Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-caed-2_90-cv-00520/USCOURTS-caed-2_90-cv-00520-1029/pdf.json

Nature of Suit Code: 550
Nature of Suit: Prisoner - Civil Rights (U.S. defendant)
Cause of Action: 42:1983 Prisoner Civil Rights

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Stip. & Order Approving CDCR’s Telepsychiatry Policy (2:90-cv-00520 KJM-DB (PC)) 

XAVIER BECERRA, State Bar No. 118517 

Attorney General of California 

ADRIANO HRVATIN, State Bar No. 220909 

Supervising Deputy Attorney General 

ELISE OWENS THORN, State Bar No. 145931 

TYLER V. HEATH, State Bar No. 271478 

KYLE A. LEWIS, State Bar No. 201041 

LUCAS HENNES, State Bar No. 278361 

Deputy Attorneys General 

455 Golden Gate Avenue, Suite 11000 

San Francisco, CA 94102-7004 

Telephone: (415) 510-3585 

Fax: (415) 703-5843 

E-mail: Kyle.Lewis@doj.ca.gov 

Attorneys for Defendants 

ROMAN M. SILBERFELD, State Bar No. 62783 

GLENN A. DANAS, State Bar No. 270317 

ROBINS KAPLAN LLP

2049 Century Park East, Suite 3400 

Los Angeles, CA 90067-3208 

Telephone: (310) 552-0130 

Fax: (310) 229-5800 

E-mail: RSilberfeld@RobinsKaplan.com 

Special Counsel for Defendants

IN THE UNITED STATES DISTRICT COURT 

FOR THE EASTERN DISTRICT OF CALIFORNIA 

SACRAMENTO DIVISION 

RALPH COLEMAN, et al., 

Plaintiffs, 

v. 

GAVIN NEWSOM, et al., 

Defendants. 

2:90-cv-00520 KJM-DB (PC) 

STIPULATION AND ORDER 

APPROVING THE CALIFORNIA 

DEPARTMENT OF CORRECTIONS 

AND REHABILITATION’S 

TELEPSYCHIATRY POLICY 

 On January 17, 2020, Defendants and Plaintiffs attended a settlement conference before 

District Judge Dale A. Drozd, with the Special Master and his experts also present. (ECF Nos. 

6429, 6449.) The conference’s purpose was to foster agreement among the parties concerning a 

policy on the California Department of Corrections and Rehabilitation’s (CDCR) use of 

telepsychiatry to provide psychiatric services to its patient population. 

 Before the conference, Defendants circulated a proposed policy defining CDCR’s use of 

telepsychiatry for patients at various levels-of-care in the Mental Health Services Delivery 

System (MHSDS) and related operational and administrative details. With Judge Drozd’s 

assistance, the parties, with guidance from the Special Master and his experts, negotiated aspects 

Case 2:90-cv-00520-KJM-SCR Document 6539 Filed 03/27/20 Page 1 of 12
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Stip. & Order Approving CDCR’s Telepsychiatry Policy (2:90-cv-00520 KJM-DB (PC)) 

of Defendants’ proposal and reached an agreement in principle concerning CDCR’s 

telepsychiatry policy. After the conference, Defendants prepared a revised policy reflecting the 

parties’ collective work, and the parties continued to meet, confer, and discuss the policy with 

input from the Special Master. 

 On February 12, 2020, the parties reached an agreement on the terms of CDCR’s 

telepsychiatry policy, which is entitled Telepsychiatry and submitted as Exhibit A. The parties 

agree that this is a provisional policy that will not be part of the MHSDS Program Guide, and that 

the provisional period will last eighteen months from the date of the policy’s full implementation 

throughout CDCR, which will occur within 120 days of the date of the Court’s approval of this 

stipulation. During this 120-day period, Defendants will complete the internal monitoring 

process which will allow Defendants to provide notice to Plaintiffs and the Special Master, as 

required by the provisional policy. If Defendants believe that the 120-day period may need to be 

extended due to the COVID-19 pandemic impacts on CDCR, they will meet and confer with 

Plaintiffs’ counsel and the Special Master concerning an extension. If no agreement is reached, 

Defendants may seek an order from the Court extending the 120-day period. Defendants will 

provide regular updates to Plaintiffs’ counsel and the Special Master regarding the progress of 

developing and implementing the internal monitoring process. The parties further agree that this 

policy replaces all previous policies concerning CDCR’s use of telepsychiatry, and that it will be 

CDCR’s operative telepsychiatry policy during the provisional period, unless and until otherwise 

modified upon the agreement of the parties and the Special Master. 

