Health Care Policy Manual

Policy Number Policy Name Review Date Revised Date
AD - Administrative

I. Organization

AD I-1 Health Services Mission, Vision, Goals and Objective 2-2012 2-2012
AD I-2 Health Care Treatment Philosophy 2-2012 2-2012
AD I-3 Overall Responsibilities 7-2010 10-2008
AD I-4 Facility Procedures 8-2010 8-2010
AD I-5 Definitions of Medical Mission 1-2012 4-2008
AD I-6 Nursing Procedure Manual 1-2012 6-2007
  II. Performance Improvement and Risk Management
AD II-1 Performance Improvement Plan 7-2017 7-2017
AD II-2 Health Services Peer Review 4-2010 9-2008
AD II-3 Medical Statistics and Reports 4-2010 10-2007
AD II-4 Inmate Injuries (workman's comp) 4-2010 5-2002
AD II-5 Medication Variances and Incidents Reports 4-2010 4-2009
AD II-6 Medical Incidents & Adverse Events 4-2016 4-2016
AD II-7 Internal Medical Review 4-2010 4-2009
AD II-8 Forensic Investigation 4-2010 4-2009
AD II-9 Nursing Quality Control Monitoring 1-2012 4-2011
AD II-10 Health Services Comprehensive Audits 3-2013 3-2013
AD II-11 Instruments, Sharps, Key Control 4-2010 3-2009
AD II-12 Identification of Patients N/A 9-2013
AD II-13 Cardiopulmonary Resuscitation N/A 12-2013
  III. Managed Care
AD III-1

Inmate Co-Pay

1-2016 1-2016
AD III-2 Processing Disability Claims 5-2010 5-2002
AD III-3 Utilization Review Plan 6-2014 6-2014
AD III-4 Cosmetic Surgery 11-2010 5-2002
AD III-5 Medical Claims Receipt 1-2012 10-2007
AD III-6 Pended UR Requests 9-2016 9-2016
AD III-7 Utilization Review Policies 4-2010 12-2010
  IV. Patient's Rights
AD IV-1 Informed Consent 2-2014 2-2014
AD IV-2 Involuntary Commitment 4-2010 9-2007
AD IV-3 Confidentiality 4-2014 4-2014
AD IV-4 Medical Research 5-2014 5-2014
AD IV-5 Inmate Right to Refuse Medical Treatment 5-2014 5-2014
AD IV-6 Access to Foreign Language Translation 1-2012 1-2012

