Suicide Risk Management and Intervention

Idaho
Department
of Correction Standard
Operating
Procedure
Title:
Suicide Risk Management and
Intervention

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315.001
Version:
8
Adopted:
04/26/2005

Liz Neville, Chief of the Division of Prisons, approved this document and it
was published on 06/29/2026.
Open to the public: Yes No This document is referenced in a POST
lesson plan.
SCOPE
This standard operating procedure applies to all Idaho Department of Correction
(IDOC) employees and residents in all IDOC and IDOC-contracted correctional
facilities.
Version Summary
Version 8: This SOP renumbers previous SOP 315.02.01.001 v7.0. It provides
more detail, aligns with industry standards, clarifies definitions, updates
responsibilities, and expands monitoring procedures.
TABLE OF CONTENTS
Scope ................................................................................................... 1
Table of Contents .................................................................................... 1
A. Statutory Authority ............................................................................. 2
B. Board of correction idapa rule number ................................................... 2
C. Governing Policy Statement ................................................................. 2
D. Purpose ............................................................................................ 3
E. Responsibility .................................................................................... 3
F. Definitions ......................................................................................... 4
G. Standard Procedures ........................................................................... 4
1. Suicide Risk Prevention Overview ........................................................... 4
2. Facility Mental Health Intake Procedure .................................................. 5
3. Monitoring Methods ............................................................................. 5
4. Suicide Risk Protocols .......................................................................... 8
5. Emergency Procedures (FM Required) ................................................... 10
6. Responding to a Suicide Attempt ......................................................... 11
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7. Physical Structure Requirements (FM Required) ..................................... 12
8. Mental Health Interactions .................................................................. 13
9. Transport of Residents on Monitoring .................................................... 13
10. Conditions of Monitoring ................................................................... 14
11. Monitoring Documentation ................................................................ 14
12. Restrictive Housing Units .................................................................. 15
13. Emergency Transfers ....................................................................... 16
14. Companion Program (FM Required) .................................................... 16
15. Suicide Resulting in Death ................................................................ 17
16. Program Review and Assessment ....................................................... 18
17. Suicide Risk Management Training ..................................................... 18
H. References ...................................................................................... 19

A. STATUTORY AUTHORITY
1. Idaho Code § 20-244, Government and Discipline of the Correctional Facility
– Rules and Regulations
B. BOARD OF CORRECTION IDAPA RULE NUMBER
None
C. GOVERNING POLICY STATEMENT
1. It is the policy of IDOC to develop and maintain a method for the
identification and care of potentially suicidal residents. Although suicide
attempts cannot be eliminated, IDOC is responsible for maintaining the
health of individual residents, and for ensuring that procedures are pursued
to help preserve life. In managing potentially suicidal residents, a safe,
humane, and healthful environment based on ethical, moral, and legal
considerations is a primary goal.
2. The suicide risk management SOP must include the following:
a. Screening procedures to identify suicide risk of incoming residents.
b. Procedures for placing residents who display potential signs of suicide
under safety precautions or close observation.
c. Methods for reporting to administrative staff when suicide risk
management interventions occur.
d. Procedures for releasing residents from safety precautions or close
observation back into general housing.
e. Staff training related to suicide risk management and emergency
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response.
f. Methods of documenting suicide risk interventions with individual residents
when placed under close observation or safety precautions.
g. Procedures for investigation in the event of a resident’s death to include
notifying law enforcement and coroner.
h. Procedures for critical incident debriefing for staff and residents affected
by a suicide attempt.
i. Procedures for administrative review when a suicide occurs.
D. PURPOSE
To establish comprehensive guidelines for the identification and management of
potentially suicidal individuals in IDOC custody.
E. RESPONSIBILITY
1. Chief of the Division of Prisons
a. Collaborate with the IDOC chief psychologist or designee to approve all
facility field memorandums associated with this SOP.
2. Facility Heads
a. Implement the provisions of this SOP at their facility.
b. Establish suicide-resistant housing to be used for suicide monitoring.
c. Ensure that all correctional officers, and other staff the facility head deems
necessary, receive and maintain CPR training from a certified instructor.
