Health Care Department Operations Manual

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Chapter 5 – Administrative

Article 1 – General Administration

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5.1.5 Disability Placement Program and Developmental Disability Program Staff Accountability

  • 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.

  • References

    • California Code of Regulations, Title 15, Division 3, Chapter 1, Subchapter 5, Article 2, Section 3392, Employee Discipline

    • Armstrong Injunction Order, Armstrong v. Newsom, United States District Court of Northern California, January 18, 2007

    • Armstrong Remedial Plan, Armstrong v. Newsom, United States District Court of Northern California, Amended January 3, 2001

    • Clark Remedial Plan, Clark v. California, United States District Court of Northern California, March 1, 2002

    • Order Denying Motion for Contempt, Denying as Moot Motion to Strike and Modifying Permanent Injunction, Armstrong v. Newsom, United States District Court of Northern California, August 22, 2012

    • Order Revising the Modified Injunction, Armstrong v. Newsom, United States District Court of Northern California, December 5, 2014

    • Order Modifying January 18, 2007 Injunction, Armstrong v. Newsom, United States District Court of Northern California, December 29, 2014

    • California Department of Corrections and Rehabilitation, Department Operations Manual, Chapter 3, Article 22, Personnel, Training, and Employee Relations

    • California Correctional Health Care Services, Armstrong Staff Non-Compliance Log Memorandum, November 2, 2012

    • California Correctional Health Care Services, Order Modifying January 18, 2007 Armstrong Injunction Memorandum, January 13, 2015

    • California Correctional Health Care Services, Receiver’s Memorandum of Understanding, August 24, 2012

    • California Department of Corrections and Rehabilitation, California Correctional Health Care Services, Disability Placement Program Compliance Evaluation and Hiring Authority Accountability Memorandum, November 21, 2008

    • California Department of Corrections and Rehabilitation, Expectations for Staff Accountability and Non-Compliance of the Disability Placement Program Memorandum, March 29, 2012

    • California Correctional Health Care Services, Revision to Staff Accountability Procedures Memorandum, June 8, 2017

  • Revision History

    • Effective: 12/2010
      Revised: 09/20/2023