Cal. Code Regs. Tit. 15, § 3999.98 - Definitions
For the purposes of this chapter, the following definitions apply:
Accommodation means reasonably necessary and appropriate modification or adjustment, not imposing a disproportionate or undue burden, to ensure a patient with a disability has equal access to programs, services, and activities.
Administer means the direct application of a drug or device to the body of a patient by injection, inhalation, ingestion, or other means.
Administrative Supervision means staff in supervisory positions who are responsible for administrative tasks for assigned employees including, but not limited to, completing probationary and annual evaluations, assessing proficiency in job duties, authorizing time off, and timekeeping activities.
Advance Directive for Health Care means a written instrument which allows the patient to do either or both of the following:
Advanced Practice Provider means Nurse Practitioner (NP) and Physician Assistant (PA) staff who are authorized to provide health care and dispense controlled substances by the state in which they practice.
After-hours means times when the pharmacy is closed or unavailable including holidays, weekends, and after regular business hours.
Agent means an individual designated in a power of attorney for health care to make a health care decision for the principal, regardless of whether the person is known as an agent, legally recognized decision-maker, or attorney-in-fact, or by some other term. Agent includes a successor or alternate agent.
Allied Health Services means health care professions including clinical laboratory personnel, physical therapy, occupational therapy, dietetic services, medical record personnel, radiologic services, speech-language pathology and audiology, and respiratory therapy that promote interdisciplinary communication and collaboration and the efficient use of resources by various health care providers to improve health care.
Basic Life Support means emergency care performed to sustain life that includes cardiopulmonary resuscitation, automated external defibrillation, control of bleeding, treatment of shock, and stabilization of injuries and wounds.
Breach means the unauthorized acquisition, access, use, or disclosure of Protected Health Information (PHI) or Personally Identifiable Information (PII) that compromises the security, confidentiality, or integrity of personal information maintained by the Department.
Business Associate means an individual or corporate "person" who performs on behalf of the Department or on behalf of another business associate of the Department any function or activity involving the use or disclosure of PHI for which the Department is responsible, and is not a member of the Department's workforce.
Business Day means Monday through Friday, except for holidays.
California Department of Corrections and Rehabilitation Heart Healthy Diet means a diet plan restricted in sodium and fat while supplying adequate calories, fiber and all essential nutrients, provided by the Department and approved by a Registered Dietitian.
California Department of Corrections and Rehabilitation Standardized Master Menu means a four-week menu cycle based on the California Department of Corrections and Rehabilitation (CDCR) Heart Healthy Diet that is planned by the CDCR Food Administrator and approved by a Registered Dietitian.
Capacity or Lack of Capacity is to be determined by evaluating the person's:
Care Coordination means the deliberate organization of patient care activities between two or more participants involved in a patient's care to facilitate the appropriate delivery of health care services and minimize the danger of care fragmentation.
Care Management means a collaborative process of patient assessment, evaluation, advocacy, care planning, facilitation, and coordination. The extent of care management services varies according to the complexity of the patient.
Care Team means an interdisciplinary group of health care professionals who combine their expertise and resources to provide care for a panel of patients.
Case Conference means an action recommended by the Medical Peer Review Committee (MPRC) requesting that the originating institution's Chief Medical Executive (CME) meet with all medical staff to discuss a specific concern(s) resulting from a peer review case.
Chronic Care means the ongoing care for a current health problem that impacts or has the potential to impact a patient's functioning and long-term prognosis and has lasted, or is expected to last, for more than six months.
Clinical Pathway means a complex, interdisciplinary management tool and series of interventions based on evidence-based practice for the mutual decision-making and organization of care processes for a well-defined group of patients with a predictable clinical course.
Clinical Performance Appraisal means an evaluation conducted at the request of the MPRC or the Health Care Executive Committee (HCEC).
Clinical Practice means the skill, knowledge, and competency of a licensed medical provider reflected in the licensed medical provider's quality of care.
Clinical Supervision means staff in supervisory positions who are responsible for the supervision of clinical tasks. This includes the institution Physician Managers which are comprised of the Chief Physician and Surgeon, Chief Medical Executive, Chief Psychiatrist, and Supervising Psychiatrist, and Institution Nursing Managers which include Chief Nurse Executive, Supervising Registered Nurse, Unit Supervisor, and Nurse Consultant III.
Coccidioidomycosis 2 Area means institutions that pose the highest risk of coccidioidomycosis (cocci) exposure.
Coccidioidomycosis 2 Restriction means a medical restriction based on a combination of a history of cocci disease, medical high risk, negative cocci skin test results (if tested), race (e.g., African-American or Filipino), and medical conditions (e.g., diabetes mellitus); patients with a coccidioidomycosis 2 restriction are designated as such in the cocci risk registry.
Coccidioidomycosis Skin Test means the skin test used to determine hypersensitivity reaction to the spherulin antigen (a component of the fungus that causes cocci).
Competency means the documented demonstration of an individual having the requisite or adequate abilities or qualities capable to perform up to a defined expectation.
Complex Care Management means management of patients with complex biopsychosocial needs.
Concurrent Review means a review to evaluate the ongoing need for acute, sub-acute, or non-acute levels of care including review of admissions, continued stays, and discharge planning activities.
Contraband Surveillance Watch means the isolation and restriction of movement for observation of incarcerated persons who are suspected or known to have ingested or inserted contraband into a body cavity.
Controlled Use of Force means the force used in an institution setting when an incarcerated person's presence or conduct poses a threat to safety or security and the incarcerated person is located in an area that can be controlled or isolated. These situations do not normally involve the immediate threat to loss of life or immediate threat to institution security.
Correctional Treatment Center means a health care facility operated by the Department that provides inpatient health care services to patients who do not require a general acute care level of essential services and are in need of professionally supervised health care that cannot be provided on an outpatient basis.
Covered Entity means health plans, health care clearinghouses, and health care providers who transmit any health information in electronic form in connection with a transaction that is subject to federal Health Insurance Portability and Accountability Act (HIPAA) of 1996 requirements, as those terms are defined and used in the HIPAA regulations, 45 Code of Federal Regulations sections 160 and 164.
Credentialing means the system of screening and evaluating qualifications and other credentials including, but not limited to, licensure, certification, required education, relevant training and experience, and current competence and health status.
Data Use Agreement means a contractual agreement that establishes who is permitted to use and receive a Limited Data Set, and the permitted uses and disclosures of such information by the recipient.
Death means an individual has sustained either:
Death Review means a type of review conducted by Nurse Consultant Program Review staff which assesses the quality and appropriateness of nursing care, nursing practice issues, best practices, and factors that may have significantly impacted the quality of patient care, thereby contributing to the death of a patient.
Decision Support Tools means materials used by clinical staff to inform and support evidence-based practices based on clinical knowledge and patient specific assessments.
Determination of Death means the process of establishing death has occurred through assessment of objective data in accordance with standards of care, including obtaining an independent confirmation by another physician when death occurs due to the cessation of brain function.
Diet Instruction means specific dietary recommendations including careful food choices based on the CDCR Heart Healthy Diet, provided by a Registered Dietitian or other health care staff within the scope of their licensure.
Directly Observed Therapy means dose-by-dose administration of medications by appropriately licensed health care staff including, but not limited to, Registered Nurse (RN), Licensed Vocational Nurse (LVN), or Psychiatric Technician (PT) using the highest level of observation of ingestion of medication administered to the patient.
Disclosure means the release, transfer, provision of, access to, or divulging in any other manner of information outside the entity holding the information.
Dispense means the furnishing of drugs or devices following a prescription from a licensed prescriber or directly given to a patient by a licensed prescriber.
Do Not Resuscitate means a written order which directs that resuscitation efforts are not to be initiated in the event of cardiac or respiratory arrest.
Ducat means a CDCR 129, Incarcerated Person Pass (Rev. 07/24) There are two types of ducats, "Priority" and "Non-Priority." Priority ducats are stamped with the word "Priority" and are used for scheduled health care appointments. Non-Priority ducats are used for unscheduled appointments and unescorted movement from one location to another.