Training shall be documented and recorded in the staff members’
respective training record. No first aid or CPR certificate or card shall be
issued.
d. Ensure that all staff members are trained biannually in accordance with
this SOP and that the training is documented.
e. Review and establish or modify post orders for conducting a safety
precautions.
f. Establish a field memorandum (FM) as specified in this SOP.
3. Clinical Supervisors
a. Determine who the on-site mental health professionals (MHPs) are at each
facility.
b. Oversee the treatment of suicidal residents at their assigned facility.
c. Ensure the facility’s suicide risk management services conform to the
guidelines outlined in this SOP and the National Commission for
Correctional Health Care (NCCHC).
d. Ensure that during a clinical supervisor’s absence duties are transferred to
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another clinical supervisor and that facility staff is notified in writing
regarding the transfer of duties.
e. Ensure that MHPs are available (on-site or on-call) daily based on facility
need and communicate to the shift commander who is available at the
facility to address mental health concerns.
F. DEFINITIONS
1. Chief Psychologist: The IDOC employee who is primarily responsible for
overseeing or managing IDOCs mental health services.
2. Direct Observation: Being in the same room as the resident or looking
through the window of a cell and keeping constant observation of the
resident at all times.
3. Mental Health Professional (MHP): A staff member who has specialized
training and skills in the nature and treatment of mental illness to include,
but not limited to, psychologists, psychiatrists, licensed masters or clinical
social workers, licensed marriage and family therapists, and licensed clinical
and professional counselors who, by virtue of their education, credentials,
and experience, are permitted by law to evaluate and care for patients.
4. National Commission on Correctional Health Care: a national accrediting
agency that provides specific standards for medical and mental health care
for the delivery of quality services.
5. Sleep System/Suicide Resistant Blanket/Suicide Smock: Tear-resistant
bedding and clothing specifically designed to reduce the risk of self-injury.
G. STANDARD PROCEDURES
1. Suicide Risk Prevention Overview
a. Suicide management is a collaborative and cooperative effort between
security, administrative, medical, and mental health staff. All staff can
observe warning signs of potential suicide. All signs of potential suicide
must be taken seriously, even if information is provided by another
resident.
b. All staff are responsible for implementing the procedures in this SOP. At
the first sign of suicide potential, staff must immediately implement the
suicide risk management process by placing the resident under direct staff
observation until an MHP or medical staff member (if an MHP is not
available) assesses the resident for suicide risk.
c. Any staff member may initiate the safety precautions protocol. When an
MHP is available, only they can implement acute safety precautions. If an
MHP is unavailable, a Registered Nurse (RN) or Licensed Practical Nurse
(LPN) may determine the level of safety precautions as either Acute or
Non-acute. RNs or LPNs may not place a resident on Close Observation. If
there is no MHP, RN, or LPN available, non-acute safety precautions is
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considered the default level unless the resident’s self-harming behavior
meets the criteria for acute safety precautions.
i. Only an MHP can assess a resident and not place them on safety
precautions. If a resident makes self-harming statements or engages
in self-harm, an RN or LPN must put them on safety precautions and
will only be able to place a resident on acute or non-acute safety
precautions levels. If an RN or LPN is unsure which monitoring level to
choose, they may consult with the on-call clinical supervisor, IDOC
chief psychologist, or designee.
d. Upon a resident’s placement on safety precautions, the MHP, in
coordination with shift command, is the authority for clinical decisions and
actions regarding mental health care and suicide management, such as
modification of property and other operational order specifications.
e. Only an MHP has the authority to determine whether to decrease or
discontinue safety precautions.
2. Facility Mental Health Intake Procedure
a. All residents must be screened by medical staff for mental health and
suicide risk upon arriving at an IDOC facility. This includes residents
arriving at a reception and diagnostic unit (RDU) or those transferring
from another IDOC facility, county jail, contract facility, hospital, court,
etc.
i. The mental health screening requirement also applies to residents being
placed on restrictive housing, protective custody status, or any other
status in which a resident is isolated from general population and
receives services and activities apart from other residents.
b. Incoming residents are to be under constant direct staff observation until
they are screened.
c. If suicide risk is indicated in the disposition on the screening, medical staff
must ensure the resident is under constant direct staff observation,
immediately notify the shift commander, and implement the steps in
section G.4, Suicide Risk Protocols.
i. If the disposition on the medical screening indicates that there is no
imminent suicide risk, medical staff must forward the mental health
screening to the MHP for review.
ii. The MHP must review the screening form within 24 hours and follow up
as indicated.
