Commissioner's Directive

Date:
2011-04-18

Number - Numéro:
800

HEALTH SERVICES

Issued under the authority of the Commissioner of the Correctional Service of Canada

PDF

Policy Bulletin 324

POLICY OBJECTIVE

  1. To ensure that inmates have access to essential medical, dental and mental health services in keeping with generally accepted community practices.

AUTHORITIES

  1. Corrections and Conditional Release Act, sections 85 to 89
  2. Corrections and Conditional Release Regulations

CROSS-REFERENCES

CD 803 - Consent to Health Service Assessment, Treatment and Release of Information

CD 805 - Administration of Medication

CD 821 - Management of Infectious Diseases

CD 835 - Health Care Records

CD 840 - Psychological Services

CD 843 - Prevention, Management and Response to Suicide and Self-Injuries

CD 844 - Use of Restraint Equipment for Health Purposes

CD 850 - Mental Health Services

GL 800-1 - Hunger Strikes : Managing an Inmate's Health

DEFINITION

  1. Medical emergency: an injury or condition that poses an immediate threat to a person's health or life which requires medical intervention.

RESPONSIBILITIES

  1. The Institutional Head must ensure that:

    1. all staff have ready access to necessary protective and first aid equipment in all work locations;
    2. all Correctional Officers are issued, carry on their person and use approved protective equipment (e.g. protective masks, gloves) when administering cardiopulmonary resuscitation (CPR) or first aid;
    3. there are quarterly on-site simulations of medical emergencies that allow staff to practice and remain current in skills;
    4. the scenarios used for the medical emergency exercises take into account the institution's circumstances relating to the availability of medical resources within the community and emphasize the specific needs of the midnight shift; and
    5. procedures are in place to determine the possible negative effect of administrative decisions (such as the use of restraint equipment, segregation and transfer) on the health status of an inmate.

ESSENTIAL HEALTH SERVICES

  1. Inmates shall have access to screening, referral and treatment services. Essential services shall include:

    1. emergency health care (i.e., delay of the service will endanger the life of the inmate);
    2. urgent health care (i.e., the condition is likely to deteriorate to an emergency or affect the inmate's ability to carry on the activities of daily living);
    3. mental health care provided in response to disturbances of thought, mood, perception, orientation or memory that significantly impair judgment, behaviour, the capacity to recognize reality or the ability to meet the ordinary demands of life (this includes the provision of both acute and long-term mental health care services); and
    4. dental care for acute dental conditions where the inmate is experiencing swelling pain or trauma; preventive treatment (i.e., necessary fillings, extractions, etc.) subject to the motivation displayed by the inmate to take an active part in the process; and removable dental prostheses as recommended by the institutional Dentist. All other dental care will be initiated and funded by the inmate.
  2. Inmates shall have reasonable access to other health services (i.e., conditions not outlined above) which may be provided in keeping with community practice (e.g. prenatal care for women). The provision of these services will be subject to the length of time prior to release, operational requirements, etc.
  3. In support of essential health services, emphasis will be on health promotion and illness prevention.

HEALTH CARE DELIVERY

  1. Health services shall only be provided by health care professionals who are registered or licensed in Canada, preferably in the province of practice.
  2. Access by inmates to health services shall be available on a 24-hour basis. Access can be provided through on-site coverage, on an on-call basis, or through other Correctional Service of Canada (CSC) institutions or other community services.
  3. All staff are responsible to inform a health care professional of the condition of any inmate who appears to be ill, whether he or she complains or not.
  4. A process shall be in place to allow inmates to submit in confidence a request for health care services, indicating the reason for the request.
  5. An inmate's request for health services must be relayed to a health care professional without delay.
  6. Inmate requests for routine health services shall be screened by a Nurse or other health care professional and referred to a Clinician as appropriate.
  7. All inmate requests (form CSC/SCC 1122) must be dated and a signed response must be provided to the inmate within 15 days.

  8. Health education and promotion programs shall be provided to meet the identified needs of individual offenders and specific offender groups.

RESTRICTIONS

  1. Medication for inmates shall be prescribed by an institutional Clinician only when clinically indicated. The administration of medication to inmates for restraint or for other security purposes is not permitted.
  2. Health care personnel shall not take or assist in taking specimens for non-medical reasons.
  1. The informed consent of an inmate which may be written or implied is normally required for any health care assessment, examination, procedure or treatment. (For exception to this policy, refer to CD 803 - Consent to Health Service Assessment, Treatment and Release of Information.)

