Department Operations Manual

91080.11 Special Transportation Requirements General Requirements Every inmate who has been diagnosed as Code 31, TB Disease, Infectious, shall be moved only by special transportation using respiratory precautions. Each facility shall identify Medical Care Services staff who may issue and remove telephone medical holds pending special transportation arrangements. The facility shall also identify Classification and Custody staff who may receive special transportation instructions. The names and telephone numbers of all staff identified in this process shall be documented and distributed. Medical Care Services staff shall place medical holds pending special transportation arrangements by the end of the shift in which the status was diagnosed. Once an inmate's TB status has changed, a release of special transportation arrangements shall be placed by the end of the shift in which the status was diagnosed. Placing A Medical Hold Pending Special Transportation Arrangements Every inmate who has been coded with a TB Alert Code 31, TB Disease, Infectious, shall have a medical hold pending special transportation arrangements. Medical Care Services staff shall place a telephone call to the C&PR, the CC-III, or their designee during regular business hours (the Administrator on Duty [AOD] or their designee during non-business hours) and: • Identify the inmate as currently infectious. • Require that the inmate be transferred using special transportation and using respiratory precautions until further notice. Document the TB Alert Code as described in the DOM 91080.8. Enter the TB Alert Code as described in DOM 91080.8. Route and file the documentation as described in DOM 91080.9 . Removing a Medical Hold Pending Special Transportation Arrangements When an inmate is no longer Code 31, TB Disease, Infectious, the special transportation requirement shall be removed. Medical Care Services staff shall place a telephone call to the C&PR, the CC-III, or their designee during regular business hours (the AOD or their designee during non-business hours) and: • Identify the inmate as no longer infectious. • Remove the special transportation requirement. • Discuss any additional special transport requirements if appropriate. Document the TB Alert Code as described in DOM 91080.8. Enter the TB Alert Code as described in DOM 91080.8

91080.8 Route and file the documentation as described in DOM 91080.9. 91080.12

91080.12 Inmate TB Alert System Reports The Inmate Alert System provides two reports, 1) Medical Alert List by Arrival Date and 2) Medical Alert List by Medical Code and two screens 1) Medical Information Screen History − Diagnosis and 2) Medical Information Screen History − Movement. The reports and screens are useful in monitoring an inmate's TB status. Medical Alert List By Arrival Date The user of the Inmate TB Alert System selects the desired inmate arrival date. The selected date may be either one single day or a sequence of many days. The Medical Alert List by Arrival Date Report provides the following data elements for every inmate in the facility by date of arrival: • Bed/Cell--Most current housing status. • CDC Number. • Inmate Name. • Birth Date. • Age. • Medical Code. The Medical Alert List by Arrival Date Report may be generated daily and used for: • Inmate Tracking--Immediate action shall be taken if the inmate's TB Alert Code remains 11 after 72 hours. • Case contact investigation information. • Identification of inmates with TB Alert Code 22 who require annual PPD skin testing. • Identification of inmates with TB Alert Code 31, 32, 33, or 43 who require yearly evaluations for symptoms of coughing, night sweats, fever, and weight loss. • Assistance with identifying inmates who require Directly Observed Therapy. • Assistance in Confidential Morbidity Report and Verified Case Report card generation. Medical Alert List by Medical Code The Medical Alert List by Medical Code Report provides a list of every inmate grouped by TB Alert Codes. The report may be generated by selecting one or a combination of TB Alert Codes. Operations Manual Chapter 9 830 This report, sorted by medical alert code and description of code, provides the following data elements for every inmate in the facility: • Bed/Cell--Most current housing status. • CDC Number. • Inmate Name. • Birth Date. • Age. • Arrival. The Medical Alert List by Medical Code Report may be generated daily and used for: • Follow-up of inmates with a TB Alert Code 11 that should have progressed into another code. • Data surveillance on a daily, weekly, monthly, and annual basis. • Expediting follow-up care on inmates with TB Alert Code 21, 31, or 32. Screens The Medical Information Screen History--Diagnosis. Medical Information Screen History Diagnosis The user will read information regarding the inmate's TB history provided on the Medical Information Screen History--Diagnosis screen. Refer to the Medical Alert System User's Manual for detailed instructions. This screen provides the following data elements for every inmate in the facility: • CDC Number. • Inmate Name. • Bed/Cell--Most current housing status. • Current TB Alert Code. • Previous medical diagnosis and date of entry. Uses of the Medical Information Screen History--Diagnosis screen include: • Current TB Alert Code and date entry. • Previous medical diagnosis history. Once this screen is displayed on the DDPS terminal, a screen print may be executed on the printer. Refer to the Medical Alert System User's Manual for detailed instructions. Medical Information Screen History Movement The user will read information regarding an inmate's movement history provided on the Medical Information Screen History − Movement screen. Refer to the Medical Alert System User's Manual for detailed instructions. This screen provides the following data elements for every inmate in the facility: • CDC Number. • Inmate's Name. • Bed/Cell--Most current housing status. • Current TB Alert Code. • Transaction Message. • Facility. • Cell. • Location. • Date. • Previous CDC Number. Uses of the Medical Information Screen History − Movement include: • Assistance with case contact investigations. Once this screen is displayed on the DDPS terminal, a screen print may be executed on the printer. Refer to the Medical Alert System User's Manual for detailed instructions. 91080.13