3. Monitoring Methods
a. Suicide monitoring consists of three levels: non-acute safety precautions,
acute safety precautions, and close observation.
b. These monitoring methods are used to ensure that a resident is safe
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during critical, high-risk periods and is provided increased care by MHPs.
The resident is placed in an environment with restricted access to means
of self-harm.
c. A resident’s watch level can be increased to a more intense level
depending on the resident’s behaviors at any time during safety
precautions. If there is no MHP present, the facility shift commander has
the authority to increase a watch level based on the resident’s immediate
behaviors. The facility shift commander may consult with the facility
clinical supervisor concerning an increase in watch level.
d. Staff must document on the Behavior Observation Log when the
monitoring shift begins and ends and if watch level is changed. Staff must
document the resident’s behavior every 15 minutes or more frequently
when the following activities occur:
i. Accessing or offered shower.
ii. Accessing dental hygiene items.
iii. Accessing a toilet.
iv. Washing or sanitizing hands.
v. Accessing drinking water.
vi. Consuming meals, including washing or sanitizing hands before meals.
vii. Any odd, bizarre or concerning behavior.
viii. Any attempts at self-injury or harm.
ix. Any threats of harm to self or others.
x. Any resident-staff encounter, including the name and position of the
staff member conducting the encounter, and when encounter began
and ended.
e. Non-Acute Safety Precautions:
i. Non-acute safety precautions are designed for potentially suicidal
residents who express current suicidal ideation without a specific
threat or plan and/or have a recent history of self-harming behavior.
Residents who deny suicidal ideation or do not threaten suicide but
demonstrate other concerning behaviors indicating the potential for
self-injury should be placed on non-acute safety precautions.
ii. During non-acute safety precautions, staff are responsible for oversight
of the monitoring and must visually observe the resident at staggered
intervals not to exceed 15 minutes documenting the resident’s
behaviors.
1) Companions may supplement staff monitoring under the supervision
and direction of staff. Staff must be available to provide rapid
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assistance if a companion alerts staff to a situation requiring
immediate response.
2) Companions must receive approved training on suicide risk
management before being assigned monitoring duties.
3) Companions are not to provide observation during showers for non-
acute and/or close observation monitoring.
iii. Non-acute safety precautions must be conducted in a suicide-resistant
monitoring room and outlined in the post orders of the units with
suicide-resistant monitoring rooms. Only department-approved safety
smocks and sleep systems may be used while a resident is on non-
acute safety precautions.
iv. Each facility must establish when medical staff is permitted to
designate a resident’s safety precautions level when an MHP is not
available. This must be documented in the facility’s suicide risk
management FM.
f. Acute Safety Precautions:
i. Acute safety precautions are designed for actively suicidal residents who
have engaged in significant self-injurious behavior, including requiring
hospitalization for self-harm, or threaten suicide with a specific and
realistic plan.
1) Examples of significant self-injurious behavior include significant
cutting or injuries that require several stitches or offsite medical
treatment, or being cut down from an attempted hanging.
2) An example of a specific plan for suicide would be when the resident
describes in detail how they plan to harm themselves through
means the resident could realistically access.
ii. Acute safety precautions may only be conducted in a suicide-resistant
monitoring room designated for the purpose of suicide monitoring and
outlined in the post orders of the units with suicide-resistant
monitoring rooms.
iii. During acute safety precautions, staff members must maintain
constant, direct observation of the resident at all times.
1) Companions are not to be used for acute safety precautions
monitoring.
2) Staff may monitor more than one acutely suicidal resident at a time
if the residents are housed in the same suicide monitoring cell.
Facilities must identify suicide-resistant monitoring cells capable of
housing more than one resident in the facility FM.
