FILED 05/03/2018 1:41 PM ARCHIVES DIVISION SECRETARY OF STATE & LEGISLATIVE COUNSEL

Transcription

1 OFFICE OF THE SECRETARY OF STATE DENNIS RICHARDSON SECRETARY OF STATE LESLIE CUMMINGS DEPUTY SECRETARY OF STATE PERMANENT ADMINISTRATIVE ORDER DOC CHAPTER 291 DEPARTMENT OF CORRECTIONS ARCHIVES DIVISION MARY BETH HERKERT DIRECTOR 800 SUMMER STREET NE SALEM, OR FILED 05/03/2018 1:41 PM ARCHIVES DIVISION SECRETARY OF STATE & LEGISLATIVE COUNSEL FILING CAPTION: Health Services for Inmates in DOC facilities. EFFECTIVE DATE: 05/03/2018 AGENCY APPROVED DATE: 04/27/2018 CONTACT: Michelle Mooney Center St NE Salem,OR Filed By: Michelle Mooney Rules Coordinator RULES: , , , , , , , AMEND: REPEAL: Temporary from DOC RULE TITLE: Authority, Purpose, and Policy NOTICE FILED DATE: 01/22/2018 RULE SUMMARY: Amends to clarify Department policy regarding the provisions of health services. RULE TEXT: (1) Authority: The authority for this rule is granted to the Director of the Department of Corrections in accordance with ORS , , and (2) Purpose: The purpose of this rule is to: (a) Specify the level of healthcare services to be provided to inmates under the custody of the Department of Corrections; and (b) Establish department policies and procedures for reimbursement to those hospitals and community based healthcare professionals providing inpatient and outpatient services to inmates. (3) Policy: It is the policy of the Department of Corrections to: (a) Provide professional, quality, essential, and important healthcare services that support the health status of inmates during incarceration, including end of life care. (b) Deliver constitutionally mandated healthcare using an efficient managed care system in support of the mission of the department. (c) Ensure there is an organized system in place to provide inmates with access to care to meet their serious medical, dental, and mental health needs. (d) Conduct procedures in a clinically appropriate manner using appropriately credentialed personnel in an appropriate setting consistent with the standards for similar care provided in the community. (e) Death with Dignity Act: It is the policy of the department not to participate in or allow other health care providers to Page 1 of 21

2 participate on its premises in the Death with Dignity Act (ORS to ). Consistent with this policy, inmates will not be permitted to access end of life counseling or drugs under the DWDA, However, the department will continue to offer inmates medically appropriate end of life care, including counseling, hospice and palliative care, through Health Services. STATUTORY/OTHER AUTHORITY: , , , STATUTES/OTHER IMPLEMENTED: , , , Page 2 of 21

3 AMEND: REPEAL: Temporary from DOC RULE TITLE: Definitions NOTICE FILED DATE: 01/22/2018 RULE SUMMARY: Amends OAR to update definitions and add a new definition for the department's Health Services eyeglasses review committee. RULE TEXT: (1) Department of Corrections Facility: Any institution, facility or staff office, including the grounds, operated by the Department of Corrections. (2) Employee: Any person employed full-time, part-time, or under temporary appointment by the Department of Corrections; any person employed under contractual arrangement to provide services to the department; any person employed by private or public sector agencies who is serving under department-sanctioned special assignment to provide services or support to department programs within any Department of Corrections facility. (3) Functional Unit: Any organizational component within the Department of Corrections responsible for the delivery of services or coordination of programs. (4) Functional Unit Manager: Any person within the Department of Corrections who reports to the Director, Deputy Director, an Assistant Director or an administrator and has responsibility for the delivery of services or coordination of programs. (5) Healthcare Provider: Any professional who is licensed or certified to provide health care services, including physicians and hospitals (and the various entities/forms in which they do business), and public, quasi-public and private organizations and entities that contract with direct service providers to furnish health care services, such as insurance companies and managed care organizations. (6) Health Services Eyeglasses Review Committee: A committee normally of the local management group, Medical Services manager or designee, or a combination management representatives and the individual involved in the eyeglass program at the institution. (7) Inmate: Any person under the supervision of Department of Corrections who is not on parole, probation, or postprison supervision status. (8) Treating Practitioner: Any Health Services employee who by licensure is authorized to prescribe treatment, including but not limited to, physicians, dentists, nurse practitioners, optometrists and physician assistants. STATUTORY/OTHER AUTHORITY: , , , STATUTES/OTHER IMPLEMENTED: , , , Page 3 of 21