91080.13 Weekly Code Review General Requirements Medical Care Services staff shall conduct a weekly review of inmates with a TB Alert Code of___ (blank), 11, 21, or 31. This review shall provide Medical Care Services staff with the ability to ensure that coding and medical follow- up is properly maintained. Each facility shall identify the Medical Care Services staff who will generate, review, and follow-up on those inmates who are identified with TB Alert Codes 11, 21, or 31. Weekly Code Review Instructions Medical Care Services staff shall generate the Medical Alert List by Arrival Date Report on the DDPS each Monday morning using the arrival date for the Monday of the previous week and selecting TB Alert Codes of 11, 21, and 31. Refer to Medical Alert System User's Manual for details. Medical Care Services staff shall review medical records for each inmate who reports a TB Alert Code of 11, 21, or 31. If the TB Alert Code is 11, the Mantoux PPD skin test shall be read and interpreted or re-administered as appropriate. If the TB Alert Code is 21, the reviewing Medical Care Services staff shall determine if the diagnosis has been confirmed. If the TB Alert Code is 31, the reviewing Medical Care Services staff shall determine if the diagnosis can be updated. If the TB Alert Code is updated to Code 31, Medical Care Services staff shall issue a medical hold pending special transportation arrangements as defined in DOM 91080.11. Any TB Alert Code changes shall be documented and entered in the DDPS as described in DOM 91080.8. Route and file the documentation as described in DOM 91080.9. 91080.14

91080.14 Monthly Reporting General Requirements Each facility shall generate the Medical Alert List By Medical Code Report at the month's end and use the data to complete the Interim Tuberculosis Case Report . This report shall be submitted to the Infectious Disease Control Unit in headquarters. Monthly Report Instructions On the morning of the first day of each month, Medical Care Services staff shall generate the Medical Alert List by Medical Code Report . Refer to the Medical Alert System User's Manual for details for report generation. Medical Care Services staff shall complete the Interim Tuberculosis Case Report using the information contained in the Medical Alert List by Medical Code Report. Medical Care Services staff shall submit the Interim Tuberculosis Case Report to the Infectious Disease Control Unit in headquarters by the close of business on the 5th of the month. 91080.15

91080.15 Case Contact Investigation General Instructions As soon as a diagnosis of Infectious TB Disease is reasonably established on laboratory, clinical and/or radiographic basis, investigation of contracts shall begin. The TB Alert System can assist facilities to manage case contact investigations. • The Medical Alert List by Arrival Dates Report from the Inmate TB Alert System can assist in verifying all inmates (close contact) who were in the facility during the "period of infectivity." • The Medical Alert List by Medical Codes Report from the Inmate TB Alert System can assist in identifying the TB status of all identified close contacts. All inmates who have been identified as a close contact to the source inmate should immediately be coded TB Alert Code 11 with the appropriate documentation on the CDC Form 128-C or 128-C-1. Documentation, coding, routing, and filing for this and subsequent TB Alert Code changes follows the procedures specified in DOM 91080.8 and 91080.9. 91080.16