3) Staff must never read or do any other activity that would take away
from the ability to constantly monitor residents on a watch status.
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iv. Only department-approved safety smocks and sleep systems may be
used while a resident is on acute safety precautions.
g. Close Observation:
i. Close observation is designed to be used for residents with increased
psychotic or mental health symptoms that require placement in a
holding cell for stabilization or to decrease stimuli. Close observation
may be used as part of a risk management plan, in which a resident
has additional property and privileges compared to other safety
precautions while still being closely monitored by staff.
ii. Close observation may be used as an option for a homicidal resident
who is also mentally ill and displays an increase in mental health
symptoms and verbal threats.
iii. During close observation, staff members are responsible for oversight
of the monitoring and must visually observe the resident at staggered
intervals not to exceed 15 minutes. These observations will be
maintained in the Behavior Observation Log (Staff).
1) Companions may supplement staff monitoring under the supervision
and direction of staff. Staff must be available to provide rapid
assistance if a companion alerts staff to a situation requiring
immediate response.
2) Companions may or may not be used on Close Observation based
on MHP clinical discretion.
3) Staff members and companions must receive approved training on
suicide risk management before being assigned close observation
monitoring duties.
iv. Close observation must be conducted in a room designed for the
purpose of suicide monitoring or close observation.
v. Close observation may only be implemented by an MHP.
4. Suicide Risk Protocols
Functional Roles
and Responsibilities Step Tasks
Staff Member 1
Immediately place resident under direct staff
observation and contact the shift commander or
assistant shift commander.
Shift Commander 2
Ensure a staff member provides constant direct
observation of the resident until the MHP or a
qualified medical staff arrives
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Functional Roles
and Responsibilities Step Tasks
Shift Commander 3
During regular hours, contact the onsite MHP to
assess the resident.
After hours, during weekends, or on holidays,
contact qualified medical staff to determine the
resident’s monitoring level. Non-acute safety
precautions is the default, unless the criteria for
acute safety precautions is met.
Mental Health
Provider 4
1. Within 30 minutes of the shift commander’s
notification, assess the resident using the SRA.
a. If safety precautions are initiated when
MHP staff are not on site, an assessment
must be completed within two hours of
arrival at the facility or by 9:00am the
morning after placement.
2. Notify the shift commander of the resident’s
disposition.
3. Complete an Information Report documenting
the resident as being placed on a monitoring
status and complete a Safety Precautions /
Close Observation Order.
Shift Commander 5
1. Ensure that the resident is placed in a safe
and secure location designed for monitoring.
2. Ensure staff conducts an unclothed body
search and provide the resident with an
approved sleep system or suicide resistant
blanket and a suicide smock.
Shift Commander 6
1. Initiate the applicable safety precautions order
completed by the MHP. Or if the resident was
assessed by qualified medical staff, implement
the Default Acute Safety Precautions Order or
Default Non-Acute Safety Precautions Order.
2. Complete and send a 105 Report upon initial
placement on a monitoring status and each
time thereafter that the status changes.
Security Staff 7 Review the order and implement the level in
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5. Emergency Procedures (FM Required)
a. Cut-down Tools
i. All facilities must have a cut-down tool on every unit that the facility
head has approved. Cut down tools must be safe to use in a
correctional environment. The tool must be immediately deployable on
a routine basis to any location on the unit. A staff member may carry
the tool, or it can be secured on the unit.
Functional Roles
and Responsibilities Step Tasks
accordance with this SOP.
Mental Health
Professional 10
1. Visit the monitored resident daily and
document the visit in the resident’s medical
file notes by the end of the shift.
2. If reducing the monitoring status:
a. Complete an SRA by the end of the shift
and document in the resident’s medical
file.
b. Complete a new Safety Precautions / Close
Observation Order.
c. Complete an Information Report and
submit to the shift commander.
d. Update the safety precaution status in the
medical record.
3. If discontinuing the monitoring:
a. Complete an SRA by the end of the shift
and document in the resident’s medical
file.
b. Complete an Information Report and
submit to the shift commander.
c. Update the Safety Precaution status in the
medical record.
