscal irregularities.

• Managers shall take appropriate and immediate action following discovery of an incident outlined within this policy to ensure compliance with the State Administrative Manual (SAM), Section 20080, Notification of Fraud or Error, reporting requirements.  Managers shall not tolerate or condone these types of activities.

Purpose

• To ensure that incidents of actual or suspected fraud, misuse/theft, damage, and fiscal irregularities of state assets and funds are reported to the Policy and Risk Management Services, Internal Audit Program (IAP); California State Auditor (CSA); and Department of Finance, Office of State Audits and Evaluations (OSAE), as required by SAM, Section 20080.

Applicability

• This policy applies to all CCHCS civil service employees.

Reportable Incidents

• The following examples of potential reportable incidents under this policy include, but are not limited to:

• Illegal or fraudulent acts involving state property, including cash.

• Forgery or alteration of state documents including, but not limited to, checks, timesheets, payroll documents, drafts, purchase orders, invoices.

• Misappropriation of state funds, supplies, or any other state asset.

• Theft, destruction, or disappearance of state records, equipment, or other assets.

• Misrepresentation of information on state documents (e.g., travel reimbursement related documents, purchase orders, or false entries).

• Authorizing or receiving state payment for goods not received or services not performed.

• State financial reporting misrepresentation.

• Fraud in securing an appointment to a state position.

• Tampering with or inappropriate use of information technology, unauthorized disclosure of confidential or proprietary information, personal information or medical information.

• Accepting bribes (e.g., contracting, subcontracting).

• Working on incompatible activities using state resources.

• Errors that are unusual and have a fiscal impact to the state fund.

• Employee misconduct that is not subject to adverse action but may result in an informal discipline, letter of instruction, or counseling memorandum.

Filing an Incident

• Headquarters, regional offices, and institution reporting:

  • Upon discovery of an incident, the employee (staff or management) shall document the incident using an Actual or Suspected Fraud, Errors, and Improper Governmental Activities Report (herein referred to as Report).  Supporting documents (e.g., timesheets, forms, relevant emails) provided should support the alleged incident. 

  • The Report shall be documented in clear and concise statements that describe how the alleged incident was discovered, a description of the incident, sequence (chronology) of events, internal controls compromised (e.g., any action inconsistent with policy, improper approval), and any statutes, regulations, procedures or rules violated (e.g., Government Code, Penal Code, State Administrative Manual, Department Operations Manuals).

  • The employee shall scan and immediately email the Report to the Chief, IAP, at CCHCSIAP@cdcr.ca.gov.  The employee shall share the report with the employee’s supervisor prior to submission, unless the supervisor is involved in the subject of the report or unless the employee fears retaliation if the employee were to share the report with the supervisor.

  • If complete information is not available following discovery of the incident, IAP shall either reject the Report or request additional information.

  • IAP shall determine whether this incident is reportable under SAM, Section 20080, and address as appropriate.

  • IAP shall reject Reports submitted anonymously.

  • IAP shall determine if CSA and OSAE are to be notified of reported incidents.  For incidents that require reporting to external agencies, other than CSA and OSAE, IAP shall first review the matter with appropriate management and CCHCS’ Office of Legal Affairs. 

  • Once IAP determines material or substantive information exists to support the incidents and activities alleged, the Chief, IAP, shall follow SAM, Section 20080, procedures to notify and follow up with OSAE and the CSA no later than 30 calendar days following the discovery of the incident.

    • Updated reports are required every 180 days until the incident is resolved.

    • Incidents are resolved when corrective action is taken or a referral is made to the proper authority (e.g., the Attorney General, California Highway Patrol, outside law enforcement).

  • IAP shall notify the reporting employee when the incident is received.  IAP shall notify the reporting hiring authority of incidents reported and when incidents are resolved. 

  • Each reporting employee has an obligation to exercise sound judgment to avoid baseless allegations of incidents. Reporting employees may not be notified on how reported incidents are resolved.