4 AMEND: REPEAL: Temporary from DOC RULE TITLE: Delivery of Inmate Healthcare NOTICE FILED DATE: 01/22/2018 RULE SUMMARY: Amends OAR to update and readopt OAR (2), which had previously been declared invalid in Smith v. Department of Corrections, 276 Or App 862 (2016). Specifies that the Health Services clinical director (medical director) is responsible for oversight of clinical health care providers, decisions requiring medical judgment and directly affecting outcomes of clinical practice, and the appointment of chief medical officers to provide oversight of each Department correctional institution. RULE TEXT: (1) The Health Services administrator is responsible for directing inmate healthcare services in the Department of Corrections. These activities include: (a) Developing standards for the organization, coordination and delivery of inmate healthcare; (b) Ensuring the organization and delivery of inmate healthcare meets established standards; and (c) Ensuring the operation of all areas of inmate healthcare, including medical, dental, mental health care and pharmacy services comply with appropriate professional standards, statutory requirements, and administrative rules and policies of the department. (2) The Health Services clinical medical director is responsible for professional oversight of clinical healthcare providers. (a) The Health Services clinical medical director has authority for all decisions requiring medical judgment and directly affecting outcomes of clinical practice. (b) The Health Services clinical medical director shall appoint a chief medical officer to provide oversight for professional clinical services to inmates for each Department of Corrections facility. (3) The Pharmacy and Stores administrator is responsible for the overall organization and delivery of Pharmacy services. (4) The Behavioral Health Services administrator is responsible for the overall organization and delivery of mental health services to inmates. (5) The Chief Psychiatrist shall have clinical oversight of the professional services of behavioral health prescribers. (6) The administrator for Clinical Operations is responsible for the overall organization and delivery of institutional clinical care. (7) The administrator for Business Operations is responsible for the overall organization and coordination of business functions, including fiscal management and organizational development. (8) The Dental Program director, a licensed dentist, is responsible for the overall organization, delivery, and professional oversight of dental services. (9) Health Services administration shall appoint a Medical Services manager to organize and coordinate delivery of healthcare services to inmates for each Department of Corrections facility. (10) Inmates are prohibited from performing any healthcare duties reserved for licensed or certified health professionals. Inmates may be assigned to assist other inmates with activities of daily living as are commonly done in the community by family or friends. STATUTORY/OTHER AUTHORITY: , , , STATUTES/OTHER IMPLEMENTED: , , , Page 4 of 21

5 AMEND: REPEAL: Temporary from DOC RULE TITLE: Health Evaluation and Screening NOTICE FILED DATE: 01/22/2018 RULE SUMMARY: Amends OAR to add provisions concerning dental screenings and examinations after admission to Department correctional institutions RULE TEXT: (1) During the admission process each inmate shall receive a baseline medical, dental, and mental health evaluation. (a) The medical evaluation shall consist of a physical examination and medical history including a review of available information and verification of any medication, care, or treatment requirements. The evaluation should occur within seven days of admission. (b) A dental screening will be performed by authorized Health Services staff within seven days of admission that includes visual examination of the teeth and gums with any obvious abnormalities or inmate complaints noted. (A) A baseline dental intake examination shall be completed by a fully licensed dentist within 30 days of admission to include review of the dental and medical history, charting of the teeth including identification of decayed, missing, or filled teeth, examination of the oral cavity, diagnostic X-rays (as indicated), oral hygiene instructions, access to care instructions, inquiry regarding emergent or urgent dental problems, and documentation of procedures performed in the dental record by the dentist. If there is documented evidence of an examination of the inmate's dental condition within the previous year, a dental exam is not required unless determined to be clinically necessary by the treating dentist. (B) Access-to-care instructions are given such that inmates are aware of how to follow up with dental care at the receiving institution. Formal treatment plans are not provided as part of the intake examination. They are performed at the receiving institution per inmate request. (c) The mental health evaluation will include a screening for the presence of mental illness and suicide history. Inmates who have a history of mental illness, or suicide attempts, or who report current suicidal ideations will be referred for further evaluation by a mental health treatment provider. Inmates with mental illness will be housed in a facility with services appropriate for their treatment needs. (d) A clinical record will be initiated at the time of initial admission into the Department of Corrections. (e) If the inmate has a documented baseline evaluation from the department within the previous 90 days, the prior evaluation and health record is reviewed and updated as clinically necessary. (f) Inmates will be informed of relevant recommendations based on the baseline health evaluations and will be provided with self-care instruction. (2) Health Screening at Transfer: (a) A brief health screening shall be completed on all inmates received on intra-department transfers by Health Services staff at the receiving facility. This shall include review of medical, dental, and mental health records information transferred with the inmate and verification of any care or treatment requirements prearranged by the sending facility Medical Services manager. (b) This information will be used to determine disposition of the inmate. STATUTORY/OTHER AUTHORITY: , , , STATUTES/OTHER IMPLEMENTED: , , , Page 5 of 21

