COMMISSIONER'S DIRECTIVE

URINALYSIS TESTING IN INSTITUTIONS

Policy Bulletin 190

POLICY OBJECTIVES

1. To establish the procedures for the collection, storage, shipment, and testing of urine samples in institutions.

2. To ensure that the urinalysis program is conducted in a fair and consistent manner.

AUTHORITY

3. Commissioner's Directive 566 - Prevention of Security Incidents.

DEFINITIONS

4. Laboratory: A laboratory contracted by CSC to analyze samples is an authorized laboratory for the purposes of section 60 of the CCRR.

5. Cut-off level: concentration of a drug in the urine used to determine at which limit of quantitation the test will be considered positive or negative as per Annex A.

6. Direct observation: manner in which inmates shall supply a urine sample in open view, allowing the container, as well as the urine sample entering the container, to be seen at all times by the collector.

7. Positive test results: a urine sample containing a concentration equal to or greater than the established cut-off levels listed in Annex A.

8. Negative test results: a urine sample containing a concentration below the established cut-off levels listed in Annex A.

9. Urine sample: a quantity of urine of at least 40 ml, supplied at one time, sufficient to permit analysis by an authorized laboratory.

10. Diluted sample: the creatinine concentration in the urine sample is below the range of normal human urine.

RESPONSIBILITIES OF THE DIRECTOR GENERAL, SECURITY

11. The Director General, Security shall ensure the following:

1. that a national coordinator is identified;
2. that the training needs for Urinalysis Program Coordinators and collectors are identified and to provide the appropriate support;
3. the development and maintenance of a framework for the institutional random selection program; and
4. provide to the Institutional Head, the list of randomly selected inmates.

INSTITUTIONAL HEAD'S RESPONSIBILITIES

12. The Institutional Head shall be responsible for:

1. the implementation and maintenance of the Urinalysis Program;
2. designating a Urinalysis Program Coordinator and collectors; and
3. ensuring that the Urinalysis Program Coordinator and collectors are properly trained.

13. The Institutional Urinalysis Program Coordinator shall be anyone at or above the level of Correctional Supervisor as determined by the Institutional Head for the purpose of this policy.

REQUIREMENT TO PROVIDE A SAMPLE

Random Selection

14. The National Urinalysis Program Coordinator shall generate a random list of names of inmates for each institution based on a minimum of 5% of the institution's population.

15. The National Urinalysis Program Coordinator shall forward the random selection list to each Institutional Urinalysis Program Coordinator.

16. The Institutional Urinalysis Program Coordinator shall follow the rank order of the list.

17. If an inmate is incapacitated (due to illness or injury) or not in the institution to provide a sample when his or her name is reached, that inmate's name shall fall to the bottom of the list.

18. The random selection list is valid only for the month in which it is issued.

19. All demands for a sample shall be presented to the inmate using Notification to Provide a Urine Sample form (CSC/SCC 1064).

20. The inmate shall be required to provide a sample within two hours from the time of the request.

21. In the case of a demand based on reasonable grounds, the inmate may be provided up to two hours to submit any objection concerning the sample requirement. This time period is concurrent to the above.

22. Also during the same two hours, the inmate may drink fluids.

COLLECTION OF SAMPLES

23. The date and time of demands for samples shall be irregular. Inmates shall not be informed of the date and time when they will be required to provide a urine sample.

24. The collection area shall be searched by the collector prior to the inmate's arrival.

25. Access to the collection area shall be controlled while the urine collection is in progress.

26. The collector shall escort the inmate to the collection area and may conduct a routine non-intrusive search or a routine frisk search of the inmate as set out in the Institutional Search Plan.

27. The collector shall require that the inmate remove any bulky clothing, such as a coat or loose fitting outer garments, in order to reduce the possibility of an attempt to alter or falsify the urine sample.

28. Collection and storage of samples shall be conducted according to laboratory procedures.

29. The number of persons involved in handling samples shall be kept at a minimum.

30. A completed copy of the Chain of Custody form (CSC/SCC 1065) shall be enclosed in a sealed, waterproof bag and inserted into the shipping container.

31. Each shipping container shall be sealed, signed and dated by the collector or the Urinalysis Program Coordinator across a tamper resistant tape affixed on the top of the shipping container. The tape shall overlap the top and go down on both sides.

32. The shipping container shall be transported to the laboratory by a designated governmental or private courier service.

TESTING OF SAMPLES

33. After testing, the urinalysis results shall be transmitted by the laboratory to the specific responsibility centre, in accordance with the contractual requirements.

REPORTING OF TEST RESULTS

34. The test results for an inmate shall be forwarded to the inmate's Parole Officer, the Substance Abuse Program Coordinator, the Preventive Security Officer and as required, Health Care staff.

35. If an inmate disputes a positive test result and wishes to have a retest of the same sample, the Institutional Urinalysis Program Coordinator shall contact the National Urinalysis Program Coordinator who in turn shall process the request.

36. Payment for a retest is the responsibility of the inmate and shall be paid in advance.

CONSEQUENCES OF POSITIVE TEST RESULTS

37. Further to administrative consequences, the inmate shall be subject to the disciplinary process.

DATA COLLECTION PROCEDURES

38. The Institutional Urinalysis Program Coordinator shall ensure that all relevant data related to the urinalysis testing are properly recorded in the Offender Management System (OMS) in a timely fashion.

39. All inmate information related to the Urinalysis Program shall be classified "PROTECTED B".

40. Notwithstanding any other provisions of this CD and based on his/her informed consent, an inmate may be requested to provide a urine sample for on-site urinalysis pre-screening as part of an established program or activity that requires monitoring of abstinence from intoxicants as a condition of voluntary participation in that program or activity. Any potential administrative consequences flowing from a non-negative pre-screening test result must be clearly understood for consent to be informed, and no other consequences may be imposed for failing to provide consent or failing to provide a sample when requested.

Commissioner,

Original signed by
Lucie McClung

ANNEX A - CLASS OF INTOXICANTS

¹. If the confirmation for subgroup a) of Benzodiazepines is negative, the laboratory will sequentially proceed to confirm subgroup b) and then subgroup c) using the limit of quantitation for each drug.

². If the confirmation for subgroup a) of Opiates is negative, the laboratory will proceed to confirm subgroup b) using a 300 ng/ml cut-off value.

ANNEX B - ANALYSIS OF DILUTED/ADULTERATED SAMPLES

1. If the creatinine concentration in the urine sample is less than 20mg/dL and/or the specific gravity is less than or equal to 1.003, a comprehensive forensic toxicology drug screening of the urine specimen for Group 1 drugs will be completed.

2. The confirmatory cut-off value for each substance are shown in the table below.

* The confirmation LOQ numbers are subject to change upon method revalidation.

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