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MEDICAL G-120 FRESNO COUNTY SHERIFF'S OFFICE JAIL DIVISION POLICIES AND PROCEDURES TITLE: MEDICAL HEALTH SERVICES NO: G-120 FILE: MEDICAL EFFECTIVE DATE: 01-01-93 REVISED: 12-25-94, 02-01-98, 01-01-00, 06-15-18 AUTHORITY: Sheriff J. Zanoni APPROVED BY: Assistant Sheriff T. Gattie REFERENCE: Penal Code Sections 3407, 3440, 4011, 4011.2, 4011.5, 4015, 4023, 4023.5, 4023.6, and 4028; Government Code Sections 26605 and 26605.5; Health and Safety Code Section 123462; California Code of Regulations, Title 15, Sections 1041, 1058.57 12027 12037 12047 12057 12067 12077 1207.57 12087 1208.57 12107 12117 12137 12147 12157 12167 1240, and 1248; Prison Rape Elimination Act of 2003 (42 USC 15601); 28 CFR 115.327 115.357 115.817 115.827 115.83; 45 CFR 164.512; Estelle v. Gamble, 420 U.S. 97 (1976); and Hall v. County of Fresno, E.D. Cal. No: 1:11-CV-02047-LJO-BAM (2015). PURPOSE: The provision of adequate health services in a custody setting is a constitutional right afforded to all inmates. The purpose of this policy is to establish guidelines for the adequate medical health care of inmates housed in the Fresno County Sheriff's Office Detention Facilities. POLICY: It is the policy of the Fresno County Sheriffs Office Jail Division to provide necessary, adequate, and timely medical care to all inmates in custody in a manner consistent with all applicable standards of medical care and in accordance with applicable federal, state, and local laws, codes, regulations, directives, and court orders. The Fresno Sheriff's Office is responsible for the on-site and off-site medical health care services for the inmates at the Fresno County Jail. With the approval of the Fresno County Board of Supervisors, such services may be contracted to a private service provider. The service provider shall operate a medical health care program that meets the local community standards of care and supply all services under the terms of the negotiated contract. Page 1 of 25 FRESNO COUNTY SHERIFF'S OFFICE JAIL DIVISION POLICIES AND PROCEDURES TITLE: MEDICAL HEALTH SERVICES NO: G-120 FILE: MEDICAL PROCEDURES: I. MEDICAL HEALTH STAFF A. Health care staff shall be appropriately credentialed according to the licensure, certification, and registration requirements for the state of California. B. The Jail Medical Director shall be Board Certified or Board eligible in Internal Medicine or Family Practice. C. Health care performed by personnel other than a physician shall be performed pursuant to written protocol or order of the responsible health care staff. Assessment and treatment shall be performed by either licensed health personnel or by persons operating under the authority and/or direction of licensed health personnel. D. Medical health staff will coordinate with mental health staff to ensure that health care is appropriately integrated, and that medical and mental health needs are met for all inmates. E. Medical staff will coordinate with correctional staff so that inmates receive safe and timely access to care and medications. II. HEALTH CARE RESPONSIBILITIES The medical services provider/contractor has the responsibility for the overall administration of the medical clinics in the Jail facilities. A. Specific medical services provided on-site at each facility shall include, but may not be limited to: 1. Health care intake screening 2. Health appraisals/behavioral health assessments 3. Sick call 4. On-call emergency coverage 24/7 5. Psychiatric crisis intervention 6. Physician services Page 2 of 25 FRESNO COUNTY SHERIFF'S OFFICE JAIL DIVISION POLICIES AND PROCEDURES TITLE: MEDICAL HEALTH SERVICES NO: G-120 FILE: MEDICAL 7. Pharmaceuticals (and pharmacist consulting services) 8. Pharmaceutical distribution/monitoring 9. Chronic conditions care (i.e., chronic disease management program) 10. Infectious diseases prevention (i.e., Infection Prevention Plan) 11. X-ray and EKG services 12. Laboratory services 13. Communicable disease control 14. First aid and emergency response / minor trauma capabilities (e.g., sutures) 15. Outpatient Housing Unit 16. Dental services 17. Medical and dental prosthetic devices and durable medical equipment 18. Optometric and optician services (including glasses) 19. Prenatal, pregnancy, postpartum, counseling, and obstetrical care 20. Health education 21. Physical therapy 22. Suicide prevention program 23. Chemical dependency/ substance abuse / detoxification 24. Medical diets 25. Nursing Encounter Protocol/Tools that are appropriate to the level of skill and preparation of the nursing personnel who will carry them out and comply with the relevant state practice acts. 26. Health care maintenance for inmates undergoing prolonged incarceration B. Complete and accurate medical health, behavioral health, optometry and dental records shall be maintained. C. The County will provide an adequate number of clinic examination rooms to deliver adequate health care. Page 3 of 25 FRESNO COUNTY SHERIFF'S OFFICE JAIL DIVISION POLICIES AND PROCEDURES TITLE: MEDICAL HEALTH SERVICES NO: G-120 FILE: MEDICAL D. Medical equipment and medical exam rooms/clinics are to be maintained in a hygienic and adequate manner. Clinic rooms shall have standardized equipment and par levels of supplies in a standardized presentation. E. The quality and adequacy of health care and pharmaceutical services are to be audited and assessed annually. A written report on health care and pharmaceutical services delivered shall be provided to the Sheriff on an annual basis. F. With the exception of elective abortions, the medical services provider shall not be responsible for elective medical care. Elective medical care is defined as medical care, which, if