HomeMy WebLinkAboutMental Health Services SystemIdaho
Department of
Correction
Standard
Operating
Procedure
Title:
Mental Health Service System
Page:
1 of 10
Control Number:
327.02.01.002
Version:
2.0
Adopted:
09/25/2017
IDOC Data Sensitivity Classification - L3 Restricted
Chad Page, chief of the Division of Prisons and Walter Campbell, chief psychologist,
approved this document on 07/27/2020.
Open to the public: Yes
SCOPE
This standard operating procedure (SOP) applies to all Idaho Department of Correction
(IDOC) employees, and incarcerated individuals in all IDOC and IDOC-contracted
correctional facilities.
Revision Summary
Revision date (07/27/2020) version 2.0: Revised to reflect the ability to facilitate groups with
the Level of Care (LOC) of CMHS-2; LOCs were updated, including the removal of LOC
Mental Health Prior (MHP); the referral process for the admittance into the mental health
unit(s) was updated.
TABLE OF CONTENTS
Board of correction IDAPA R ule Number .............................................................................. 2
Policy Control Number 327................................................................................................... 2
Purpose ................................................................................................................................ 2
Responsibility ....................................................................................................................... 2
Standard procedures ............................................................................................................ 3
1. Scheduling ................................................................................................................... 3
2. Training ........................................................................................................................ 3
3. Mental Health Screening .............................................................................................. 4
4. Mental Health Assessment ........................................................................................... 4
5. Level of Care (LOC) ..................................................................................................... 4
6. Treatment Planning ...................................................................................................... 6
7. Access to Care ............................................................................................................ 7
8. Refusals of Care .......................................................................................................... 7
9. Documentation of Mental Health Services ................................................................... 7
10. Mental Health Units ...................................................................................................... 8
11. Mental Health Emergencies ......................................................................................... 9
12. Reports Provided ......................................................................................................... 9
Control Number:
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13. Annual Policy and SOP Update ...................................................................................10
Definitions ...........................................................................................................................10
References ..........................................................................................................................10
BOARD OF CORRECTION IDAPA RULE NUMBER
None
POLICY CONTROL NUMBER 327
Mental Health Services System
PURPOSE
The purpose of this SOP is to provide standardized guidance for the delivery of mental
healthcare services in Idaho Department of Correction facilities.
RESPONSIBILITY
The division of prisons chief or designee, in collaboration with the IDOC chief psychologist,
is responsible to approve all facility field memoranda.
Chief Psychologist is responsible for:
• Oversight and standardization of all mental health care in prison facilities.
• Functioning as the mental health authority for the IDOC.
• Overseeing the development and subsequent revisions of this SOP.
• Monitoring the adherence to this SOP and all other policy and procedure related to
mental healthcare services.
Facility Heads are responsible for:
• Ensuring the facility’s implementation of this SOP.
• Establishing processes and systems of control to ensure that security staff and
mental healthcare services staff support each other in day-to-day operations.
• Ensuring mental health services are discussed at administrative meetings that occur
at least quarterly.
• Ensuring that health services meetings occur monthly, including discussion of mental
health services, and that mental health staff members are present.
Clinical Supervisors are responsible for:
• Providing direct oversight and supervision of clinicians, psychiatric treatment
coordinators, and psychiatric technicians.
• Designating clinical coverage at the facility by establishing a schedule for mental
healthcare services staff, including clinical supervision coverage.
• Functioning as the suicide risk management coordinator at their assigned
institution(s).
• Ensuring on a quarterly basis that all clinical staff members have a current license.
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Clinicians are responsible for:
• Providing mental health treatment to incarcerated individuals in accordance with this
SOP and other IDOC policies and procedures.
• Consulting with case managers, medical and mental healthcare staff, and security
staff regarding the mental health needs of incarcerated individuals.
• Maintaining a current license and reporting to the chief psychologist any actions
against the license, including but not limited to complaints or other disciplinary action.
STANDARD PROCEDURES
Mental health staff must provide timely, mental health services that optimize the level of
individual functioning of mentally ill incarcerated individuals and those vulnerable to mental
health disorders in the least restrictive environment. Any incarcerated individual can request
mental health services at any time, regardless of any previous mental health treatment or
diagnosis.