• The following incidents do not apply to this policy and will not be reviewed by IAP:

  • Incidents that have been first reported to external agencies (e.g., California State Auditor Whistleblower, State Personnel Board, Office of Inspector General, or the Attorney General’s Office) unless directed by external agencies.

  • Bargaining Unit (Union) specific grievances and complaints.

  • Complaints regarding harassment and unlawful discrimination.

Whistleblower Protection Act and Employee Retaliation

• The California Whistleblower Protection Act authorizes CSA to receive complaints from state employees and members of the public who wish to report an improper governmental act.  All employees and members of the public may file a Whistleblower complaint directly with CSA.  For instructions on filing a Whistleblower complaint, refer to CSA’s website at https://www.auditor.ca.gov/whistleblower/.

• Labor Code, Section 1102.5, prohibits an employer from retaliating against an employee who discloses information that would result in a potential violation or noncompliance of statute or regulation to a governmental or law enforcement agency, to a person with authority over the employee, or another employee who has the authority to investigate.  The Labor Code also protects employees who refuse to participate in an activity that would result in a potential violation or noncompliance of statute or regulation.

Training

• All CCHCS civil service employees are required to complete the read and sign training via the online Learning Management System upon hire and annually thereafter.

Policy

• The California Correctional Health Care Services (CCHCS) shall ensure all staff comply with the requirements outlined in the Disability Placement Program (DPP) and the Developmental Disability Program (DDP) by maintaining a process to report, log, track, and initiate inquiries into allegations of non-compliance with the DPP and DDP and ensure corrective action where applicable.

Responsibility

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

Procedure

• Reporting Allegations

  • All staff are responsible for identifying and reporting allegations of staff non-compliance with the DPP or Armstrong Remedial Plan, DDP or Clark Remedial Plan, or any subsequent court orders associated with the Armstrong or Clark litigation, even if the non-compliance was unintentional, unavoidable, done without malice, done by an unidentified staff or subsequently remedied.

  • All allegations shall be reported via written report (e.g., memorandum, e-mail, audit results) and include any supporting documentation.

  • Allegations may be identified through, but not limited to:

    • Internal audits

    • Staff observation

    • Health care grievances

    • Reasonable modification or accommodation request

    • Third party (e.g., Release of Information Log, advocacy letters, monitoring tour reports)

• Tracking Allegations

  • Allegations of staff non-compliance require placement into the Allegation Log Tracking System (ALTS) if:

    • The patient is a participant in the DPP or DDP, has a learning disability, verified or unverified, or requires accommodation based on a reading level score of 4.0 or lower, which includes zero or no reading score.

    • The patient claims denial of equal access to programs, activities or services, or claims a discriminatory or retaliatory action based on the patient’s disability.

    • The allegation involves a staff member or contracted employee.

  • Allegations of non-compliance that do not require placement within ALTS are:

    • Effective Communication (EC) is not appropriately documented pursuant to EC procedures, but is documented elsewhere (e.g., progress notes, physician’s orders, and chronos).

    • Allegations regarding lost or misplaced Durable Medical Equipment as a direct result of a community ambulance transport.

    • Entries in the Electronic Health Records System not matching entries in the Strategic Offender Management System. Inconsistent entries shall be resolved as appropriate.

    • With the exception of patients with DPW or DPO codes, if a patient arrives at an institution after hours and is placed in a bed that does not meet their Americans with Disabilities Act needs, but the patient is moved to an appropriate bed the following calendar day.

• Allegation Inquiry

  • There shall be an inquiry into all allegations of staff non-compliance regardless of whether the allegation contains the name of staff members.

  • In rare instances where the date of discovery is 16 months or older, the allegation shall be discussed with the California Department of Corrections and Rehabilitation (CDCR), Office of Legal Affairs to determine whether the incident is too old to initiate an inquiry.

  • Initiation of a timely inquiry is necessary to ensure allegations are reviewed while memories are fresh, the facts surrounding the allegations are still in existence, and the violation can be remedied.