6 AMEND: REPEAL: Temporary from DOC RULE TITLE: Healthcare and Treatment NOTICE FILED DATE: 01/22/2018 RULE SUMMARY: Amends OAR to clarify health care and treatment procedures for inmates, and clinical review procedures. RULE TEXT: (1) Health care procedures will be conducted in a clinically appropriate manner by appropriately credentialed personnel in an appropriate setting. (2) Health care and treatment is authorized and provided according to priorities established by the Health Services clinical medical director and is subject to peer review. Medical care and treatment is generally prioritized into four levels. (3) Level 1 Care and Treatment: (a) Level 1 care and treatment (or medically mandatory care and treatment) is defined as care and treatment that is essential to life and health, without which rapid deterioration may be an expected outcome and where medical or surgical intervention makes a very significant difference or has a very high cost-effectiveness. Level 1 care and treatment may include, but is not limited to: (A) Acute problems, potentially fatal, where treatment prevents death and allows full recovery, (for example, appendectomy for appendicitis, repair of deep open wound in neck, myocarditis, myocardial infarction); (B) Acute problems, potentially fatal, where treatment prevents death but does not necessarily allow for full recovery (for example, burn treatment, treatment for severe head injuries, myocardial infarction); or (C) Maternity care (for example, monitoring, delivery, hypertension in pregnancy) (b) Level 1 care and treatment is generally provided to all inmates by the department. A treating practitioner may authorize Level 1 care and treatment. In emergency situations, any qualified licensed DOC health professional may authorize Level 1 care and treatment. (4) Level 2 Care and Treatment: (a) Level 2 care and treatment (or presently medically necessary care and treatment) is defined as care and treatment without which an inmate could not be maintained without significant risk of either further serious deterioration of the condition or significant reduction in the chance of possible repair after release or without significant pain or discomfort. Level 2 care and treatment may include, but is not limited to: (A) Chronic, usually fatal conditions where treatment improves life span and quality of life, (for example, medical management of insulin dependent diabetes mellitus, surgical treatment for treatable cancer of the uterus, medical management of asthma, hyper tension, etc.); (B) Immunizations; (C) Comfort care such as pain management and hospice type care for the end stages of diseases such as cancer and AIDS; (D) Proven effective preventive care for adults, e.g., preventive dental care, mammograms, pap smears, blood pressure screenings; (E) Acute but non-fatal conditions where treatment causes a return to previous state of health, (for example, fillings for dental cavities, medical treatment of various infectious disorders); or (F) Acute non-fatal conditions where treatment allows the best approximation of return to previous health (for example, reduction of dislocated elbow, repair of corneal laceration). (b) Level 2 care and treatment may be provided to inmates and, when not of an emergency nature, subject to periodic utilization review and appropriateness by the Health Services clinical medical director. A treating practitioner may authorize Level 2 care or treatment. (5) Level 3 Care and Treatment: Page 6 of 21

7 (a) Level 3 care and treatment (or medically acceptable but not medically necessary care and treatment) is defined as care and treatment for non-fatal conditions where treatment or intervention may improve the quality of life for the inmate. Level 3 care and treatment may include but is not limited to routine hernia repair, treatment of non-cancerous skin lesions, corneal transplant for cataract, hip replacement, etc. (b) Level 3 care and treatment may be authorized on an individual-by-individual basis or on a problem-by-problem basis as follows: (A) Medical or surgical care and treatment that can be appropriately done on premises in a routine clinic and that is within the skills of the attending practitioner may be offered at the discretion of the treating practitioner. Any such care and treatment may be referred by an attending practitioner to the Health Services clinical medical director for clinical review as provided in OAR (9) to determine whether to authorize the medical or surgical care and treatment. (B) Other medical or surgical care and treatment, including offsite procedures and therapies for chronic diseases may be referred to the Health Services clinical medical director for clinical review as provided in OAR (9) to determine whether to authorize the medical or surgical care and treatment. (6) Level 4 Care and Treatment (Of Limited Medical Value): (a) Level 4 care and treatment (or care and treatment of limited medical value) is defined as care and treatment that may be valuable to a certain individual but is significantly less likely to be cost-effective or to produce substantial long-term gain or improvement. (A) Level 4 care and treatment includes care and treatment of minor conditions where treatment merely speeds recovery, where treatment gives little improvement in quality of life, offers minimal palliation of symptoms, or is exclusively for the convenience of the individual. (B) Level 4 care and treatment may include but is not limited to tattoo removal, minor nasal reconstruction, oral aphthous ulcers, elective circumcision, common cold, infectious mononucleosis, surgery for gynecomastia. (b) Level 4 care and treatment will not be routinely provided. Inmates may obtain Level 4 care and treatment as provided in OAR (7) The department is not obligated to carry out any recommendations or treatment plans formulated by any outside practitioners if ongoing care is required. (8) Exceptions: (a) The four defined levels of care are general categories of diagnoses, therapies, or procedures. Depending on the individual circumstances, the department may consider additional factors in deciding whether to provide particular care and treatment. (b) Also, there may be an occasion when the level of care of a certain condition or disorder is unclear, or when it is not appropriate to apply the levels of care to an individual inmate, for example (when it may not seem appropriate to provide Level 2 care and treatment, or when it may seem appropriate to provide Level 4 care and treatment). (c) Any individual case may be referred to the Health Services clinical medical director for clinical review as provided in OAR (9) to determine whether to authorize or not authorize medical or surgical care and treatment. (9) Clinical Review (a) Under appropriate circumstances, individual cases may be referred to the Health Services clinical medical director for clinical review. The Health Services clinical medical director may form a review committee comprised of one or more department practitioners and the Medical Services manager to review care and treatment requests on a case-by-case basis. The final authority in any review is the Health Services clinical medical director or designee. (b) Factors that the Health Services clinical medical director and a review committee may consider, either singularly or in combination, when deciding whether specified care and treatment should be provided, may include, but are not limited to: (A) The urgency of the care and treatment, and the length of the inmate's remaining sentenced stay. Whether the care and treatment could be or could not be reasonably delayed without causing a significant progression, complication, or deterioration of the condition and would not otherwise be in clear violation of sound medical principles. Page 7 of 21