  V. Death and Dying

AD V-1 Rights to a Natural Death 1-2012 2-2002
AD V-2 Procedures in Case of Death of an Inmate 6-2012 6-2012
AD V-3 Organ Donations 1-2010 1-2009
AD V-4 Transporting Bodies 5-2010 5-2010
AD V-5 Revocation of DNR Orders 4-2010 4-2009
AD V-6 Right to Healthcare Decisions 5-2011 5-2011
AD V-7 Recognition of DNR Status N/A 1-2012
  VI. Medical Records
AD VI-1 Purpose and Composition of Medical Record 5-2014 5-2014
AD VI-2 Medical Record Committee 6-2010 4-2000
AD VI-3 Release of Confidential Information 5-2014 5-2014
AD VI-4 Combining Records & Creating Additional Volumes 8-2014 8-2014
AD VI-5 Mental Health Records/Tracking System 6-2010 1-2006
AD VI-6 Photographs and Videotapes 5-2014 5-2014
AD VI-7 Transfer of Medical Records 5-2014 5-2014
AD VI-8 Record Retention 8-2010 8-2010
AD VI-9 Retrieval of Parole/Release Records 4-2011 4-2011
AD VI-10 Coding and Indexing 8-2010 8-2009
AD VI-11 Medical Alert Labels 4-2014 4-2014
AD VI-12 Basic Medical Record Documentation 4-2014 4-2014
AD VI-13 Forms Management 5-2014 5-2014
AD VI-14 Problem List 9-2014 9-2014
AD VI-15 Dialysis Records 9-2016 9-2016
AD VI-16 Recording Data in OPUS 9-2016 9-2016
AD VI -17 HERO Downtime Policy and Procedure 9-2016 9-2016
  VII. Facilities
AD VII-1 Facilities, Equipment, Supplies 1-2012 4-2011
AD VII-2 First Aid Kits 7-2010 9-2005
AD VII-5 Emergency Medical Response 6-2012 6-2012
  VIII. Reporting
AD VIII-2 Notification of Serious Illness, Injury or Death of Hospitalized Patient 8-2010 3-2004
AD VIII-3 Duty to Warn 1-2014 1-2014
AD VIII-4 Deleted refer to CP 18 Deleted Deleted
AD VIII-5 Reporting Positive Drug Finding During Dx. Work-up 3-2014 3-2014
AD VIII-6 Medical Notification to Excuse from Work 11-2014 11-2014
P - Personnel
P-1 Nursing Staffing Standards 1-2012 1-2012
P-2 Professional Licensure and Credentials Verification 4-2011 4-2011
P-3 Continuing Education 5-2010 5-2008
P-4 Use of Physician Extenders 8-2010 8-2009
P-5 Use of Inmates in Delivery of Health Care 1-2012 10-2007
P-6 Nursing: Verification of Valid Professional Licenses/Listings 1-2012 4-2011
P-7 Medication Technicians 1-2016 1-2016
P-8 Nursing Coverage 1-2012 3-2010
P-9 Nursing Orientation, Mandatory Training and Competency Evaluation 1-2012 5-2010
P-10 Requesting Flexible Schedule 1-2012 1-2012
P-11 Social Work Staffing 5-2012 5-2012
  II. Employee Health
P II-1 Employee Vaccinations and TB Screening 4-2014 4-2014
P II-2 Moved to IC-12    
P II-3 Treatment of Injured or Sick Staff 6-2014 6-2014
P II-4 Moved to IC-14    
P II-5 BBP Exposure to DOP Employees 7-2014 7-2014
P II-6 BBP Exposure to Employees of Other Agencies 7-2014 7-2014
A - Assessment of Patient
A-1 Receiving Screening 1-2014 1-2014
A-2 Intake Physical Exam and PULHEAT System 3-2013 3-2013
A-3 Lab Services 5-2014 5-2014
A-4 Radiology Services 5-2014 5-2014
A-5 Offenders in Segregation 11-2014 11-2014
A-6 Disciplinary Actions for Mental Health Patients 6-2010 12-2008
A-7 Court Ordered STD Testing 2-2014 2-2014
A-8 Paternity Testing 11-2014 11-2014
A-9 Patient Acuity Rating System 4-2016 4-2016
A-10 Falls Screening Alert 4-2010 8-2004
A-11 Vision Screening 6-2014 6-2014
A-12 Intersystem and Intrasystem Mental Health Services Screening, Appraisal and Evaluation 4-2012 4-2012
A-13 Infusion Therapy and Blood N/A 1-2016
PL - Planning Patient Care
PL-1 Procedures for Chronic Disease 6-2013 6-2013
PL-2 Initial Nursing Care Plan for Mental Health 1-2012 3-2002
PE - Patient Education
PE-1 Health Orientation 1-2014 1-2014
PE-2 Inmate Health Education/Health Promotion 10-2014 10-2014
PE-3 Refer to Policy N-1   Deleted Policy Deleted Policy Deleted
PE-4 Refer to Policy TX-7   Deleted Policy Deleted Policy Deleted
TX - Care and Treatment of Patient
  I. Access to Services
TX I-1 Sick Call 1-2016 1-2016
TX I-2 Specialty Medical Clinics 9-2016 9-2016
TX I-3 Mental Health Clinics 6-2011 6-2011
TX I-4 Medical Treatment Services Outside DOP 7-2012 7-2012
TX I-5 Mental Health Services Outside DOP Policy Deleted Policy Deleted
TX I-6 Mental Health Day Treatment 11-2010 12-2008
TX I-8 Telephone Triage 1-2017 1-2017
TX I-9 Detoxification and Drug Withdrawal 1-2012 1-2012
TX I-10 Oxygen 6-2014 6-2014
TX I-11 Mass Casualties 9-2016 9-2016
TX I-12 Mental Health Outpatient Services - Telepsychiatry Clinics   4-2012
TX I-13 Evaluation and Management of Disorders of Gender Identity 10-2014 10-2014
TX I-14 Adult Residential Treatment Services N/A 10-2013
  II. Medication Administration
TX II-1 Drug Formulary 4-2012 4-2012
TX II-2 Inmate Initially Received into the System with Medication 1-2012 1-2012
TX II-3 Valid Orders and Treatment Protocols 1-2017 1-2017
TX II-4 Medication Procurement and Returns 1-2017 1-2017
TX II-5 Starter Dose Program 1-2017 1-2017
TX II-6 Inmate Transferred on Medication 1-2012 2-2012
TX II-7 Methods of Medication Administration 1-2012 2-2012
TX II-8 Involuntary Administration of Psychotropic Medication 6-2012 6-2012
TX II-9 Medication Duration for Outpatient Services 1-2017 1-2017
TX II-10 Documentation of Medication Administration 3-2013 3-2013
TX II-11 Psychotropic Medication Review 12-2016 12-2016
TX II-12 Controlled Substances 1-2017 1-2017
TX II-13 Non-Prescription Medication in Canteen 1-2017 1-2017
TX II-14 Drug Storage 1-2017 1-2017
TX II-15 Drug Recall 1-2017 1-2017
TX II-16 Inmate Release with Medications 12-2015 12-2015
TX II-17 Pharmacy and Therapeutics Committee 1-2012 1-2012
TX II-18 Inmate Medication Refill Request System 4-2012 4-2012
TX II-19 PRN (as needed) Medication, administration of 4-2010 6-2007
TX II-20 Transcription of Orders 1-2012 6-2011
TX II-21 Procuring Medications for Inmate Workman's Comp Cases 1-2012 10-2007
TX II-22 Mental Health Preferred Drug List N/A 11-2010
  III. Restrictive Procedures
TX III-1 Therapeutic Seclusion 7-2010 9-2007
TX III-2 Therapeutic Restraint 7-2010 10-2008
TX III-3 Use of Restraints for Medical Purposes 10-2014 10-2014
TX III-4 Use of Administrative Segregation for Behavioral Observation 7-2010 10-2008
TX III-5 Assessment and Care of Patient on Special Management  Meals 10-2014 10-2014
TX III-6 Assessment and Care for Patient on Finger Food Diet 10-2010 10-2008
TX III-7