 During the provisional period, the Special Master will monitor the use of telepsychiatry 

under the provisional policy. After completion of the eighteen-month provisional period, the 

parties will meet and confer with the assistance of the Special Master concerning a final 

telepsychiatry policy. The parties will have 30 days from the end of the provisional period to 

determine whether any alterations to the provisional policy are necessary. If no alterations are 

necessary, Defendants will submit the final telepsychiatry policy for the Court’s approval. If a 

party proposes to alter the provisional policy, the parties, under the guidance of the Special 

Master, will have a total of 60 days from the end of the provisional period to agree on a modified 

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Stip. & Order Approving CDCR’s Telepsychiatry Policy (2:90-cv-00520 KJM-DB (PC)) 

final policy. If no resolution is reached, the parties have 90 days from the end of the provisional 

period to submit their positions and proposed language for the final telepsychiatry policy to the 

Special Master for review. The Special Master will, within 30 days of receiving the parties’ 

positions, provide the parties with his guidance and recommendation. If the parties are unable to 

reach an agreement after receipt of the Special Master’s input, the Special Master will file a 

recommendation with the Court within 45 days, after which the parties’ will have 30 days to 

respond consistent with the Order of Reference (ECF No. 640). 

The Special Master has reviewed and concurs with this stipulation. 

IT IS SO STIPULATED. 

Dated: March 25, 2020 XAVIER BECERRA

Attorney General of California 

ADRIANO HRVATIN

Supervising Deputy Attorney General 

/S/ Kyle A. Lewis 

Kyle A. Lewis 

Deputy Attorney General 

Attorneys for Defendants 

Dated: March 25, 2020 ROSEN BIEN GALVAN & GRUNFELD LLP

/S/ Lisa Ells

Lisa Ells 

Attorneys for Plaintiffs 

The stipulation of the parties is approved, as is the telepsychiatry policy appended to this 

order. While the coronavirus pandemic may require use of the emergency provisions of the 

policy, the court understands from the Special Master that these emergency provisions were 

intended for short-term staffing shortages and not for pandemics. 

IT IS SO ORDERED. 

Dated: March 27, 2020. 

Case 2:90-cv-00520-KJM-SCR Document 6539 Filed 03/27/20 Page 3 of 12
EXHIBIT A

Case 2:90-cv-00520-KJM-SCR Document 6539 Filed 03/27/20 Page 4 of 12
12.08.100: Telepsychiatry Page 1 of 8 

VOLUME 12: 

MENTAL HEALTH SERVICES

Effective Date: 

CHAPTER 8:

PSYCHIATRY SERVICES 

Revision 

Date(s): 

Supersedes: 

12.08.100 

TELEPSYCHIATRY 

Attachments: Yes No 

Director 

Approval:

Policy The Telepsychiatry Program enables psychiatrists to provide real-time psychiatric 

evaluations and treatment to patients by utilizing videoconferencing to facilitate live 

communication between the telepsychiatrist, the patient, and the patient’s treatment 

team. Telepsychiatry is designed to facilitate improved patient outcomes and thereby 

reduce the need for hospitalization and emergency services. Telepsychiatric services, as 

stated in this policy and procedure, can be a safe and efficient vehicle to provide 

psychiatric care to CDCR’s mental health population.

