Mental Health Service System

Idaho
Department
of Correction Standard
Operating
Procedure
Title:
Mental Health Service System

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327.002
Version:
3
Adopted:
09/25/2017

Liz Neville, Chief of the Division of Prisons and Walter Campbell, Chief
Psychologist, approved this document and it was published on
02/05/2026.
Open to the public: Yes
SCOPE
This standard operating procedure (SOP) applies to all Idaho Department of
Correction (IDOC) employees, and residents in all IDOC and IDOC-contracted
correctional facilities.
Version Summary
Version 3: This version revises and renumbers SOP 327.02.01.002 v2.0. The
policy statement was updated and included in this SOP. Updates were made to
match current terminology and practices and to comply with current National
Commission on Correctional Health Care (NCCHC) standards.
TABLE OF CONTENTS
Scope ................................................................................................... 1
Table of Contents .................................................................................... 1
A. Statutory Authority .......................................................................... 2
B. Board of correction idapa rule ............................................................ 2
C. Governing Policy Statement .............................................................. 2
D. Purpose ......................................................................................... 3
E. responsibility .................................................................................. 3
F. Definitions ...................................................................................... 4
G. Standard procedures ........................................................................ 5
1. Introduction ................................................................................... 5
2. Scheduling ..................................................................................... 5
3. Training ......................................................................................... 5
4. Mental Health Screening ................................................................... 6
5. Mental Health Assessment ................................................................ 6
6. Level of Care (LOC) ......................................................................... 6
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7. Treatment Planning .......................................................................... 9
8. Access to Care ................................................................................ 9
9. Refusals of Care ............................................................................ 10
10. Documentation of Mental Health Services ....................................... 10
11. Mental Health Units ..................................................................... 10
12. Mental Health Emergencies .......................................................... 12
13. Reports Provided ........................................................................ 12
14. Annual Policy and SOP Update ...................................................... 13
H. References ................................................................................... 13

A. STATUTORY AUTHORITY
1. Idaho Code § 20-217A, Appointment of Director – Salary – Powers and
Duties
2. Idaho Code § 20-244, Government and Discipline of the Correctional Facility
– Rules and Regulations
B. BOARD OF CORRECTION IDAPA RULE
None
C. GOVERNING POLICY STATEMENT
1. It is the policy of the Idaho Department of Correction (IDOC) to develop and
maintain a method for the identification and care of residents with mental
illness and related behaviors. Although mental illness cannot be eliminated,
IDOC is responsible for maintaining the health of individual residents, and for
ensuring that procedures are pursued to help residents obtain and/or
maintain prosocial activities, interpersonal connectedness, self-sufficiency,
and to preserve life. In managing mentally ill residents, a safe, humane, and
healthful environment based on ethical, moral, and legal considerations are
primary goals.
2. Each division, as needed, will establish an SOP to achieve the following:
a. Screening procedures to identify mental illness of incoming residents
b. Procedures for placing residents with mental illness into specialized
housing when needed
c. Methods for reporting to administrative staff when emergent actions are
taken due to a resident’s mental illness
d. Staff training related to managing mentally ill residents
e. Methods of documenting interactions with mentally ill residents to include
screenings, assessments, treatment, and interventions
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f. Procedures for administrative review when emergency interventions occur
due to mental illness
D. PURPOSE
The purpose of this SOP is to provide standardized guidance for the delivery of
mental healthcare services in IDOC prison facilities.
E. RESPONSIBILITY
1. Chief of the Division of Prisons
Approving all facility field memoranda in collaboration with the IDOC chief
psychologist.
2. IDOC Psychologist (including both the IDOC Chief Psychologist and IDOC
associate chief psychologist)
a. Oversight and standardization of all mental healthcare in prison facilities.
b. Functioning as the mental health authority for the IDOC.
c. Overseeing the development and subsequent revisions of this SOP.
d. Monitoring the adherence to this SOP and all other policies and
procedures related to mental healthcare services.
3. Facility Heads
a. Ensuring their facility’s implementation of this SOP.
b. Establishing processes and systems of control to ensure that security staff
and mental healthcare services staff support each other in day-to-day
operations.
c. Ensuring mental health services are discussed at administrative meetings
that occur at least quarterly.
d. Ensuring that health services meetings occur monthly, include discussion
of mental health services, and that mental health staff members are
present.