not provided would not (in the reasonable medical opinion of the contractor's medical director) cause the inmate's health to deteriorate or cause definite harm to the inmate's well-being. Examples of such elective medical care includes: breast reduction, gastric bypass, or facelift surgery. III. INITIAL HEALTH CARE SCREENING FOR ARRESTEES A. All arrestees shall be screened by the Booking Nurse (i.e., registered nurse or nurse practitioner) prior to their acceptance for booking. B. All inmates shall receive a thorough nursing intake screening to include, but not be limited to, medical and mental health problems, developmental disabilities, tuberculosis and other communicable diseases, vital signs, capillary blood glucose testing for persons with diabetes, peak expiratory flow rate for persons with asthma, and oxygen saturation for persons with emphysema. 1. The Intake/Receiving Screening Form includes questions on the history of HIV/AIDS, tuberculosis, kidney disease, legal and illegal drug use (e.g., type, time of last use, and quantities), as well as questions regarding history of mental health problems or treatment, hospitalizations, and current or previous thoughts of self-harm. 2. Tuberculosis screening shall include the following: a. Screenings provided in accord with Centers for Disease Control and Prevention guidelines. Page 4 of 25 FRESNO COUNTY SHERIFF'S OFFICE JAIL DIVISION POLICIES AND PROCEDURES TITLE: MEDICAL HEALTH SERVICES NO: G-120 FILE: MEDICAL b. Inmates shall receive either Mantoux skin testing or Interferon- gamma release assays (IGRAs) within five (5) days of intake. c. Inmates who present with an initial positive tuberculosis screening result shall receive a chest radiograph. 3. Inmates identified as having developmental disabilities, mental retardation, and/or learning disabilities will be referred to mental health staff for assessment. Mental health staff will be responsible to contact the Central Valley Regional Center for the purpose of diagnosis and/or treatment within twenty-four (24) hours of such determination, excluding holidays and weekends. 4. Inmates displaying signs of suicide risk at intake screening will be referred for mental health evaluation. C. The Booking Nurse may recommend that any arrestee who is in need of obvious acute medical attention not be accepted into custody. (The screening shall be fully completed, so that all detectable medical needs can be addressed prior to acceptance.) 1. The recommendation will be reviewed and approved by the Watch Commander. 2. The arresting/transporting officer shall be responsible to transport the arrestee to Community Regional Medical Center (CRMC) or other medical facility so that his or her medical needs can be addressed prior to booking into the Jail. The transporting officer will be required to provide a copy of the CRMC medical clearance paperwork, upon return. 3. If the Booking Nurse again finds the arrestee not fit for confinement, the nurse shall consult with the on-duty (or on-call) physician (or psychiatrist, as applicable). 4. If the physician/psychiatrist concurs with the Booking Nurse and rejects the arrestee, the Watch Commander will "override" the decision and accept the arrestee into custody. 5. The Watch Commander will coordinate with Medical/Mental Health to transport the inmate back to CRMC via the site Emergency Room transfer process to address the inmate's medical care and fitness for confinement needs. Page 5 of 25 FRESNO COUNTY SHERIFF'S OFFICE JAIL DIVISION POLICIES AND PROCEDURES TITLE: MEDICAL HEALTH SERVICES NO: G-120 FILE: MEDICAL 6. The contracted medical provider will be responsible to coordinate with CRMC regarding subsequent care of the inmate, to ensure their fitness for confinement upon discharge from the Emergency Room, as necessary. [See flowchart on Addendum A.] D. If the arrestee is found fit for incarceration but requires further medical attention, he/she shall be treated by the jail medical staff. If the arrestee requires psychiatric treatment, he/she shall be provided a mental health evaluation by health services staff, who shall consult with Population Management staff regarding appropriate housing for the inmate. IV. SPECIAL MENTAL DISORDER ASSESSMENT An additional mental health screening will be performed on women who have given birth within the past year and are charged with murder or attempted murder of their infants. Such screening will be performed at intake and, if the assessment indicates postpartum psychosis, a referral for further evaluation will be made. V. ACCESS TO MEDICAL TREATMENT A. Access to medical care may be accomplished through various methods- 1. Licensed health care initiated appointments. Access to care includes planned health care encounters, scheduled and initiated as part of ongoing treatment planning and care management to address health care needs. 2. Inmate request for services. Access to care also includes episodic encounters requested by inmates either through written request, or verbal report/demonstration of urgent/emergent health care needs. 3. Emergency care. Inmates with life-threatening medical symptoms shall receive immediate medical attention. 4. Urgent care. Inmates with urgent medical symptoms will be scheduled for a same day face-to-face visit with appropriate health care staff as indicated by symptoms. Page 6 of 25 FRESNO COUNTY SHERIFF'S OFFICE JAIL DIVISION POLICIES AND PROCEDURES TITLE: MEDICAL HEALTH SERVICES NO: G-120 FILE: MEDICAL B. Medical service requests for non-emergent illnesses and injuries are to be made in writing, utilizing a Health Services Request Form. Exceptions will be made when the request involves the need for immediate medical attention, or involves the personal safety of staff, inmates, or the public. 