Health Evaluations Segregated Restrictive

Idaho
Department of
Correction

Standard
Operating
Procedure

Operations
Division

Operational
Services
Control Number:
401.06.03.045
Version:
2.2
Page Number:
1 of 5
Adopted:
3-11-1999
Reviewed:
5-30-2012

Title:
Health Evaluations for Offenders in
Segregated/Restrictive Housing Units

This document was approved by Shane Evans, director of the Education,
Treatment, and Reentry Bureau, on 5/30/12 (signature on file).
Open to the general public: Yes
BOARD OF CORRECTION IDAPA RULE NUMBER 401
Medical Care
POLICY CONTROL NUMBER 401
Clinical Services and Treatment
DEFINITIONS
Standardized Terms and Definitions List
Clinical Setting: An environment in which an examination or treatment room is
appropriately supplied and equipped to address a patient’s confidential healthcare needs.
Contract Medical Provider: A private company or other entity that is under contract with
the Idaho Department of Correction (IDOC) to provide comprehensive medical, dental,
and/or mental health services to the IDOC’s incarcerated offender population.
Facility Health Authority: The contract medical provider employee who is primarily
responsible for overseeing the delivery of medical services in an Idaho Department of
Correction (IDOC) facility.
Facility Medical Director: The highest ranking physician in an Idaho Department of
Correction (IDOC) facility.
Health Authority: The Idaho Department of Correction (IDOC) employee who is primarily
responsible for overseeing or managing the IDOC’s medical services. (The health authority
is commonly referred to as the health services director.)
Qualified Health Professional: A physician, physician assistant, nurse practitioner, nurse,
dentist, mental health professional, or other health professional who — by virtue of his
education, training, credentials, and experience — is permitted by law (within the scope of
his professional practice) to educate, train, evaluate, provide services, and care for patients.
Restrictive Housing: Housing that (a) separates offenders from the general population,
and (b) includes administrative segregation, disciplinary detention, protective custody (PC),
transit, segregation pending investigation (SPI), pre-hearing segregation (PHS), and those
offenders under sentence of death.
Sick Call: The evaluation and treatment of an ambulatory patient in a clinical setting, either
on- or off-site, by a qualified health professional.
Control Number:
401.06.03.045
Version:
2.2
Title:
Health Evaluations for Offenders in
Segregated/Restrictive Housing
Units
Page Number:
2 of 5

PURPOSE
The purpose of this standard operating procedure (SOP) is to establish procedures for
ensuring that offenders placed in segregated housing units (i.e., restrictive housing) will
have direct access to healthcare services staff.
SCOPE
This SOP applies to all Idaho Department of Correction (IDOC) healthcare services staff,
offenders, contract medical providers and subcontractors.
RESPONSIBILITY
Health Authority
The health authority is responsible for:
• Monitoring and overseeing all aspects of healthcare services, and
• The implementation and continued practice of the provisions provided in this
SOP.
When healthcare services are privatized, the health authority will also be responsible for:
• Reviewing and approving (prior to implementation) all applicable contract medical
provider policy, procedure, and forms; and
• Monitoring the contract medical provider’s performance, to include but not limited
to reviewing processes, procedures, forms, and protocols employed by the
contract medical provider to ensure compliance with all healthcare-related
requirements provided in respective contractual agreements, this SOP, and in
the following National Commission on Correctional Health Care (NCCHC)
standard P-E-09, Segregated Inmates. (See section 2 of this SOP.)
Contract Medical Provider
When healthcare services are privatized, the contract medical provider is responsible
for:
• Implementing and practicing all provisions of this SOP, unless specifically
exempted by written contractual agreements;
• Ensuring that all aspects of this SOP and NCCHS standard P-E-09 are
addressed by applicable contract medical provider policy and procedure;
• Ensuring facility health authorities utilize all applicable contract medical provider
policy, procedure, forms, and educational information to fulfill all healthcare-
related requirements provided in this SOP, NCCHC standard P-E-09, or as
indicated in their respective contractual agreement(s);
Note: Nothing in this SOP shall be construed to relieve the contract medical provider(s)
of any obligation and/or responsibility stipulated in respective contractual agreements.
Facility Health Authority
The facility health authority will be responsible for:
Control Number:
401.06.03.045
Version:
2.2
Title:
Health Evaluations for Offenders in
Segregated/Restrictive Housing
Units
Page Number:
3 of 5