Durable Medical Equipment means equipment prescribed by a licensed provider to meet medical equipment needs of the patient that can withstand repeated use; is used to serve a medical purpose; is not normally useful to an individual in the absence of an illness, injury, functional impairment, or congenital anomaly; and is appropriate for use in or out of the institutional housing.
Emergency Response means the organizing, coordinating, and directing of available resources in order to respond to an event and bring the emergency under control.
Endorsed Institution means a CDCR institution where a patient is assigned and housed.
Expected Death means a medically anticipated death which is related to the natural course of a patient's illness or underlying condition.
Final Proposed Action means the MPRC recommended final action to modify privileges in any manner which includes a chronology of the major events in the peer review process and supporting documentation that is submitted to the HCEC.
First Aid means emergency care administered to an injured or sick patient before health care staff is available.
First Responder means the first staff member certified in Basic Life Support (BLS) on the scene of a medical emergency.
Focused Professional Practice Evaluation means an evaluation process comprised of chart reviews and licensed medical provider's input to obtain a generalized or focused overview of a licensed medical provider's clinical performance.
Foreign Body means an object within the body that has been introduced from the outside, including but not limited to contraband items.
Governing Body means a person, persons, board of trustees, directors, or other body in whom the authority and responsibility is vested for the conduct and oversight of a licensed inpatient facility.
Handoff means a transfer of information from one health care staff or care team to another for the purpose of ensuring the continuity and safety of the patient's care.
Health Care First Responder means the first health care staff member certified in BLS to arrive at the scene of a medical emergency.
Health Care Grievance Communications means patient specific communication provided through health care grievance interviews, institution level responses, rejection notices, or withdrawal notices.
Health Care Incident means an unusual or unexpected occurrence in the clinical management of a patient or patients, such as an error, sentinel event, near miss, accident, or medication event that has or may have adverse health consequences for patients or staff, and requires submission of a written description of the event to the Statewide Health Care Incident Review Committee.
Health Care Operations means any health care activities of the Department or a covered entity to the extent that the activities are related to conducting quality assessment and improvement activities; population-based activities; reviewing the competence or qualifications of health care professionals; conducting or arranging for medical review, legal services, and auditing functions; business planning and development; and business management and general administrative activities.
Health Care Provider means a Medical Doctor, Doctor of Osteopathy, Doctor of Podiatric Medicine, Clinical Psychologist, Dentist, Clinical Social Worker, NP, or PA.
Health Care Services means medical, mental health, dental, pharmaceutical, diagnostic and ancillary services to identify, diagnose, evaluate, and treat a medical, mental health, or dental condition.
Health Care Services Dashboard means a monthly report that consolidates strategic performance information across key health care areas and provides data at both statewide and institution levels and shows trends in performance over time.
Health Care Staff means those persons licensed by the state to provide health care services, who are employed by the Department or are working under direct or indirect contract with the Department to provide health care services.
Health Care Treatment Areas means any location where patient health care services are provided including, but not limited to, medical clinics, dental clinics, designated triage and treatment areas, or standby emergency rooms where urgent/emergent treatment may be required and the location is not licensed by the California Department of Public Health under California Code of Regulations, Title 22, Division 5, or by the California State Board of Pharmacy pursuant to Business and Professions Code section 4187.
Health Maintenance Services means a systematic program or procedure planned to prevent illness, maintain maximum function, and promote health.
Health Record(s) means paper-based records, electronic records, and other media that document the patient's health care and provide a chronological account of a patient's examinations and treatments. Health records shall be maintained in a manner that supports continuity of care.
Heat Alert Medications means medications that can pose a serious risk to a patient's health during times of extreme heat by impairing the body's ability to regulate temperature.
High Alert Medications means a drug that bears a heightened risk of causing significant patient harm when used in error. Mistakes may or may not be more common with these drugs, but the consequences of an error are more devastating to patients.
Hoarding means stockpiling of medications by the patient.
Hospice means services that are designed to provide palliative services to patients needing end-of-life care.
Hygiene Supplies means supplies available without a prescription for personal care. Hygiene supplies are generally used for non-medical purposes and are not medical supplies.
Individual Hunger Strike Participant means an incarcerated person who is identified by Department custody staff as a participant in an individual hunger strike.
Informal Hearing means a hearing offered to licensed medical providers who are subject to a modification of privileges in order to provide a licensed medical provider with an opportunity to respond to and provide evidence to refute the allegations that provide the basis for the modification of clinical privileges.
Informed Consent means a patient who has the capacity to make informed decisions is made aware of risks, benefits, and alternatives to proposed treatment for a disease or condition from which the patient suffers, and the patient is able to agree and clearly agrees to the recommended treatment without duress or coercion.
Informed Refusal occurs when a patient who has documented capacity to give informed consent and elects to knowingly refuse to consent to a given medication or recommended course of treatment.
Interested Person means any blood relative of the first, second, or third degree, or in a capital case, the patient's designated next-friend.
Interferon-Gamma Release Assays Test means the standard method used by the Department for the detection of recent or past Tuberculosis (TB) infection.
Interventions means actions that focus on the execution of the specific care management activities that are necessary for accomplishing the goals set forth in the patient's treatment plan, linking the patient to the services needed to optimize health.
Judicial Review Committee means a three-member panel composed of independent and impartial physicians who shall, by majority vote, determine the final outcome of a privileging action taken against a licensed medical provider when appealed by the licensed medical provider.
Keep-on-Person means medications that the prescriber believes can be safely self-administered by the patient.
Layover means a temporary delay or stop at an intermediate location during the transportation phase of a transfer of care.
Legally Recognized Decision-Maker means an agent designated in an advance directive, orally designated surrogate, spouse, registered domestic partner, parent of a minor, closest available relative, court-appointed conservator or guardian, or person whom the patient's Primary Care Provider believes best knows what is in the patient's best interest and shall make decisions in accordance with the patient's expressed wishes and values to the extent known.
Licensed Medical Provider means CME, Deputy Medical Executive, Chief Physician and Surgeon, Physician and Surgeon, NP, PA, Nurse Anesthetist, Podiatrist, and Specialty Consultant Practitioners.
Licensed Units means any health care treatment area which has beds that have been licensed by the California Department of Public Health under California Code of Regulations, Title 22, Division 5 or a health care treatment area that has been licensed by the California State Board of Pharmacy pursuant to Business and Professions Code Chapter 9, Division 2, Article 13.5, section 4187.
Limited Data Set means PHI that excludes the following direct identifiers of the patient or of relatives, employers, or household members of the patient: names; postal address information other than town or city, state and zip code; telephone numbers; fax numbers; electronic mail addresses; social security numbers; health record numbers; health plan beneficiary numbers (such as Medi-Cal numbers); account numbers; certificate/license numbers; vehicle identifiers and serial numbers, including license plate numbers.
Lockdown means an emergency safety procedure where a portion of the institution is affected by suspension of required programs or services, and patients are not released except as determined by the institution administration on an individual, case-by-case basis.
Locked Unit means a restricted or segregated program housing unit including, but not limited to, Protective Housing Units, Psychiatric Services Units, Security Housing Units, and Administrative Segregation Units.
Mass Organized Hunger Strike means an organized hunger strike including multiple incarcerated persons who have a common goal or set of demands.
Mass Organized Hunger Strike Participant means an incarcerated person identified by Department custody staff as participating in a mass organized hunger strike.
Medical Assistant means the same thing as in Business & Professions Code section 2069(b)(1).
Medical Classification means the process of mapping patient attributes to Medical Classification Factors.
Medical Classification System means the system that provides the matching between patients and institutions based on patient attributes and institution attributes.
Medical Emergency means any medical, mental health, or dental condition, as determined by health care staff, for which immediate evaluation and treatment are necessary to prevent death, severe or permanent disability, or to alleviate disabling pain. A medical emergency exists when there is a sudden marked change in an individual's medical condition so that action is immediately necessary for the preservation of life, alleviation of severe pain, or the prevention of serious bodily harm to the patient or others.
Medical High Risk means patients who have a medical risk designated as high per the automated clinical classification system.
Medical/Psychiatric and Return means the process used when a patient requires medically necessary health care services which are only accessible at or via a CDCR institution other than the patient's endorsed institution. Medical/psychiatric and return requires an overnight stay at the treating institution prior to the return to the endorsed institution.