    • The inquiry shall be assigned to an appropriate supervisor or manager and initiated within ten business days of being discovered or reported to staff.  The inquiry shall be completed within 30 business days of being assigned.

    • The inquiry shall include a review of all information necessary to determine whether the allegation is “confirmed” or “not confirmed” or “entered in error”.

    • The inquiry shall include a mandatory interview with the affected patient with the following exceptions:

      • Instances regarding EC where it is determined that EC was not appropriately documented (check boxes not completed or EC documented elsewhere [EC documentation error]).

      • When an allegation is raised via a CDCR 602 HC, Health Care Grievance, a CDCR 1824, Reasonable Accommodation Request, or a third party and, as a result of that process, a patient interview is conducted that meets the inquiry requirements.

    • The inquiry shall be conducted at the institution where the allegation occurred. If the patient transfers prior to completion of the inquiry and an interview is required, the assigned supervisor or manager shall contact the patient’s new institution and arrange an interview.

    • The inquiry shall include an interview with the employee against whom the allegation is made unless investigation determines that the allegation has no merit.

    • The outcome of the inquiry shall be documented as “confirmed”, “not confirmed” or “entered in error”.

  • The Health Care Compliance Analyst shall forward allegations and all supporting documentation to the appropriate institution or hiring authority where applicable.

• Written Report of the Inquiry

  • The inquiry shall result in a written report containing the following:

    • Date of discovery

    • Type of allegation

    • Name and title of person conducting the inquiry

    • Patient interview

    • Summary of findings

    • List of all sources of information relied upon (including any staff interviews)

    • Other allegations of non-compliance discovered at the time of the inquiry

    • Conclusion: Confirmed or Not Confirmed

  • The completed inquiry form and all corresponding supporting case documents shall be uploaded and retained within ALTS.

• Progressive Discipline

  • The CEO shall determine whether to initiate corrective action, or to submit a confidential request for investigation or approval for direct adverse action to the Office of Internal Affairs for an employee found in non-compliance.  The following factors shall be considered:

    • Number of prior violations in relation to the overall number of encounters

    • Serious harm occurred or could have occurred to the patient

    • Culpability of the employee

    • Systemic issue

  • The CEO shall discipline employees consistent with the Employee Disciplinary Matrix set forth in the CDCR, Department Operations Manual, Chapter 3, Article 22, Employee Discipline and the California Code of Regulations, Title 15, Section 3392, Employee Discipline.

• Disclosure

  • Corrections Services staff shall collect, aggregate, analyze, and submit the statewide ALTS logs to Plaintiffs on a monthly basis.

  • The statewide ALTS, DDP, and DPP logs shall be reported separately.

  • Staff names shall be omitted.

• Continuous Process Improvement

  • The Statewide Quality Management Committee shall:

  • Periodically evaluate ALTS data to identify systemic themes that may pose quality and patient safety risks, and

  • Prioritize and initiate process improvement activities, as necessary or appropriate.

Policy

• California Correctional Health Care Services (CCHCS) shall provide Non-Paragraph 7 (Non-P7) responses that address Prison Law Office (PLO) questions and concerns regarding issues not covered under the patient-specific Paragraph 7 (P7) process, pursuant to the Plata Stipulation for Injunctive Relief, dated June 13, 2002. CCHCS shall ensure timely response to the PLO’s inquiry within 30 calendar days of receipt.  Responses shall be provided by the responsible program, region, or institution and vetted through CCHCS Office of Legal Affairs (COLA) and Office of Legal Affairs (OLA), California Department of Corrections and Rehabilitation, prior to release to the PLO. Issues addressed via the Non-P7 process shall include the following:

  • Systemic health care issues identified by the PLO through P7 cases, tours, or other sources of information.

  • Significant institution compliance issues requiring headquarters attention and intervention.

Responsibility

• The Health Care Compliance Support Section (CSS) is responsible for facilitating the Non-P7 process and providing formal responses to PLO inquiries.  CSS is responsible for soliciting and maintaining a current listing of point of contact designees for each program area.

