Health Care Department Operations Manual

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Chapter 5 – Administrative

Article 1 – General Administration

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5.1.1 Regulations and Policy Management

  • 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.

  • References

    • California Government Code, Title 2, Division 3, Part 1, Chapter 1, Article 1, Section 11017.6

    • California Government Code, Title 2, Division 3, Part 1, Chapter 3.5, Article 1, Section 11340 et seq.

    • California Government Code, Title 2, Division 3, Part 1, Chapter 3.5, Article 3, Section 11343

    • California Government Code, Title 2, Division 3, Part 1, Chapter 3.5, Article 5, Sections 11346.4, 11346.8 and 11347

    • California Government Code, Title 2, Division 3, Part 1, Chapter 5.6, Section 11546.7

    • California Penal Code, Part 3, Title 1, Chapter 2, Section 2080

    • California Penal Code, Part 3, Title 7, Chapter 2, Section 5058

    • California Code of Regulations, Title 1

    • California Department of Corrections and Rehabilitation, Department Operations Manual, Chapter 1, Article 6, Section 12010 et seq.

    • Health Care Department Operations Manual, Chapter 1, Article 2, Section 1.2.20, Fiscal Impact Resource and Strategy Team

    • Statewide Health Information Policy Manual, Sections 3.4.1, III, D, 3, and 4.1.1, III, A, 4

    • Thomson Reuters Westlaw, California Code of Regulations,
      https://govt.westlaw.com/calregs/Index?bhcp=1&transitionType=Default&contextData=%28sc.Default%29

  • Policy Control Executive Sponsor: Deputy Director, Policy and Risk Management Services
    Effective: 07/31/2020 Revised: 07/20/2021, 11/01/2022, 10/03/2024, 09/16/2026