4. After release from any monitoring status, visit
the resident daily for three consecutive days
following the release and document the visit in
the resident’s medical file notes by the end of
the shift.
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ii. In high-risk units, such as restrictive housing or mental health units, all
uniformed staff members must carry the tool on their person.
iii. Each facility must specify in its field memorandum the number of tools
in the facility, where the tools are located, and the methods of
securing the tools.
b. Checking for Vital Signs
i. Vital signs can be difficult to detect in emergencies; therefore, staff
members who discover a resident during a suicide attempt should not
presume the resident is dead, even if no vital signs are detected.
ii. Responding staff must always initiate and continue appropriate life-
saving measures until relieved by on-scene medical staff or
paramedics. Once emergency life-saving measures are initiated, only a
physician, physician’s assistant or nurse practitioner is qualified to
pronounce death or stop the lifesaving efforts. Paramedics may also
terminate life-saving measures per their protocol.
6. Responding to a Suicide Attempt
a. Protecting the crime scene is important, but the resident's life, and rescue
attempts to save the resident's life, are the most important. Life-saving
efforts must never be limited or terminated for the purpose of preserving
the crime scene.
b. Staff members must:
i. Immediately implement the Incident Command System and request
emergency medical assistance from facility medical staff.
ii. Assess the environment to ensure the scene appears to be safe. If the
scene is unsafe, implement measures to make the scene safe.
iii. If the resident is hanging, immediately cut the resident down, taking
precautions to prevent additional injury to the resident and taking
precautions to protect staff from the weight of the resident
iv. If possible, attempt to preserve the knot in hanging events; however,
saving the resident's life is most important.
v. If not a hanging, take other first aid action as called for in the
emergency (e.g., clear airway or control bleeding).
vi. Place the resident on a hard surface to facilitate CPR efforts.
vii. Immediately begin CPR, unless the resident is breathing.
viii. Continue CPR or, if breathing, monitor the resident's condition closely
until medical staff arrives.
ix. If the resident stops breathing, immediately begin CPR.
c. When medical staff arrive, they should assess the situation and take over
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life-saving efforts; notify the shift commander of the resident's status;
and if necessary, arrange transport of the resident to the nearest medical
facility for additional life saving measures.
d. The shift commander must:
i. Provide appropriate security for the resident.
ii. Preserve the area and any evidence as a crime scene (see SOP
504.02.01.001, Investigations and Intelligence Program).
iii. Contact local law enforcement and request an investigation.
iv. Complete a 105 Report and ensure all involved staff complete
Information Reports.
7. Physical Structure Requirements (FM Required)
a. The facility head, with input from the chief psychologist or designee, is
responsible for designating all rooms/cells used for safety precautions in a
FM. Such rooms must provide the ability to observe, protect, and
maintain adequate control of the resident while on monitoring. Typically,
the suicide-resistant monitoring rooms are in the health services area.
b. Every effort must be made to remove or modify fixtures or architectural
features that would facilitate quick or easy self-injury or permit easy
attachment for a ligature. Only limited and secure furnishings are allowed.
c. Each cell used for close observation or safety precautions must have the
following:
i. A track or rod system affixed above each cell front.
ii. A curtain with a minimum of 12 inches clearance from the floor.
iii. The top of the curtain must be clear.
iv. The curtain must be closed anytime a clinical encounter occurs. The
curtain will remain open at all other times.
d. The following facilities must designate and maintain suicide-monitoring
rooms, to include staffing to operate them. These facilities must also
implement a resident companion program.
i. Idaho State Correctional Institution (ISCI)
ii. South Idaho Correctional Institution (SICI)
iii. Idaho Correctional Institution-Orofino (ICIO)
iv. Idaho Maximum Security Institution (IMSI)
v. Idaho State Correctional Center (ISCC)
vi. Pocatello Women’s Correctional Center (PWCC)
vii. South Boise Women’s Correctional Center (SBWCC)
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viii. North Idaho Correctional Institution (NICI)
8. Mental Health Interactions
a. Residents must be provided an opportunity to meet in a private location
for a face-to-face assessment with mental health staff. If unit staff refuse
to move a resident to a private location, the mental health staff must
contact the shift commander immediately.
b. There may be times when movement to a private location is unavailable or
a resident may refuse to be moved. When a private location is
unavailable, clinicians will meet with the resident at cell front. Privacy
measures must be used to include a curtain and a white noise generator
(or comparable devices designed to maximize privacy).
c. The mental health staff must document the level of privacy offered for
every encounter. If the encounter did not occur in a private location, the
reason must be documented.