91080.16 TB Documentation for Transfer Endorsement General Requirements An inmate's transfer endorsement shall be deferred if the TB Alert Code is not documented on a CDC Form 128-C or CDC Form 128-C-1, Medical/Psychiatric/Dental Chorine, and filed in their C-File at the time of endorsement. The CSR or CC-III (for DPU cases) shall be responsible for deferring endorsement of any case with incomplete TB status information. The inmate's C-File shall have a documented TB Alert Code of 21, 22, 31, 32, 33, or 43. The C&PR or CC-III shall notify Medical Care Services staff of any missing documentation. Medical Care Services staff is responsible for reviewing the inmate's Medical File, completing or providing the appropriate copy of the CDC Form 128-C or CDC Form 128-C-1 and forwarding it to Case Records within 24 hours from the date of notice by the C&PR or CC-III. Case Records shall file the CDC Form 128-C or CDC Form 128-C-1 in the inmate's C-File within 24 hours. Operations Manual Chapter 9 831 Classification Referral Instructions As is current practice, the C&PR, CC-III, or their designee shall audit all files prepared for CSR review and endorsement to ensure proper casework. No case shall be presented for CSR action without a valid TB Alert Code of 21, 22, 31, 32, 33, or 43 documented on a CDC Form 128-C or CDC Form 128- C-1 in the inmate's C-File. The C&PR, CC-III, or their designee shall notify the Inmate TB Alert System Coordinator in Medical Care Services of the missing CDC Form 128-C or CDC Form 128-C-1 within 24 hours of review. The Inmate TB Alert System Coordinator shall provide the CDC Form 128-C or CDC Form 128-C-1 within 24 hours of notification. Should a case inadvertently be presented to a CSR for transfer endorsement and lack a valid TB Alert Code of 21, 22, 31, 32, 33, or 43 documented on a CDC Form 128-C or CDC Form 128-C-1, the case shall be deferred. The CSR shall notify the C&PR, CC-III, or their designee of the missing information that same day. The C&PR, CC-III, or their designee shall follow step two above. Special Transportation Instructions If an inmate with a TB Alert Code of 11, 21, or 31 requires movement, special transportation arrangements are required. A CDC Form 128-C or CDC Form 128-C-1 shall document a doctor-to-doctor agreement for appropriate housing, type of transportation, and any medical concerns and restrictions per DOM 62080.16. Following transfer endorsement by a CSR, transportation arrangements shall be coordinated by the C&PR, CC-III, or their designee. The C&PR or CC-III shall refer to DOM 91080.19 for specific guidelines. If an emergency transfer of an inmate is required for other than medical reasons and the TB Alert Code does not authorize a normal move, the C&PR, CC-III, or their designee shall contact Medical Care Services staff during regular business hours (the Medical Officer on Duty [MOD] during non- business hours) and receive verbal TB Alert Code verification for inclusion on the CDC Form 135, Warden's Check-out Order. If the transfer takes place after regular working hours, arrangements shall be made through the Watch Commander, AOD, MOD, and Supervising RN (SRN) if applicable. Transportation precautions shall be taken accordingly. Within 24 hours of verbal verification, Medical Care Services staff shall provide appropriate documentation on a CDC Form 128-C or CDC Form 128-C-1 to Case Records for inclusion in the inmate's C-File and update the TB Alert Code in DDPS if required. They will also contact the receiving facility's Medical Care Services staff with any relevant medical information pertaining to the transferred inmate. 91080.17

91080.17 Distribution and Review of the CDC Form 7343 A CDC Form 7343 generated at each facility shall contain the TB Alert Transportation Instruction for every inmate listed. The facility's AISA routinely extracts (downloads) information from DDPS and enables the ATS access to this information during the generation of the CDC Form 7343. The ATS reads each inmate's TB Alert Code from the extracted information, generates the appropriate TB Alert Transportation Instruction based on the TB Alert Code, and prints the TB Alert Transportation Instruction on the CDC Form 7343. Medical Care Services staff shall review the CDC Form 7343 to ensure the appropriate TB Alert Transportation Instructions have been identified and medications are prepared for transfer if appropriate. A description of the TB Alert Transportation Instructions can be found in DOM 91080.19. CDC Form 7343 Using ATS AISA shall download DDPS to ATS before the CDC Form 7343 is generated. Follow the normal process to generate the CDC Form 7343. CDC Form 7343 Distribution Instructions The Inmate TB Alert System Coordinator shall walk to Case Records and obtain a copy of the CDC Form 7343 as soon as it is printed and as subsequent changes occur. CDC Form 7343 Review Instructions Medical Care Services staff shall immediately notify Case Records of any TB Alert Transportation Instruction changes by telephone. Upon completion of review, Medical Care Services staff shall sign the CDC Form 7343 denoting approval and route the CDC Form 7343 to Case Records. If Medical Care Services staff do not have 24 hours to review the CDC Form 7343, changes and approvals shall immediately be communicated with the appropriate staff by telephone. 91080.18