1. Supplies of blank request forms should be available inside the housing unit, or will be provided by correctional staff, upon request. Only health care staff shall collect completed health service request forms. 2. Inmates are to place the completed forms in the locked boxes located inside each pod. Health Service Request Forms will be collected by health care staff during medication passes at least twice a day. Health care staff will pick up completed health service request forms directly from inmates in lockdown units during medication passes twice a day. 3. Any inmate requesting medical attention shall be given such attention. C. Any inmate who attempts to submit an emergency medical request to staff shall be interviewed in person by the floor officer (or present medical staff) to determine the seriousness, nature, and validity of the request. 1. In the event the request for emergency medical treatment appears to be valid, or the floor officer cannot determine whether the request constitutes an emergency, the on-duty Charge Nurse (or present medical staff) shall be immediately notified. 2. In the event the request is clearly not an emergency (e.g., if an inmate attempts to expedite a routine request by misrepresenting it as an emergency), the request form shall be submitted via normal channels to medical staff. D. The Charge Nurse shall review and triage each request prior to placement of the inmate's name on the sick call list and/or scheduling an appointment. 1. Completed health service request forms will be triaged at least twice a day to determine the urgency based on the complaint. Page 7 of 25 FRESNO COUNTY SHERIFF'S OFFICE JAIL DIVISION POLICIES AND PROCEDURES TITLE: MEDICAL HEALTH SERVICES NO: G-120 FILE: MEDICAL 2. All inmates with emergent issues shall be seen immediately, urgent issues within 24 hours, and routine requests shall be scheduled within 72 hours. 3. All inmates experiencing symptoms shall have vital signs taken during their face-to-face evaluations. 4. Nurses shall review the charts of the inmates being evaluated during all triages. E. When a nurse determines clinician follow-up is necessary for diagnosis and treatment of an inmate's condition, the inmate shall be referred to a physician, physician's assistant, or nurse practitioner for a face-to-face evaluation that takes place immediately for emergent concerns, within 24 hours for urgent concerns, and within 14 days for non-emergent or non-urgent concerns. F. Medical problems which are cosmetic, elective or long standing, and are not a threat to the inmate's overall health condition may not be treated. VI. SICK CALL A. Sick call is conducted on a daily basis by qualified medical staff. B. All nursing sick call encounters shall occur in a room with an examination table, sink, proper lighting, proper equipment, and with a medical record. C. Sick call is conducted in as much privacy as security concerns will allow. (Refer to section XV/Privacy.) D. A confidential and accurate medical record shall be kept on each inmate assessed during sick call. Inmate medical records shall be kept separate from all other Jail Division and Sheriffs Office records. E. Inmates scheduled for sick call and a court appearance on the same day will be sent to the Main Jail 2nd floor to be seen by medical staff before court, or upon their return from court, whenever possible. Page 8 of 25 FRESNO COUNTY SHERIFF'S OFFICE JAIL DIVISION POLICIES AND PROCEDURES TITLE: MEDICAL HEALTH SERVICES NO: G-120 FILE: MEDICAL F. If an inmate refuses to attend scheduled sick call, an officer assigned to the inmate's housing floor shall cancel the event via Offendertrak (Miscellaneous4Scheduling) and notify medical staff. The inmate should be escorted to the sick call area to refuse in person and to sign a refusal form. If the inmate refuses to sign, the refusal must be witnessed by a second person (usually the floor officer). Medical staff will make an appropriate notation in the inmate's medical chart/record. VI I. HEALTH SERVICES CO-PAYMENT A. Inmates are required to reasonably contribute to the cost of providing their health care. Inmates who have $5 or more in their personal accounts are charged $3 for inmate-initiated medical and dental visits. The co-payment fees are billed to their accounts within thirty (30) days of their medical appointments. If an inmate does not have any money at the time of the appointment, but money is later added to the inmate's account, the co-payment fee will be subtracted from the inmate's account within the 30-day billing cycle period. B. Exceptions to the co-payment are as follows: 1. Services for emergencies or life-threatening conditions (i.e., to prevent death, severe or permanent disability, or to alleviate or lessen objectively apparent and disabling pain). 2. Follow-up or referral visits made by the health services staff. 3. Communicable disease testing or treatment. 4. Any and all services related to pregnancy, including testing. 5. The visit was for the initial booking/screening of the inmate. Vill. OUTPATIENT HOUSING UNIT (OHU) A. Only those inmates who are currently receiving medical care or treatment are to be assigned to the Outpatient Housing Unit (OHU) located on the Main Jail 2nd floor. An exception shall only apply if there is no other housing location where the inmate can be reasonably accommodated. Page 9 of 25 FRESNO COUNTY SHERIFF'S OFFICE JAIL DIVISION POLICIES AND PROCEDURES TITLE: MEDICAL HEALTH SERVICES NO: G-120 FILE: MEDICAL B. The following procedures for inmates housed in the OHU for medical treatment shall be followed- 1. Physicians, nurse practitioners, or physician's assistants shall sign an admittance order for inmates housed in the OHU. This shall be followed by a complete history and exam within 72 hours. 