• Ensuring the presence of an adequate number of appropriately trained staff and
materials are available to meet the requirements of this SOP;
• Establishing and monitoring applicable contract medical provider policy and
procedure to ensure that all elements of this SOP and NCCHC standard P-E-09
are accomplished as required. (Also see section 1.)
Qualified Health Professional
The qualified health professional will be responsible for:
• Reviewing the offender’s healthcare record to determine whether existing
medical, dental, or mental health needs contraindicate placement or require
accommodation;
♦ If the review determines contraindicate placement is needed, the qualified
health professional will (a) notify and consult with the shift commander (or
designee) regarding housing alternatives, and (b) document the notification
and consultation in the offender’s healthcare record.
♦ If the offender is transferred from one correctional facility’s
segregated/restrictive housing unit to another’s (including IDOC facilities,
county jails, privately managed facilities, and out-of-state facilities), the
qualified health professional will also review related documentation such as
the intrasystem transfer form and document receipt in the receiving progress
note.
• Documenting the completed review in the healthcare record.
• Scheduling appointments for the offender to meet with the appropriate
practitioner (e.g., a physician, nurse practitioner, physician assistant, dentist, or
mental health professional) in a timely manner. (Note: This is only required when
a medical, dental, or mental health need requires evaluation and/or intervention.)
(Also see section 1.)
• Referring the offender to the appropriate mental health professional for further
evaluation (if indicated/documented in the record). (Also see section 1.)
• Making visual and verbal contact (i.e., wellness checks) with offenders placed in
segregated/restrictive housing, and documenting each contact on the appropriate
form. (Note: Contact shall occur at least three (3) times per week.) (Also see
section 1.)
Qualified Mental Health Professional
When receiving a referral from the qualified health professional, the qualified mental
health professional will be responsible for:
• Providing the evaluation and documenting the evaluation in the offender’s
healthcare record;
• Documenting the completed review in the healthcare record;
• Referring the offender to the appropriate mental health provider for further
evaluation (if indicated/documented in the record).
Control Number:
401.06.03.045
Version:
2.2
Title:
Health Evaluations for Offenders in
Segregated/Restrictive Housing
Units
Page Number:
4 of 5

Licensed Medical or Mental Health Provider
When receiving a referral from the qualified health professional or qualified mental health
professional, the licensed medical or mental health provider will be responsible for:
• Providing timely and appropriate healthcare services, and
• Documenting all services/contacts rendered in the offender’s healthcare record.
Facility Head
The facility head will be responsible for ensuring that procedures are in place for
immediately notifying the facility health authority (or designee) when an offender is
placed in segregated/restrictive housing.
Shift Commander
The shift commander (or designee) will be responsible for immediately notifying the
facility health authority (or designee) when an offender is placed in segregated/restrictive
housing.
Table of Contents
General Requirements ......................................................................................................... 4
1. Guidelines ...................................................................................................................... 4
2. Compliance .................................................................................................................... 5
References ........................................................................................................................... 5
GENERAL REQUIREMENTS
1. Guidelines
To ensure that an offender’s placement in segregated/restrictive housing is not
contraindicated based on medical and/or mental health concerns, healthcare services staff
will conduct an initial and ongoing evaluation as described in this section and make referrals
for medical, dental, and/or mental health care as clinically indicated.
Upon receiving notification of an offender’s placement in segregated/restrictive housing, the
facility health authority (or designee) must ensure that all of the responsibilities noted above
(see the section titled ‘Responsibility’) and the following elements and standards are
accomplished:
• If the offender is currently receiving mental health treatment, a referral will be made
to the appropriate mental health provider for further evaluation. The referral and
evaluation will be documented in the offender's healthcare record.
• Visual and verbal contact (i.e., wellness checks) with offenders will be noted on the
appropriate forms maintained on each individual offender in segregated/restrictive
housing. Documentation should include the date, time, and the signature (or initials)
of the qualified health professional completing the wellness check. Upon release
from segregated/restrictive housing, documentation of all wellness checks will be
placed in the offender's healthcare record.
Control Number:
401.06.03.045
Version:
2.2
Title:
Health Evaluations for Offenders in
Segregated/Restrictive Housing
Units
Page Number:
5 of 5

• Non-emergency health care requests and services (i.e., sick call) will be provided in
segregated/restrictive housing units in accordance with SOP 401.06.03.037, Non-
emergency Healthcare Requests and Services, and nothing in this SOP shall be
construed as eliminating the need for routine sick call services to be provided for all
inmates in segregated/restrictive housing units as delineated in NCCHS standard P-
E-07, Non-emergency Healthcare Requests and Services. Clinical encounters will
take place in an appropriate clinical setting.
• Upon identification of any medical, dental, or mental health need requiring evaluation
and/or intervention by a physician, mid-level provider, dentist, or mental health
professional, arrangements will be made to provide timely examination, assessment,
and/or treatment by scheduling an appointment with the appropriate practitioner.
Note: Placement in segregated/restrictive housing shall not preclude or in any way be used
as a barrier to an offender’s access to care.
2. Compliance
Compliance with this SOP and all related IDOC-approved protocols will be monitored by the
health authority (or designee) by using various sources to include: this SOP, clinical practice
guidelines, routine reports, program reviews, and record reviews.
The health authority (or designee) must conduct two (2) audits per year, per facility (or more
frequently as desired based on prior audit results). The audits must consist of monitoring
applicable contract medical provider, IDOC policy and procedures, applicable NCCHC
standards, and the review of a minimum of 15 individual records.
REFERENCES
National Commission on Correctional Health Care (NCCHC), Standards for Health Services
in Prisons, Standard P-E-07, Non-emergency Healthcare Requests and Services
National Commission on Correctional Health Care (NCCHC), Standards for Health Services
in Prisons, Standard P-E-09, Segregated Inmates
Standard Operating Procedure 401.06.03.037, Non-emergency Healthcare Requests and
Services
– End of Document –