REQUIREMENTS - RECEPTION

  1. Within 24 hours of initial arrival to any CSC institution (including following a court return, an inter or intra-regional transfer and a warrant of suspension), every offender must undergo a nursing assessment. The Nurse must complete Section I of form CSC/SCC 1244E - Intake Health Status Assessment and make any necessary referrals to the appropriate health care professional. This nursing assessment must, at a minimum, screen for:

    1. communicable conditions;
    2. acute medical, mental or dental conditions;
    3. conditions requiring continuing treatment; and
    4. activity limitations.
  2. Within 14 days of admission to CSC, each offender must be offered a comprehensive nursing assessment. This assessment must also be offered to offenders:

    1. re-admitted to CSC following a period of release to the community for more than 12 months; or
    2. who resided in the community for less than 12 months but have had significant changes in their health status within that period.
  3. The comprehensive nursing assessment must consist of Section II of form CSC/SCC 1244E - Intake Health Status Assessment, form CSC/SCC 1244-01 - Health Status Admission Assessment for Those Aged Fifty and Older and/or Those with Self-Care Needs (as applicable) and form CSC/SCC 1244-ID- Intake Health Status Assessment - Infectious Disease Screening which consist of:

    1. inmate's health status (present, historical and family);
    2. update of immunization status in accordance with the recommendations of the Canadian Immunization Guide;
    3. screening and immunization (if indicated) for hepatitis A and B;
    4. screening for hepatitis C;
    5. screening for tuberculosis in accordance with provincial regulations and practice if recent documented evidence of such testing is not available (Regional Headquarters, through Regional Instructions, shall ensure that institutions are aware of provincial legislation and provide direction on the medical management of affected inmates);
    6. screening and pre and post-test counselling for human immunodeficiency virus (HIV);
    7. screening for sexually transmitted infections (STIs);
    8. health education and promotion programs to meet the identified health needs of individual inmates and specific inmate groups; and
    9. referral to other health care professionals if deemed appropriate.
  4. The findings of nursing assessments shall determine the requirements for treatment, hospitalization, special housing and/or program placement.
  5. Procedures regarding prophylaxis, treatment and reporting of infectious or communicable diseases shall be in accordance with provincial health regulations.

REPORTING REQUIREMENTS

  1. Prior to expected reception of inmates with mandatory treatment requirements, institutional health care staff shall inform the Medical Officer of Health.

ROUTINE CARE AND MEDICAL EMERGENCY SITUATIONS

  1. Procedures for health care emergencies shall be in place in all institutions.
  2. Medical Directives must be established to outline the course of action to be taken by health services staff in both routine and emergency situations when there is no Physician on site. When 24-hour nursing coverage is not provided, on-site staff with current certification in basic first aid and CPR training must be available on site. A list of staff maintaining this certification must be routinely accessible throughout the institution.

RESPONSE TO MEDICAL EMERGENCIES

  1. In responding to a medical emergency, the primary goal is the preservation of life and all staff must act to preserve life:

    1. non-health services staff arriving on the scene of a possible medical emergency must immediately call for assistance, secure the area, and initiate CPR/first aid without delay;
    2. non-health services staff must initiate CPR/first aid where physically feasible even in cases where signs of life are not apparent;
    3. non-health services staff must continue to perform CPR/first aid until relieved by health services staff or the ambulance service;
    4. the decision to discontinue CPR/first aid can be made only by authorized health services staff or the ambulance service;
    5. initiation of CPR by non-health services staff is not required in the following situations:
      • decapitation (i.e. the complete severing of the head from the remainder of the body),
      • decomposition (i.e. condition of decay, deterioration, disintegration of the body),
      • when non-health services staff are aware that a valid DO NOT RESUSCITATE (DNR) order exists as per the CSC Palliative Care Guidelines,
      • CPR is not to be initiated in cases where the inmate is believed to be dying from natural causes and has a known valid DNR order posted;
    6. the existence of a DNR order does not preclude the use of other forms of treatment or care (i.e. treatment for a non-life threatening injury);
    7. non-health services staff must use approved protective equipment when administering CPR/first aid;
    8. as soon as a possible medical emergency is identified, the Correctional Manager or officer-in-charge must notify health services and the ambulance service in accordance with the Institutional Contingency Plan, Standing Orders or Post Orders;
    9. the Correctional Manager or officer-in-charge must immediately establish appropriate security for responding staff and the ambulance service;
    10. once on the scene, health services or the ambulance service shall be responsible for determining the medical response to the situation;
    11. correctional staff on the scene will continue to provide assistance as directed by health services or the ambulance service;
    12. the Institutional Head shall ensure that debriefings occur immediately following a medical emergency (to inform CSC managers of the details related to the medical emergency) and offer critical incident stress management services to all staff involved in the incident as set out in Guidelines 253-2 - Critical Incident Stress Management; and
    13. immediately following a medical emergency:
      • the Correctional Manager must complete form CSC/SCC 1323-01 - Response to Incidents Involving a Medical Emergency - Correctional Manager / Officer-In-Charge Checklist,
      • the Correctional Manager must ensure that only one form CSC/SCC 1323-02 - Response to Incidents Involving a Medical Emergency - Staff Checklist is completed collectively by the appropriate responding non-health services staff member(s).
  2. The responsibility of health care personnel for both visitors and staff shall be limited to emergency care until outside services are available.