2. Inmates admitted to the OHU shall receive daily checks to include review of symptoms and vital signs by RNs. This shall be documented in the inmate's medical record. 3. Physicians shall examine inmates who have been admitted to the OHU no less frequently than every 14 days. 4. Correctional officers shall notify medical staff immediately if an inmate in the OHU requests medical assistance. IX. SAFETY CELL A. A medical assessment shall be completed prior to the initial placement (absent exigent circumstances) but no later than a maximum of two (2) hours from the time of initial placement. Inmates shall be medically cleared by qualified medical staff for continued retention every four (4) hours thereafter. B. The inmate must be reviewed for continued retention in the safety cell a minimum of every four (4) hours by the on-duty Watch Commander. However, nothing shall preclude correctional, medical, or mental health staff from recommending removal prior to that time. C. Whenever health care staff members wish to recommend either the placement of an inmate into a safety cell, or the removal of an inmate from a safety cell, they shall contact the Watch Commander. The Watch Commander will then approve or refuse safety cell placement or removal and ensure all subsequent custody notifications are made. D. Health care staff shall use Crisis Management Plan forms (commonly referred to as "Restriction forms") to document inmate safety cell placement and removal and to indicate if an inmate requires to be placed on any restrictions (e.g., full restriction, "no sharps" restriction, etc.) following the safety cell removal. Crisis Management Plan forms shall be submitted to the Watch Commander for approval/signature and Page 10 of 25 FRESNO COUNTY SHERIFF'S OFFICE JAIL DIVISION POLICIES AND PROCEDURES TITLE: MEDICAL HEALTH SERVICES NO: G-120 FILE: MEDICAL the signed forms are then delivered (by the mental health staff) to Population Management staff. Upon safety cell removal, Population Management will house the inmate accordingly. E. Inmates will not be housed in safety cells for medical reasons. X. DETOXIFICATION A. Detoxification shall occur only under medical supervision in accordance with local, state, and federal laws. B. Detoxification from alcohol, opiates, hypnotics, other stimulants, and sedative hypnotic drugs shall be conducted under medical supervision when performed at the detention facility. C. Inmates being detoxified shall be monitored by a physician. D. Specific guidelines shall be followed for the treatment and observation of inmates manifesting mild or moderate symptoms of intoxication or withdrawal from alcohol and other drugs. E. Monitoring shall be structured and documented in accordance with the Clinical Institute Withdrawal Assessment (CIWA) or the Clinical Opiate Withdrawal Scale (COWS). F. Inmates arrested for PC647(f) and/or those who appear to be inebriated on alcohol or drugs will be placed into the sobering units on the Main Jail 1st floor. They shall be checked by a member of the medical staff a minimum of once every two (2) hours. If inmates are held in sobering units more than six (6) hours, they shall receive a recorded medical examination by a medical staff member to determine if they have urgent medical problems. G. Inmates experiencing severe, life threatening intoxication (an overdose) or withdrawal shall be transferred under appropriate security conditions to a facility where specialized care is available. Page 11 of 25 FRESNO COUNTY SHERIFF'S OFFICE JAIL DIVISION POLICIES AND PROCEDURES TITLE: MEDICAL HEALTH SERVICES NO: G-120 FILE: MEDICAL XI. PHARMACY AND MEDICATION DISTRIBUTION A. Prescription medications shall only be prescribed by licensed physicians, physician's assistants, or nurse practitioners, within the scope of their licensures. B. Continuity of medications shall occur within twenty-four (24) hours for inmates with chronic illness, unless there are extenuating circumstances that prevent the prescription of such medications, in which case the inmate shall be evaluated by a physician or mid-level practitioner within twenty-four (24) hours to determine an alternative treatment plan. C. Medications shall be distributed to the inmates twice a day, seven (7) days a week at designated times by a medication nurse. Inmates who require more frequent dosing (or alternative medication schedules) will be routed to the Main Jail 2nd floor to receive their medications, or housed in the Outpatient Housing Unit (OHU), as appropriate. [Refer to policy G-105/Medication Pass (FILE: MEDICATION PASS) for procedures.] D. All hygiene practices while dispensing and administering medications shall conform to nationally accepted professional standards. E. All methadone treatment services for inmates shall conform with state and federal regulations. F. Access to pharmacy keys shall be limited only to health care staff assigned to work in the pharmacy and the Director of Nursing. The pharmacy door shall remain closed and locked when pharmacy staff is not present. All medication cabinets shall remain locked at all times. Nursing Supervisors and the Director of Nursing shall monitor control of the pharmacy daily by direct observation. XII. INFORMED CONSENT A. General consent for medical treatment is explained to each inmate at the time of intake in a language understood by them. Page 12 of 25 FRESNO COUNTY SHERIFF'S OFFICE JAIL DIVISION POLICIES AND PROCEDURES TITLE: MEDICAL HEALTH SERVICES NO: G-120 FILE: MEDICAL B. Inmates are provided information necessary to give informed consent before a treatment, examination, or procedure. 