8 (B) The necessity of the care or treatment, including: (i) Any relevant functional disability and the degree of functional improvement to be gained; (ii) Medical necessity, or the overall morbidity and mortality of the condition if left untreated; (iii) Pre-existing conditions, whether the condition existed prior to the inmate s incarceration and, if treatment was not obtained previously, the reasons for not obtaining earlier treatment; (iv) The probability the procedure or therapy will have a successful outcome along with relevant risks; (v) Alternative therapy or procedures that may be appropriate; (vi) The inmate's desire for the procedure and the likelihood of the inmate's cooperation in the treatment efforts; (vii) Any known risks or benefits relative to those risks; (viii) Any known costs or benefits relative to those costs; (ix) Pain complaints or pain behaviors; and (x) Any other factors that are relevant or pertinent in light of the circumstances presented. (10) Therapeutic diets may be ordered by a treating practitioner for an inmate with a medical condition requiring nutritional adjustment that is not obtainable from the regular food services menu. Diets to achieve weight loss are the responsibility of the individual inmate. (11) Health Services will screen inmates for work limitations at the assignment supervisor s request. Ongoing daily review of inmate workers for symptoms of illness that would interfere with the work assignment is the responsibility of the on-site work supervisor. STATUTORY/OTHER AUTHORITY: , , , STATUTES/OTHER IMPLEMENTED: , , , & 1987 OL, Ch. 486 Page 8 of 21

9 ADOPT: REPEAL: Temporary from DOC RULE TITLE: Dental Care and Treatment NOTICE FILED DATE: 01/22/2018 RULE SUMMARY: Adopts OAR to specify dental care and treatment procedures for inmates, and clinical review procedures RULE TEXT: (1) Dental care procedures will be conducted in a clinically appropriate manner by appropriately credentialed personnel in an appropriate setting. (2) Dental care and treatment is authorized and provided according to priorities established by the clinical medical director and the dental director. Dental care is subject to peer review. Dental care and treatment will be provided, authorized, and prioritized based on four levels of care. (3) Level 1 Dental Care: (a) Level 1 Dental Care (or medically mandatory dental care) is defined as care that is essential to life and health, without which rapid deterioration may be an expected outcome and where medical or surgical intervention makes a very significant difference or has a very high cost-effectiveness. Level 1 care and treatment may include but is not limited to: (A) Acute problems, potentially fatal, where treatment prevents rapid deterioration of health (for example, treatment for severe cellulitis, osteomyelitis, or serious oral pathology); (B) Acute problems, potentially fatal, where treatment prevents deterioration but does not necessarily allow for full recovery (for example, treatment for severe oral pathology); or (C) Other conditions of care identified as Level 1 dental care in Exhibit 1. (b) Level 1 dental care shall be routinely provided to all inmates by the department. A treating practitioner may authorize Level 1 dental care. In emergency situations, nursing staff may authorize Level 1 dental care. (4) Level 2 Dental Care: (a) Level 2 dental care (or presently medically necessary dental care) is defined as care without which an inmate could not be maintained without significant risk of further serious deterioration of the condition, or significant reduction of the chance to repair the condition after release or without significant pain or discomfort. Level 2 dental care may include but is not limited to: (A) Acute or chronic conditions where treatment facilitates a return to oral health e.g., exodontic procedures, treatment for infected or inflamed oral structures, fillings for dental cavities; (B) Upper or lower dentures for those who have no remaining teeth; (C) Chronic conditions where treatment causes a return to previous state of health, e.g., fillings for dental cavities, treatment of various infectious disorders; (D) Comfort care such as pain management, except chronic pain management that may be referred to institution physicians; (E) Proven effective preventive care for adults, e.g., debridement of calculus, home care instructions; or (F) Other conditions or care and treatment identified as Level 2 dental care in Exhibit 1. (b) Level 2 dental care may be routinely provided to inmates upon request and may be authorized by any institution staff dentist. Treatment decisions are subject to periodic review by the chief medical officer or dental director for utilization review and appropriateness. (5) Level 3 Dental Care: (a) Level 3 dental care (or medically acceptable but not medically necessary care and treatment) is defined as care for conditions where treatment may improve the quality of life for the inmate but with minimal overall medical impact, e.g., dental prosthetic appliances, removal of impacted wisdom teeth. Level 3 dental care may include, as an example, dental prosthetic devices and other conditions or care and treatment identified as Level 3 dental care in Exhibit 1. (b) Level 3 dental care may be authorized on a case-by-case basis. Level 3 dental care procedures, whether performed Page 9 of 21