The Telepsychiatry Program provides mental health services to the Correctional Clinical 

Case Management System (CCCMS) level of care and may, under specified 

circumstances outlined in this policy and procedure, be used for higher levels of mental 

health care. On-site psychiatrists shall remain the preferred method of psychiatric care 

for Enhanced Outpatient Program (EOP), Mental Health Crisis Bed (MHCB), and 

Psychiatric Inpatient Program (PIP)1

 programs. To ensure continuity of care for patients 

within the program, telepsychiatrists will work from CDCR-operated California hubs 

supervised by local civil service psychiatry supervisors and will be assigned to caseloads 

at the institution(s) they serve. As appropriate, some telepsychiatrists may not be 

assigned to caseloads and may instead be used as short term coverage for times when 

the assigned on-site psychiatrist or telepsychiatrist is unavailable to provide treatment to 

his or her assigned caseload. For purposes of this assignment, registry telepsychiatrists 

who have less than five years of experience working for CDCR or the Department of 

State Hospitals will not be assigned. 

Definitions

The following term is defined for use in this policy only:

x Supplement means at least 1.0 personnel year (PY) equivalent on-site 

psychiatrist shall be assigned to each EOP program (e.g., EOP General 

Population, EOP Administrative Segregation Unit Hub, or Psychiatric Services 

Unit) per yard at each institution. For each program on a yard that is allocated 

less than 1.0 PY equivalent for psychiatry per the current approved Staffing Plan, 

the position shall be filled by on-site psychiatrists. Whenever possible, the 

assigned on-site psychiatrist shall be full-time, as opposed to assigning several 

part-time psychiatrists to provide EOP care. 

Equipment

The telepsychiatrist shall be given the following equipment and resources: 

x Computer, monitor, speaker, microphone, camera, scanner/printer (can be 

individual and/or shared), and phone with access to an outside line. 

1 PIP units provide Acute Psychiatric Program (APP) and Intermediate Care Facility (ICF) levels of care. 

Case 2:90-cv-00520-KJM-SCR Document 6539 Filed 03/27/20 Page 5 of 12
12.08.100: Telepsychiatry Page 2 of 8 

x A single, enclosed, and confidential office space with a door, desk, and chair. This 

office space will be sound-proofed, where possible. 

x Computer access to all resources, or equivalent resources utilized by on-site 

psychiatrists. 

x Internet access of sufficient speed and stability to allow a videoconference where 

patient and telepsychiatrist can be seen and heard clearly. 

x Access to the Electronic Health Records System (EHRS). 

Professional and Patient Identity 

At the beginning of an initial appointment with a patient, the telepsychiatrist’s and 

patient’s identities shall be verified verbally and/or by showing their CDCR-issued photo 

identification card on the video screen. At the beginning of the patient’s first telepsychiatry 

contact, the telepsychiatrist shall explain the treatment modality, including a description 

of the role of the tele-presenter (an institutional staff member in an approved clinical 

classification who facilitates patient encounters with the telepsychiatrist), a plan for a 

response to interruption in services, and conditions under which a referral is made to in 

person care.

Participation in Interdisciplinary Treatment Teams, Meetings, and Huddles

Telepsychiatrist participation in the Interdisciplinary Treatment Teams (IDTT) is required. 

As such, telepsychiatrists shall participate in the receiving institution’s IDTT meetings. To 

facilitate telepsychiatrists’ participation in IDTTs, IDTT meetings that include a 

telepsychiatrist shall be held in a location that is appropriately wired to allow for the 

telepsychiatrist’s full participation when their patients are being reviewed. 

In addition to IDTT meetings, telepsychiatrists shall participate to the same extent as onsite psychiatrists in all meetings and huddles relevant to the clinical care of their patients. 

Refusals

If a patient refuses treatment via telepsychiatry, the patient’s telepsychiatrist may meet 

with the other members of the patient’s treatment team to consider mental health 

reasons, behavioral issues, custodial issues, and any other relevant factors to determine 

whether telepsychiatry is an appropriate delivery method for the patient. The treatment 

team may work toward resolving any issues contributing to the patient’s refusal of 

telepsychiatry services. A member from the treatment team may utilize brief, focused 

cell-front discussions with the patient to determine the reasons for appointment refusals. 

If the patient requires a psychiatric contact, the telepsychiatrist may request a 

consultation from an on-site provider or conduct a cell-front telepsychiatry contact, as 

clinically required. 

If the treatment team has not been successful in resolving the patient’s refusal of 

telepsychiatric visits, a formal IDTT meeting shall be convened. During this IDTT 

meeting, the treatment team shall develop a plan to address the reasons for the patient’s 

refusals and contingency plans shall also be made to provide in-person psychiatric care 

to the patient.