1. Written consent is not required in every instance, but information is presented to allow the inmate to make an informed decision. 2. For invasive procedures or any treatment where there is some risk to the inmate, informed consent is documented on a written form containing the signatures of the inmate and health services staff witness. C. Consents for off-site procedures are obtained by and are the responsibility of the off-site provider. D. In the event of an emergency where informed consent cannot be immediately obtained and the inmate's life is in danger, informed consent will be implied and consent to treatment will be obtained from the Watch Commander. XIII. RIGHT TO REFUSE A mentally competent inmate has the constitutional right to refuse medical treatment. A. Health care treatment, including medications, shall not be forced over the objections of a mentally competent inmate, except when permitted by law (e.g., to prevent infectious disease). A court order is required before involuntary medical treatment can be administered to an inmate. B. Inmates who refuse an essential medication will be required to refuse directly to the medication nurse and to sign a refusal form. The inmate should be escorted to the medication pass area to refuse in person. Any deviation will require the refusal form to be signed by both the nurse and the officer. XIV. RESTRAINTS A. Restraints shall not be used for medical purposes or during any medical procedures. Page 13 of 25 FRESNO COUNTY SHERIFF'S OFFICE JAIL DIVISION POLICIES AND PROCEDURES TITLE: MEDICAL HEALTH SERVICES NO: G-120 FILE: MEDICAL B. Medical staff shall not participate in decisions to initiate use of restraints by correctional staff. C. Medical staff shall take all necessary measures to maintain proper peripheral circulation during the use of restraints. D. A registered nurse (RN) or LVN under the supervision of an RN shall document vital signs, mental status, sensation of limbs, and check for injuries incurred during the restraining application within the first hour of placement. Medical staff shall check all restraints to ensure the inmate has proper circulation and document vital signs, mental status, and sensation of limbs at least once every sixty (60) minutes thereafter. XV. PRIVACY A. Health care encounters and discussions, including medical and mental health interviews, examinations, and procedures, are to be conducted in a setting that respects the inmate's privacy. To the degree permitted by security considerations, clinical encounters are conducted in private, without being observed or overheard. 1. Officers are to remain in close proximity only if the urgent or emergent nature of the clinical encounter warrants such, or the inmate poses a probable risk to the safety of the health care provider or others. 2. If the officer is satisfied that the safety of medical staff will not be jeopardized, the officer may permit an inmate who requires escort to be consulted, examined, and/or treated outside of the officer's view. The officer is to remain outside the curtain/door or in close proximity to the place of treatment at all times. 3. Officers shall stand-by anytime an inmate deemed to be high security (i.e., wearing a yellow jumpsuit) is not fully restrained in shackles, handcuffs and/or belly chain. B. Any information overheard during a health encounter shall remain confidential, unless the information is necessary to preserve the health and safety of the inmate, other inmates, volunteers, visitors, contracted employees, or correctional staff. Information provided to correctional Page 14 of 25 FRESNO COUNTY SHERIFF'S OFFICE JAIL DIVISION POLICIES AND PROCEDURES TITLE: MEDICAL HEALTH SERVICES NO: G-120 FILE: MEDICAL staff addresses only the medical needs of the inmate as it relates to housing, program placement, security and transport. C. If the exam requires the inmate to disrobe and/or expose the buttocks or genitalia (or breasts, if female), and the health provider is the opposite sex of the inmate, a witness of the same sex shall be present. The witness may be another health care staff member. XVI. INMATE INJURIES AND EMERGENCY MEDICAL CARE A. When an officer becomes aware that an inmate has sustained an injury, the officer's first concern should be to secure the scene and obtain treatment for the inmate's injuries. B. Verbal inmate reports involving a medical emergency shall be immediately investigated by staff for appropriate action. C. In the event the verbal request for medical treatment appears to be valid, medical staff shall be immediately notified. If the request does not appear to be an emergency, the inmate will be advised to submit a Health Service Request Form. Written inmate requests will be reviewed by the Charge Nurse. D. In the event of any serious emergency illness or injury, discovering correctional staff should call (via radio) for a medical emergency, and depending on the severity, may request an ambulance to respond. Responding medical staff will evaluate the situation and may also recommend (to the Watch Commander) that the inmate be transported to CRMC for further treatment. E. An incident report shall be written by the correctional officer in ALL cases where an inmate is provided with immediate medical attention/sent to Main Jail 2nd floor unless the medical attention is provided during inmate's scheduled sick call. XVII. PRIVATE MEDICAL TREATMENT A. When an inmate desires to be attended by his/her private physician and/or at a hospital other than one normally utilized by the Fresno County Sheriff's Office, he/she will need to obtain a court order. Page 15 of 25 FRESNO COUNTY SHERIFF'S OFFICE JAIL DIVISION POLICIES AND PROCEDURES TITLE: MEDICAL