91080.18 Deletion of Inmates From the CDC Form 7343 Medical Care Services staff shall notify Case Records if an inmate's TB Alert Code has changed. Inmates remaining on the CDC Form 7343 with a TB Alert Code of 11, 21, or 31 shall not be moved on regular CDC transportation. The inmate's name shall be deleted from the CDC Form 7343 by telephone request. See DOM 91080.4 for additional information. If it is necessary to move the inmate, a CDC Form 128-C or CDC Form 128-C-1, documenting the special transportation instructions, shall be requested from Medical Care Services staff. 91080.19

91080.19 TB Alert Transportation Instructions The TB Alert Transportation Instructions shall be found on the CDC Form 135. A description of each TB Alert Transportation Instructions is as follows: TB Alert Transportation Instruction: Med Alert Sp Trans 11. Meaning: TB status unknown. Action: Inmates with Code 11 have an unknown TB status, either because their screening test has not yet been performed or has not been read and interpreted. These inmates pose a high risk of transporting TB Infection and cannot be put on regular CDC transportation, including buses and transportation used to move inmates from CDC facilities to CCFs. These inmates shall be transferred by special transportation using respiratory precautions. TB Alert Transportation Instruction: Med Alert Sp Trans 21. Meaning: The inmate's PPD was significant and the inmate is being diagnosed for suspected TB Disease. Action: Inmates with Code 21 had a significant PPD and remain under diagnosis. These inmates pose a high risk of transporting TB Infection and cannot be put on regular CDC transportation, including buses and transportation used to move inmates from CDC facilities to CCFs. These inmates shall be transferred by special transportation using respiratory precautions. TB Alert Transportation Instruction: Clear For Transportation 22. Meaning: The inmate's PPD was non-significant and the inmate is cleared for transportation. Action: Inmates with Code 22 had a non-significant PPD and are not infectious. These inmates shall be transferred by regular CDC transportation. TB Alert Transportation Instruction: Med Alert Sp Trans 31. Meaning: The inmate has been diagnosed with infectious TB Disease. Transfer should be done only under the approval and direction of Medical Care Services. Action: Inmates with Code 31 have TB Disease and are currently infectious. These inmates pose a high risk of transmitting TB Infection and cannot be put on regular CDC transportation, including buses and transportation used to move inmates from CDC facilities to CCFs. These inmates shall be transferred by special transportation using respiratory precautions. TB Alert Transportation Instruction: Clear For Transportation 32. Meaning: The inmate's PPD was significant due to prior infection. The inmate is cleared for transport. Action: Inmates with Code 32 had a significant PPD from prior TB Infection and are not currently infectious. These inmates shall be transferred by regular CDC transportation. TB Alert Transportation Instruction: INH Medication 33. Meaning: The inmate has TB Infection but is not infectious. The inmate is on INH medication. Action: Inmates with Code 33 have TB Infection but are not infectious. Medications shall be transferred with the inmate or Medical Care Services staff shall arrange for medications with the receiving facility. These inmates shall be transferred by regular CDC transportation. TB Alert Transportation Instruction: Multiple TB Medication 43. Meaning: The inmate has TB Disease but is not infectious. The inmate is on medication. Action: Inmates with Code 43 have TB Disease but are not infectious. Medications shall be transferred with the inmate. These inmates shall be transferred by regular CDC transportation. Operations Manual Chapter 9 832 91080.20

91080.20 Review of Inmate TB Alert Transportation Instructions by the Transportation Sergeant The CDC Transportation Sergeant shall be required to review the TB Alert Transportation Instructions of each inmate before boarding the bus. Inmates with TB Alert Codes of 11, 21, or 31 shall not be put on regular CDC transportation, which includes movement from CDC facilities to CCFs. These inmates shall be transferred by special transportation using respiratory precautions. 91080.21

91080.21 Review of Inmate TB Alert Transportation Instructions by the Receiving and Release Staff If an inmate arrives at the receiving facility with a TB Alert Code 11, 21, or 31, R&R staff shall immediately notify Medical Care Services staff. The inmate shall be placed in a separate cell until Medical Care Services staff move the inmate to the facility's infirmary. 91080.22

