CALIFORNIA CODE OF REGULATIONS - State of California

§ 79611 CALIFORNIA CODE OF REGULATIONS
Page 670
diagnostic psychological assessment and treatment. Primary services
may also be provided to inmates not requiring admission to a licensed
bed.
(b) Inmate–patients requiring 24–hour treatment for a mental
disorder shall be admitted to a correctional treatment center only if the
facility meets the requirements for a mental health treatment program
or has policies, procedures and sufficient staff to handle the
emergency, pending transfer to a licensed psychiatric facility.
NOTE: Authority cited: Sections 208(a) and 1267.10(a), Health and
Safety Code. Reference: Sections 1250(j) and 1254, Health and Safety
Code.
§ 79611. Psychiatrist/Psychologist Service General
Requirements.
(a) There shall be a sufficient number of psychiatrists and
psychologists on the staff to meet the needs of the patients.
(b) A psychiatrist or psychologist shall be responsible for
examining, diagnosing, classifying and prescribing treatment for
patients. The psychiatrist or psychologist shall also record progress
notes, review and update treatment orders and make other appropriate
entries in the patient record.
(c) Written policies and procedures shall be developed and
maintained by the person responsible for the service in consultation
with other appropriate health professionals and administration.
Policies and procedures shall be approved by the administration and
medical director. These shall include, but not be limited to:
(1) Description of the type and scope of services to be provided.
(2) Policies relating to patient care.
(3) Planning for follow–up care of patients treated.
(4) Arrangements for referral to other agencies or health facilities.
(5) Documentation requirements for each evaluation and treatment
encounter.
(d) Medical examination shall be performed by a physician as often
as indicated by the medical needs of the inmate–patient.
(e) The responsibility and accountability of the
psychiatrist/psychologist service to the medical staff, administration
and governing body shall be defined.
NOTE: Authority cited: Sections 208(a) and 1267.10(a), Health and
Safety Code. Reference: Sections 1250(j) and 1254, Health and Safety
Code.
§ 79613. Psychiatrist/Psychologist Service Staff.
(a) A clinical director shall have overall responsibility for the
psychiatrist/psychologist service.
(b) The clinical director responsible for the service, acting alone or
through an organized staff, shall have the following responsibilities:
(1) Establishing, reviewing and maintaining policies and
procedures for the psychiatrist/psychologist service. Policies and
procedures shall include, but not be limited to, policies related to
patient care, type and scope of services available, follow–up care and
consultation and referral. These shall be reviewed at least annually.
(2) Assuring the quality of psychiatrist/psychologist services
provided to inmate–patients in the correctional treatment center.
(3) Reviewing credentials and specifying clinical privileges for
psychiatrist/psychologist staff, including other mental health
professionals.
(c) Psychiatric and psychological postgraduate trainees, interns,
residents, postdoctoral fellows or instructors may provide psychiatric
and psychological services under the provisions of Sections 2065 and
2911 of the Business and Professions Code.
NOTE: Authority cited: Sections 208(a) and 1267.10(a), Health and
Safety Code. Reference: Sections 1250(j) and 1254, Health and Safety
Code; and Sections 2065 and 2911, Business and Professions Code.
§ 79615. Psychiatrist/Psychologist Service Space.
(a) There shall be sufficient space for conducting the service,
including:
(1) Suitable space for interviewing.
(2) Office space.
NOTE: Authority cited: Sections 208(a) and 1267.10(a), Health and
Safety Code. Reference: Sections 1250(j) and 1254, Health and Safety
Code.
§ 79625. Nursing Service.
Nursing service means a service organized, staffed and equipped
to provide skilled nursing care to inmate–patients on a continuous
basis.
NOTE: Authority cited: Sections 208(a) and 1267.10(a), Health and
Safety Code. Reference: Sections 1250(j) and 1254, Health and Safety
Code.
§ 79627. Nursing Service General Requirements.
(a) Written policies and procedures shall be developed and
maintained by the director of nursing in consultation with other
appropriate health professionals and administration. Policies and
procedures shall be approved by the administration and medical
director when required by governing body bylaws.
(b) Nursing service shall include, but not be limited to, the
following:
(1) Planning of patient care, which shall include at least the
following:
(A) Identification of care needs based upon an initial written and
continuing assessment of the patient’s needs with input, as necessary,
from health professionals involved in the care of the patient. Initial
assessments shall commence at the time of admission of the patient
and be completed within seven days after admission.
(B) Development of an individual, written patient care plan which
specifies the care to be given, the objectives to be accomplished, and
the professional discipline responsible for each element of care.
Objectives shall be measurable and time–limited. Each
inmate–patient’s care shall be based on this plan.
(C) Reviewing, evaluating and updating of the patient care plan, as
necessary, by the nursing staff and other professional personnel
involved in the care of the patient, at least monthly, and more often as
the patient’s condition warrants.
(2) Notifying the attending physician or the attending clinician
promptly of:
(A) The admission of a patient.
(B) Any sudden and/or marked adverse change in signs, symptoms
or behavior exhibited by a patient.
(C) An unusual occurrence involving a patient.
(D) Any untoward response or reaction by a patient to a medication
or treatment.
(E) Any error in the administration of a medication or treatment to
a patient.
(F) The facility’s inability to obtain or administer, on a prompt and
timely basis, drugs, equipment, supplies or services as prescribed
when this presents a risk to the health, safety, or security of the patient.
(G) The inmate–patient’s refusal to accept a prescribed
medication, treatment, or diagnostic procedure.
(c) All attempts to notify physicians or the attending clinician shall
be noted in the patient’s health record including the time and method
of communication and the name of the person acknowledging contact,
if any.
(d) Licensed nursing personnel shall verify that patients are served
the diets as prescribed.
(e) Nursing staff shall maintain timely and accurate patient record
documentation including:
(1) Signed, dated, nursing notes reflecting implementation of the
patient care plan, the patient’s response to care, and changes in
patients’ symptoms or behavior.
(2) A record of all medications and treatments administered.
(3) A record of all personal patient care including dietary intake
and patient activity.
(4) A record of patient vital signs, weight and other appropriate
measurements.