HEALTH SERVICES NO: G-120 FILE: MEDICAL B. In the event an inmate elects to decline treatment by medical staff and is willing to provide medical treatment at his/her own expense, the inmate may be transported from the jail to a privately owned and operated medical facility or hospital that is located in the County and approved by a judge of the Superior Court for such treatment. C. The inmate shall be liable for the costs incurred by the County in providing the necessary transportation and security of the inmate only to the extent that such costs exceed the costs which would have been incurred by the County in providing such custody and security if it had provided treatment for the inmate. D. The inmate shall at all times remain in the location specified by the court and will not be permitted to be housed, treated, or detained at any facility other than that designated. E. The private physician shall coordinate with the Watch Commander when an inmate is to be moved from the jail to any medical facility. F. The inmate's private physician may choose to examine and treat the inmate at the jail. Appointment time should be arranged with a Charge Nurse. The inmate and/or his/her family shall be responsible for all charges incurred. The physician shall be required to provide proper photo identification before being permitted to enter the jail. XVIII. INDIVIDUALIZED TREATMENT PLANS A. For each inmate treated for health conditions for which additional treatment, special accommodations and/or a schedule of follow-up care is/are needed during the period of incarceration, medical staff shall develop a treatment plan. Custody staff shall be informed of the treatment plan when necessary, to ensure coordination and cooperation in the ongoing care of the inmate. B. Treatment plans may include medical, dental, or mental health referrals, initiation of treatment, and any recommendations regarding housing, work, or program participation. 1. Development and implementation of a treatment plan shall be done within the scope of state licensure. Page 16 of 25 FRESNO COUNTY SHERIFF'S OFFICE JAIL DIVISION POLICIES AND PROCEDURES TITLE: MEDICAL HEALTH SERVICES NO: G-120 FILE: MEDICAL 2. Only practitioners licensed to diagnose may diagnose. C. The minimum time period between intake screening and the first history and physical examination shall be specified and based on acuity (not to exceed 14 days for all inmates). D. The minimum time period between physician evaluations shall be specified based on acuity. XIX. SUICIDE PREVENTION A. All arrestees and inmates are medically screened at the time of intake by the Booking Nurse for possible signs and symptoms of suicidal behavior. B. Inmates displaying signs of suicide risk are referred to a mental health clinician for an evaluation. C. Mental health clinicians are responsible to complete a comprehensive suicide risk assessment form for all inmates who display signs of suicide risk to determine if the inmate presents a low, moderate, or high risk of suicide. (Refer also to policy D-260/Suicide Prevention [FILE: SUICIDE].) XX. SERIOUS MENTAL ILLNESS Serious mental illness (SMI) is defined as any mental disorder that results in comparatively severe impairment in major areas of functioning, such as cognitive capabilities or disruption in normal developmental processes and requires significant mental health treatment. The term is synonymous with "severe mental illness." A. Mental health staff shall create an "SMI" Alert in Offendertrak for all SMI inmates. B. SMI inmates shall receive an evaluation from health care staff (i.e., an LMFT or RN) prior to their release to the community. The LMFT/RN will review the discharge plan with the inmate and ensure that any medication order is called in for the inmate by the appropriate personnel. (Refer also to policy G-130/Mental Health Services [FILE: MENTAL].) Page 17 of 25 FRESNO COUNTY SHERIFF'S OFFICE JAIL DIVISION POLICIES AND PROCEDURES TITLE: MEDICAL HEALTH SERVICES NO: G-120 FILE: MEDICAL XXI. LOCKDOWN INMATES Medical staff shall complete health checks on all inmates in any locked down administrative segregation or disciplinary housing unit in the Jail system at least three (3) times a week and document the checks to include any verbal exchange allowing inmates to report any health or mental health needs or concerns. XXII. SEXUAL ABUSE VICTIMS A. If an inmate indicates during intake screening that they have experienced prior sexual victimization, whether it occurred in an institutional setting or in the community, the inmate shall be offered a follow-up meeting with a medical or mental health practitioner to take place within fourteen (14) days of the intake screening. B. If an inmate is a victim of sexual assault that occurs while in-custody, the inmate/victim must be provided with timely, unimpeded access to emergency medical treatment and crisis intervention services. C. Medical staff shall assess the inmate's acute medical needs. 1. If any life-threatening injuries exist, response may include the need to request emergency transportation (i.e., ambulance). When the call is made to request an ambulance, the dispatcher should be informed that the injured inmate is the victim of sexual assault. 2. Medical staff shall be cognizant to maintain intact any physical evidence which may be found on the victim's person or clothing. 