91080.22 Coordinating With Medical Services-Special Circumstance Moves If an emergency transfer of an inmate is required for other than medical reasons and the TB Alert Code does not authorize a normal move, the C&PR, CC-III, or their designee shall contact Medical Care Services staff during regular business hours and receive verbal TB Alert Code verification for inclusion on the CDC Form 135 or Warden's Check-out Order. If the transfer takes place after regular working hours, arrangements shall be made through the Watch Commander, AOD, MOD, and SRN if applicable. Transportation precautions shall be taken accordingly. Within 24 hours of verbal verification, Medical Care Services staff shall provide appropriate documentation on a CDC Form 128-C or CDC Form 128-C-1 to Case Records for inclusion in the inmate's C-File and update the TB Alert Code in DDPS if required. They will also contact the receiving facility's Medical Care Services staff with any relevant medical information pertaining to the transferred inmate. 91080.23

91080.23 Revisions The Deputy Director, HCSD, or designee shall be responsible for ensuring that the contents of this article are kept current and accurate. 91080.24

91080.24 References PC §§ 3053, 5054, 5058, 6006, 6007, and 6008. Medical Alert System User's Manual. W&I § 1768.10 A RTICLE 9 — I NVOLUNTARY P SYCHIATRIC M EDICATIONS Revised May 6, 2015 91090.1

91090.1 Policy The Department may administer involuntary psychiatric medication to an inmate only if the procedures in Penal Code (PC) Section 2602 are followed. 91090.2

91090.2 Purpose The purpose of this article is to set forth CDCR’s operational procedures and expectations of its employees concerning all aspects of involuntary psychiatric medication, including proper pre-court and post-court documentation, criteria for initiation, criteria for renewal, scheduling, initiation, renewal, non-renewal, interface with the inmate’s attorney, interface with the Office of Legal Affairs (OLA), interface with the Office of Administrative Hearings (OAH), inmate post-hearing remedies, and proper use of electronic charting resources to document assessments, both what is observed and court results. 91090.3

91090.3 General Provisions Involuntary psychiatric medication should not be used in a psychiatric context: • To control behavior that is not related to a diagnosable psychiatric disorder. • When an inmate is capable of giving informed consent and objects to such medication, unless the inmate is a danger to self or others. • Unless called for in a medical emergency as defined in CCR, Title 15, Section 3351, (a). • In doses other than that for which the drug is approved by the Food and Drug Administration (FDA) or by community standards of professional practice or by nationally recognized guidelines or by legitimate scientific and medical opinion. • In doses that diverge widely from appropriate dose recommendations, as defined by CCHCS care guidelines, nationally recognized guidelines, legitimate scientific and medical opinion, and by parameters provided by the FDA. Formulary decisions should conform to the CCHCS statewide formulary. 91090.4

91090.4 Long-Acting Medication When filing a non-emergency initial petition, clinical staff may not administer involuntary medication beyond the initial 72-hour emergency period. When filing an emergency initial petition, clinical staff should administer no medications involuntarily that have substantial, clinically relevant actions due to the fact that they stay in the bloodstream longer than 10 calendar days, including the initial 72-hour emergency period. The medication or medications that cause the least restrictive effects yet accomplishes their purpose should be chosen. After the conclusion of the administrative hearing, if the court order is granted, clinical staff may administer long-acting medication. 91090.5

91090.5 Medication Supervision and Observation A physician, psychiatrist, licensed vocational nurse, registered nurse, licensed psychiatric technician, or psychiatric nurse practitioner should be physically present to observe the emergency administration of involuntary medication. That person should create a note in a health record, which should include: • Personnel administering medication. • Observation. • Physical room or setting in institution where medication was administered. • Resistance. • Reason for medication. • Time. • Date. • Form of medication (tablet, liquid, injection) and dosage. • Injury. • Force. • Reaction. If the inmate is not already in an inpatient setting, the inmate should be observed twice per day by a health care staff to monitor for side effects until the inmate is deemed at low risk for side effects by a psychiatric physician, medical physician, or nurse practitioner. Observations will be noted in appropriate health records. Anytime force is observed or used by health care staff, the procedures and documentation requirements referenced in DOM Chapter 5, Article 2, Section 51020.17.6 must be followed. 91090.6