1. Scheduling
Each site’s clinical supervisor, in conjunction with the facility head or designee, must develop
a daily clinical staff schedule that meets the needs of the facility. This schedule must be
available to shift commanders, facility administration, the chief psychologist, and other IDOC
staff who need to be aware of mental health staffing at the facility.
For facilities where clinical staff members are not on site seven days a week, an on-call
schedule must be generated by the facility clinical supervisor for all weekends and holidays.
Approved schedules will be disseminated to shift commanders, central control officers,
facility administration, chief psychologist, and clinical supervisors a minimum of 24 hours
before the start of the schedule.
2. Training
All mental healthcare staff will receive an initial, basic orientation that occurs at the facility
with the clinical supervisor or designee on the first day of employment, which includes:
• Orientation to all security, mental health, and medical services
• Facility emergency procedures
• Functional position description
• Appropriate boundaries
• Safety and security practices
Within ninety days of employment, mental healthcare staff will receive in-depth orientation
covering:
• All mental health and relevant medical policies
• Typical mental health needs of patients
• Infection control and standard precautions
• Confidentiality of mental health records
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• Mental healthcare staff also receive all training required of other facility personnel
• The requirement that mental health staff members receive at least twenty hours of
Idaho Bureau of Licensing-approved training annually, per Idaho licensure standards.
For all mental healthcare staff, completion of the orientation program is documented and
kept on file by the clinical supervisor.
3. Mental Health Screening
All incarcerated individuals entering an IDOC facility as a new arrival, a return, or a transfer
from another IDOC facility, will receive a mental health screening by a mental health-trained
staff member immediately upon entry to the facility but no later than twelve hours after
arrival. The inmate handbook, which contains information about mental health services, is to
be provided to incarcerated individuals upon arrival to RDU. Written information is also to be
posted in the area where intake procedures occur.
Mental health screens are also conducted for all incarcerated individuals entering restrictive
housing prior to placement in a restrictive housing cell.
Only mental health or mental health-trained staff may complete a mental health screen;
security staff or any other non-medical or non-mental health staff cannot conduct these
screens. Mental health screens must be reviewed within twenty-four hours by a licensed
clinician and follow up care must be provided within the time frame indicated by the mental
health disposition.
If the incarcerated individual refuses to cooperate in the screening process, they must be
placed on suicide watch in accordance with SOP 315.02.01.001, Suicide Risk Management
and Intervention.
4. Mental Health Assessment
When an incarcerated individual’s initial mental health screen indicates follow up
assessment is needed, an initial Mental Health Assessment will be completed by a licensed
clinician within fourteen days of admission to the facility.
The Mental Health Assessment is to be conducted by a clinician and requires informed
consent to be obtained and documented in the medical record. In addition, a Consent for
Release of Confidential Information must be requested, if clinically indicated.
A Mental Health Assessment Update will be completed annually by a licensed clinician, as
deemed necessary by the incarcerated individual’s Level of Care (LOC) (see Section 5
below). Informed consent and LOC (see below) must be renewed and documented annually.
5. Level of Care (LOC)
The LOC identifies the incarcerated individual’s level of clinical need and provides directives
and timeframes for mental health treatment services.
Each incarcerated individual should be assigned an LOC that matches their level of clinical
need. If a new LOC is needed, the decision to increase or decrease the LOC must be made
by a clinician based on the incarcerated individual’s demonstrated stability and level of
functioning through a face to face assessment. In cases when the decision whether to
decrease or increase an LOC is unclear, the clinician should consult with the facility clinical
supervisor.
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In the event that an incarcerated individual refuses mental health services, their refusal
should be signed and documented and the clinician will determine an appropriate LOC
regardless of the refusal, and services will still be offered according to the LOC.
At a minimum, if the LOC requires, the LOC should be evaluated annually during the mental
health assessment update and updated in the offender management system regardless of
whether or not the level changes. If an LOC is created or changed, it must be entered into
the offender management system within twenty-four hours.
These LOC standards are guidelines and individual cases may require deviation from these
guidelines. In such cases, clinical discretion may be used to alter the treatment plan if
justification is documented in the electronic medical record with approval from the site
clinical supervisor or other clinical supervisor as assigned.
There are six LOC designations that may be assigned to an incarcerated individual:
Acute Correctional Mental Health Services (ACMHS)
• This LOC is for incarcerated individuals with the most profound and debilitating
impairments in functioning. These incarcerated individuals may present a serious risk
to the safety of self and others. Those at this LOC must be housed in a specialized
Acute Mental Health Unit unless imminent security issues exist, in which case
alternative placement must be approved by the chief psychologist and facility head.