• Headquarters program managers, institution leadership, or regional executives are responsible for providing comprehensive responses to CSS within the timeframes specified, and appointing a designee and back-up from their program area to be the point of contact for any follow-up questions.  It is the responsibility of headquarters program managers, institution leadership, or regional executives to ensure any corrective actions included within a formal response to the PLO are implemented, monitored, and sustained.

• The Associate Director (AD), Risk Management Branch (RMB), Deputy Director (DD), Policy and Risk Management Services (PRMS), Director, Health Care Policy and Administration, Director, Health Care Services, COLA, and OLA, as well as appropriate program leadership or designees (when applicable), are responsible for reviewing responses to ensure accuracy, completion, and appropriate corrective actions (if applicable) prior to releasing to the PLO.

• The DD, PRMS, or designee, upon approval from COLA and OLA, has authority to release responses and shall ensure departmental compliance with this policy.

Non-P7 Database Tracking

• CSS shall utilize a designated database for tracking each Non-P7 inquiry and response.  Appropriate documentation of timeframes and status updates shall be input timely by designated CSS staff.

Reporting Requirements

• The AD, RMB, or designee, shall email a weekly status report of open Non-P7 inquiries to COLA and OLA, and applicable headquarters Directors, program managers and designees, institutional leadership, and regional executives.

Policy

• California Correctional Health Care Services (CCHCS) shall maintain a health care grievance (grievance) process to provide an administrative remedy to patients under health care’s jurisdiction (medical, mental health, and dental) for review of complaints of applied health care policies, decisions, actions, conditions, or omissions that have a material adverse effect on their health and welfare.  Any grievance which contains allegations against health care staff behavior or activity which would constitute staff misconduct if true, must be processed as a health care staff complaint (staff complaint).

Purpose

• To maintain the integrity of CCHCS and the Division of Health Care Services through fair, objective, and effective review of the patient’s complaints; provide for the resolution of a grievance at the lowest possible administrative level with timely responses to the patient; provide the patient intervention as deemed medically necessary by health care staff to address an identified health care issue and/or staff complaint; and afford the patient an avenue for the exhaustion of administrative remedies prior to initiation of a court action.

Responsibilities

• All health care staff involved in the grievance process shall be responsible for the effective operation of the grievance process and ensure that every grievance and staff complaint is reviewed thoroughly and answered appropriately in accordance with California Code of Regulations (CCR), Title 15, Division 3, Chapter 2, Subchapter 2, Article 5, Health Care Grievances, and applicable rules, regulations, and policies.

• Institutional Level

  • The Chief Executive Officer, or designee, is responsible for the institution’s grievance process, ensuring it operates effectively and consistently and is the institutional level reviewing authority.

  • Each institution shall have a Health Care Grievance Office (HCGO) and assigned staff, including a Health Care Appeals Registered Nurse and a Health Care Grievance Coordinator, responsible for the processing of all grievances and staff complaints.

  • Health care staff with supervisory authority over the subject of a staff complaint is responsible for conducting the confidential inquiry.

• Headquarters’ Level

  • The Chief, Health Care Correspondence and Appeals Branch (HCCAB), and the Deputy Director, Policy and Risk Management Services, are responsible for oversight of the statewide grievance process, ensuring it operates effectively and consistently. 

  • The Chief, HCCAB, is the headquarters’ level reviewing authority.

  • HCCAB shall have assigned staff, including licensed clinical staff, responsible for the processing of all health care grievance appeals and staff complaints.

Procedure

• Institutional Level

  • Grievances and staff complaints are subject to an institutional level review. 

  • HCGO staff shall process all grievances and staff complaints, prepare a response for each accepted grievance or staff complaint, and route the prepared response to the reviewing authority for review and signed approval. 

  • Completed grievances and staff complaints shall be mailed/delivered to the patient within 45 business days of receipt, unless processed as an expedited health care grievance pursuant to CCR, Title 15, Section 3999.233(b). 

  • Additional information related to institutional level grievance procedures are outlined in the Health Care Grievances Operating Standards: Correspondence and Appeals Branch – HCG-Complete.pdf – All Documents (sharepoint.com).