3. Inmates shall be offered timely information about and timely access to emergency contraception and sexually transmitted infections prophylaxis, in accordance with professionally accepted standards of care, where medically appropriate. D. The ongoing evaluation and treatment of such victims shall include, as appropriate, follow-up services, treatment plans, and when necessary, referrals for continued care. Page 18 of 25 FRESNO COUNTY SHERIFF'S OFFICE JAIL DIVISION POLICIES AND PROCEDURES TITLE: MEDICAL HEALTH SERVICES NO: G-120 FILE: MEDICAL E. If the alleged sexual assault is reported or discovered more than seventy-two (72) hours after the incident, a medical opinion shall be obtained to determine whether the victim is to be taken for a forensic examination. (Refer also to D-360/Sexual Misconduct and Abuse [FILE: SEXUAL ABUSE].) XXIII. MEDICAL DIETS A. Medical diets are special diets ordered for temporary or permanent health conditions that restrict the types, preparation, and/or amounts of food. Medical diets do not include special diets ordered for religious or security reasons. Medically necessary diets shall be made available to inmates. B. The medical diets shall be planned, prepared, and served with consultation from a registered dietitian. The medical diet manual, which includes sample menus of medical diets, shall be available in both the medical unit and the food service office for reference and information. C. A registered dietitian shall review, and the responsible physician shall approve, the diet manual on an annual basis. XXIV. CHRONIC CONDITIONS CARE Medical staff is responsible for consistency of care for inmates with chronic conditions (e.g., diabetes, epilepsy, asthma, etc.). A. Health care services shall include a chronic disease management program. B. The chronic disease management program shall conform to contemporary standards of care such as the National Health Lung and Blood Institute; asthma, hypertension, and lipid guidelines; and American Diabetes Association guidelines. C. All inmates with chronic illness shall be tracked on a chronic illness roster by medical staff. D. The chronic disease management program shall measure the number of inmates with chronic illness who receive their medication within a day of incarceration. Page 19 of 25 FRESNO COUNTY SHERIFF'S OFFICE JAIL DIVISION POLICIES AND PROCEDURES TITLE: MEDICAL HEALTH SERVICES NO: G-120 FILE: MEDICAL XXV. INFECTIOUS DISEASES PREVENTION Medical staff is responsible for consistency of care and prevention for inmates with infectious diseases. A. The Infection Prevention Plan shall include procedures for identification, treatment, isolation, surveillance, immunization (when applicable), prevention, education, and follow-up related to infectious diseases. B. All tuberculosis screening and management shall be conducted in accordance with the American Correctional Association (ACA) and the National Commission on Correctional Health Care (NCCHC), "Standards for Health Services," as endorsed under recommendations of the Center for Disease Control (CDC) guidelines. XXVI. DENTAL CARE Dental staff is responsible to provide timely access to adequate dental care. A. Routine dental services are available Monday through Friday, and some Saturdays. Emergency care is available on a 24-hour, seven (7) days per week basis. B. Emergency and medically required dental care shall be provided to each inmate, upon request, under the direction and supervision of a dentist licensed in the state. C. In order to receive dental care, inmates must complete a Health Services Request Form. D. A qualified or appropriately trained clinician shall triage dental care requests to identify emergent or urgent issues that require treatment of pain or infection. XXVII. VISION CARE Health staff is responsible to provide timely access to adequate vision care. A. All inmates are screened for vision problems at the time of the initial health assessment, and may again be screened at the time of the periodic health assessment. Inmates who are: Page 20 of 25 FRESNO COUNTY SHERIFF'S OFFICE JAIL DIVISION POLICIES AND PROCEDURES TITLE: MEDICAL HEALTH SERVICES NO: G-120 FILE: MEDICAL 1. Aged 65 and older will be referred to the optometry clinic annually. 2. Aged 40-64 will be referred to the optometry clinic every 2-4 years. 3. Aged 18-39 will be referred to the optometry clinic as clinically indicated. 4. Diabetic will receive a dilated exam annually. 5. Designated by the optometrist as having a higher risk for glaucoma will receive a dilated exam every two (2) years. B. Inmates who complain that they are having difficulty with visual acuity will be advised to submit a Health Services Request Form to obtain a Snellen vision screening. Inmates may request vision screening annually. XXVIII. CARE OF PREGNANT INMATES A. Upon identification of a pregnant inmate by pregnancy test, the inmate will be seen by medical staff within twenty-four (24) to forty-eight (48) hours of arrival, or within seventy-two (72) hours if incarcerated over the weekend. A list of all pregnant inmates and their disposition, including their release, will be maintained by medical staff. 1. Upon confirmation of an inmate's pregnancy, the inmate must be advised orally or in writing of the standards and policies governing pregnant inmates. The Pregnancy Services pamphlet contains the required information and should be given to all pregnant inmates. 