4. Clinical Supervisors
a. Providing direct oversight and supervision of clinicians, psychiatric
treatment coordinators, and psychiatric technicians.
b. Designating clinical coverage at the facility by establishing a schedule,
including clinical supervision coverage in times of absence.
c. Ensuring on a quarterly basis that all clinical staff members have a
current license.
d. Maintaining a current license and reporting to the designated IDOC
psychologist any actions against the license, including but not limited to
complaints or other disciplinary action.
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5. Clinicians
a. Providing mental health treatment to residents in accordance with this
SOP and other IDOC policies and procedures.
b. Consulting with case managers and security staff regarding the mental
health needs of residents.
c. Maintaining a current license and reporting to an IDOC psychologist any
actions against the license, including but not limited to complaints or
other disciplinary action.
F. DEFINITIONS
1. Clinician: A mental health professional licensed in the state of Idaho as a
Licensed Master's Social Worker, Licensed Clinical Social Worker, Licensed
Professional Counselor or Licensed Clinical Professional Counselor. Clinical
interns who are approved by the IDOC to perform mental health tasks under
the supervision of an IDOC clinician may also function in this role.
2. Correctional Management System (CMS): a digital platform used by
correctional agencies to store, manage, and analyze comprehensive data
about individuals throughout their entire criminal justice process, including
intake, sentencing, incarceration, parole, and probation, allowing for
informed decision-making regarding their supervision and rehabilitation. This
includes systems such as Laserfiche and Atlas.
3. Electronic Medical Record (EMR): A digital platform used by medical and
mental health providers to maintain a record of health care for residents.
IDOC currently uses eOMIS EMR.
4. Mental Health-Trained Staff Member: includes qualified health care
providers, administrative and support staff technicians, behavioral health
staff, and others who have received instruction and supervision in identifying
and interacting with individuals in need of mental health services.
5. Multidisciplinary Treatment Team (MDTT): An integrated team of
professionals from different disciplines, such as mental health, medical,
security, and/or case management, that meets to identify and meet the
needs of residents with complex needs that require cooperation of multiple
disciplines to address.
6. Resident: A person who has been convicted of a crime against the laws of
the state and ordered into the care and custody of the Board of Correction.
Resident includes any use in Idaho law, Board of Correction rule, or IDOC
policy or procedure of the terms “offender(s),” “prisoner(s)”, “inmate(s)”,
“incarcerated person(s)”, or any other term referring to a person residing in a
correctional facility in the care and custody of the Board of Correction. This
term also incorporates individuals placed in the Idaho Security Medical
Program.
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7. Site Clinical Supervisor: for sites with a mental health unit that have a
clinical supervisor employed by the medical contractor, the Site Clinical
Supervisor is the IDOC clinical supervisor.
G. STANDARD PROCEDURES
1. Introduction
a. Clinicians must provide timely, mental health services that optimize the
level of resident functioning of mentally ill residents and those vulnerable
to mental health disorders in the least restrictive environment. Any
resident, irrespective of previous assessment of diagnosis status, can
request mental health services at any time.
b. All standard forms used to carry out this SOP can be found in the EMR
system.
2. Scheduling
a. 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, an IDOC psychologist, and other IDOC staff who
need to be aware of mental health staffing at the facility.
b. For all facilities, an on-call schedule must be generated by the site clinical
supervisor for all weekends and holidays. Approved schedules will be
made available to shift commanders and site leadership.
3. Training
a. For all clinicians, psych techs, and clinical interns, an initial, basic
orientation occurs at the facility with the clinical supervisor or designee on
the first day of employment, which includes:
i. Orientation to all security, mental health, and medical services
ii. Facility emergency procedures
iii. Functional position description
iv. Appropriate boundaries to set with residents
v. Safety and security practices
b. Within ninety days, documented in-depth orientation will occur covering:
i. All mental health and relevant medical policies
ii. Typical mental health needs of patients
iii. Infection control and standard precautions
iv. Confidentiality of mental health records
c. Clinicians and other mental health staff also receive all training required
of other facility personnel
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d. Clinicians and other mental health staff members maintain appropriate
continuing education per Idaho licensure standards.
e. For all mental health staff, completion of the orientation program is
documented and kept on file by the agency training department.