• Individual clinical contacts must occur weekly with a clinician or psychologist.
• The treatment plan must be reviewed every thirty days and updated as appropriate.
Intermediate Correctional Mental Health Services (ICMHS)
• An incarcerated individual at this LOC demonstrates some significant functional
impairment. These incarcerated individuals require specialized housing with a
treatment goal of improving functioning and returning to general population.
• These incarcerated individuals must be housed in a Behavioral Health Unit or Acute
Mental Health Unit, unless imminent security reasons exist, in which case alternative
placement must be approved by the chief psychologist and the facility head.
• Individual clinical contact with a licensed clinician must occur at a minimum of every
thirty days.
• The treatment plan must be reviewed every ninety days and updated as appropriate.
Correctional Mental Health Services 1 (CMHS-1)
• This LOC indicates an incarcerated individual who is diagnosed with a mental illness
and demonstrates some functional impairment. Incarcerated individuals on this LOC
may require housing in a specialized unit or may be able to be housed in general
population.
• Individual clinical contacts with a licensed clinician must occur every sixty days.
• The treatment plan should be reviewed every six months and updated as
appropriate.
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Correctional Mental Health Services 2 (CMHS-2)
• Incarcerated individuals on this LOC are diagnosed with a mental illness; however,
symptoms are stable with psychotropic medication or with structured supportive
group participation, but clinical psychotherapeutic interventions (i.e. individual
sessions) are not clinically indicated.
• If an incarcerated individual was assessed by a psychiatric staff member (including
nurse practitioner and physician’s assistant), a clinician does not need to conduct
additional mental health evaluation unless there are additional mental health
concerns. In such a case, the psychiatric staff members will alert the site clinical
supervisor of the status of the incarcerated individual’s mental health need in order to
put the appropriate LOC into the offender management system.
• Informed consent is required for incarcerated individuals attending supportive
groups. Group placement is based on clinician referral. If additional services are
needed after attending two groups within a year, an LOC increase is required.
• Because groups at this LOC represent preventative services, clinicians who lead the
group will use the subjective, objective, assessment plan (SOAP) note for the final
group session to determine ongoing need in the Assessment/Plan section.
• If on medications, these incarcerated individuals must be seen by a psychiatric
provider at least every ninety days. Treatment plans are maintained by the
psychiatric provider.
• Incarcerated Individuals whose psychiatric medication is discontinued should
demonstrate a minimum of three months of stability without medication before the
clinician considers decreasing the LOC.
Correctional Mental Health Services Medical Necessity (MHMN)
• This LOC is designed for incarcerated individuals who experience an acute stress
response to a situation or for whom additional assessment is needed.
• Incarcerated Individuals at this LOC will have clinical contacts monthly and may be
enrolled in groups. This LOC cannot exceed ninety days. After ninety days, the
clinician must assess the incarcerated individual to determine if the LOC will be
increased or decreased.
Mental Health Clear (MHC)
• This LOC describes an incarcerated individual who is not currently reporting mental
health symptoms and is functioning appropriately in a correctional environment but
has a history of mental health concerns or diagnoses (including self-harm) during a
current or previous incarceration with IDOC.
• No individual clinical contact or treatment plan is required unless the incarcerated
individual requests care. No annual update is required for this LOC.
6. Treatment Planning
A treatment plan is an individualized document created by the incarcerated individual’s
assigned clinician or psychiatric provider that outlines problem areas, treatment goals, and
recommended interventions to support the incarcerated individual in reaching those goals.
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Group therapy is generally the primary modality of mental health treatment. Clinicians may
initiate individual therapy when group therapy is ineffective and/or when individual treatment
is clinically indicated, with clinical supervisor approval.
The treatment plan includes the following:
• Frequency of follow up for evaluation and adjustment of treatment modalities.
• Recommendations regarding adjustment of psychotropic medications, if needed.
• Referrals for psychological testing, medical testing, and evaluation, including blood
levels for medication monitoring as required.
• When appropriate, instructions about diet, exercise, personal hygiene, and
adaptation to the correctional environment.
• Documentation of treatment goals and objectives, interventions necessary to achieve
those goals, and notation of clinical progress.