If the treatment team concludes telepsychiatry is not an appropriate treatment modality 

for the patient because of refusals, the team shall report this finding to the Mental Health 

Leadership (Chief and/or Senior Psychiatrist and Chief of Mental Health) of the institution 

receiving telepsychiatry services as well as the Chief of Telepsychiatry. If it is determined 

that the patient is not appropriate for telepsychiatry, the Chief of Telepsychiatry will work 

Case 2:90-cv-00520-KJM-SCR Document 6539 Filed 03/27/20 Page 6 of 12
12.08.100: Telepsychiatry Page 3 of 8 

with the Mental Health Leadership at the institution to ensure the patient has access to 

appropriate on-site psychiatric treatment. 

Cell Front Telepsychiatry

Telepsychiatry may be used cell front when it is necessary for the telepsychiatrist to 

speak with the patient and the patient does not attend the scheduled appointment. 

However, non-confidential telepsychiatry contacts, including cell-front contacts, shall not 

be considered a Program Guide required clinical contact under any circumstance. 

Contraindications for Telepsychiatry

Patients shall not be entirely excluded from participation in the Telepsychiatry Program 

based solely on their level of care or their diagnosis. If the telepsychiatrist and Chief of 

Telepsychiatry determine that the patient needs to be seen by an on-site psychiatrist, he 

or she will work with the Mental Health Leadership at the institution (Chief and/or Senior 

Psychiatrist and Chief of Mental Health) to make sure the patient has an appropriate 

on-site psychiatrist assigned. Similarly, if the treatment team thinks that telepsychiatry is 

not appropriate for a patient, the team will work with Mental Health Leadership to make 

sure that the patient is assigned to an on-site psychiatrist. 

Telepsychiatry and Levels of Care

Telepsychiatrists will be assigned to CCCMS, unless they are needed to supplement in 

the EOP program or there is an emergency situation as determined by Mental Health 

headquarters. If an institution requires telepsychiatry services, on-site psychiatrists shall 

be assigned to the higher levels of care. 

Correctional Clinical Case Management Services

Telepsychiatry may replace on-site psychiatry at the CCCMS level of care provided all 

other conditions pertaining to the CCCMS level of care contained within this policy are 

adhered to and good faith efforts to recruit on-site psychiatrists continue. 

Enhanced Outpatient Program 

Telepsychiatry may supplement on-site psychiatry at the EOP level of care, but it should 

not replace on-site psychiatry. On-site psychiatrists shall remain the preferred method of 

psychiatric care for each program providing EOP level of care, consistent with the 

requirements of the current approved Staffing Plan. Good faith efforts shall be made to 

recruit and retain on-site psychiatrists to provide services at the EOP level of care. If 

these good faith efforts are unsuccessful, psychiatric services may be supplemented via 

telepsychiatry consistent with the requirements described in other sections of this policy 

and procedure. If an EOP program does not have the on-site psychiatry required by this 

policy for 30 consecutive calendar days that would not be consistent with this policy’s 

objectives. In such a case, CDCR headquarters shall immediately provide notice via 

electronic mail to the Special Master and Coleman Plaintiffs’ counsel. Within 60 calendar 

days from the provision of notice, CDCR headquarters shall also provide a plan to 

address the staffing issue or provide information regarding how that issue has been 

resolved. 

Mental Health Crisis Bed

Telepsychiatry may not be used at the MHCB level of care except as a last resort in 

emergency situations when an on-site psychiatrist is not assigned to the program. Good 

Case 2:90-cv-00520-KJM-SCR Document 6539 Filed 03/27/20 Page 7 of 12
12.08.100: Telepsychiatry Page 4 of 8 

faith efforts shall be made to recruit and retain on-site psychiatrists to provide services at 

the MHCB level of care. If these good faith efforts are unsuccessful, psychiatric services 

may be provided via telepsychiatry. If a telepsychiatrist is required to serve in an MHCB 

for greater than 14 consecutive calendar days, this would not be consistent with this 

policy’s objective. In such a case, CDCR headquarters shall immediately provide notice 

via electronic mail to the Special Master and Coleman Plaintiffs’ counsel. Within 16 

calendar days from the provision of the notice, CDCR headquarters shall also provide a 

plan to address the staffing issue or provide information regarding how the staffing issue 

was resolved. 