2. Pregnant inmates with a recent history of opiate, methadone, buprenorphine, or similar drugs will be reported to the physician on site or the on-call physician is called if no physician is on-site for appropriate treatment which may include referral to the BAART Opioid Treatment Program (OTP). B. Pregnant inmates will receive timely and appropriate prenatal care, postpartum care, counseling, and specialized obstetrical services when indicated, to include: 1. Initial and regular prenatal exams Page 21 of 25 FRESNO COUNTY SHERIFF'S OFFICE JAIL DIVISION POLICIES AND PROCEDURES TITLE: MEDICAL HEALTH SERVICES NO: G-120 FILE: MEDICAL 2. Laboratory and diagnostic testing, including syphilis testing 3. Immunizations, including TDAP (Tetanus, Diphtheria, and Pertussis) 4. Management of high risk pregnancies 5. Management of obstetrical emergencies 6. Drug and alcohol detoxification 7. Opioid Treatment Program (OTP) 8. Prenatal diet, vitamins, and exercise 9. Abortion 10. Postnatal care, including accommodation for lactating women 11. Monitoring for postpartum depression 12. Initiation of contraception as needed 13. Perinatal education C. Pregnant inmates will be provided with educational classes/pregnancy management services that include: self-care, nutrition, parenting skills, medications, pregnancy testing, immunizations, routine and high-risk prenatal care, labor and delivery, postnatal care, identification of postpartum depression, and counseling. D. Pregnant inmates shall be provided a balanced, nutritious diet approved by a doctor. E. Pregnant inmates will be transported to Community Regional Medical Center (CRMC) for labor and delivery whenever possible. Pregnant inmates who require transport due to imminent delivery or other emergent condition will be taken to the nearest emergency department with obstetrical services. (Refer also to D-230/Use of Restraint Devices [FILE: RESTRAINTS] for the use of restraints on pregnant inmates.) F. Sterilization for the purpose of birth control, including, but not limited to, during labor and delivery is prohibited. Page 22 of 25 FRESNO COUNTY SHERIFF'S OFFICE JAIL DIVISION POLICIES AND PROCEDURES TITLE: MEDICAL HEALTH SERVICES NO: G-120 FILE: MEDICAL XXIX. SPECIALTY CARE A. Specialty care appointments (to include pulmonology and ophthalmology) shall be tracked in a log that identifies the referral date, the date the referral was sent to the clinic, the date the appointment was confirmed, and, if the appointment was rescheduled or canceled, the reason it was rescheduled or canceled. B. Inmates whose specialty appointment exceeds three (3) months should be examined by a physician, physician's assistant, or nurse practitioner monthly and evaluated to determine if urgent evaluation is indicated. XXX. HEALTH CARE RECORDS A. Medical staff shall maintain accurate records on each individual inmate, in compliance with state statute and IMQ/CMA accreditation guidelines. Complete and dated health records shall include, but not be limited to: 1. Receiving screening form/history. 2. Health evaluation reports. 3. Complaints of illness or injury. 4. Names of personnel who treat, prescribe, and/or administer/deliver prescription medication. 5. Location where treated. 6. Medication records. 7. Diagnostic studies. 8. Individual treatment plans. 9. Records of services provided by the various mental health staff members in sufficient detail to make possible an evaluation of services, and contain all the data necessary in reporting to the state, including records of inmate interviews and progress notes. B. Health care record and health information, both oral and documented, is confidential protected health information. The minimum necessary health information is to be disclosed to health care staff providing health care or to jail authorities when necessary for the protection of the Page 23 of 25 FRESNO COUNTY SHERIFF'S OFFICE JAIL DIVISION POLICIES AND PROCEDURES TITLE: MEDICAL HEALTH SERVICES NO: G-120 FILE: MEDICAL welfare of the inmate or others, management of the jail, or maintenance of jail security and order. C. All health care records must comply with state and federal regulations pertaining to access, disclosure, and/or use of health information. D. Each inmate's health care record (paper or electronic) shall be maintained separately from and in no way be part of the inmate's other jail records. E. Correctional staff shall not have access to the completed intake screening form. XXXI. TRAINING A. All health care staff shall receive structured orientation and training specific to providing health services in a correctional setting. B. All health care staff shall receive training regarding suicide prevention during new employee orientation, and updated training annually. The training shall be provided by a licensed clinician having expertise in correctional suicide prevention and the use of a suicide risk assessment form. C. All full- and part-time medical care practitioners shall be trained in how to detect and assess signs, preserve physical evidence, respond effectively, and report allegations or suspicions of sexual abuse and sexual harassment. D. Mock fire drills are conducted by the Jail Division at least twice a year to ensure all staff members are familiar with safety procedures and evacuation methods. Health care staff shall participate in the fire drills at least once each year. XXXII. STAFF ACCESS TO MEDICAL SERVICES A. All jail medical areas are off limits to jail personnel with the exception of jail staff members specifically assigned to work in that area. B. Medical staff shall not provide medical services, including drugs or any other medication to employees, except in emergency situations. Page 24 of 25 FRESNO COUNTY SHERIFF'S OFFICE JAIL DIVISION POLICIES AND PROCEDURES TITLE: MEDICAL HEALTH SERVICES NO: G-120 FILE: MEDICAL C. In the event of an emergency, the first concern shall be to have the jail staff member evaluated and first aid provided, if indicated. Subsequently, the following reports shall be completed and forwarded to the Watch Commander: 1. An incident report detailing the circumstances of the illness/injury. 2. A Supervisor's Investigation Report (SIR). D. A Worker's Compensation Package shall be provided to the staff member and a receipt for same shall be signed by the injured employee and forwarded to the Watch Commander. Page 25 of 25