Or. Admin. Code § 291-124-0041

Current through Register Vol. 63, No. 12, December 1, 2024

Section 291-124-0041 - Healthcare and Treatment

(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 Chief of Medicine and is subject to peer review. The department is not obligated to carry out any recommendations or treatment plans formulated by any outside providers if ongoing care is required. Medical care and treatment is generally prioritized into the following four levels of care and treatment:

(a) Level 1 Care and Treatment (Medically Mandatory Care and Treatment): Level 1 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.

(A) Level 1 care and treatment may include, but is not limited to:

(i) 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);

(ii) 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

(iii) Maternity care (for example, monitoring, delivery, hypertension in pregnancy)

(B) Level 1 care and treatment is generally provided to all AICs by the department. A treating provider may authorize Level 1 care and treatment. In emergency situations, any qualified licensed DOC health professional may authorize Level 1 care and treatment.

(b) Level 2 Care and Treatment (Presently Medically Necessary Care and Treatment): Level 2 care and treatment is defined as care and treatment without which an AIC 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.

(A) Level 2 care and treatment may include, but is not limited to:

(i) 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, hypertension, etc.);

(ii) Immunizations;

(iii) Comfort care such as pain management and hospice type care for the end stages of diseases such as cancer and acquired immunodeficiency syndrome (AIDS);

(iv) Proven effective preventive care for adults, e.g., preventive dental care, mammograms, pap smears, blood pressure screenings;

(v) 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

(vi) 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 AICs and, when not of an emergency nature, subject to periodic utilization review and appropriateness by the Health Services Chief of Medicine. A treating practitioner may authorize Level 2 care or treatment.

(c) Level 3 Care and Treatment (Medically Acceptable or Appropriate but Not Medically Necessary): Level 3 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 AIC.

(A) 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, and hip replacement.

(B) Level 3 care and treatment may be authorized on an individual-by-individual basis or on a case-by-case basis as follows:

(i) 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 provider may be offered at the discretion of the treating provider or may be referred by an attending provider to the Health Services Chief of Medicine for clinical review under this rule to determine whether to authorize the medical or surgical care and treatment.

(ii) Other medical or surgical care and treatment, including offsite procedures and therapies for chronic diseases may be referred to the Health Services Chief of Medicine for clinical review under this rule to determine whether to authorize the medical or surgical care and treatment.

(iii) Care and treatment described in OAR 291-124-0043 (eyeglasses), OAR 291- 124-0044 (hearing aids, and OAR 291-124-0045 (durable medical equipment) may be authorized as provided in those rules.

(d) Level 4 Care and Treatment (Of Limited Medical Value): Level 4 care and treatment 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 may include 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. Examples of Level 4 care and treatment include but is not limited to tattoo removal, minor nasal reconstruction, oral aphthous ulcers, elective circumcision, care or treatment for the common cold or infectious mononucleosis, surgery for gynecomastia.

(B) Level 4 care and treatment will not be routinely provided. AICs may be eligible to pay for Level 4 care and treatment as provided in OAR 291-124-0085.

(3) Exceptions to Levels of Care and Treatment: The four Levels of Care and Treatment 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. Also, there may be circumstances in which the level of care or treatment for a certain condition or disorder may be unclear, or in which it may not be appropriate to apply a specific level of care and treatment. In any case, a provider may refer an individual case to the Health Services Chief of Medicine for clinical review under this rule to determine whether to authorize care or treatment.

(4) Clinical Review: Under appropriate circumstances, individual cases may be referred to the Health Services Chief of Medicine for clinical review. The Health Services Chief of Medicine may form a review committee (sometimes referred to as a "Therapeutic Levels of Care Committee" or "TLC Committee",) which may include one or more department providers, the Medical Services Manager, and other appropriate Department staff. The TLC Committee review care and treatment requests on a case-by-case basis, with the Health Services Chief of Medicine (or designee) as the final authority in any review. Factors that the TLC Committee may consider include, but are not limited to:

(a) The urgency of the care and treatment, and the length of the AIC'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.

(b) The necessity of the care or treatment, including:

(A) Any relevant functional disability and the degree of functional improvement to be gained;

(B) Medical necessity, or the overall morbidity and mortality of the condition if left untreated;

(C) Pre-existing conditions, whether the condition existed prior to the AIC's incarceration and, if treatment was not obtained previously, the reasons for not obtaining earlier treatment;

(D) The probability the procedure or therapy will have a successful outcome along with relevant risks;

(E) Alternative therapy or procedures that may be appropriate;

(F) The AIC's desire for the procedure and the likelihood of the AIC's cooperation in the treatment efforts;

(G) Any known risks or benefits relative to those risks;

(H) Any known costs or benefits relative to those costs;

(I) Pain complaints or pain behaviors; and

(J) Any other factors that are relevant or pertinent in light of the circumstances presented.

(c) When considering whether to provide devices described in OAR 291-124-0043 (eyeglasses), OAR 291-124-0044 (hearing aids), or OAR 291-124-0045 (durable medical equipment), the TLC Committee shall consider the AIC's ability to engage in activities of daily living and ability to access programs, services, and activities of the institution.

(5) Therapeutic Diets: Therapeutic diets may be ordered by a treating provider for an AIC 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 AIC.

(6) Work Limitations: Health Services will screen AICs for work limitations at the assignment supervisor's request. Ongoing daily review of AIC workers for symptoms of illness that would interfere with the work assignment is the responsibility of the on-site work supervisor.

Or. Admin. Code § 291-124-0041

CD 18-1995, f. 9-25-95, cert. ef. 10-1-95; DOC 16-2010, f. &cert. ef. 11-19-10; DOC 17-2017, temporary amend filed 11/07/2017, effective 11/07/2017 through 05/05/2018; DOC 3-2018, amend filed 05/03/2018, effective 5/3/2018; DOC 6-2020, amend filed 04/10/2020, effective 4/10/2020; DOC 14-2021, temporary amend filed 10/28/2021, effective 10/28/2021through 4/25/2022; DOC 4-2022, amend filed 04/21/2022, effective 4/21/2022; DOC 5-2023, amend filed 03/10/2023, effective 3/10/2023; DOC 17-2024, amend filed 08/13/2024, effective 8/13/2024

Statutory/Other Authority: ORS 179.040, 423.020, 423.030 & 423.075

Statutes/Other Implemented: ORS 179.040, 423.020, 423.030 & 423.075