Psychiatric Inpatient Program

Telepsychiatry may not be used at the PIP level of care except as a last resort in 

emergency situations when an on-site psychiatrist is not assigned to the program. Good 

faith efforts shall be made to recruit and retain on-site psychiatrists to provide services at 

the PIP level of care. If these good faith efforts are unsuccessful, psychiatric services 

may be provided via telepsychiatry. If a telepsychiatrist is required to serve in a PIP for 

greater than 30 consecutive calendar days, this would not be consistent with this policy’s 

objective. In such a case, CDCR headquarters shall immediately provide notice via 

electronic mail to the Special Master and Coleman Plaintiffs’ counsel. Within 30 calendar 

days from the provision of the notice, CDCR headquarters shall also provide a plan to 

address the staffing issue or provide information regarding how the staffing issue was 

resolved. 

Clinical Emergency Management

If a clinical emergency arises during a telepsychiatry session (for example, a suicidal, 

violent or homicidal patient), the telepsychiatrist shall immediately notify the appropriate 

institution staff as identified by the institution’s LOP. The telepsychiatrist shall coordinate 

with institutional Mental Health Leadership and follow local institutional protocol for 

managing such emergencies. This may include, but is not limited to, arrangements for 

the patient to be seen by an on-site psychiatrist, arrangements for safe holding, transport 

to an emergency triage area, communication with local emergency team members, and 

placing emergency orders for medications, etc.

EOP, MHCB and Psychiatric Inpatient Programs

In the event that a telepsychiatrist is needed in an EOP, MHCB or inpatient setting, the 

telepsychiatrist shall, to facilitate familiarity with the program and patients, participate in 

clinical staff meetings and case conferences, and coordinate patient care. On-site staff 

shall ensure that the telepsychiatrist has the necessary and pertinent information about 

the patient and the unit for the ongoing assessment and treatment of the patient. Similar 

to on-site psychiatrists, telepsychiatrists shall be involved in treatment and discharge 

decisions. 

In urgent cases when a patient requires seclusion and restraints, the nurse shall notify 

the telepsychiatrist, who may place orders remotely, as appropriate. All other elements 

of seclusion and restraint protocol shall follow existing policies and procedures and all 

applicable laws and regulations, including the need for a backup physician (psychiatrist 

or medical provider) who can physically examine the patient within the mandated 

timeframes. Emergency medications may be ordered by telepsychiatrists, as clinically 

appropriate.

To ensure continuity of care, telepsychiatrists shall provide relevant clinical information 

during the hand off to the on-call psychiatrist to convey details regarding a new 

Case 2:90-cv-00520-KJM-SCR Document 6539 Filed 03/27/20 Page 8 of 12
12.08.100: Telepsychiatry Page 5 of 8 

admission, to coordinate patient care tasks that require follow up during after-hours 

coverage, or if they anticipate specific patient concerns.

Telepsychiatrists and clinical staff, including nursing staff when needed, shall have 

access to each other to address patient needs.

Site Visits

Telepsychiatrists are responsible for maintaining relationships with members of the 

on-site treatment team through regular communication and by visiting institutions. 

Telepsychiatrists shall visit their assigned institution within 30 days of assignment. The 

frequency of follow-up visits shall be determined by the telepsychiatrist’s assigned level 

of care. The telepsychiatrist will spend at least one full working day, consisting of the 

regular number of hours they would normally be scheduled to work, during each site visit 

at the facility, and attend meetings as described below:

Level of Care Frequency of Site Visit 

CCCMS Biannually 

EOP, MHCB, PIP Quarterly 

During each visit, the telepsychiatrist shall participate in the IDTT, meet with necessary 

health care staff, and see patients face-to-face. 

