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COMMISSIONER'S DIRECTIVE
HEALTH SERVICES
Issued under the authority of the Acting Commissioner of the Correctional Service of Canada |
1. To ensure that inmates have access to essential medical, dental and mental health services in keeping with generally accepted community practices.
2. Corrections and Conditional Release Act, sections 85 to 89;
Corrections and Conditional Release Regulations.
3. Medical emergency: an injury or condition that poses an immediate threat to a person's health or life which requires medical intervention.
4. Inmates shall have access to screening, referral and treatment services. Essential services shall include:
- emergency health care (i.e., delay of the service will endanger the life of the inmate);
- 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);
- mental health care provided in response to disturbances of thought, mood, perception, orientation or memory that significantly impairs 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
- 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.
5. Inmates shall have reasonable access to other health services (i.e., conditions not outlined above) which may be provided in keeping with community practice. The provision of these services will be subject to considerations such as the length of time prior to release and operational requirements.
6. In support of providing essential health services, emphasis will be placed on health promotion/illness prevention.
7. Health services shall only be provided by health care professionals who are registered or licensed in Canada, preferably in the province of practice.
8. 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.
9. All staff shall be responsible for bringing to the attention of a health care professional, the condition of any inmate who appears to be ill, whether he/she complains or not.
10. A process shall be in place to allow inmates the opportunity to submit in confidence a request for health care services, indicating the reason for the request.
11. An inmate's request for health services attention shall be relayed to a health care professional without delay.
12. Inmate requests for routine health services shall be screened by a nurse or other health care professional and referred to a clinician as appropriate.
13. The Institutional Head shall ensure 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.
14. Health Education and Promotion programs shall be provided to meet the identified needs of individual offenders and specific offender groups.
15. Medication for inmates shall be prescribed by an institutional clinician only when clinically indicated. Accordingly, the administration of medication to inmates for restraint or for other security purposes shall not be undertaken. In addition, health care personnel shall not take or assist in taking specimens for non-medical reasons.
16. 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 Commissioner's Directive 803.)
17. Within two (2) working days of initial reception, including a warrant of suspension, every inmate shall be given a nursing assessment and a referral to an appropriate clinician, if necessary. This nursing assessment shall, at a minimum, screen for:
- communicable conditions;
- acute medical, mental or dental conditions;
- conditions requiring continuing treatment; and
- activity limitations.
18. Within 14 days of admission to the CSC, each inmate shall be offered a comprehensive nursing assessment which shall include:
- inmate's health status (present, historical and family);
- update of immunization status in accordance with the recommendations of the Canadian Immunization Guide;
- immunization for Hepatitis B;
- 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);
- counselling regarding Human Immunodeficiency Disease (HIV) and offer screening for the infection;
- health education and promotion programs to meet the identified health needs of individual inmates and specific inmate groups; and
- referral to other health care professionals if deemed appropriate.
19. The findings of nursing assessments shall determine the requirements for treatment, hospitalization, special housing and/or program placement.
20. Procedures regarding prophylaxis, treatment and reporting of infectious or communicable diseases shall be in accordance with provincial health regulations.
21. Prior to expected reception of inmates with mandatory treatment requirements, institutional health care staff shall inform the Medical Officer of Health.
22. Inmates shall have access to 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.
ROUTINE CARE AND MEDICAL EMERGENCY SITUATIONS
23. Procedures for health care emergencies shall be in place in all institutions.
24. In the absence of a clinician Health Care Orders shall be established to outline the course of action to be taken by health service staff in both routine and emergency situations. When 24-hour nursing coverage is not provided, on-site staff with current certification in basic first aid and cardiopulmonary resuscitation (CPR) training will be available on site. A list of staff maintaining this certification shall be routinely accessible throughout the institution.