10 onsite or offsite, require review and authorization by the Therapeutic Levels of Care (TLC) Committee as provided in OAR (8). (6) Level 4 Dental Care (Of Limited Medical Value): (a) Level 4 dental care (or care and treatment of limited medical value) is defined as elective care that may be valuable to a certain individual but significantly less likely to be cost-effective or to produce substantial long-term gain or improvement, or care that does not result in a reliable outcome that is corroborated by evidence-based data. Level 4 Care includes conditions where alternate treatments are available or where treatment gives little improvement in the overall quality of life, offers minimal palliation of symptoms, or is exclusively for the convenience of the individual. Examples may include: fixed bridgework; TMJ surgery; orthodontics; endodontics (root canals); custom crowns; and dental prostheses that are considered predominately cosmetic in nature. Other Level 4 dental care is identified in Exhibit 1. (b) Level 4 dental care is generally not provided. However, Level 4 dental care may be approved by the TLC Committee if significant and compelling overriding circumstances exist, Refer to OAR (14)(a). (A) If level 4 dental care is not authorized by the TLC Committee, the inmate may obtain Level 4 dental care as provided in OAR (B) The department is not obligated to carry out any recommendations or treatment plans formulated by any outside practitioners if ongoing care is required. (7) Exceptions: (a) The four defined Levels of dental care are general categories of diagnoses, therapies, or procedures. (b) Depending on the individual circumstances, the department may consider additional factors in deciding whether to provide particular care, or whether it is appropriate to apply a specific level of care to an individual inmate. (c) Any individual case may be referred for further clinical review pursuant to OAR (8) to determine whether to authorize or not authorize dental care and treatment. (8) Clinical Review: (a) For all Level 3 and Level 4 dental care, individual cases must be referred to the dental director for clinical review. The dental director may form a review committee (Therapeutic Levels of Care Committee or TLC Committee) comprised of one or more department dentists, and the Health Services clinical medical director to review care and treatment requests on a case-by-case basis. The final authority in any review is the Health Services clinical medical director or designee, e.g., dental director. (b) Factors that the Health Services dental director and a review committee may consider, either singularly or in combination, when deciding whether specified care and treatment should be provided include: (A) The urgency of the care and the length of the inmate's remaining sentence. Whether the care could be delayed without causing a significant progression, complication, or deterioration of the condition; (B) The necessity of the care, including: (i) Any relevant functional disability and the degree of functional improvement to be gained; and (ii) Medical necessity, or the overall morbidity and mortality of the condition if left untreated. (iii) Pre-existing Conditions: Whether the condition existed prior to the inmate s incarceration. If no treatment was provided in the community, the reasons for not obtaining prior treatment should be ascertained; (iv) The probability the procedure or therapy will have a successful outcome along with relevant risks; (v) The availability of clinically acceptable alternative treatments; (vi) The inmate's desire for the procedure and the likelihood of the inmate's cooperation in the treatment efforts; (vii) A risk-benefit analysis; and (viii) A cost-benefit analysis. (c) After completion of a review, dental staff will schedule an appointment with the inmate to discuss the review decision and next steps, as applicable. (9) Emergency Dental Treatment: Emergency dental treatment is available to all inmates during hours that Health Services staff members are on duty and may include treatment for pain, swelling, infection, bleeding, and suspected Page 10 of 21

11 injuries. (10) Non-emergency Dental Treatment: Non-emergent dental treatment may be accessed and acquired by inmate request, by referrals from the initial dental screening and exam, periodic or emergency dental examinations, and Health Services staff. Treatments will be prioritized as provided by the following criteria: (a) All Level 1 and Level 2 procedures may be indicated and completed by the attending dentist upon recommendation. If any Level 1 or Level 2 procedures require referral to an outside provider, the TLC Committee must review the referral. However the review may take place after the referral if the treatment is of an urgent nature. (b) Level 3 and Level 4 procedures will only be performed after approval from the Therapeutic Levels of Care Committee. (11) Periodontal Treatment: Periodontal treatment will be provided upon recommendation of the dentist and will be prioritized according to the severity of the condition. (a) Emergent periodontal treatment will be available to all inmates and may be scheduled by the dentist after evaluation of the inmate, or by an interview request from an inmate stating an urgent condition (i.e., pain, swelling, and/or bleeding.) (A) Inmates will be scheduled on an emergency basis and the specific problem will be addressed. The initial treatment will usually consist of gross debridement. (B) The need for follow-up treatment will be documented and the inmate will be schedules as time permits. (b) Routine Treatment is divided into two classes: (A) Class I includes inmates whose periodontal conditional has progressed to the point that surgical intervention is needed. Health Services will try and stabilize the condition, maintain the inmate s dentition until extraction of the affected teeth becomes necessary. The treatment may consist of gross debridement or hand scaling or both. Inmates may go to an outside provider for surgical intervention pursuant to OAR (B) Class II includes inmates with good oral hygiene and minor periodontal conditions. Inmates will be scheduled, time permitting for preventative treatment. These appointments will be scheduled by an inmate sending in a written request for treatment. (c) Additional periodontal procedures may be performed if authorized pursuant to OAR (8). (12) Periodic dental exams will be available to inmates serving more than a one-year sentence. Exams will be made available on an annual basis; however, the interval may vary depending on the specific needs of the inmate as determined by the attending dentist. (13) Dental Prostheses: Dental prosthetic appliances are generally considered elective care; however, they may be made available to inmates as a co-pay service if certain criteria are met. (a) Dental prosthetic appliances or procedures may include: (A) Complete Denture: A dental prosthetic appliance that replaces all teeth in upper or lower arch. (B) Partial Denture: A dental prosthetic appliance that replaces some teeth in the upper or lower arch. A cast partial denture is made on a frame that is cast metal. An acrylic partial denture does not have a cast metal frame, and is used when the remaining natural teeth are not strong enough to support a cast partial denture. A flipper is an acrylic partial denture designed predominately as a cosmetic appliance, replacing one to four teeth missing in the front part of the mouth. (C) Reline: A procedure that is done to improve the fit of a denture or partial. (b) To be eligible for the co-pay service, an inmate must demonstrate two years remaining on their DOC sentence from the date of their first request for the prosthesis. (A) Approval for Partial Denture: (i) If an inmate meets the two-year threshold and requests a partial, the request must be submitted for review and approval by the TLC Committee. (ii) Partial dentures will generally not be provided if the TLC Committee determines the inmate demonstrates sufficient existing occlusion, or if the remaining teeth are not sound enough to sustain a partial denture adequately. (iii) Partial dentures also will not be provided if the TLC Committee determines the appliance is predominately cosmetic Page 11 of 21