• Headquarters’ Level

  • Grievances and staff complaints may receive a headquarters’ level review, if requested by the patient.

  • HCCAB staff shall process all grievance appeals and staff complaints, prepare a response for each accepted grievance appeal or staff complaint, and route the prepared response to the reviewing authority for review and signed approval. 

  • Completed grievance appeals and staff complaints shall be mailed/delivered to the patient within 60 business days of receipt, unless processed as an expedited health care grievance appeal pursuant to CCR, Title 15, Section 3999.233(b). 

  • A headquarters’ level grievance appeal disposition exhausts administrative remedies.

  • Additional information related to headquarters’ level grievance appeal procedures are outlined in the Health Care Grievances Operating Standards: Correspondence and Appeals Branch – HCG-Complete.pdf – All Documents (sharepoint.com)

Training and Resources

• HCGO and HCCAB staff shall complete grievance and staff complaint process training via the online Learning Management System upon hire and annually thereafter. 

• Supervisory staff who conduct staff complaint confidential inquiries shall complete staff complaint training for supervisors.

• Health care staff involved in the grievance process shall utilize the Health Care Grievances Operating Standards and Standard Grievance Language resource documents available on the Department intranet.

Policy

• The Health Care Correspondence and Appeals Branch (HCCAB) shall maintain a Compliance and Support Team (CAST) to assist Health Care Grievance Offices (HCGO) statewide to ensure compliance with California Code of Regulations, Title 15, Division 3, Chapter 2, Subchapter 2, Article 5, Health Care Grievances; court mandates; and departmental policies and procedures related to the health care grievance (grievance) process; efficient grievance processing at the institutional and headquarters’ levels; and a meaningful administrative remedy process for patients. 

Purpose

• To maintain the integrity of the grievance process by promoting accountability through compliance reviews and provision of assistance and/or training; tracking and monitoring of action items, Corrective Action Plans (CAP), and recommendations; identifying and implementing processes to increase efficiencies and mitigate risk; and compiling and reporting compliance review findings, CAST activities, and key performance metrics and trends.

Responsibilities

• The Chief, HCCAB, and the Deputy Director, Policy and Risk Management Services (PRMS), are responsible for:

  • The oversight and management of the statewide grievance program and implementation of this policy and procedure, and the Health Care Grievances Operating Standards, Section 4.1, Compliance and Support Team.

  • Approving requests and referrals for CAST Support.

  • Issuing Compliance Review Exit Memorandums.

  • Compiling and issuing CAST metrics as appropriate.

• The Chief Executive Officer (CEO) is responsible for:

  • Compliance with this policy and procedure at the institution level.

  • Responding to the Compliance Review Exit Memorandum and taking corrective action to resolve identified non-compliance issues.

• All California Correctional Health Care Services and Division of Health Care Services staff involved in the grievance process are responsible for the efficient operation of the grievance process and supporting CAST activities to ensure compliance with applicable regulations, court mandates, and departmental policies and procedures.

Procedure

• Compliance Review

  • Prior to a compliance review site visit, CAST shall utilize the Compliance Review Tool to conduct a preliminary assessment consisting of a review of grievances and staff complaints closed in the Health Care Appeals and Risk Tracking System (HCARTS) in the most recent three months to identify applicable areas of non-compliance and general grievance processing issues.

  • During the site visit, CAST shall discuss the results of the preliminary assessment, interview HCGO staff to complete the questions in the Compliance Review Tool that require on-site responses, and review hard copies of staff complaint packages selected during the preliminary assessment.

  • Upon return from the site visit, CAST shall draft a Compliance Review Exit Memorandum, which shall:

    • Be addressed to the CEO, with copies to the appropriate headquarters and institution chain of command.

    • Outline the observations, compliance ratings for the quantifiable indicators, action items, and/or CAP, if applicable.

    • Be routed for HCCAB management review within ten business days.

    • Be emailed with the completed Compliance Review Tool to the addressees within 15 business days.