9. Transport of Residents on Monitoring
a. Residents may be transferred to another facility with suicide monitoring
rooms at the discretion of the facility head, or facility duty officer, in
coordination with the facility clinical supervisor.
i. Residents on close observation or non-acute safety precautions must be
transferred before residents on acute safety precautions.
b. In the event of a transport, a special transport must be initiated in which
the individual resident is transported individually or with other residents
under suicide monitoring to maintain close supervision and ensure
privacy.
c. Prior to the transfer, all clinical and medical documentation must be up to
date and complete, including the applicable safety precautions order(s),
safety precautions disposition (if indicated), suicide risk assessments
(SRAs), and clinical case notes.
d. Transport of residents on suicide monitoring must comply with
requirements of SOP 322.001, Transports: Medical, Court, Family
Emergency, and State.
e. The following facilities without designated suicide monitoring rooms must
transport residents to a facility with designated suicide monitoring rooms:
ii. Mountain View Transformation Center (MVTC) – Transport to ISCC,
then ISCI
iii. St. Anthony Work Camp (SAWC) – Transport to ISCI
iv. East Boise Community Reentry Center (CRC-EB) – Transport to SBWCC
v. Treasure Valley – Community Reentry Center (CRC-TV) – Transport to
ISCI
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vi. Nampa Community Reentry Center (CRC-N) – Transport to ISCI
vii. Idaho Falls Community Reentry Center (CRC-IF) – Transport to ISCI
f. Residents transferred to another facility on a watch or monitoring status
will be seen and followed by the sending facility’s MHP. The sending
facility’s MHP is responsible for providing follow up services and
documentation for the resident while the resident is on watch to include
completing the SRA, daily clinical contact and corresponding notes,
Information Reports, and monitoring orders.
10. Conditions of Monitoring
a. Residents should have a safe environment, hygiene supplies, and meals.
Any additional daily items must be approved by the MHP and shift
commander on the Safety Precautions / Close Observation Order. If there
is disagreement between the clinician and shift commander, the default
safety precautions order applies. The clinical supervisor and facility head
must review item approvals the following day.
b. Residents on safety precautions or close observation must have access to
the following unless the MHP, in consultation with shift commander,
determines that one or more are a risk to safety or security:
i. The opportunity to shower at least once every 72 hours with necessary
hygiene items.
ii. Access to dental hygiene items twice daily.
iii. Regular access to a toilet.
iv. Opportunity to wash or sanitize hands.
v. Access to water every two hours, which may include the use of a small
paper cup.
vi. Items of clothing to allow modesty, which include suicide prevention
smock and paper underwear.
vii. Dietary needs met and utensils as needed to consume meals and the
opportunity to wash or sanitize hands before meals.
viii. Mattress and suicide resistant bedding.
c. The MHP must arrange medical providers for resident’s needs and
document restrictions in both the SRA and provider notes. Restrictions or
denials of equipment by the MHP and shift commander are only allowed
when essential for safety, with reasons recorded in a Safety Precautions /
Close Observation Order and clinical case note. Approval from the facility
head (or duty officer after hours) is required before enforcing restrictions.
11. Monitoring Documentation
a. All residents must have an SRA completed within 24 hours upon initial
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placement on monitoring, when modified to another monitoring status, or
when released from monitoring.
b. An MHP must see residents daily while on a monitoring status and daily for
three consecutive days after release from a monitoring status. Each
clinician’s visit must be documented on a clinical case note if an SRA is
not required.
c. Each day the MHP must review the Conditions of Monitoring, the Safety
Precautions / Close Observation Order, and the Companion Watch Sheet,
and document the review in the Behavior Observation Log (Staff).
d. Behavioral Observation Log (Staff)
i. Staff must maintain a behavior observation log for each resident
assigned to monitoring. Assigned staff members must document their
observations of the resident every fifteen minutes or more frequently
as indicated. Activities such as searches, behavioral observations,
review of the issued safety precautions order, and other information
that may indicate a mental health need or decompensation must be
documented.
ii. At the conclusion of the monitoring, the behavior observation log must
be forwarded to medical records for inclusion in the resident’s medical
file.