12 in nature, unless the TLC Committee determines that overriding circumstances allow approval, e.g., an inmate who entered DOC physical custody with all upper anterior teeth present, and then requires removal of one or more of those anterior teeth during incarceration. (B) Approval for Complete Denture: If an inmate meets the two-year threshold and requests a denture, no review or approval by the TLC Committee is required. (c) If an inmate fails to meet the two-year threshold, the TLC Committee may review the request for approval and may approve the request if overriding circumstances exist. Overriding circumstances may include an inmate who entered DOC physical custody completely edentulous requiring no extractions or prep work, or an inmate requiring minimal prep work who falls one or two months short of the two-year threshold. (d) Health Services may participate in a co-pay service for dental prostheses or relines for each inmate a maximum of once every five years. If replacement is necessary prior to five years, the case must be sent to the TLC Committee for review. (e) An inmate who requests a dental prosthesis must sign a request for withdrawal of funds for the following amounts: (A) Complete Denture - $280 (B) Partial Denture (Cast or Flex) - $310 (C) Acrylic Partial Denture - $270 (D) Flipper - $150 (E) Reline Partial or Denture - $110 (F) Occlusal Splint - $40 (G) Denture or partial repairs - By reported cost (f) An inmate shall be responsible to pay laboratory fees for any repairs unless provider or laboratory error can be demonstrated. (14) Dental Root Canals and Custom Crowns: Dental root canals and custom crowns are not generally provided by the department. (a) The department may approve an inmate request for a dental root canal or custom crown on a co-pay basis if a sufficient number of compelling overriding circumstances are present. Examples of overriding circumstances include the following: (A) Required for Approval: For new inmates, a dental examination that reveals a low decay rate with no deep caries on any specific teeth; for other inmates, recall examinations that reveal a low decay rate and good oral hygiene. (B) Required for Approval: An absence of significant periodontal disease on the tooth in question. (C) Other overriding circumstances for consideration: (i) If the inmate is new to the department, the inmate demonstrated good dental care prior to incarceration, including regular trips to the dentist for check-ups. (ii) The tooth is in an arch displaying no missing teeth. (iii) The tooth has an opposing tooth in the opposite arch placing it firmly in function. (iv) The tooth has a specific and significant strategic purpose with regard to overall function. (v) The tooth is an upper anterior and all other upper anteriors are present and in good shape. (vi) Treatment is required due to a previous trauma and not gross neglect of the teeth. (vii) The tooth deteriorated while in DOC custody, despite repeated requests for treatment. (viii) The tooth has a favorable long term prognosis. (ix) The inmate expended considerable resources on their dentition prior to incarceration. (x) For custom crown requests, the inmate has more than five years remaining to serve. Stainless steel crowns are a clinically acceptable alternative for those with less than five years remaining. (b) All requests for root canals and custom crowns (a full coverage dental crown that is custom-made for a specific tooth by a dental laboratory) must be reviewed and approved by the TLC Committee. (c) A request for a for a stainless steel crown (a full coverage crown that is prefabricated, and is not custom-made in a dental laboratory) does not require approval by the TLC Committee. Page 12 of 21

13 (e) The department charges a co-pay amount for any root canals and custom crowns that are approved by the TLC Committee. An inmate who is approved for a root canal or custom crown must sign a request for withdrawal of funds for the following amounts: (A) Custom Crown Full Metal - $120 (B) Custom Crown Porcelain / Metal - $120 (C) Custom Crown Full Ceramic - $120 (D) Root Canal Anterior Tooth - $100 (E) Root Canal Bicuspid Tooth - $140 (G) Root Canal Molar Tooth - $180 (17) Elective Dental Treatment: (a) Pursuant to OAR , inmates may utilize the services of outside providers for any elective dental treatment that has not been authorized for completion within the department. Requests to purchase outside dental care require review and approval from the TLC Committee to ensure the procedures are medically appropriate and are consistent with community standards for dental care and the department s concerns for institution security. (b) An inmate may initiate a request for elective dental treatment. (c) A staff dentist will assess the inmate to substantiate the dental procedure in question and submit the case to the TLC Committee for approval and review prior to referral to an outside provider. (d) If the requested elective dental procedure is approved, the inmate may purchase and receive the treatment pursuant to the procedures set forth in OAR STATUTORY/OTHER AUTHORITY: , , , STATUTES/OTHER IMPLEMENTED: , , , Page 13 of 21

14 EXAMPLES OF CONDITIONS AND ASSOCIATED LEVELS (List is not exhaustive) LEVEL I Excision of malignant tumor Incision and drainage of abscess Emergency tracheotomy Treatment of Osteomyelitis Mandibular fractures (open and closed reductions) Maxillary fractures (open and closed reductions) Fractures of facial bones Severe cellulitis Screening and treatment for oral cancer Severe oral and facial injuries Treatment by approved Level I and II nursing protocols Treatment of pain Treatment of oral abscesses and infections Dislocated mandible Hemorrhage Palliative Treatment LEVEL 2 Sedative fillings Pain medication Antibiotic therapy Prescription of any medication in the Pharmacy formulary Treatment of pulpitis Removal of necrotic teeth Treatment of gingival sensitivity All local anesthetic procedures Diagnostic Treatment Inside consults Dental X-rays Bacteriological cultures Biopsies Page 14 of 21