Medical Supplies means supplies prescribed by a licensed provider to meet medical supply needs of the patient that meet the following criteria: cannot withstand repeated use; are usually disposable in nature; are used to serve a medical purpose; are not useful to an individual in the absence of an illness, injury, functional impairment, or congenital anomaly; and are intended for use by the patient in an outpatient setting.
Medically Necessary means health care services that are determined by the attending or primary medical, mental health, or dental care provider(s) to be needed to protect life, prevent significant illness or disability, or alleviate severe pain, and are supported by health outcome data or clinical evidence as being an effective health care service for the purpose intended or in the absence of available health outcome data is judged to be necessary and is supported by diagnostic information or specialty consultation.
Medication Adherence means the extent to which patients take medications as prescribed.
Medication Administration Area means all areas that store medications located outside of the correctional pharmacy irrespective of license (e.g., medication cart, medication room, nursing stations, or Triage and Treatment Area).
Medication Error means any preventable event that may cause or lead to inappropriate medication use or patient harm as a result of professional practice, health care products, procedures, and systems.
Medication Refusal means the patient declines the prescribed medication (Directly Observed Therapy [DOT], Nurse Administered, or Keep-on-Person) or declines to comply with medication procedures either at the cell front or during medication line.
Medication Renewal means a new medication order which is required for dispensing of any medication for which the current order is expired or expiring.
Mental Health Evaluation means a psychological evaluation performed by a mental health clinician that includes a brief narrative of the presenting problem, historical information of relevance, a mental status examination and assessment of level of functioning, determination of need for mental health treatment and recommended level of care, and a referral to a psychiatrist if there is a possible need for psychotropic medication or other psychiatric intervention.
Modified Program means the suspension or restriction of patient program activities or movement that impacts less than all programs or less than all patients. A modified program may either occur independently in response to an incident or unusual occurrence or may occur as a facility transitions from a lockdown to regular programming.
Near Miss means an event or situation that could have resulted in a health care incident but did not, either by chance or through timely intervention.
Non-business Days means Saturdays, Sundays and State holidays.
Normal Business Hours means a minimum of eight hours per business day. These hours may vary by institution, but are generally between the hours of 0700 and 1800.
Nourishments means approved food items, in addition to the standard meal, ordered for patients with certain medical or dental conditions.
Nurse Administered means dose-by-dose administration of medications by appropriately licensed health care staff that do not require DOT procedures, only reasonably observed ingestion of medication.
Nurse Practitioner means the same thing as in 16 California Code of Regulations section 1480(o).
Nurse Protocol means a specific written procedure that prescribes nursing actions in a given situation.
Nursing means the protection, promotion, and optimization of health and abilities, prevention of illness, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, communities, and populations.
Open Access means a scheduling strategy that involves "doing today's work today" and seeing patients as soon as possible after they request care, and on the same day if appropriate. Open access slots are appointment times or blocks that are left open and unscheduled until one to two days prior to that date, allowing the care team to accommodate walk-in patients, patients with urgent health needs, and patients with routine health needs that would benefit from expedited services.
Opt-Out Screening Method means the patient is informed of the routine laboratory tests that will be performed as part of the RC Initial Health Screening and Triage unless the patient specifically declines a test.
Order Sets means printed or electronic orders available for commonly performed interventions. These are different from standing orders in that they are not conditional. The provider determines whether the order sets will be used, and if variations to the order sets are required, the provider notes the variation in the patient's chart.
Outcome Data or Clinical Evidence means the professionally accepted results of studies and analyses, using evidence-based methodologies and expert clinical judgment, regarding the effectiveness of various health care services, how those services relate to patient morbidity and mortality, and overall efficiency and effectiveness of care.
Outpatient Housing Unit means a designated housing area within institutions designed to provide supportive services, including low-intensity nursing care, for patients who may require limited assistance with activities of daily living or short-term observations.
Outpatient Therapeutic Diet means a medically necessary therapeutic diet ordered by a PCP or dentist.
Over-the-Counter Products means commonly utilized health care products which are available to the general public without a prescription.
Palliative Care means services that support a patient in managing his or her health care needs associated with a serious illness. Services are designed to provide comfort, relief from pain, support the patient, and to maintain or improve functioning and quality of life. Palliative care services can be provided at any stage of illness and at all levels of care within the Department.
Parole means release of an incarcerated person from imprisonment to the community by a releasing authority prior to the expiration of the incarcerated person's prison term.
Patient means an incarcerated person who is seeking or receiving health care services or who is assigned to a care team.
Patient Panel means a clearly defined group of patients that are assigned to a particular care team. Every care team has one panel of patients, and every patient is assigned to a care team.
Patient Registries means lists of patients with specific conditions or eligible for certain preventive services that include clinical information helpful to the management of these patients.
Patient Safety Alert means a bulletin issued to all institutions informing them of a patient safety issue with statewide implications, which may include actions to mitigate harm to patients.
Patient-initiated means the patient sought health care services through Department staff or reported to health care staff for consultation and/or treatment without having first been contacted or scheduled by health care staff.
Payment means the activities undertaken by the Department to obtain or provide reimbursement for the provision of health care.
Peer Review Formal Investigation means an investigation into the clinical performance or conduct of a licensed medical provider pursuant to allegations that the licensed medical provider's clinical performance or conduct falls below the applicable standard of care. A Formal Investigation is an investigation as that term is used in Business and Professions Code sections 805(c) and 805.01(b).
Performance Improvement Plan means a plan that identifies priority areas for improvement, as well as performance objectives and strategies used to achieve objectives.
Permanent means expected to last longer than six months.
Personal Representative means a person who has authority, under applicable state law, to act on behalf of a patient in making health care decisions related to the patient.
Personally Identifiable Information means any information that is maintained by the Department that identifies or describes an individual, including, but not limited to, his or her name; social security number; physical description; home address; home telephone number; education; financial matters; and medical or employment history. It includes statements made by, or attributed to, the individual. PII may include information that is not necessarily PHI and may pertain to the Department employees, members of the public, or other individuals who may or may not be patients.
Physician Assistant means the same thing as in Business & Professions Code section 3501(d).
Physician Orders for Life-Sustaining Treatment means a physician order that documents a patient's "preferred intensity of care" concerning life-sustaining treatment and end of life care, including resuscitation status, and which translates those expressed preferences into a physician's order.
Population means a group of patients sharing a common health characteristic, such as age, gender, race or ethnicity, risk level, or chronic condition.
Population Management means systematic assessment, monitoring, and management of the health care needs for identified groups of patients.
Potential Quality Issue means a health care incident, regardless of severity, which occurs during the course of treatment by a Healthcare Provider Network facility or provider and requires submission of a written Potential Quality Issue referral.
Prescription means oral, written, or electronic transmission that is given to the person for whom ordered and is issued by a physician, dentist, Optometrist, Podiatrist, naturopathic doctor, NP, PA or other person lawfully authorized to prescribe pursuant to their license in the State of California.
Primary Care Provider means a physician, NP, or PA designated to have primary responsibility for the patient's health care or, in the absence of a designation or if the designated physician is not reasonably available or declines to act as primary physician, a physician who undertakes the responsibility.
Primary Care Team means an interdisciplinary team that organizes and coordinates services, resources, and programs to ensure consistent delivery of appropriate, timely, and patient-centered, evidence-based care to a designated patient panel.
Privilege Modification means a temporary or permanent change in a licensed medical provider's privileges including a denial, suspension, restriction, reduction, or revocation of any or all of a licensed medical provider's privileges.
Privileging means the process by which a licensed medical provider is permitted by law and the facility to provide specified medical or other patient care services. Clinical privileges must be facility-specific, provider-specific, and within available resources.
Proctoring means the assignment of a licensed medical provider to observe the practice of another licensed medical provider performing specified activities and to provide required reports on those observations.
Procurement means the purchase of pharmaceuticals by the pharmacy.
Professional Misconduct means conduct and behavior that disrupts, or is likely to disrupt, clinical operations and may impact patient or staff safety, or is "unprofessional" pursuant to California Business and Professions Code sections 2220 et seq.
Pronouncement of Death means the formal process of recording the death in the health record and communicating the death to the patient's next of kin.