12. Restrictive Housing Units
a. Restrictive housing units are high risk for suicide attempts. Restrictive
housing includes administrative segregation, disciplinary detention,
transit, segregation pending investigation (SPI), pre-hearing segregation
(PHS), residents under sentence of death, and residents placed on cell
restriction.
b. The MHP must make weekly rounds of restrictive housing units and
document that contact in a clinical case note.
i. Prior to conducting rounds, the MHP must consult with security and unit
staff concerning any residents needing special attention or that staff is
concerned about. The MHP must also review and initial the Conditions
of Monitoring noting any variation in the resident’s routine or behavior
that might indicate a change in mental health status or concern about
the resident’s well-being.
ii. The MHP’s contact with the residents may be performed cell-side if it is
sufficient to assess the resident’s well-being. In cases in which a
change in mood, routine, or behavior is noted, or in which there is a
recent mental health history, contact with the residents must occur out
of cell.
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13. Emergency Transfers
a. When an MHP determines that an emergency transfer of the resident is
necessary due to acute mental illness, need for a higher level of care in a
mental health unit, or due to an inability to provide adequate security or
supervision resources, the MHP must contact the shift commander and
indicate an emergency transfer is needed.
b. The shift commander notifies the facility duty officer and, if approved,
contacts the shift commander at the receiving facility to initiate the
transport.
14. Companion Program (FM Required)
a. The facility head may using resident companions to supplement monitoring
during non-acute safety precautions and close observation.
b. In facilities with a companion program, an MHP or designee is responsible
for the selection, training, assignment, performance, and removal of
companions. The MHP must maintain an accurate and up-to-date list of
approved companions in the facility. This list must be available to the shift
commanders.
c. Companions must be selected based upon their ability to perform the job
and their reputation within the facility. Companions should be mature,
reliable, credible, and demonstrate mental health stability with staff and
residents. They must be able to protect the privacy of the resident on
watch from other residents while being accepted in the role by staff.
i. Companions must complete training before being assigned to
monitoring. A sufficient number of companions should be trained, and
alternate candidates should always be available. MHPs or designees
may remove any companion from the program at their discretion.
ii. Resident companions are not to have direct line of sight supervision of
residents on suicide during showers. When a resident on suicide is
showering, any line-of-sight observation must be conducted by a staff
member.
d. Except under unusual circumstances, companions do not conduct
monitoring longer than 4 hours during a 24-hour period. The shift
commander must approve any extension up to an additional four hours.
Companions may not assist with monitoring for longer than 8 hours in a
24-hour period. Companions document their work hours using the
Companion Time Sheet.
e. If a companion observes a resident on watch engaging in any type of self-
injurious behavior, they must immediately report the activity to staff.
Each facility must identify, in a FM, how trained companions contact staff
during their monitoring duty. The companion performing monitoring must
have access to a means to immediately summon help.
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f. Companions document their observations of the resident in a Companion
Watch Sheet a minimum of every 5 minutes. The resident’s Companion
Watch Sheet is forwarded to medical records for inclusion in the resident’s
medical file once the monitoring has concluded.
g. Training Companions
i. Companions must receive training approved by the chief psychologist or
designee and sign a Companion Agreement of Understanding and
Expectations. The companion must successfully complete an initial
four-hour structured training prior to being assigned to complete a
monitoring shift. To remain active in the companion program,
companions must receive an additional four hours of refresher training
semi-annually.
ii. Companions must meet at least quarterly with the MHP or designee to
review procedures, discuss issues, and supplement training. The MHP
or designee must maintain a file containing documentation of
attendance and topics discussed at training meetings.
h. Supervision of Companions
i. Companions must maintain direct, line-of-sight supervision of residents
on non-acute safety precautions or close observation and must never
read, complete homework, or do any other activity that would interfere
with their ability to constantly monitor the resident on a monitoring
status. Companions are allowed listen to music with only one earbud.
ii. Staff supervising the companion are required to ensure that the
companion follows this process and is responsible for providing
direction or removing a companion if there is a safety concern about
the companion’s ability to monitor. Staff monitoring of companions
must occur at intervals not to exceed 15 minutes and be documented
on the Behavior Observation Log.