25. In responding to a medical emergency, the primary goal is the preservation of life and each staff member has an important role to play:
- 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;
- responding staff must attempt CPR/first aid where physically feasible even in cases where signs of life are not apparent (pronouncement of death can be done only by authorized health personnel in accordance with provincial laws);
- staff must use approved protective equipment when administering CPR/first aid;
- once initiated, staff will continue to perform CPR until relieved by Health Services staff or the ambulance service;
- as soon as a possible medical emergency is identified, the Correctional Supervisor or officer-in-charge must notify Health Services and the ambulance service in accordance with the Institutional Contingency Plan, Standing Orders or Post Orders;
- the Correctional Supervisor or officer-in-charge must immediately establish appropriate security for responding staff and the ambulance service;
- once on the scene, Health Services or the ambulance service shall be responsible for determining the medical response to the situation;
- correctional staff on the scene will continue to provide assistance as directed by Health Services or the ambulance service;
- the Institutional Head shall ensure all staff have ready access to necessary protective and first aid equipment in all work locations;
- all correctional officers shall be issued approved protective masks and gloves that must be carried on their person; and
- the Institutional Head shall ensure that debriefings occur immediately following a medical emergency and offer Critical Incident Stress Debriefing (CISD) to all staff involved in the incident as set out in the Guidelines on Critical Incident Stress Management and within two working days.
26. The Institutional Head must ensure there are quarterly on-site simulations of medical emergencies that will allow staff to practice and remain current in skills. The scenarios used for the medical emergency exercises shall be developed in consideration of the particular institution's circumstances relating to the availability of medical resources within the community and will emphasize the specific needs of the midnight shift.
27. The responsibility of health care personnel for both visitors and staff shall be limited to emergency care until outside services are available.
28. 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:
- official authorization is obtained from both the medical authorities and the health care administration authorities of the institution;
- a certification procedure is established; and
- a regular evaluation of competence is established for each delegated medical act.
29. 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
30. All inmate-requested services deemed non-essential by the institutions 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.
31 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 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.
32. 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 physicians from a recognized gender identity disorder clinic.
33. 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.
34. 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.
35. Sex reassignment surgery shall be considered during incarceration only when:
- 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
- the recognized gender identity specialist recommends surgery during incarceration.
36. 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.
37. CSC shall proceed without delay to determine the timing of the surgery taking into account operational considerations and the offender's release date.
38. 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.
39. The Institutional Head shall ensure that staff who have regular contact with offenders with gender identity disorder have been provided with the knowledge to effectively respond to their needs.
40. Subject to operational considerations, offenders diagnosed with gender identity disorder shall be permitted to cross-dress.
41. Offenders with opioid addictions are eligible for methadone treatment, in accordance with the Methadone Treatment Guidelines.
42. 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 inmate-patients with incapacitating illness, who are chronically sick and have impairments which have one or more of the following characteristics:
- are residual;
- leave residual disability;
- are caused by non-reversible pathological alteration; and
- require a long period of supervision, observation or care.
43. Accommodation shall be provided for pre- and post-natal care; however, arrangements shall be made for delivery at an outside hospital.
44. 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.
45. 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.
46. 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.
47. 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.
48. 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.
49. The sending institution is responsible for all health-related care until the inmate reaches the receiving institution.
50. 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 Commissioner's Directive 835.
51. With the inmate's consent, a referral for follow up shall be made for essential treatment. A health care administrative summary, in the language of the receiving operational unit, shall be sent prior to transfer.
52. Offenders on full parole, statutory release and 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.
53. The Service is responsible for providing essential health services for offenders residing in a Community Correctional Centre.
54. 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.
55. 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.
56. Offenders requesting services at the expense of the CSC shall obtain Service approval for all non-insured, non-emergency health services, prior to obtaining that service.
57. For eligible offenders, pre-release arrangements shall include application for provincial health care coverage.
58. Provincial medical coverage for inmates being released shall be part of pre-release arrangements in accordance with the Case Management Manual.
A/Commissioner,
Original signed by
Don Head