Prospective Review means a review conducted prior to services being rendered to determine whether the patient's illness necessitates the requested level of care or services or could be provided at a lower level of care.
Protected Health Information means information created or received by the Department which identifies or can be used to identify an individual as it relates to past, present, or future health conditions; health care services provided to the individual; or health care related payments. This applies to information that is transmitted or maintained in verbal, paper, or electronic form.
Protocols means evidenced based practice procedures that represent the framework for managing a specific disorder or clinical situation by outlining the desired outcome, the process steps and tasks, the skills and competencies required, scope of practice, and action taken.
Provider Network means a group of licensed health care practitioners and hospitals working under a contract with the Department who provide health care services to CDCR patients.
Psychotherapy Notes means notes recorded in any medium by a health care provider who is a mental health professional documenting or analyzing the contents of conversation during a private counseling session or a group, joint, or family counseling session, and that are separated from the rest of the patient's medical record.
Reading Glasses means ready-made, single-vision glasses that are designed to lessen the focusing burden during up close activities, such as reading.
Reception Center Focused Health Assessment means a face-to-face focused physical assessment performed by a PCP and documented in the health record during the RC Initial Screening.
Reception Center Initial Health Screening and Triage means a face-to-face assessment conducted by licensed nursing staff, which includes a review of the patient's available health records, an interview, a brief health history, and a focused objective physical assessment based on the records review and patient interview.
Retrospective Review means a review to evaluate the medical necessity and appropriateness of treatment after it has been rendered, as well as to compare billed services with the actual treatment authorized.
Risk Stratification means the continuous use of data and predictive modeling to differentiate patients into risk levels.
Root Cause Analysis means a structured and standardized process by which a multidisciplinary team analyzes a health care incident, near miss, or sentinel event, determines the fundamental reasons why the event occurred, and designs and implements a plan of action to prevent similar events from occurring in the future.
Rounds means the act of seeing a patient in an inpatient setting to observe and communicate with the patient, evaluate the patient's current condition, their response to treatment, determine if their care needs are being met by the current plan of care and to assess their environment of care. Rounds may be conducted by individual disciplines, or they may be multidisciplinary.
Safety Assessment means an evaluation to determine whether failure to take immediate action regarding the clinical performance of a licensed medical provider may result in imminent danger to the health of patient(s) or staff.
Sentinel Event means a patient safety event, including adverse events as defined in California Health and Safety Code section 1279.1, not primarily related to the natural course of the patient's illness or underlying condition that results in death, permanent harm, or a temporary impairment that affects the patient and limits their ability to function normally for a significant amount of time.
Severe Pain means a degree of discomfort that significantly disables the patient from reasonable independent function.
Significant Illness and Disability means any medical, mental health, or dental condition that causes or may cause, if left untreated, a severe limitation of function or ability to perform the daily activities of life or that may cause premature death.
Skilled Nursing Facility means a health facility or a distinct part of a hospital which provides continuous skilled nursing care and supportive care to patients whose primary need is for skilled nursing care on an extended basis. It provides 24-hour inpatient care and at a minimum includes physician, skilled nursing, dietary, and pharmaceutical services as well as an activity program.
Specialized Health Care Housing means a distinct housing unit located within a facility or institution operated by the Department that provides health care services 24 hours a day to patients who are in need of professionally supervised health care. Specialized Health Care Housing units may, or may not be licensed or accredited. Specialized Health Care Housing units include the following levels of care: Outpatient Housing Unit, Correctional Treatment Center, Mental Health Crisis Bed, Psychiatric Inpatient Program, Skilled Nursing Facility, Hospice, Acute Care Facility, and Intermediate Care Facility.
Specific Authorization means the same thing as in Business & Professions Code section 2069(b)(2).
Standard of Care means the reasonable degree of skill, knowledge, care, and conduct ordinarily possessed and exercised by members of the discipline and profession under similar circumstances.
Substantial Evidence means relevant evidence that a reasonable person could accept as adequate to support a conclusion.
Supplement means medically necessary high caloric drinks ordered by a PCP or dentist.
Technical Supportive Services means the same thing as in Business & Professions Code section 2069(b)(4)(A).
Texture Modified Diet means a CDCR Heart Healthy Diet or therapeutic diet that has been modified to allow ease in chewing or swallowing.
Transfer means the transportation of a patient between two points, such as from one prison to another or from one law enforcement entity (a state prison or a county jail) to another.
Transport means movement of a patient from their endorsed institution for the purposes of accessing health care or other services that are not available at the endorsed institution.
Treating Institution means the institution where a patient is sent to receive medically necessary health care services that cannot be provided at the endorsed institution.
Treatment means the provision, coordination, or management of health care related services by one or more health care providers, including the coordination or management of health care by a health care provider with a third party; consultation between health care providers relating to a patient; or for the referral of a patient for health care from one health care provider to another.
Tuberculin Skin Test means a method of determining whether a person is infected with Mycobacterium TB.
Tuberculosis Disease means a disease caused by bacteria known as Mycobacterium TB. TB is a treatable infectious disease that usually affects the lungs and airway, but may also affect other parts of the body.
Unit, when referring to OTC products, means a single manufacturer-packaged quantity of a particular OTC product. Examples include a single tube of cream, single bottle of lotion, single bottle of the same medication, or single box of blister cards filled with the same medication.
Urgent, when referring to medication orders, means needed in less than three business days based on the clinical judgment of the prescriber.
Use, when referring to PHI and PII, means the sharing, employment, application, utilization, examination, or analysis of information that identifies, or reasonably can be used to identify, an individual within the Department.
Workforce means employees, volunteers, trainees, and other persons whose conduct, in the performance of work for the Department or a business associate, is under the direct control of the Department or a business associate, whether or not they are paid by the Department or the business associate.
X-Ray means a photographic or digital image of the internal composition of something, especially a part of the body, produced by X-Rays being passed through it and being absorbed to different degrees by different materials.
Notes
Note: Authority cited: Section 5058, Penal Code. Reference: Section 5054, Penal Code; and Plata v. Newsom (No. C01-1351 JST), U.S. District Court, Northern District of California.
Note: Authority cited: Section 5058, Penal Code. Reference: Section 5054, Penal Code; and Plata v. Newsom (No. C01-1351 JST), U.S. District Court, Northern District of California.
2. Amendment of section heading, section and Note refiled 1-7-2019 as an emergency, with further amendments; operative
3. Change without regulatory effect relocating and amending former section 3364.1, subsections (a)(6)-(7) to add definitions of "Capacity or Lack of Capacity" and "Informed Refusal" to section 3999.98 and amending Note filed 4-15-2019 pursuant to section 100, title 1, California Code of Regulations (Register 2019, No. 16).
4. Certificate of Compliance as to 1-17-2019 order, including amendment changing the definition of "Necessary" to "Medically Necessary," transmitted to OAL 4-9-2019 and filed 5-20-2019; amendments operative
5. Amendment filed 7-1-2019 as an emergency; operative
6. Amendment refiled 12-5-2019 as an emergency; operative
7. Amendment refiled 3-9-2020 as an emergency; operative
8. Certificate of Compliance as to 3-9-2020 order, including amendment of section, transmitted to OAL 6-8-2020 and filed 7-20-2020; amendments operative
9. New definitions of "Informed Consent" and "Interested Person" filed 3-1-2021; operative
10. New definition of "Health Record(s)" filed 10-28-2021; operative
11. New definitions of "Administrative Supervision," "Clinical Supervision," "Death," "Determination of Death," "Medical Assistant," "Nurse Practitioner," "Pronouncement of Death," "Specific Authorization" and "Technical Supportive Services" filed 5-22-2023; operative
12. New definition of "Reading Glasses" filed 5-31-2023; operative
13. Removal of previous definition of "Nurse Practitioner" inadvertently retained in 5-22-2023 order filed 6-13-2023 (Register 2023, No. 24).
14. Editorial correction restoring inadvertently omitted definition of "California Department of Corrections and Rehabilitation Heart Healthy Diet" (Register 2023, No. 44).
15. Change without regulatory effect amending section filed 7-1-2024 pursuant to section 100, title 1, California Code of Regulations (Register 2024, No. 27).