15 Preventive Treatment Oral hygiene instructions Access to care instructions Oral exam and dental history screening Periodic dental exams Removal of calculus Acute gingivitis treatment Acute periodontal treatment Acrylic partial denture repairs Cast partial denture repairs Full denture repairs Relines (lab and chair side) Tissue conditioner (for existing dental prosthesis) Stabilization of loose teeth Reimplantation if appropriate Operative Treatment Temporary restorations Amalgam restorations Resin restorations Stainless steel crowns Resin crowns Prosthetic Treatment Any cases that may be exceptions may be submitted to TLC for consideration. Conventional maxillary and mandibular dentures Minimum 2 year sentence Page 15 of 21

16 Surgical Treatment Extractions Removal of root tips Removal of cysts and abscesses Treatment for infections Removal of foreign bodies Alveoplasty Fistula drains and closures Sutures Treatment for dry sockets Any other post-surgical treatments LEVEL 3 TMJ splints Occlusal Guards All outside referrals including treatment for the following conditions: a) Removal of impacted wisdom teeth (third molars) b) Osseous surgery c) Periodontal procedures d) Oral pathology consultations and treatment (non-emergent) e) TMJ consults and/or treatment Removal of pre-existing tooth fragments or foreign bodies (not painful or progressive) Facial prostheses due to injuries Physical Therapy All Cast partial dentures 2 year sentence requirement Repairs of pre-existing facial fractures Speech appliances Obturator appliances Sealants Frenectomies LEVEL 4 Fixed bridgework Custom laboratory crowns Cosmetic crown repair Inlays / Onlays Oral implants of any kind Orthodontic procedures Surgical repositioning of teeth TMJ surgery Cosmetic surgery Teeth whitening procedures Any prosthetic treatment determined to be predominately cosmetic in nature Page 16 of 21

17 Prosthetic treatment for patients having adequate occlusion (Generally described as 10 or more teeth in occlusion) Immediate upper or lower dentures Any endodontic procedures (root canal treatment) IV sedation for routine dental treatment, including surgery or operatives Page 17 of 21

18 AMEND: REPEAL: Temporary from DOC RULE TITLE: Patient Rights NOTICE FILED DATE: 01/22/2018 RULE SUMMARY: Amends OAR to specify medical procedures that require written informed consent to treatment, information that may be provided before obtaining informed consent, and special circumstances in which informed consent of the inmate is not required. RULE TEXT: (1) Medical Research: The use of inmates for medical, psychiatric, or psychological experimentation or research is prohibited as stipulated in ORS (2) Informed Consent: (a) The inmate's written informed consent or refusal shall be obtained prior to a healthcare procedure that is invasive or with major adverse health risks or prior to beginning non-emergent mental health or medication services. (A) Examples of such healthcare procedures include: incision and drainage; skin removal, including biopsy; cauterization; contraception methods/prescription; all major and minor surgical procedures; immunizations; psychotropic/neuroleptic medication; articular and bursa injections; other procedures in which there is a probability of major adverse risks; and all invasive dental procedures. (B) An inmate may change their informed consent or refusal. (b) Informed consent shall include providing the inmate with information about: (A) The nature, purpose, and benefits of the procedure or treatment; (B) The risks, if any, of the procedure or treatment; and (C) Any alternative procedures or methods of treatment that is available; and (D) Supplemental written information may be incorporated as part of the informed consent process. (c) Informed consent is not required in: (A) A medical emergency if the inmate is unable to give or to refuse consent and there is an immediate threat to the life of, or irreversible bodily harm to, the inmate; (B) A medical or psychiatric emergency if the inmate does not have the mental capacity to make an informed decision; (C) Where there is a court order to provide the medical treatment or procedures; (D) Informed consent given by the legal guardian; and (E) Certain public health matters. (3) Confidentiality: (a) The inmate's healthcare record, which includes medical, dental, and mental health information obtained by Health Services employees, is confidential and shall not be released except as provided in ORS through , and other Oregon statutes. (b) Health Services employees shall communicate to correctional employees pertinent information that has a direct impact on the safety and security of the facility or is relevant to the inmate's ability to function. (4) Inmates may use the inmate grievance system as outlined in OAR for health related issues. STATUTORY/OTHER AUTHORITY: , , , STATUTES/OTHER IMPLEMENTED: , , , Page 18 of 21