DELEGATED MEDICAL ACTS

  1. Consistent with the standards of the professional associations of the province or territory of practice, medical acts may be delegated to nursing staff only when:

    1. official authorization is obtained from both the medical authorities and the health care administration authorities of the institution;
    2. a certification procedure is established; and
    3. a regular evaluation of competence is established for each delegated medical act.

OUTSIDE CONSULTATION

  1. Outside consultation or treatment for essential services may be sought by the institutional Clinician. Consistent with community standards, treatment recommendations by consultants are subject to approval of the referring institutional Clinician.

NON-ESSENTIAL INMATE-REQUESTED SERVICES

  1. All inmate-requested services deemed non-essential by the institutional Physician will be at the inmate's complete expense including consultation fees and at the discretion of Institutional Heads, any associated escort costs. Health services shall be responsible for the coordination of arrangements for all inmate-requested services.

GENDER IDENTITY DISORDER

  1. CSC recognizes that some offenders may have gender identity disorder. Where there are reasonable grounds to believe that such a condition exists, a referral by the institutional Psychiatrist shall be made to a Psychiatrist who is a recognized expert in the area of gender identity, if and when available, for an assessment and possible diagnosis of gender identity disorder. For those diagnosed with gender identity disorder, there shall be continuity of care with respect to the provision of health services.
  2. Inmates with diagnosed gender identity disorder shall be able to initiate or to continue hormone therapy as prescribed by either a Psychiatrist who is a recognized expert in the area of gender identity or other specialist Physicians in the area of gender identity disorders or endocrinology, if and when available.
  3. Pre-operative male to female offenders with gender identity disorder shall be held in men's institutions and pre-operative female to male offenders with gender identity disorder shall be held in women's institutions.
  4. For all placement and program decisions, individual assessments shall be conducted to ensure that offenders diagnosed with gender identity disorder are accommodated with due regard for the vulnerabilities with respect to their needs, including safety and privacy.
  5. Sex reassignment surgery shall be considered during incarceration only when:

    1. a recognized gender identity specialist has confirmed that the offender has satisfied the real life test, as described in the Harry Benjamin Standards of Care, for a minimum of one year prior to incarceration; and
    2. the recognized gender identity specialist recommends surgery during incarceration.
  6. If the recognized gender identity specialist provides an opinion that sex reassignment surgery is an essential medical service under CSC's policy, CSC will pay the cost. In making the decision the specialist shall consult with CSC.
  7. CSC shall proceed without delay to determine the timing of the surgery taking into account operational considerations and the offender's release date.
  8. The recognized gender identity specialist shall normally be the same specialist who provided care to the offender throughout the transition prior to his or her incarceration, unless the offender and CSC agree to a different choice of gender identity specialist.
  9. The Institutional Head shall ensure that staff who have regular contact with offenders with gender identity disorder have the necessary knowledge to effectively respond to their needs.
  10. Subject to operational considerations, offenders diagnosed with gender identity disorder shall be permitted to cross-dress.

HUNGER STRIKES

  1. Inmates who declare a hunger strike will be managed according to GL 800-1 - Hunger Strike: Managing an Inmate's Health, issued by the Assistant Commissioner, Health Services.

TREATMENT OF OPIATE DEPENDENCE

  1. Offenders with opioid addictions are eligible for treatment in accordance with the CSC Specific Guidelines for Treatment of Opiate Dependence.

TERMINAL OR CHRONIC ILLNESS

  1. If an inmate is terminally or seriously chronically ill, the Service shall consult with the National Parole Board to determine eligibility for parole. This would include those inmates with incapacitating illness, who are chronically sick and have impairments which have one or more of the following characteristics:

    1. are irreversible;
    2. leave residual disability;
    3. are caused by non-reversible pathological alteration; and
    4. require a long period of supervision, observation or care.
  2. When an inmate is diagnosed with a terminal/life-threatening illness, palliative care services shall be initiated in accordance with the CSC Palliative Care Guidelines.

PREGNANT INMATES

  1. Accommodation shall be provided for pre- and post-natal care; however, arrangements shall be made for delivery at an outside hospital.