Upon completion of the treatment plan the incarcerated individual will review and sign a
copy of the plan with the clinician.
Treatment plans will be reviewed and updated as determined by an incarcerated individual’s
LOC or when a significant event occurs.
7. Access to Care
An incarcerated individual can request mental health care at any time during their
incarceration by requesting a mental health appointment through the use of the Health
Service Request (HSR) process, in accordance with SOP 401.06.03.037, Nonemergency
Health Care Requests and Services.
These requests will be screened for risk of harm to self or others by the receiving health
care staff member. The requests are then triaged by a mental health staff member within
twenty-four hours of submission. If an HSR reports a clinical symptom, the incarcerated
individual is to be seen face-to-face by a mental health staff member within twenty-four
hours of receipt of the HSR in accordance with SOP 401.06.03.037, Non-emergency
Healthcare Requests and Services.
8. Refusals of Care
When incarcerated individuals refuse to participate in mental health services, they must sign
a Refusal of Mental Health Services form. The clinician will ensure that the incarcerated
individual refusing to participate understands how to access mental health services, will
discuss potential negative outcomes for refusing to participate in the evaluation, and will
document the encounter in the electronic medical record (see section 9 below). Refusal of
services does not preclude completion of assessments, parole board reports, or assignment
of LOC.
9. Documentation of Mental Health Services
Electronic Medical Record
All clinical interactions with incarcerated individuals must be documented in the
electronic medical record. All documentation required pursuant to this SOP must be
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done according to the templates, forms, or other formatting required in the electronic
medical record system and follow the SOAP format.
Medical records will only be released to a third party via legally valid releases of
information signed by the incarcerated individual, a court order, or other legal process.
Questions or concerns about appropriate release of medical record information should
be directed to the facility clinical supervisor.
Group attendance will be documented in the electronic medical record.
10. Mental Health Units
Housing in mental health units is available for incarcerated individuals with serious mental
health disorders, major functional impairment, or who present a threat of harm to self or
others. Placement in a mental health unit is determined by clinician referral and approval by
the facility clinical supervisor. These housing units are located at the following:
• Behavioral Health Unit (for males at ISCI, for females at PWCC)
• Acute Mental Health Unit (for males at IMSI, for females at PWCC)
A referral to or discharge from an IDOC mental health unit requires that the sending clinical
supervisor reviews and approves the referral and ensures the LOC, treatment plan, and
mental health assessments are up to date. If the incarcerated individual will be transferred to
another facility, the clinical supervisor at the sending facility is responsible to ensure the
referral has been sent to the clinical supervisor at the receiving facility. The clinical
supervisor at the receiving facility is responsible to review and approve the referral and to
facilitate the transfer of the incarcerated individual, in cooperation with the clinical supervisor
at the sending facility and the receiving facility’s movement coordinator and/or shift
commander. If the clinical supervisors at the sending and receiving facilities do not agree on
the approval, the IDOC chief psychologist will work with leadership at the facilities to arrive
at a decision. The chief psychologist is the final decision maker on referrals to mental health
units.
The treatment plan must be updated within thirty days of admission to any mental health unit
to accommodate the needs of the incarcerated individual within that housing unit.
Within the mental health unit, any level, progression, or token economy system must be
clearly outlined and defined via Field Memorandum and approved by the facility head and
chief psychologist.
Idaho Security Medical Program
The Idaho Security Medical Program is located at IMSI for males and PWCC for
females. This program is designed to house, assess, and treat incarcerated individuals
who have been deemed Dangerously Mentally Ill per Idaho Code section 66-1305.
Any reports required pursuant to Idaho Codes 18-212, 66-329, and 66-337 must be
completed by the site psychologist. The site psychologist is responsible to submit such
reports to the IDOC chief psychologist two weeks prior to the date required pursuant to
statute, court order or relevant hearing date. The chief psychologist will submit these
reports to the deputy attorney general assigned to IDOC for submission to the court.
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Multidisciplinary Treatment Team
Multidisciplinary Treatment Team (MDTT) meetings in mental health units are an
opportunity for staff from various disciplines to collaboratively discuss an incarcerated
individual’s needs, goals, and treatment plan. The MDTT will review the treatment plan
within two weeks of the date it is created or updated by the clinician and incarcerated
individual and ensure all disciplines are aware of the incarcerated individual’s treatment
goals. When an MDTT meets, the clinician chairs the meeting and facilitates discussion.