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
For the purposes of this chapter, the following definitions apply:
Accommodation means reasonably necessary and appropriate modification or adjustment, not imposing a disproportionate or undue burden, to ensure a patient with a disability has equal access to programs, services, and activities.
Administer means the direct application of a drug or device to the body of a patient by injection, inhalation, ingestion, or other means.
Administrative Supervision means staff in supervisory positions who are responsible for administrative tasks for assigned employees including, but not limited to, completing probationary and annual evaluations, assessing proficiency in job duties, authorizing time off, and timekeeping activities.
Advance Directive for Health Care means a written instrument which allows the patient to do either or both of the following:
Advanced Practice Provider means Nurse Practitioner (NP) and Physician Assistant (PA) staff who are authorized to provide health care and dispense controlled substances by the state in which they practice.
After-hours means times when the pharmacy is closed or unavailable including holidays, weekends, and after regular business hours.
Agent means an individual designated in a power of attorney for health care to make a health care decision for the principal, regardless of whether the person is known as an agent, legally recognized decision-maker, or attorney-in-fact, or by some other term. Agent includes a successor or alternate agent.
Allied Health Services means health care professions including clinical laboratory personnel, physical therapy, occupational therapy, dietetic services, medical record personnel, radiologic services, speech-language pathology and audiology, and respiratory therapy that promote interdisciplinary communication and collaboration and the efficient use of resources by various health care providers to improve health care.
Basic Life Support means emergency care performed to sustain life that includes cardiopulmonary resuscitation, automated external defibrillation, control of bleeding, treatment of shock, and stabilization of injuries and wounds.
Breach means the unauthorized acquisition, access, use, or disclosure of Protected Health Information (PHI) or Personally Identifiable Information (PII) that compromises the security, confidentiality, or integrity of personal information maintained by the Department.
Business Associate means an individual or corporate "person" who performs on behalf of the Department or on behalf of another business associate of the Department any function or activity involving the use or disclosure of PHI for which the Department is responsible, and is not a member of the Department's workforce.
Business Day means Monday through Friday, except for holidays.
California Department of Corrections and Rehabilitation Heart Healthy Diet means a diet plan restricted in sodium and fat while supplying adequate calories, fiber and all essential nutrients, provided by the Department and approved by a Registered Dietitian.
California Department of Corrections and Rehabilitation Standardized Master Menu means a four-week menu cycle based on the California Department of Corrections and Rehabilitation (CDCR) Heart Healthy Diet that is planned by the CDCR Food Administrator and approved by a Registered Dietitian.
Capacity or Lack of Capacity is to be determined by evaluating the person's:
Care Coordination means the deliberate organization of patient care activities between two or more participants involved in a patient's care to facilitate the appropriate delivery of health care services and minimize the danger of care fragmentation.
Care Management means a collaborative process of patient assessment, evaluation, advocacy, care planning, facilitation, and coordination. The extent of care management services varies according to the complexity of the patient.
Care Team means an interdisciplinary group of health care professionals who combine their expertise and resources to provide care for a panel of patients.
Case Conference means an action recommended by the Medical Peer Review Committee (MPRC) requesting that the originating institution's Chief Medical Executive (CME) meet with all medical staff to discuss a specific concern(s) resulting from a peer review case.
Chronic Care means the ongoing care for a current health problem that impacts or has the potential to impact a patient's functioning and long-term prognosis and has lasted, or is expected to last, for more than six months.
Clinical Pathway means a complex, interdisciplinary management tool and series of interventions based on evidence-based practice for the mutual decision-making and organization of care processes for a well-defined group of patients with a predictable clinical course.
Clinical Performance Appraisal means an evaluation conducted at the request of the MPRC or the Health Care Executive Committee (HCEC).
Clinical Practice means the skill, knowledge, and competency of a licensed medical provider reflected in the licensed medical provider's quality of care.
Clinical Supervision means staff in supervisory positions who are responsible for the supervision of clinical tasks. This includes the institution Physician Managers which are comprised of the Chief Physician and Surgeon, Chief Medical Executive, Chief Psychiatrist, and Supervising Psychiatrist, and Institution Nursing Managers which include Chief Nurse Executive, Supervising Registered Nurse, Unit Supervisor, and Nurse Consultant III.
Coccidioidomycosis 2 Area means institutions that pose the highest risk of coccidioidomycosis (cocci) exposure.
Coccidioidomycosis 2 Restriction means a medical restriction based on a combination of a history of cocci disease, medical high risk, negative cocci skin test results (if tested), race (e.g., African-American or Filipino), and medical conditions (e.g., diabetes mellitus); patients with a coccidioidomycosis 2 restriction are designated as such in the cocci risk registry.
Coccidioidomycosis Skin Test means the skin test used to determine hypersensitivity reaction to the spherulin antigen (a component of the fungus that causes cocci).
Competency means the documented demonstration of an individual having the requisite or adequate abilities or qualities capable to perform up to a defined expectation.
Complex Care Management means management of patients with complex biopsychosocial needs.
Concurrent Review means a review to evaluate the ongoing need for acute, sub-acute, or non-acute levels of care including review of admissions, continued stays, and discharge planning activities.
Contraband Surveillance Watch means the isolation and restriction of movement for observation of incarcerated persons who are suspected or known to have ingested or inserted contraband into a body cavity.
Controlled Use of Force means the force used in an institution setting when an incarcerated person's presence or conduct poses a threat to safety or security and the incarcerated person is located in an area that can be controlled or isolated. These situations do not normally involve the immediate threat to loss of life or immediate threat to institution security.
Correctional Treatment Center means a health care facility operated by the Department that provides inpatient health care services to patients who do not require a general acute care level of essential services and are in need of professionally supervised health care that cannot be provided on an outpatient basis.
Covered Entity means health plans, health care clearinghouses, and health care providers who transmit any health information in electronic form in connection with a transaction that is subject to federal Health Insurance Portability and Accountability Act (HIPAA) of 1996 requirements, as those terms are defined and used in the HIPAA regulations, 45 Code of Federal Regulations sections 160 and 164.
Credentialing means the system of screening and evaluating qualifications and other credentials including, but not limited to, licensure, certification, required education, relevant training and experience, and current competence and health status.
Data Use Agreement means a contractual agreement that establishes who is permitted to use and receive a Limited Data Set, and the permitted uses and disclosures of such information by the recipient.
Death means an individual has sustained either:
Death Review means a type of review conducted by Nurse Consultant Program Review staff which assesses the quality and appropriateness of nursing care, nursing practice issues, best practices, and factors that may have significantly impacted the quality of patient care, thereby contributing to the death of a patient.
Decision Support Tools means materials used by clinical staff to inform and support evidence-based practices based on clinical knowledge and patient specific assessments.
Determination of Death means the process of establishing death has occurred through assessment of objective data in accordance with standards of care, including obtaining an independent confirmation by another physician when death occurs due to the cessation of brain function.
Diet Instruction means specific dietary recommendations including careful food choices based on the CDCR Heart Healthy Diet, provided by a Registered Dietitian or other health care staff within the scope of their licensure.
Directly Observed Therapy means dose-by-dose administration of medications by appropriately licensed health care staff including, but not limited to, Registered Nurse (RN), Licensed Vocational Nurse (LVN), or Psychiatric Technician (PT) using the highest level of observation of ingestion of medication administered to the patient.
Disclosure means the release, transfer, provision of, access to, or divulging in any other manner of information outside the entity holding the information.
Dispense means the furnishing of drugs or devices following a prescription from a licensed prescriber or directly given to a patient by a licensed prescriber.
Do Not Resuscitate means a written order which directs that resuscitation efforts are not to be initiated in the event of cardiac or respiratory arrest.
Ducat means a CDCR 129, Incarcerated Person Pass (Rev. 07/24) There are two types of ducats, "Priority" and "Non-Priority." Priority ducats are stamped with the word "Priority" and are used for scheduled health care appointments. Non-Priority ducats are used for unscheduled appointments and unescorted movement from one location to another.
Durable Medical Equipment means equipment prescribed by a licensed provider to meet medical equipment needs of the patient that can withstand repeated use; is used to serve a medical purpose; is not normally useful to an individual in the absence of an illness, injury, functional impairment, or congenital anomaly; and is appropriate for use in or out of the institutional housing.