    • Request a response from the CEO to address the action items and/or CAP within 25 business days of receipt.

  • Within 25 business days of receipt of the Compliance Review Exit Memorandum, the CEO shall prepare a memorandum confirming each action item has been implemented and/or completed, including a CAP, if applicable, and email the signed response to CAST.

• CAST Support

  • CAST shall assist in the development and implementation of effective training curriculum and utilize appropriate training methods to deliver onboarding and ad-hoc training to institution and headquarters staff involved in the health care grievance process.

  • HCGO Support

    • Upon identifying the need for CAST Support, the HCGO or HCCAB staff shall complete and submit a CAST Support Request and Referral Form to HCCAB management for approval.

    • The Chief, HCCAB, and the Deputy Director, PRMS, shall review requests and referrals for approval within ten business days of receipt.

    • Upon approval of a request or referral for CAST Support, CAST shall review monitoring data and may use applicable sections of the Compliance Review Tool to conduct a spot check consisting of review of grievances and staff complaints closed in HCARTS in the most recent three months to identify risks, trends, training needs, and process improvement opportunities.

    • While on-site in the HCGO, CAST shall:

      • Observe HCGO operations to analyze training needs, develop customized training plans, identify process improvement opportunities, and provide guidance in the development of local operating procedures.

      • Provide assistance and/or training and recommendations to HCGO staff and other institutional staff, as necessary.

    • CAST shall provide ongoing support to HCGO staff as deemed necessary by CAST management and the Chief, HCCAB.

CAST Reporting

• Metrics Report

  • CAST management shall generate the Metrics Report by the tenth day of the month after the end of the reporting period for issuance to the Chief, HCCAB.  The Metrics Report shall consolidate the previous month’s CAST activities and performance information across key areas of the grievance process.

• Regional Report

  • CAST management shall generate the Regional Report by the tenth day of the month after the end of the fiscal year for issuance to headquarters executives and the Regional Health Care Executives.  The Regional Report shall consolidate CAST activities and performance trends identified in the previous fiscal year’s Metrics Reports.

Policy

• The California Whistleblower Protection Act protects all state civil service employees and applicants for state employment who make a protected disclosure in good faith from suffering retaliation. It is illegal for state officers and employees to retaliate against a state civil service employee or applicant for state civil service appointment for informally or formally reporting improper governmental activities or for refusing to obey an illegal order.

• California Correctional Health Care Services (CCHCS) and the California Department of Corrections and Rehabilitation (CDCR) shall protect whistleblowers from retaliation by reviewing complaints of whistleblowers, notification of incidents of fraud or errors, harassment, discrimination, and retaliation and investigate as appropriate.

Purpose

• To ensure all CCHCS state civil service employees and applicants for state employment are protected from retaliation.

Applicability

• This policy and procedure applies to all CCHCS state civil services employees.

Retaliation Complaint Procedure

• Internal

  • Complaints of retaliation shall be resolved at the lowest level.

  • Hiring authorities have the responsibility to protect all employees who report misconduct from retaliation by ensuring that all necessary measures are taken to protect whistleblowers during the investigation process as well as after the case has been adjudicated.

  • Labor Code, Section 1102.5, prohibits an employer from retaliating against an employee who discloses information that would result in a potential violation or noncompliance of statute or regulation to a governmental or law enforcement agency, to a person with authority over the employee, or another employee who has the authority to investigate. The Labor Code also protects employees who refuse to participate in an activity that would result in a potential violation or noncompliance of statute or regulation.

  • Allegations of retaliation shall be forwarded by the hiring authority to the Office of Internal Affairs (OIA) via a CDCR 989, Confidential Request for Internal Affairs Investigation/Notification of Direct Adverse Action, when a reasonable belief of misconduct occurred and the alleged misconduct, if proven true, would result in adverse action as defined in the CDCR’s Department Operations Manual, Chapter 3, Article 22, Adverse Personnel Actions.