4. Mental Health Screening
a. All residents 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 Qualified Health Care Professional immediately upon entry to the
facility.
i. The Resident Handbook, which contains information about mental
health services, is to be provided to residents upon arrival at the
Reception and Diagnostic Unit (RDU). Written information is also to be
posted in the area where intake procedures occur.
b. Mental health screens are also provided for all those who enter restrictive
housing prior to placement in a restrictive housing cell.
c. Mental health screens must be reviewed within twenty-four hours by a
clinician and follow-up care must be provided within the time frame
indicated by the mental health disposition.
d. If the resident 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.
5. Mental Health Assessment
a. A Mental Health Assessment will be completed by a clinician within
fourteen days of admission if deemed necessary by clinical staff.
b. 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.
c. A Mental Health Assessment Update will be completed annually by a
clinician, as deemed necessary by the resident’s Level of Care (see
Section G.6 below). Informed consent and Level of Care must be renewed
and documented annually.
6. Level of Care (LOC)
a. The LOC identifies the resident’s level of clinical need and provides
directives and timeframes for mental health treatment services.
b. Each resident should be assigned a LOC that matches their level of clinical
need. If a new LOC is needed, the decision to increase or decrease a LOC
must be made by a clinician based on the resident’s demonstrated
stability and level of functioning through a face-to-face or telehealth
assessment. In cases when the decision whether to decrease or increase
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a level of care is unclear, the clinician should consult with the facility
clinical supervisor.
c. In the event that a resident refuses mental health services, their refusal
should be signed by both the resident and the clinician. The clinician will
determine an appropriate level of care regardless of the refusal, and
services will still be offered according to the LOC.
d. At a minimum, a mental health assessment update should be completed
and updated in the CMS if the level changes. If an LOC is created or
changed, it must be entered into the CMS within twenty-four hours.
e. These LOC standards are guidelines, but individual cases may require
deviation from these guidelines. In such cases, clinical discretion may be
used if thoroughly justified in the EMR, and as approved by site clinical
supervisor, or other clinical supervisor as assigned.
f. There are six LOC designations that may be assigned to a resident:
i. Acute Correctional Mental Health Services (MH 6 ACMHS - Acute
Mental Health Services)
1) This LOC is for residents with the most profound and debilitating
impairments in functioning. These residents may present a serious
risk to the safety of self and others or have been determined to be
gravely disabled. 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 an IDOC
psychologist and facility head.
2) Resident clinical contacts must occur weekly with a clinician or
psychologist.
3) The treatment plan of residents at this LOC must be reviewed every
thirty days and updated if indicated.
ii. Intermediate Correctional Mental Health Services (MH 5 ICMHS -
Intermediate Mental Health Services)
1) A resident at this LOC demonstrates some significant functional
impairment. These residents require specialized housing with a
treatment goal of improving functioning and returning to the
general population.
2) These residents 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 an IDOC
psychologist and the facility head.
3) Resident clinical contact with a clinician must occur at a minimum
of every thirty days.
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4) The treatment plan must be reviewed every ninety days and
updated as appropriate.
iii. Correctional Mental Health Services Medical Necessity (MH 4 MHMN -
Mental Health Assessment Period)
1) This LOC is designed for residents who experience an acute stress
response to a situation or for whom additional assessment is
needed.
2) Residents at this LOC will have clinical contacts monthly and may
be enrolled in groups. This LOC cannot exceed ninety days. After
ninety days, a clinician must assess the resident to determine if the
LOC will be increased or decreased.
iv. Correctional Mental Health Services 1 (MH 3 CMHS1 - Mental Health
Services)
1) This LOC indicates a resident is diagnosed with a mental illness and
demonstrates some functional impairment. Residents on this LOC
may require housing in a specialized unit or may be able to be
housed with the general population.
2) Resident clinical contacts with a clinician must occur every sixty
days.
3) The treatment plan should be reviewed every six months and
updated as appropriate.
v. Correctional Mental Health Services 2 (MH2 CMHS-2 Psychiatric
Services)
1) Residents on this LOC are diagnosed with 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.
2) For those attending supportive groups, informed consent is
required. Group placement is based on clinician referral.
3) If on medications, these residents must be seen by a psychiatric
provider at least every ninety days. Treatment plans are maintained
by the psychiatric provider.