Emergency Response means the organizing, coordinating, and directing of available resources in order to respond to an event and bring the emergency under control.
Endorsed Institution means a CDCR institution where a patient is assigned and housed.
Expected Death means a medically anticipated death which is related to the natural course of a patient's illness or underlying condition.
Final Proposed Action means the MPRC recommended final action to modify privileges in any manner which includes a chronology of the major events in the peer review process and supporting documentation that is submitted to the HCEC.
First Aid means emergency care administered to an injured or sick patient before health care staff is available.
First Responder means the first staff member certified in Basic Life Support (BLS) on the scene of a medical emergency.
Focused Professional Practice Evaluation means an evaluation process comprised of chart reviews and licensed medical provider's input to obtain a generalized or focused overview of a licensed medical provider's clinical performance.
Foreign Body means an object within the body that has been introduced from the outside, including but not limited to contraband items.
Governing Body means a person, persons, board of trustees, directors, or other body in whom the authority and responsibility is vested for the conduct and oversight of a licensed inpatient facility.
Handoff means a transfer of information from one health care staff or care team to another for the purpose of ensuring the continuity and safety of the patient's care.
Health Care First Responder means the first health care staff member certified in BLS to arrive at the scene of a medical emergency.
Health Care Grievance Communications means patient specific communication provided through health care grievance interviews, institution level responses, rejection notices, or withdrawal notices.
Health Care Incident means an unusual or unexpected occurrence in the clinical management of a patient or patients, such as an error, sentinel event, near miss, accident, or medication event that has or may have adverse health consequences for patients or staff, and requires submission of a written description of the event to the Statewide Health Care Incident Review Committee.
Health Care Operations means any health care activities of the Department or a covered entity to the extent that the activities are related to conducting quality assessment and improvement activities; population-based activities; reviewing the competence or qualifications of health care professionals; conducting or arranging for medical review, legal services, and auditing functions; business planning and development; and business management and general administrative activities.
Health Care Provider means a Medical Doctor, Doctor of Osteopathy, Doctor of Podiatric Medicine, Clinical Psychologist, Dentist, Clinical Social Worker, NP, or PA.
Health Care Services means medical, mental health, dental, pharmaceutical, diagnostic and ancillary services to identify, diagnose, evaluate, and treat a medical, mental health, or dental condition.
Health Care Services Dashboard means a monthly report that consolidates strategic performance information across key health care areas and provides data at both statewide and institution levels and shows trends in performance over time.
Health Care Staff means those persons licensed by the state to provide health care services, who are employed by the Department or are working under direct or indirect contract with the Department to provide health care services.
Health Care Treatment Areas means any location where patient health care services are provided including, but not limited to, medical clinics, dental clinics, designated triage and treatment areas, or standby emergency rooms where urgent/emergent treatment may be required and the location is not licensed by the California Department of Public Health under California Code of Regulations, Title 22, Division 5, or by the California State Board of Pharmacy pursuant to Business and Professions Code section 4187.
Health Maintenance Services means a systematic program or procedure planned to prevent illness, maintain maximum function, and promote health.
Health Record(s) means paper-based records, electronic records, and other media that document the patient's health care and provide a chronological account of a patient's examinations and treatments. Health records shall be maintained in a manner that supports continuity of care.
Heat Alert Medications means medications that can pose a serious risk to a patient's health during times of extreme heat by impairing the body's ability to regulate temperature.
High Alert Medications means a drug that bears a heightened risk of causing significant patient harm when used in error. Mistakes may or may not be more common with these drugs, but the consequences of an error are more devastating to patients.
Hoarding means stockpiling of medications by the patient.
Hospice means services that are designed to provide palliative services to patients needing end-of-life care.
Hygiene Supplies means supplies available without a prescription for personal care. Hygiene supplies are generally used for non-medical purposes and are not medical supplies.
Individual Hunger Strike Participant means an incarcerated person who is identified by Department custody staff as a participant in an individual hunger strike.
Informal Hearing means a hearing offered to licensed medical providers who are subject to a modification of privileges in order to provide a licensed medical provider with an opportunity to respond to and provide evidence to refute the allegations that provide the basis for the modification of clinical privileges.
Informed Consent means a patient who has the capacity to make informed decisions is made aware of risks, benefits, and alternatives to proposed treatment for a disease or condition from which the patient suffers, and the patient is able to agree and clearly agrees to the recommended treatment without duress or coercion.
Informed Refusal occurs when a patient who has documented capacity to give informed consent and elects to knowingly refuse to consent to a given medication or recommended course of treatment.
Interested Person means any blood relative of the first, second, or third degree, or in a capital case, the patient's designated next-friend.
Interferon-Gamma Release Assays Test means the standard method used by the Department for the detection of recent or past Tuberculosis (TB) infection.
Interventions means actions that focus on the execution of the specific care management activities that are necessary for accomplishing the goals set forth in the patient's treatment plan, linking the patient to the services needed to optimize health.
Judicial Review Committee means a three-member panel composed of independent and impartial physicians who shall, by majority vote, determine the final outcome of a privileging action taken against a licensed medical provider when appealed by the licensed medical provider.
Keep-on-Person means medications that the prescriber believes can be safely self-administered by the patient.
Layover means a temporary delay or stop at an intermediate location during the transportation phase of a transfer of care.
Legally Recognized Decision-Maker means an agent designated in an advance directive, orally designated surrogate, spouse, registered domestic partner, parent of a minor, closest available relative, court-appointed conservator or guardian, or person whom the patient's Primary Care Provider believes best knows what is in the patient's best interest and shall make decisions in accordance with the patient's expressed wishes and values to the extent known.
Licensed Medical Provider means CME, Deputy Medical Executive, Chief Physician and Surgeon, Physician and Surgeon, NP, PA, Nurse Anesthetist, Podiatrist, and Specialty Consultant Practitioners.
Licensed Units means any health care treatment area which has beds that have been licensed by the California Department of Public Health under California Code of Regulations, Title 22, Division 5 or a health care treatment area that has been licensed by the California State Board of Pharmacy pursuant to Business and Professions Code Chapter 9, Division 2, Article 13.5, section 4187.
Limited Data Set means PHI that excludes the following direct identifiers of the patient or of relatives, employers, or household members of the patient: names; postal address information other than town or city, state and zip code; telephone numbers; fax numbers; electronic mail addresses; social security numbers; health record numbers; health plan beneficiary numbers (such as Medi-Cal numbers); account numbers; certificate/license numbers; vehicle identifiers and serial numbers, including license plate numbers.
Lockdown means an emergency safety procedure where a portion of the institution is affected by suspension of required programs or services, and patients are not released except as determined by the institution administration on an individual, case-by-case basis.
Locked Unit means a restricted or segregated program housing unit including, but not limited to, Protective Housing Units, Psychiatric Services Units, Security Housing Units, and Administrative Segregation Units.
Mass Organized Hunger Strike means an organized hunger strike including multiple incarcerated persons who have a common goal or set of demands.
Mass Organized Hunger Strike Participant means an incarcerated person identified by Department custody staff as participating in a mass organized hunger strike.
Medical Assistant means the same thing as in Business & Professions Code section 2069(b)(1).
Medical Classification means the process of mapping patient attributes to Medical Classification Factors.
Medical Classification System means the system that provides the matching between patients and institutions based on patient attributes and institution attributes.
Medical Emergency means any medical, mental health, or dental condition, as determined by health care staff, for which immediate evaluation and treatment are necessary to prevent death, severe or permanent disability, or to alleviate disabling pain. A medical emergency exists when there is a sudden marked change in an individual's medical condition so that action is immediately necessary for the preservation of life, alleviation of severe pain, or the prevention of serious bodily harm to the patient or others.
Medical High Risk means patients who have a medical risk designated as high per the automated clinical classification system.
Medical/Psychiatric and Return means the process used when a patient requires medically necessary health care services which are only accessible at or via a CDCR institution other than the patient's endorsed institution. Medical/psychiatric and return requires an overnight stay at the treating institution prior to the return to the endorsed institution.