Physical Environment

The patients’ interview room/environment shall allow for both the telepsychiatrist and the 

patient to be seen and heard clearly. The patient’s and telepsychiatrist’s camera shall be 

positioned with their faces clearly visible to each other. The telepsychiatrist shall also be 

able to clearly see the patient’s body to assess for any signs of movement disorders. 

When indicated, the telepsychiatrist can request assistance from the tele-presenter, who 

shall receive appropriate training on how to assess for such physical signs. The 

telepsychiatry administration and the institution receiving services shall ensure privacy 

so that others are not able to enter the telepsychiatrist’s or patient’s room accidently or 

overhear conversations from inside or outside the rooms. Seating and lighting should be 

adjusted to provide the clearest video and audio transmission, as well as to ensure the 

safety of the participants. Rooms for the telepsychiatrist and the patient will be 

appropriately sound-proofed, when possible, or alternative mechanisms will be utilized 

(for example, sound-cancelling devices) to ensure privacy. When possible, the telepresenter should be seated closest to the door. 

Organizational Structure

All telepsychiatry staff report within the Telepsychiatry Program supervisory chain.

Psychiatric Nurse Practitioners shall not be permitted to provide care through 

telepsychiatry.

Workflow Interruptions 

In the event of technology or equipment failure, telepsychiatrists shall immediately notify 

their direct telepsychiatry supervisor and Mental Health Leadership at the institution 

(Chief and/or Senior Psychiatrist and Chief of Mental Health), as well as the Integrated 

Communications Technology Unit. The telepsychiatrist shall also make arrangements 

with institutional Mental Health Leadership to ensure appropriate patient coverage based 

on patient need (for example, coverage by on-site provider or rescheduling of 

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12.08.100: Telepsychiatry Page 6 of 8 

appointments). Telepsychiatrists may also be redirected to another telepsychiatry 

assignment when this occurs.

On-Call Coverage by Telepsychiatry 

The telepsychiatry team shall contribute to on-call coverage as assigned, and their 

provision of services shall be in accordance with California Correctional HealthCare 

System (CCHCS) Health Care Department Operations Manual (HCDOM), Headquarters’ 

Mental Health Policy, and applicable bargaining unit Memorandums of Understanding. 

Telepsychiatrists are not required to travel to the institution where they are providing oncall coverage. Therefore, institutions receiving on-call coverage from the Telepsychiatry 

Program shall provide a backup physician (psychiatrist or medical provider). This backup 

physician shall be within one hour of travel time to the facility in order to physically 

examine a patient if needed (for example, in the case of a patient who requires placement 

into seclusion or restraints). 

Responsibilities The receiving facility shall be responsible for providing the following:

x Timely access for patients to the telepsychiatrist. 

x A dedicated and appropriately clinically trained tele-presenter who presents the 

patient from the originating site to the telepsychiatrist, and is responsible for 

providing clinical support and coordination. The tele-presenter shall be required 

to introduce themselves and explain that they are subject to the same 

confidentiality requirements as the telepsychiatrist and other medical providers. 

Responsibilities include, but are not limited to, reviewing the patient health record 

prior to the appointment and remaining with the patient during the appointment. 

Tele-presenters shall be assigned from position classifications in the following 

order of priority: medical assistant2, certified nursing assistant, psychiatric 

technician, licensed vocational nurse, registered nurse, clinical nurse specialist, 

nurse practitioner, social worker, psychologist, psychiatrist, or physician. When 

the tele-presenter is a nurse practitioner, social worker, psychologist or physician, 

the clinical contact shall be considered a joint appointment. 

x A backup tele-presenter when the primary tele-presenter is on leave or 

unavailable. 

x Institutions receiving telepsychiatry services shall have appropriate clinical staff 

available, including Nursing when needed. 

x Support staff responsible for scheduling appointments and processing clinical 

paperwork, as appropriate. 

x A contact list of important names and numbers for the institution. This includes, 

but is not limited, to the following: 

1. Laboratory 

2. Pharmacy 

3. Nursing station(s) 

4. Housing unit(s) 

5. Primary Clinician(s) 

6. Medical Provider(s) 

7. Mental Health Supervisor(s) 

8. Chief of Mental Health 

9. Chief Psychiatrist or Senior Psychiatrist Supervisor 

10. IT Department 

2 Medical Assistants cannot act as a tele-presenter for patients housed in inpatient units licensed as 

Correctional Treatment Centers

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12.08.100: Telepsychiatry Page 7 of 8 