4) Residents whose psychiatric medication is discontinued should
demonstrate a minimum of three months of stability without
medication before the clinician considers decreasing the LOC.
vi. Mental Health Clear (MHC)
1) This LOC describes residents who are not currently reporting
mental health symptoms and are functioning appropriately in a
correctional environment but have a history of mental health
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concerns or diagnoses (including self-harm) during a current or
previous incarceration with IDOC.
2) No resident clinical contact or treatment plan is required unless the
resident requests care. No annual update is required for this LOC.
7. Treatment Planning
a. A treatment plan is an individualized document created by the resident’s
assigned clinician or psychiatric provider that outlines problem areas,
treatment goals, and recommended interventions to support the resident
in reaching those goals.
b. The treatment plan includes the following:
i. Frequency of follow up for evaluation and adjustment of treatment
modalities
ii. Adjustment of psychotropic medications, if needed
iii. Referrals for psychological testing, medical testing, and evaluation,
including blood levels for medication monitoring as required
iv. When appropriate, instructions about diet, exercise, personal hygiene,
and adaptation to the correctional environment
v. Documentation of treatment goals and objectives, interventions
necessary to achieve those goals, and notation of clinical progress
c. Upon completion of the treatment plan the resident will review and sign a
copy of the plan with the clinician. If the resident refuses to sign, a
documentation of refusal should be included in the EMR.
d. Treatment plans will be reviewed and updated as determined by a
resident’s LOC or when a significant event occurs.
8. Access to Care
a. A resident 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, Non-emergency Health Care Requests and Services.
b. These requests will be screened for risk of harm to self or others by the
receiving healthcare staff member. If there is a risk of harm, staff must
follow SOP 315.02.01.001, Suicide Rick Management and Intervention.
The remaining requests are then triaged by a qualified healthcare
professional within twenty-four hours of submission. Unless the HSR does
not require a 24-hour face-to-face follow-up visit, the resident 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.
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9. Refusals of Care
When a resident refuses to participate in clinically recommended mental
health services, they must be asked to sign a Refusal of Mental Health
Services form. The clinician will ensure that the refusing resident
understands how to access mental health services and will discuss potential
negative outcomes for refusing to participate in the evaluation. The clinician
will document the encounter. Refusal of services does not preclude
completion of assessments, parole board reports, housing placement in a
mental health unit, or assignment of LOC.
10. Documentation of Mental Health Services
a. Electronic Medical Record (EMR)
All clinical interactions with residents must be documented in the EMR. All
documentation required pursuant to this SOP must be done according to
the templates, forms, or other formatting required in the EMR system.
b. Release of Medical and Mental Health Records
Medical records will only be released to a third party via releases of
information signed by the resident or a court order. Questions or concerns
about appropriate release of medical record information should be
directed to the facilities designated medical records individual or the IDOC
transparency team as appropriate.
11. Mental Health Units
a. Housing in mental health units is available for those residents 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 unit clinical
supervisor. These housing units are located at the following:
i. Behavioral Health Unit (for males at Idaho State Correctional
Institution [ISCI], for females at Pocatello Women’s Correctional
Center [PWCC])
ii. Acute Mental Health Unit (for males at Idaho Maximum Security
Institution [IMSI], for females at PWCC)
b. 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 resident 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 unit. The clinical
supervisor at the receiving unit is responsible to review and approve the
referral and to facilitate the transfer of the resident, in cooperation with
the IDOC clinical supervisor at the sending facility and the receiving
facility’s movement coordinator and/or shift commander. If the clinical
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supervisors at the sending and receiving facilities do not agree on the
approval, the IDOC psychologist will work with the leadership at the
facilities to arrive at a decision. The IDOC psychologist is the final
decision-maker on referrals to mental health units.
c. Upon admission to any mental health treatment unit, the treatment plan
must be reviewed and updated as clinically indicated within thirty days to
accommodate the needs of that resident within that housing unit.
d. 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 IDOC Psychologist.
e. Idaho Security Medical Program
i. The Idaho Security Medical Program is located at IMSI for males and
PWCC for females. This program is designed to house, assess, and
treat residents who have been deemed dangerous and mentally ill per
Idaho Code § 66-1305.
ii. Any reports required pursuant to Idaho Code § 18-212, must be
completed by the contracted psychologist. The contracted psychologist
is responsible for submitting such reports to the IDOC psychologist two
weeks prior to the date required pursuant to statute, court order or
relevant hearing date. The psychologist will submit these reports to
the deputy attorney general for submission to the court.