15. Suicide Resulting in Death
a. If it is determined that a death has occurred, the procedures described in
SOP 312.02.01.001, Death of a Resident must be followed.
b. Psychological Autopsy Procedures
i. In the event of a suicide resulting in death, the chief psychologist or
designee must conduct a psychological autopsy in accordance with
NCCHC Standards.
ii. The psychological autopsy is a written reconstruction of a resident’s life
with an emphasis on mental health factors that may have contributed
to the resident’s death. The psychological autopsy must include the
resident’s history, the resident’s behavior during the period preceding
death, any information that may suggest a reason or motive for the
suicide, and if applicable, recommendations for changes to training,
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SOPs, or other processes or procedures.
iii. Copies of the psychological autopsy must be provided to the facility
head and to the serious incident review (SIR) panel (see SOP 125.001,
Serious Incident Reviews).
c. Following any suicide attempt resulting in death, the chief of the prisons
division must establish a SIR panel in accordance with SOP 125.001,
Serious Incident Reviews.
d. Critical Incident Stress Debriefing
i. Staff: When staff are exposed to traumatic events such as suicide, they
must be given an opportunity to receive appropriate assistance. The
facility head or designee must initiate the critical incident stress
management process in accordance with SOP 112.01.01.002, Critical
Incident Stress Management Team.
ii. Residents: Counseling must be offered to residents who may be
experiencing emotional distress related to either their involvement in
the incident or involvement with the deceased resident. In addition, in
the days following the suicide, mental health staff should have an
increased presence on the unit in which the suicide occurred to ensure
the general well-being of residents and to assess additional clinical
intervention that may be needed.
16. Program Review and Assessment
a. The clinical supervisor must ensure that each facility maintains a suicide
risk management log that contains information about each safety
precautions, completed suicide, and clinical comments pertinent to the
case.
b. By the 5th calendar day of each month, the clinical supervisor at each
facility submits that facility’s suicide risk management log to the chief
psychologist.
c. The chief psychologist or designee will provide a summary report of the
suicide risk management program as requested by department
leadership.
17. Suicide Risk Management Training
a. All staff members, working in, or with access to, IDOC correctional
facilities must receive, at a minimum, training once a year in the
identification and management of potentially suicidal residents.
b. The chief psychologist or designee must approve all suicide risk
management training and lesson plans.
c. Suicide risk management training must include:
i. Identifying suicidal indicators and risk factors.
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ii. Typical resident profiles of completed suicides.
iii. Communicating with suicidal residents.
iv. Requirements for conducting formal safety precautions.
v. Policies and procedures for screening and assessment.
vi. Intervention and response to medical emergencies.
vii. Specific procedures for referring potentially suicidal residents for
appropriate assessment and monitoring.
H. REFERENCES
1. Forms
a. 105 Report
b. Behavior Observation Log (Staff)
c. Companion Agreement of Understanding and Expectations
d. Companion Time Sheet
e. Companion Watch Sheet
f. Conditions of Monitoring
g. Default Acute Safety Precautions Order
h. Default Non-Acute Safety Precautions Order
i. Information Report
j. Safety Precautions / Close Observation Order
k. Note: Other standard forms used for this SOP can be found in the
electronic medical record system.
2. Cited Documents
a. SOP 112.01.01.002, Critical Incident Stress Management Team
b. SOP 125.001, Serious Incident Reviews
c. SOP 312.02.01.001, Death of a Resident
d. SOP 322.001, Transports: Medical, Court, Family Emergency, and State
e. SOP 504.02.01.001, Investigations and Intelligence Program
3. Other Significant Documents
a. Resident Watch Companion Program Guide
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