Medical Supplies means supplies prescribed by a licensed provider to meet medical supply needs of the patient that meet the following criteria: cannot withstand repeated use; are usually disposable in nature; are used to serve a medical purpose; are not useful to an individual in the absence of an illness, injury, functional impairment, or congenital anomaly; and are intended for use by the patient in an outpatient setting.
Medically Necessary means health care services that are determined by the attending or primary medical, mental health, or dental care provider(s) to be needed to protect life, prevent significant illness or disability, or alleviate severe pain, and are supported by health outcome data or clinical evidence as being an effective health care service for the purpose intended or in the absence of available health outcome data is judged to be necessary and is supported by diagnostic information or specialty consultation.
Medication Adherence means the extent to which patients take medications as prescribed.
Medication Administration Area means all areas that store medications located outside of the correctional pharmacy irrespective of license (e.g., medication cart, medication room, nursing stations, or Triage and Treatment Area).
Medication Error means any preventable event that may cause or lead to inappropriate medication use or patient harm as a result of professional practice, health care products, procedures, and systems.
Medication Refusal means the patient declines the prescribed medication (Directly Observed Therapy [DOT], Nurse Administered, or Keep-on-Person) or declines to comply with medication procedures either at the cell front or during medication line.
Medication Renewal means a new medication order which is required for dispensing of any medication for which the current order is expired or expiring.
Mental Health Evaluation means a psychological evaluation performed by a mental health clinician that includes a brief narrative of the presenting problem, historical information of relevance, a mental status examination and assessment of level of functioning, determination of need for mental health treatment and recommended level of care, and a referral to a psychiatrist if there is a possible need for psychotropic medication or other psychiatric intervention.
Modified Program means the suspension or restriction of patient program activities or movement that impacts less than all programs or less than all patients. A modified program may either occur independently in response to an incident or unusual occurrence or may occur as a facility transitions from a lockdown to regular programming.
Near Miss means an event or situation that could have resulted in a health care incident but did not, either by chance or through timely intervention.
Non-business Days means Saturdays, Sundays and State holidays.
Normal Business Hours means a minimum of eight hours per business day. These hours may vary by institution, but are generally between the hours of 0700 and 1800.
Nourishments means approved food items, in addition to the standard meal, ordered for patients with certain medical or dental conditions.
Nurse Administered means dose-by-dose administration of medications by appropriately licensed health care staff that do not require DOT procedures, only reasonably observed ingestion of medication.
Nurse Practitioner means the same thing as in 16 California Code of Regulations section 1480(o).
Nurse Protocol means a specific written procedure that prescribes nursing actions in a given situation.
Nursing means the protection, promotion, and optimization of health and abilities, prevention of illness, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, communities, and populations.
Open Access means a scheduling strategy that involves "doing today's work today" and seeing patients as soon as possible after they request care, and on the same day if appropriate. Open access slots are appointment times or blocks that are left open and unscheduled until one to two days prior to that date, allowing the care team to accommodate walk-in patients, patients with urgent health needs, and patients with routine health needs that would benefit from expedited services.
Opt-Out Screening Method means the patient is informed of the routine laboratory tests that will be performed as part of the RC Initial Health Screening and Triage unless the patient specifically declines a test.
Order Sets means printed or electronic orders available for commonly performed interventions. These are different from standing orders in that they are not conditional. The provider determines whether the order sets will be used, and if variations to the order sets are required, the provider notes the variation in the patient's chart.
Outcome Data or Clinical Evidence means the professionally accepted results of studies and analyses, using evidence-based methodologies and expert clinical judgment, regarding the effectiveness of various health care services, how those services relate to patient morbidity and mortality, and overall efficiency and effectiveness of care.
Outpatient Housing Unit means a designated housing area within institutions designed to provide supportive services, including low-intensity nursing care, for patients who may require limited assistance with activities of daily living or short-term observations.
Outpatient Therapeutic Diet means a medically necessary therapeutic diet ordered by a PCP or dentist.
Over-the-Counter Products means commonly utilized health care products which are available to the general public without a prescription.
Palliative Care means services that support a patient in managing his or her health care needs associated with a serious illness. Services are designed to provide comfort, relief from pain, support the patient, and to maintain or improve functioning and quality of life. Palliative care services can be provided at any stage of illness and at all levels of care within the Department.
Parole means release of an incarcerated person from imprisonment to the community by a releasing authority prior to the expiration of the incarcerated person's prison term.
Patient means an incarcerated person who is seeking or receiving health care services or who is assigned to a care team.
Patient Panel means a clearly defined group of patients that are assigned to a particular care team. Every care team has one panel of patients, and every patient is assigned to a care team.
Patient Registries means lists of patients with specific conditions or eligible for certain preventive services that include clinical information helpful to the management of these patients.
Patient Safety Alert means a bulletin issued to all institutions informing them of a patient safety issue with statewide implications, which may include actions to mitigate harm to patients.
Patient-initiated means the patient sought health care services through Department staff or reported to health care staff for consultation and/or treatment without having first been contacted or scheduled by health care staff.
Payment means the activities undertaken by the Department to obtain or provide reimbursement for the provision of health care.
Peer Review Formal Investigation means an investigation into the clinical performance or conduct of a licensed medical provider pursuant to allegations that the licensed medical provider's clinical performance or conduct falls below the applicable standard of care. A Formal Investigation is an investigation as that term is used in Business and Professions Code sections 805(c) and 805.01(b).
Performance Improvement Plan means a plan that identifies priority areas for improvement, as well as performance objectives and strategies used to achieve objectives.
Permanent means expected to last longer than six months.
Personal Representative means a person who has authority, under applicable state law, to act on behalf of a patient in making health care decisions related to the patient.
Personally Identifiable Information means any information that is maintained by the Department that identifies or describes an individual, including, but not limited to, his or her name; social security number; physical description; home address; home telephone number; education; financial matters; and medical or employment history. It includes statements made by, or attributed to, the individual. PII may include information that is not necessarily PHI and may pertain to the Department employees, members of the public, or other individuals who may or may not be patients.
Physician Assistant means the same thing as in Business & Professions Code section 3501(d).
Physician Orders for Life-Sustaining Treatment means a physician order that documents a patient's "preferred intensity of care" concerning life-sustaining treatment and end of life care, including resuscitation status, and which translates those expressed preferences into a physician's order.
Population means a group of patients sharing a common health characteristic, such as age, gender, race or ethnicity, risk level, or chronic condition.
Population Management means systematic assessment, monitoring, and management of the health care needs for identified groups of patients.
Potential Quality Issue means a health care incident, regardless of severity, which occurs during the course of treatment by a Healthcare Provider Network facility or provider and requires submission of a written Potential Quality Issue referral.
Prescription means oral, written, or electronic transmission that is given to the person for whom ordered and is issued by a physician, dentist, Optometrist, Podiatrist, naturopathic doctor, NP, PA or other person lawfully authorized to prescribe pursuant to their license in the State of California.
Primary Care Provider means a physician, NP, or PA designated to have primary responsibility for the patient's health care or, in the absence of a designation or if the designated physician is not reasonably available or declines to act as primary physician, a physician who undertakes the responsibility.
Primary Care Team means an interdisciplinary team that organizes and coordinates services, resources, and programs to ensure consistent delivery of appropriate, timely, and patient-centered, evidence-based care to a designated patient panel.
Privilege Modification means a temporary or permanent change in a licensed medical provider's privileges including a denial, suspension, restriction, reduction, or revocation of any or all of a licensed medical provider's privileges.
Privileging means the process by which a licensed medical provider is permitted by law and the facility to provide specified medical or other patient care services. Clinical privileges must be facility-specific, provider-specific, and within available resources.
Proctoring means the assignment of a licensed medical provider to observe the practice of another licensed medical provider performing specified activities and to provide required reports on those observations.
Procurement means the purchase of pharmaceuticals by the pharmacy.
Professional Misconduct means conduct and behavior that disrupts, or is likely to disrupt, clinical operations and may impact patient or staff safety, or is "unprofessional" pursuant to California Business and Professions Code sections 2220 et seq.
Pronouncement of Death means the formal process of recording the death in the health record and communicating the death to the patient's next of kin.