11. Scheduler 

12. Medical Records Supervisor 

x A confidential treatment space to facilitate patient encounters. This space shall 

include all equipment needed to facilitate the telepsychiatry encounter, including 

a computer, phone, scanner, printer, desk, and chair. 

x Caseload assignments and scheduled appointments for the telepsychiatrist. 

x The maintenance of telemedicine connectivity between institutions and 

telepsychiatrists. 

x Ensuring that telepsychiatrists are appropriately privileged to provide clinical 

services to any licensed or inpatient units, when applicable. 

x Audit reports for local compliance of items such as, but not limited to, Medication 

Administration Process Improvement Project (MAPIP) criteria and Effective 

Communication requirements. 

x Organized tours for the telepsychiatrists during their initial visits to the institution. 

x Developing on-site clinical contingency plans and patient prioritization strategies 

to manage absences of telepsychiatrists. 

x A Local Operating Procedure (LOP) for Telepsychiatry shall be submitted to the 

Chief of Telepsychiatry, or designee, for review and approval prior to local 

distribution or implementation. Telepsychiatry services at an institution will not 

commence until an LOP for Telepsychiatry has been submitted and approved. 

Current and active LOPs shall be revised as necessary by the institution and 

submitted to the Chief of Telepsychiatry or designee. Any revisions of the LOP 

for Telepsychiatry shall be reviewed and approved by the Chief of Telepsychiatry 

or designee prior to implementation at the institution. 

x Routine system tests to ensure that equipment is safe, operational, and secure. 

Purpose 

 

This policy ensures services provided by the Telepsychiatry Program comply with

CDCR’s MHSDS Program Guidelines. Telepsychiatrists shall conduct care consistent 

with CDCR rules, regulations, policies, and local operating policies and procedures of 

the institution(s) to which they provide services.

Compliance

Indicators To be in compliance with this policy, the following requirements shall be met jointly by 

the Telepsychiatry Program and the institution receiving services: 

1. Telepsychiatrists are provided with the appropriate equipment and resources. 

2. Telepsychiatrists participate in the same manner as on-site psychiatrists in the 

receiving institutions’ IDTTs and all meetings and huddles relevant to the clinical 

care of their patients. 

3. On-site staff and members of the treatment team communicate with the 

telepsychiatrist any important patient issues and concerns related to patient care. 

4. Telepsychiatrists have access to all necessary clinical information via the health 

record. 

5. Telepsychiatrists will communicate any important patient issues and concerns 

related to patient care to the on-site staff and members of the treatment team.

6. Patients are not entirely excluded from participation in the Telepsychiatry 

Program based solely on their level of care or their diagnosis. 

7. Telepsychiatrists complete all documentation in the health record by the close of 

each business day. 

8. Telepsychiatrist and patient identity are verified at the beginning of a mental 

health treatment videoconference. 

9. Telepsychiatrists visit their receiving institutions as directed by policy. 

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12.08.100: Telepsychiatry Page 8 of 8 

10. Ongoing mandatory trainings for all telepsychiatrists. 

11. Telepsychiatrists are privileged at each licensed or inpatient unit they serve. 

Action

Required

The following action is required for your institution to be in compliance with the new 

policy. 

If your institution... then...

has a local operating 

procedure (LOP)

amend the current LOP to meet the new policy via an 

addendum within 30 days of the effective date valid until 

the next LOP revision date. Ensure the LOP is reviewed 

annually. 

does not have an LOP ensure that one is completed within 30 days of the 

effective date and create an LOP to meet the new policy 

requirements. Ensure the LOP is reviewed annually. 

References CDCR Mental Health Services Delivery System (MHSDS) Program Guide, 2009 

Revision 

Questions If you have any questions or need any additional information related to this policy, you 

may contact the policy unit via e-mail at: CDCR MHPolicyUnit@CDCR 

Case 2:90-cv-00520-KJM-SCR Document 6539 Filed 03/27/20 Page 12 of 12