• External

  • This policy does not alter the ability or right of employees to file retaliation complaints directly, even if there is no formal complaint filed with the OIA, or other state agencies including, but not limited to, the following:

  • The State Personnel Board Appeals Division within 12 months from the most recent act of reprisal: https://www.spb.ca.gov/appeals/general_information.aspx.

  • California Department of Human Resources: http://www.calhr.ca.gov/state-hr-professionals/Pages/appeals-and-grievances.aspx.

  • The Office of the Inspector General: https://www.oig.ca.gov/pages/about-us/how-to-file-a-complaint.php.

  • The Public Employee’s Relations Board: https://www.perb.ca.gov/UPCByMail.aspx.

  • Worker’s Compensations Appeals Board:  https://www.dir.ca.gov/dlse/dlseRetaliation.html.

  • The Department of Fair Housing and Employment: https://www.dfeh.ca.gov/complaint-process/.

Discipline and Liability

• In accordance with the provisions of Penal Code, Section 6129(c)(2), any employee of CDCR found to have engaged in retaliatory acts shall be disciplined by, at a minimum, a suspension without pay for 30 days.

• Pursuant to Government Code, section 8547.8(c), in addition to all other penalties provided by law, any person who intentionally engages in acts of reprisal, retaliation, threats, coercion, or similar acts against a state employee or applicant for state employment for having made a protected disclosure shall be liable in an action for damages brought against him or her by the injured party.  Punitive damages may be awarded by the court where the acts of the offending party are proven to be malicious.  Where liability has been established, the injured party shall also be entitled to reasonable attorney’s fees as provided by law.  However, any action for damages shall not be available to the injured party unless the injured party has first filed a complaint with the State Personnel Board pursuant to subdivision (a), and the board has issued, or failed to issue, findings pursuant to Section 19683.

Training

• All CCHCS civil service employees are required to complete the read and sign training via the online Learning Management System upon hire and annually thereafter.

Policy

• California Correctional Health Care Services (CCHCS) headquarters (HQ) operations and processes are reviewed periodically by external audit agencies. When an external audit agency initiates an audit, investigation, or compliance review, herein referred to as an audit, CCHCS shall cooperate fully and ensure timely and comprehensive responses. The CCHCS’ Internal Audit Program (IAP) may serve as the audit liaison between external audit agencies and CCHCS HQ program areas. The IAP responsibilities may include coordination and collaboration between the external auditor and CCHCS HQ program areas including scheduling entrance and exit conferences, assisting in obtaining documentation and ensuring all responses are accurate, within scope, and submitted timely. The IAP shall retain a copy of all documentation that is created, sent, or received in connection with external audits as required by policy, regulation, or statute.

Purpose

• To define the role of the IAP and CCHCS HQ program areas during an audit performed by an external audit agency, including, but not limited to, the review of processes, written policies and procedures, products, services, systems, and employees.

Responsibility

• The Deputy Director (DD), Policy and Risk Management Services (PRMS), or designee, is responsible for departmental compliance with this policy.

• The IAP Senior Management Auditor, or designee, is responsible for the monitoring and evaluation of this policy.

• CCHCS HQ program area DDs are responsible for ensuring:

  • Requested documentation and inquiry responses are provided timely to the IAP or the external audit agency as agreed upon prior to the start of an external audit.

  • A copy of the final audit report is provided to the IAP.

  • The implementation and monitoring of any Corrective Action Plan (CAP) in compliance with the external audit.

Applicability

• This policy applies to any audits of CCHCS HQ operations and processes performed by an external audit agency with proper authority and jurisdiction. This policy does not apply to:  

• Medical inspections performed by the Office of the Inspector General who is responsible for reviewing and reporting on the delivery of the ongoing health care provided to incarcerated persons in the California Department of Corrections and Rehabilitation.

• Reviews conducted by court order or for purposes of litigation (e.g., Prison Law Office Plata Tours).

Procedure

• Initial Contact from an External Audit Agency

  • Any CCHCS HQ program contacted by an external audit agency regarding an appraisal shall immediately notify the IAP via email at CCHCSInternalAudits@cdcr.ca.gov.