19 AMEND: REPEAL: Temporary from DOC RULE TITLE: Charges for Elective Care or Treatment NOTICE FILED DATE: 01/22/2018 RULE SUMMARY: Amends OAR to specify several procedures concerning requesting, obtaining, and purchasing orthoses, prosthetic devices, refractive eye examinations, mechanical aids, self-care items, eyeglasses, and footwear. Clarifies those procedures that apply to inmates on short-term transitional leave or non-prison leave. RULE TEXT: (1) An inmate may request approval to purchase healthcare from a healthcare provider in the community. The department will only approve those requests that in the department s judgment are medically appropriate and are otherwise consistent with the department s concerns for institution security and order, public safety, and sound correctional practice. (a) The inmate's trust account must have sufficient funds to pay for the purchase of care BEFORE the treatment is scheduled unless other financial arrangements have been made. Cost of care includes expenses associated with providing the treatment, including follow-up care, as well as all costs associated with transport and security. (b) For medical requests, the chief medical officer of the facility must review and approve follow-up care and treatment recommended by community practitioners. Any requests to purchase elective dental care from community providers must be reviewed and approved by the department s dental director. (2) Orthoses, Prosthetics Devices, Mechanical Aids, and Self Care Items: Orthoses, prosthetic devices, and mechanical aids are specialized mechanical devises used chronically to support or supplement joints or limbs, or are artificial devices to replace missing body parts. (a) An inmate is generally required to pay for orthoses, prostheses devices, or other mechanical aids that become the personal property of the inmate. An inmate is not generally required to pay for medical aids provided for acute treatment of a limited medical condition (casts, splints, ace wraps) short-term usage of aids (e.g., canes, crutches, or braces), or hardware that is an essential part of a medically necessary procedure (e.g., heart valves, cardiac stent, interocular lens implants). (b) Health Services allows appropriate but elective orthoses, prostheses, or other mechanical aids that are not essential to prevent significant deterioration in the health of the inmate but are nevertheless reasonably expected to significantly improve the quality of life of the inmate as it relates to a proven chronic or ongoing medical condition. Examples of such items include: dentures; dental prosthetics; glasses; contact lenses; artificial eyes; artificial limbs; knee/ankle/foot braces; hearing aids; support hose; transcutaneous electrical nerve stimulation (TENS) units; non-institution issued shoes; suspenders; batteries for hearing aids or other devices; maintenance or repair of any such item. (c) Health Services may decline to authorize elective orthoses, prostheses, or other mechanical aids that are of minimal proven medical value, and authorization decisions must be weighed against safety and security concerns. Examples of items that are not generally authorized include but are not limited to high-top tennis shoes, soft pillows, heating pads, and knee sleeves for sports. (d) Health Services may consider the following when determining whether to allow elective orthoses, prosthetic devices, and mechanical aids and whether the inmate must pre-pay for the item prior to ordering or delivery, or whether the inmate may incur indebtedness to obtain the item: (A) Urgency of need; (B) Time left on sentence; (C) Overall necessity; (D) Morbidity; (E) Mortality; (F) Functional disability; (G) Expected improvement; Page 19 of 21

20 (H) Alternatives; (I) Risks and benefits; (J) Costs and benefits; and (K) Security concerns. (e) Refractive Eye Examinations and Eyeglasses: Health Services offers inmates to obtain a refractive eye examination on a co-pay basis ($45 co-pay per exam) once every two years. (A) An inmate may purchase eyeglasses, eyewear, and eyewear accessories from the department. (B) The Health Services Eyeglasses Review Committee may approve an inmate to incur debt to obtain an eye examination or purchase eyeglasses on a case-by-case basis. The Eyeglasses Review Committee will make that approval based on a review of the inmate s release date, past optical information, current visual acuity, and a six-month review of the inmate s trust fund activities, and the inmate s effort and compliance with a correctional case management plan. (D) Health Services does not provide contact lens examinations. Inmates may purchase contact lenses and lens solution. (f) Footwear: Health Services may approve special footwear if that footwear is a recognized and appropriate part of a medical treatment plan or may be medically necessary (e.g., peripheral vascular disorders, diabetic complications, amputation, clubfoot) if there would be serious deterioration or significant risk to the inmate s basic health without the special footwear, and if no reasonable treatment alternative exists. An inmate may incur indebtedness to obtain special footwear approved by the department. (g) The inmate must sign a withdrawal request (CD28) before the service or item is provided. The inmate's trust account will be charged for the estimated or actual cost of the device. If an inmate must pre-pay before obtaining a service or item, the inmate must sign a withdrawal request (CD28) with sufficient funds available and debited before the service or item is provided. (h) Upon delivery of the device, any variance from the actual cost will be indebted or credited to the inmate's trust account accordingly. (i) An inmate shall not be denied prostheses or other devices that are medically necessary because of lack of funds. However, the inmate may incur debt if his/her trust account does not have sufficient funds to cover the cost of the device. (j) Items for self-care are available on the commissary list. An inmate may be advised to purchase a particular self-care item by Health Services employees. Such advice is intended as education in self-care and is not a directive that the item is considered medically necessary. (3) Expenses for Medical Care for Inmates on Escape, Short-Term Transitional Leave, Non-Prison Leave, Parole, Post- Prison Supervision, or Emergency Leave: (a) Expenses incurred for healthcare of offenders on parole or post-prison supervision are the responsibility of the offender. (b) Expenses incurred for healthcare of inmates on escape status are not the responsibility of the department. (c) Expenses incurred for healthcare of inmates on short-term transition leave and non-prison leave are the responsibility of the inmate. (4) Refusal of Medical Appointments: (a) Any inmate who willfully refuses to keep a prearranged medical appointment in the community may have his/her trust account charged or indebted. (b) A decision under this section to charge or indebt an inmate's trust account is subject to the administrative review process in the rules on Trust Accounts (Inmate) (OAR ). (5) Destruction of Property: Any inmate who willfully destroys or misuses Health Services equipment or supplies is subject to disciplinary action in accordance with the rules on Prohibited Inmate Conduct and Processing Disciplinary Actions (OAR ). STATUTORY/OTHER AUTHORITY: , , , STATUTES/OTHER IMPLEMENTED: , , , Page 20 of 21