Self Injurious Behavior Intervention 

6-2016 6-2016
TX III-8 Medical Care After Use of Force and/or Incidents Involving Trauma to an Inmate 10-2014 10-2014
TX III-9 Suicide Prevention Program (Effective 09/01/2016) 6-2016 6-2016
  IV. Infection Control
TX-VI Moved to IC Section of Manual Policy Moved Policy Moved
  V. Dental Services
TX V-1 Dental Responsibilities 5-2014 5-2014
TX V-2 Asepsis Dental Procedures 5-2014 5-2014
TX V-3 Dental Exams and Assessment 3-2016 3-2016
TX V-4 Access to Dental Care and Dental Priorities 5-2014 5-2014
TX V-5 Preventive Dentistry 5-2014 5-2014
TX V-6 Types of Dental Treatments Provided 3-2016 3-2016
TX V-7 Periodontal Treatment 3-2016 3-2016
TX V-8 Orthodontics 5-2014 5-2014
TX V-9 Dental Records and Reports 5-2014 5-2014
TX V-10 Dental Hygiene Under Direction 5-2014 5-2014
TX V-11 Dental Holds 3-2016 3-2016
  VI. Activities of Daily Living
TX VI-1 Inmate Personal Hygiene 1-2012 2-2002
TX VI-2 Therapeutic Diets & Supplemental Nourishment 8-2010 8-2009
TX VI-3 Refer to Policy N-5  Deleted Policy Deleted Policy Deleted
TX VI-4 Grinding of Toe Nails & Calluses 11-2010 2-2002
  VII. Disabilities
TX VII-1 Development Disabilities 8-2010 8-2007
TX VII-2 Physical, Mental, or Cognitive Disabilities 8-2010 8-2009
TX VII-3 Medical Prosthesis and Appliances Including Footwear 10-2014 10-2014
CC - Continuity Patient Care
CC-1 Continuity of Care 4-2014 4-2014
CC-2 Hospitalization & In-Patient Medical Services 4-2014 4-2014
CC-3 Transfers, Appropriate Medical Placements & Medical Holds 5-2014 5-2014
CC-4 Pregnant Inmates 3-2014 3-2014
CC-5 Aged and Infirmed Inmate 5-2014 5-2014
CC-6 Mental Health Services - Case Finding and Patient Flow 8-2010 10-2008
CC-7 Transfer Procedures for Referral to Mental Health 8-2010 10-2008
CC-8 Aftercare Planning for Inmate Health Services 1-2012 11-2007
CC-9 Social History 5-2010 5-2003
CC-11 Extending the Limits of Confinement 4-2010 9-2007
CC-12 Medical Release 12-2014 12-2014
CC-13 Inmate and Family Correspondence and Calls 3-2014 3-2014
CC-14 Medicaid Application Process N/A 12-2012
N - Nutrition
N-1 Therapeutic Diet Orientation 03-2016 03-2016
N-5 Management of Offenders Refusing to Eat 10-2014 10-2014
IC - Infection Control
IC-1 Sterilization & Disinfection  1-2016 1-2016
IC-2 Sanitation of Medical Areas & Equipment 9-2016 9-2016
IC-3 Communicable Disease 1-2016 2-2016
IC-4 Standard Precautions 1-2015 1-2015
IC-5 Inmate Exposure to BBP 9-2016 9-2016
IC-6 Tuberculosis Control Plan 3-2011 3-2011
IC-7 Management of HIV Infection/Acquired 1-2012 9-2010
IC-8 Immunizations 5-2016 5-2016
IC-10 BBP Exposure/Employees of Other Agencies 9-2016 9-2016
IC-11 Employee Vaccinations and TB Screening 9-2016 9-2016
IC-12 Injuries to Staff and Occupational Exposure to DPS Staff and Staff from other Agencies 1-2016 1-2016
IC-13 Treatment of Injured or Sick Staff 9-2016 9-2016
IC-14 Health Care Worker's Infected with HIV and/or HBV 1-2016 1-2016

Associated Files