Prospective Review means a review conducted prior to services being rendered to determine whether the patient's illness necessitates the requested level of care or services or could be provided at a lower level of care.
Protected Health Information means information created or received by the Department which identifies or can be used to identify an individual as it relates to past, present, or future health conditions; health care services provided to the individual; or health care related payments. This applies to information that is transmitted or maintained in verbal, paper, or electronic form.
Protocols means evidenced based practice procedures that represent the framework for managing a specific disorder or clinical situation by outlining the desired outcome, the process steps and tasks, the skills and competencies required, scope of practice, and action taken.
Provider Network means a group of licensed health care practitioners and hospitals working under a contract with the Department who provide health care services to CDCR patients.
Psychotherapy Notes means notes recorded in any medium by a health care provider who is a mental health professional documenting or analyzing the contents of conversation during a private counseling session or a group, joint, or family counseling session, and that are separated from the rest of the patient's medical record.
Reading Glasses means ready-made, single-vision glasses that are designed to lessen the focusing burden during up close activities, such as reading.
Reception Center Focused Health Assessment means a face-to-face focused physical assessment performed by a PCP and documented in the health record during the RC Initial Screening.
Reception Center Initial Health Screening and Triage means a face-to-face assessment conducted by licensed nursing staff, which includes a review of the patient's available health records, an interview, a brief health history, and a focused objective physical assessment based on the records review and patient interview.
Retrospective Review means a review to evaluate the medical necessity and appropriateness of treatment after it has been rendered, as well as to compare billed services with the actual treatment authorized.
Risk Stratification means the continuous use of data and predictive modeling to differentiate patients into risk levels.
Root Cause Analysis means a structured and standardized process by which a multidisciplinary team analyzes a health care incident, near miss, or sentinel event, determines the fundamental reasons why the event occurred, and designs and implements a plan of action to prevent similar events from occurring in the future.
Rounds means the act of seeing a patient in an inpatient setting to observe and communicate with the patient, evaluate the patient's current condition, their response to treatment, determine if their care needs are being met by the current plan of care and to assess their environment of care. Rounds may be conducted by individual disciplines, or they may be multidisciplinary.
Safety Assessment means an evaluation to determine whether failure to take immediate action regarding the clinical performance of a licensed medical provider may result in imminent danger to the health of patient(s) or staff.
Sentinel Event means a patient safety event, including adverse events as defined in California Health and Safety Code section 1279.1, not primarily related to the natural course of the patient's illness or underlying condition that results in death, permanent harm, or a temporary impairment that affects the patient and limits their ability to function normally for a significant amount of time.
Severe Pain means a degree of discomfort that significantly disables the patient from reasonable independent function.
Significant Illness and Disability means any medical, mental health, or dental condition that causes or may cause, if left untreated, a severe limitation of function or ability to perform the daily activities of life or that may cause premature death.
Skilled Nursing Facility means a health facility or a distinct part of a hospital which provides continuous skilled nursing care and supportive care to patients whose primary need is for skilled nursing care on an extended basis. It provides 24-hour inpatient care and at a minimum includes physician, skilled nursing, dietary, and pharmaceutical services as well as an activity program.
Specialized Health Care Housing means a distinct housing unit located within a facility or institution operated by the Department that provides health care services 24 hours a day to patients who are in need of professionally supervised health care. Specialized Health Care Housing units may, or may not be licensed or accredited. Specialized Health Care Housing units include the following levels of care: Outpatient Housing Unit, Correctional Treatment Center, Mental Health Crisis Bed, Psychiatric Inpatient Program, Skilled Nursing Facility, Hospice, Acute Care Facility, and Intermediate Care Facility.
Specific Authorization means the same thing as in Business & Professions Code section 2069(b)(2).
Standard of Care means the reasonable degree of skill, knowledge, care, and conduct ordinarily possessed and exercised by members of the discipline and profession under similar circumstances.
Substantial Evidence means relevant evidence that a reasonable person could accept as adequate to support a conclusion.
Supplement means medically necessary high caloric drinks ordered by a PCP or dentist.
Technical Supportive Services means the same thing as in Business & Professions Code section 2069(b)(4)(A).
Texture Modified Diet means a CDCR Heart Healthy Diet or therapeutic diet that has been modified to allow ease in chewing or swallowing.
Transfer means the transportation of a patient between two points, such as from one prison to another or from one law enforcement entity (a state prison or a county jail) to another.
Transport means movement of a patient from their endorsed institution for the purposes of accessing health care or other services that are not available at the endorsed institution.
Treating Institution means the institution where a patient is sent to receive medically necessary health care services that cannot be provided at the endorsed institution.
Treatment means the provision, coordination, or management of health care related services by one or more health care providers, including the coordination or management of health care by a health care provider with a third party; consultation between health care providers relating to a patient; or for the referral of a patient for health care from one health care provider to another.
Tuberculin Skin Test means a method of determining whether a person is infected with Mycobacterium TB.
Tuberculosis Disease means a disease caused by bacteria known as Mycobacterium TB. TB is a treatable infectious disease that usually affects the lungs and airway, but may also affect other parts of the body.
Unit, when referring to OTC products, means a single manufacturer-packaged quantity of a particular OTC product. Examples include a single tube of cream, single bottle of lotion, single bottle of the same medication, or single box of blister cards filled with the same medication.
Urgent, when referring to medication orders, means needed in less than three business days based on the clinical judgment of the prescriber.
Use, when referring to PHI and PII, means the sharing, employment, application, utilization, examination, or analysis of information that identifies, or reasonably can be used to identify, an individual within the Department.
Workforce means employees, volunteers, trainees, and other persons whose conduct, in the performance of work for the Department or a business associate, is under the direct control of the Department or a business associate, whether or not they are paid by the Department or the business associate.
X-Ray means a photographic or digital image of the internal composition of something, especially a part of the body, produced by X-Rays being passed through it and being absorbed to different degrees by different materials.
Notes
Note: Authority cited: Section 5058, Penal Code. Reference: Section 5054, Penal Code; and Plata v. Newsom (No. C01-1351 JST), U.S. District Court, Northern District of California.
Note: Authority cited: Section 5058, Penal Code. Reference: Section 5054, Penal Code; and Plata v. Newsom (No. C01-1351 JST), U.S. District Court, Northern District of California.
2. Amendment of section heading, section and Note refiled 1-7-2019 as an emergency, with further amendments; operative
3. Change without regulatory effect relocating and amending former section 3364.1, subsections (a)(6)-(7) to add definitions of "Capacity or Lack of Capacity" and "Informed Refusal" to section 3999.98 and amending Note filed 4-15-2019 pursuant to section 100, title 1, California Code of Regulations (Register 2019, No. 16).
4. Certificate of Compliance as to 1-17-2019 order, including amendment changing the definition of "Necessary" to "Medically Necessary," transmitted to OAL 4-9-2019 and filed 5-20-2019; amendments operative
5. Amendment filed 7-1-2019 as an emergency; operative
6. Amendment refiled 12-5-2019 as an emergency; operative
7. Amendment refiled 3-9-2020 as an emergency; operative
8. Certificate of Compliance as to 3-9-2020 order, including amendment of section, transmitted to OAL 6-8-2020 and filed 7-20-2020; amendments operative
9. New definitions of "Informed Consent" and "Interested Person" filed 3-1-2021; operative
10. New definition of "Health Record(s)" filed 10-28-2021; operative
11. New definitions of "Administrative Supervision," "Clinical Supervision," "Death," "Determination of Death," "Medical Assistant," "Nurse Practitioner," "Pronouncement of Death," "Specific Authorization" and "Technical Supportive Services" filed 5-22-2023; operative
12. New definition of "Reading Glasses" filed 5-31-2023; operative
13. Removal of previous definition of "Nurse Practitioner" inadvertently retained in 5-22-2023 order filed 6-13-2023 (Register 2023, No. 24).
14. Editorial correction restoring inadvertently omitted definition of "California Department of Corrections and Rehabilitation Heart Healthy Diet" (Register 2023, No. 44).
15. Change without regulatory effect amending section filed 7-1-2024 pursuant to section 100, title 1, California Code of Regulations (Register 2024, No. 27).