PROSTHESES AND APPLIANCES

  1. Medical, removable dental and optometric prostheses and appliances shall be provided when essential to the health of the inmate. The need for artificial devices shall be determined by the institutional Physician, Dentist or Optometrist responsible.
  2. When the inmate provides evidence that the need has arisen from normal wear and tear, the Service may assume or defray the cost of the repair or replacement of articles.
  3. The inmate shall assume the cost of the repair or replacement if it is due to either negligence or deliberate destruction by the said inmate, regardless of whether the prosthesis or appliance was originally purchased by the inmate or the Service.
  4. If an inmate does not possess sufficient funds for the repair or replacement, arrangements shall be made to recover the cost from the inmate over such a period of time as is practical.

ADMINISTRATIVE SEGREGATION

  1. Health services professionals, including Doctors, registered Nurses, Psychologists or Psychiatrists shall advise the Institutional Head in writing if they recommend the termination of administrative segregation or the alteration of the administrative segregation conditions on the grounds of the physical or mental health of the inmate.

    Psychologist

  2. At least once within the first 25 consecutive days of an inmate's placement in administrative segregation and once every subsequent 60 days, a Psychologist will provide a written psychological opinion on the inmate's current mental health status at the time of the assessment, with a special emphasis on the evaluation of the risk for self-harm (CD 709 - Administrative Segregation, Annex E). This is to be shared with the Segregation Review Board and the inmate, and placed on the inmate's file.

    Nursing Staff

  3. An inmate placed in administrative segregation must, at the time of admission or without delay, be visited by a registered Nurse to establish whether there are any health concerns resulting from placement in administrative segregation or any concerns for suicide risk or self-harm. During this visit, the Nurse must:

    1. view the inmate in person;
    2. verbally interact with the inmate to determine if he or she has any health care needs (the Nurse must ensure, to the extent possible, confidentiality during the interaction);
    3. complete the appropriate documentation as follows:
    1. the relevant section of the Segregation Log (CSC/SCC 0218) for each inmate must be initialled by the Nurse,
    2. all significant interaction which occurred between the Nurse and the inmate during the visit to administrative segregation must be recorded on the health care file.
  4. Each inmate in administrative segregation shall be visited daily, including weekends, by a registered Nurse. The visit will occur as required in subparagraphs 53 a to c.

REQUIREMENTS ON TRANSFER

  1. Prior to transfer, the inmate's health service file shall be reviewed to identify any health problems in order to ensure continuity of care and fitness for program placement at the receiving institution and to ensure that no medical complications are likely to arise during the transfer.
  2. The sending institution is responsible for all health-related care until the inmate reaches the receiving institution.
  3. If there is the potential that a medical complication may arise during the transfer, health-related information must be shared with the escorting officers on a need to know basis in accordance with CD 803 - Consent to Health Service Assessment, Treatment and Release of Information. The escorting officers must also be provided with direction regarding who to contact and what action is recommended should a complication arise.
  4. The transfer must be cancelled if the inmate is not physically able to travel (transfers to medical treatment facilities for medical purposes are exempted).
  5. Medical and dental records shall accompany the inmate and be forwarded to the institutional health service centre immediately upon their receipt. If there is no health unit at the institution, records shall be stored as outlined in CD 835 - Health Care Records.
  6. With the inmate's consent, a referral for follow up shall be made for essential treatment. Health services must complete, in the language of the receiving operation unit, a Transfer Summary (CSC/SCC 0377-1) no more than 48 hours prior to the inmate's transfer and this summary shall be sent to the receiving institution prior to the transfer.

COMMUNITY HEALTH SERVICES

  1. The Service is responsible for providing essential health services for offenders residing in a Community Correctional Centre.
  2. The Service shall be responsible for other non-insured health care expenses, for offenders residing in a Community Correctional Centre or Community Residential Centre who are unemployed and have no other source of income and who are otherwise ineligible for all other forms of government/community assistance.
  3. The Service shall be responsible for non-insured, mental health treatment costs, as stipulated by the National Parole Board or the Correctional Plan, for all conditionally released offenders.
  4. Offenders requesting services at the expense of the CSC shall obtain the approval of the Service for all non-insured, non-emergency health services, prior to obtaining those services.
  5. Offenders on full parole, statutory release or day parole who are residing in a Community Residential Centre receive essential health services in accordance with and paid by the applicable provincial health care plan.
  6. For eligible offenders, pre-release arrangements shall include application for provincial health care coverage.
  7. Provincial medical coverage for inmates being released shall be part of pre-release arrangements in accordance with case management policy.

Commissioner,

Original signed by:
Don Head