f. Multidisciplinary Treatment Team (MDTT)
i. MDTT meetings in mental health units are an opportunity for staff from
various disciplines to collaboratively discuss a resident’s needs, goals,
and treatment plan. clinician For all new admittance to mental health
units, a MDTT will convene within 45 days (or sooner) of admission. A
MDTT can also be held as clinically indicated and requested by a
member of the treatment team. When an MDTT meets, the clinician
chairs the meeting and facilitates discussion. The MDTT should consist,
at a minimum, of the following:
1) Clinician
2) Unit officer
3) Case manager
ii. Prior to the 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.
iii. The resident 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 MDTT
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Summary will be signed by all team members present and the
resident.
iv. If a resident refuses to sign the MDTT Summary or is unable to sign
(e.g. is in restraints), the clinician will note that on the Summary. The
MDTT Summary should be entered into the resident’s EMR with MDTT
members present documented.
12. Mental Health Emergencies
a. When alerted to mental health emergencies, mental health staff members
must respond, if clinically indicated, as quickly as possible, assess the
needs, and determine what follow-up action is necessary to stabilize the
situation.
b. There will be no informal sanctions or cell restrictions used for
problematic behavior outside of the disciplinary or restrictive housing
SOPs.
c. Any instances of self-injury or suicidal ideation must be addressed in
accordance with SOP 315.02.01.001, Suicide Risk Management and
Intervention.
d. Involuntary emergency medication needs must be addressed in
accordance with SOP 401.06.03.067, Involuntary Medication and
Treatment.
13. Reports Provided
a. IDOC provides reports to the Commission of Pardons and Parole and
courts for consideration in determining parole or probation. The IDOC
psychologist must approve any requests for reports outside of those listed
below.
b. Retained Jurisdiction
If a resident on retained jurisdiction has a LOC of CMHS-1 (MH 3) or
above, a clinician will complete a Mental Health Discharge Summary
within seven days of receiving the request from the case manager, as an
attachment to the Addendum Pre-Sentence Investigation (APSI), per SOP
324.02.01.001, Retained Jurisdiction.
c. Commission of Pardons and Parole
i. Mental Health Evaluation (MHE):
1) MHEs must be completed for residents with the following Levels of
Care:
a) MH 6 ACMHS - Acute Mental Health Services
b) MH 5 ICMHS - Intermediate Mental Health Services
c) MH 4 MHMN - Mental Health Assessment Period
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d)MH 3 CMHS1 - Mental Health Services
2)MHEs 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.
3)The clinician must complete the MHE 90 days prior to the resident’s
parole hearing date. Upon completion, the clinician must save the
MHE to the shared mental health drive and provide a copy to the
site records staff to be placed in the resident’s central file.
ii.Sex Offender Risk Assessment (SORA)
1)The Sex Offender Risk Assessment is a statutory requirement. The
Clinician completes the SORA for residents 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. The SORA must be updated if there has been a new
sex crime.
2)The clinician must complete the SORA 90 days prior to the
resident’s parole hearing date, or as soon as practicable when
requested after that 90-day time frame. Upon completion, the
clinician must save the SORA to the shared mental health drive and
provide a copy to the site records staff to be placed in the
resident’s central file.
14.Annual Policy and SOP Update
This SOP must be reviewed annually by the chief of prisons and an IDOC
psychologist. This review must occur by January 31st of each calendar year
and must include all revisions made to the SOP and the date of approval.
H.REFERENCES
1.Forms
All standard forms used to carry out this SOP can be found in the EMR
system.
2.Cited Documents
a.Idaho Code § 18-212
[https://legislature.idaho.gov/statutesrules/idstat/Title18/T18CH2/SECT18
-212/]
b.Idaho Code § 66-1305
[https://legislature.idaho.gov/statutesrules/idstat/Title66/T66CH13/SECT6
6-1305/]
c.Resident Handbook
d.SOP 315.02.01.001, Suicide Risk Management and Intervention
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e.SOP 324.02.01.001, Retained Jurisdiction
f.SOP 401.06.03.037, Nonemergency Health Care Requests and Services
g.SOP 401.06.03.067, Involuntary Medication and Treatment
3.Other Significant Documents
a.NCCHC Mental Health Standards [https://ncchcresources.org/]
b.SOP 319.02.01.001, Restrictive Housing
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