• Entrance Conference

  • The IAP shall coordinate all entrance conferences and invite CCHCS HQ program staff.

• Roles and Responsibilities During the External Audit

  • Following the entrance conference, the IAP and the CCHCS HQ program area DD, or designee, shall meet to determine the IAP’s specific role and responsibilities for the external audit The IAP’s responsibilities may include, but are not limited to:

    • Collecting and reviewing relevant and required documents.

    • Facilitating the timely submission of documentation.

    • Communicating with the CCHCS HQ program area and the external audit agency throughout the duration of the external audit.

    • Maintaining a list and electronic copies of information and documentation received from and provided to the external audit agency.

  • The IAP shall email their agreed upon audit-specific role and responsibilities to the CCHCS HQ program area DD and the DD, PRMS.

• During the Audit

  • If the IAP serves as the audit liaison with the external audit agency and the CCHCS HQ program area, the CCHCS HQ program area shall:

    • Submit any documentation requested from an external auditor for audit activities to the IAP at CCHCSInternalAudits@cdcr.ca.gov. Any documents provided to the IAP, which are deemed to be legally privileged or protected, shall not be released to an external auditor.

    • Provide the IAP with a list of any requested information or documentation which the program is unable to provide and include a justification of why the information or documentation is unable to be provided.

    • Discuss any potential issues identified by an external auditor with the IAP.

  • If the IAP does not serve as the audit liaison with the external audit agency and the CCHCS HQ program area, the CCHCS HQ program area shall:

    • Submit any documentation requested from an external auditor for audit activities directly to the external audit agency and copy the IAP at CCHCSInternalAudits@cdcr.ca.gov.

    • Not submit any documents deemed to be legally privileged or protected to an external auditor.

    • Ensure the IAP is invited to the exit conference.

• Closure of an External Audit

  • If the IAP served as the audit liaison with the external audit agency and the CCHCS HQ program area during the external audit, the IAP shall ensure:

    • All issues identified by the external audit agency are communicated to appropriate CCHCS leadership via email.

    • Responses are provided by the CCHCS HQ program area DD to the IAP within the deadline specified.

    • All requested documentation is submitted to the external audit agency timely.

  • If the IAP did not serve as the audit liaison with the external audit agency and the CCHCS HQ program area during the external audit, the CCHCS HQ program area DD shall ensure the IAP receives a copy of the external audit agency’s final audit report.

• External Audit Follow-ups and CAPS

  • If the IAP served as the audit liaison with the external audit agency and the CCHCS HQ program area during the external audit then:

    • The IAP shall remain as the liaison between the external audit agency and the CCHCS HQ program area throughout the follow-up process.

    • The CCHCS program area shall ensure all follow-up inquiries from external audit agencies are referred to the IAP via email at CCHCSInternalAudits@cdcr.ca.gov.

    • If a CAP is required, the IAP shall coordinate the completion of the CAP, and if requested, provide assistance to the CCHCS HQ program area to ensure issues are accurately addressed. Assistance may include, but is not limited to:

      • Recommending to CCHCS HQ program areas to incorporate issues into active improvement projects, when appropriate.

      • Negotiating timeframes with external audit agencies to allow CCHCS HQ program areas sufficient time to complete CAP activities.

      • Referring CCHCS HQ program areas to Quality Management for consultation if the program needs assistance in determining improvement strategies, models, or techniques.

    • The IAP shall be responsible for submitting the CCHCS HQ program areas responses to the external audit agency.

  • If the IAP did not serve as the audit liaison with the external audit agency and the CCHCS HQ program area during the external audit, the CCHCS HQ program area DD shall ensure:

    • The CAP, if required, is complete and all issues are accurately captured and responded to.

    • Upon completion, the CAP, if required, is submitted to the external audit agency and IAP.

• External Audit Retention

  • The IAP shall retain a copy of all documentation that is created, sent, or received, in connection with external audits as required by policy, regulation or statute.