The team should consist at a minimum of the following:
• Clinician
• Unit officer
• Case manager
Prior to the actual MDTT meeting, all staff should be reminded about the issues related
to the concepts of confidentiality, need to know, and their obligations in these areas.
The incarcerated individual should be present at the MDTT meeting, unless the clinical
supervisor and/or the unit sergeant determine that mental health or security needs
preclude their involvement. The Multidisciplinary Treatment Team Summary will be
signed by all team members present and the incarcerated individual.
If an incarcerated individual refuses to sign or is unable to sign (e.g. is in restraints), the
clinician will note that on the treatment plan. The MDTT Summary should be entered
into the incarcerated individual’s electronic medical record.
11. Mental Health Emergencies
When alerted to mental health emergencies, mental health staff members must respond as
quickly as possible, assess the needs, and determine what follow-up action is necessary to
stabilize the situation.
There will be no informal sanctions or cell restrictions used for problematic behavior outside
of the disciplinary or restrictive housing SOPs.
Any instances of self-injury or suicidal ideation must be addressed in accordance with SOP
315.02.01.001, Suicide Risk Management and Intervention.
Involuntary emergency medication needs must be addressed in accordance with SOP
401.06.03.067, Involuntary Medication and Treatment.
12. Reports Provided
IDOC provides reports to the Commission of Pardons and Parole and courts for
consideration in determining parole or probation. The chief psychologist must approve any
requests for reports outside of those listed below.
Retained Jurisdiction
If an incarcerated individual on retained jurisdiction has an LOC of CMHS-1 or above,
the mental health clinician will complete a Mental Health Discharge Summary twenty-
one days prior to the estimated retained jurisdiction completion date. Facility staff will
notify the clinical staff of the upcoming completion date within a time frame that is
adequate for the Mental Health Discharge Summary to be included as an attachment to
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the Addendum Pre-Sentence Investigation (APSI), per SOP 324.02.01.001, Retained
Jurisdiction.
Commission of Pardons and Parole
Mental Health Evaluation (MHE):
Mental Health Evaluations are completed for incarcerated individuals with an LOC of
ACMHS, ICMHS, CMHS1 or MHMN. Additional evaluations may be completed upon
request of the Commission of Pardon and Parole with approval from the chief
psychologist or designee. Mental Health Evaluations must be updated every two years
or if there has been a significant change in mental health status, e.g. change in LOC,
suicide attempt, admission to a mental health unit, etc.
The clinician must complete the Mental Health Evaluation ninety days prior to the
incarcerated individual’s parole hearing date. Upon completion, the clinician must save
the Mental Health Evaluation to the shared mental health drive, and a paper copy is to
be placed in the incarcerated individual’s central file.
Sex Offender Risk Assessment (SORA)
The Sex Offender Risk Assessment (SORA) is a statutory requirement. The clinician
completes the SORA for offenders who have been convicted of a sex offense OR for a
crime that was sexually motivated, based on the information provided in the official
records, i.e. Presentence Investigation, police report, psychosexual evaluation, etc.
SORAs must be updated every three years or if there has been a significant event (e.g.
new sex crime, institutional sexual behavior, PREA event, etc.) or participation in sex
offender treatment.
The clinician must complete the SORA ninety days prior to the incarcerated individual’s
parole hearing date. Upon completion, the clinician must save the original SORA to the
shared mental health drive, and a paper copy is to be placed in the incarcerated
individual’s central file.
13. Annual Policy and SOP Update
This standard operating procedure must be reviewed annually by the chief of prisons and
the chief psychologist. This review must include all revisions made to the SOP and the date
of approval.
DEFINITIONS
None
REFERENCES
NCCHC Mental Health Standards
Idaho Code section(s) 18-212, 66-329, 66-337, and 66-1305
SOP 315.02.01.001, Suicide Risk Management and Intervention
SOP 319.02.01.001, Restrictive Housing
SOP 324.02.01.001, Retained Jurisdiction
SOP 401.06.03.067, Involuntary Medication and Treatment
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SOP 401.06.03.037, Non-emergency Healthcare Requests and Services.
Consent for Release of Information
Mental Health Assessment
Mental Health Assessment Update
Mental Health Discharge Summary
Refusal of Mental Health Services form
Sex Offender Risk Assessment(s)
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