Program Guide Overview Mental Health Services Delivery System

CHAPTER 1
Program Guide Overview

The California Department of Corrections and Rehabilitation (CDCR) Mental Health Services
Delivery System (MHSDS) provides inmates access to mental health services. The MHSDS is
designed to provide an appropriate level of treatment and to promote individual functioning
within the clinically least restrictive environment consistent with the safety and security needs of
both the inmate-patient and the institution.

The intent of the MHSDS is to advance the CDCR’s mission to protect the public by providing
timely, cost-effective mental health services that optimize the level of individual functioning of
seriously mentally disordered inmates and parolees in the least restrictive environment. The
MHSDS has been functioning in CDCR since 1994. The MHSDS utilizes a variety of
professional clinical, custody, and support staff to provide the best available quality of care to
seriously mentally disordered inmates.

Outpatient care is provided in an array of treatment levels and modalities including a day
treatment program and an outpatient clinic level of care. The MHSDS is a decentralized, system-
wide concept using standardized evaluation and treatment. The MHSDS provides universal
screening for all incoming inmates at Reception Centers and direct transfer from the Reception
Center to the treatment facility for further evaluation and/or treatment if needed. The MHSDS
utilizes case management techniques to manage the majority of mentally disordered inmates in
the general population and provides for their access to care as needed. The MHSDS provides a
continuum of inpatient care from a contractual relationship with Department of Mental Health
(DMH) for acute and intermediate and a short-term crisis inpatient care program within CDCR
institutions. The goal is to provide constitutionally appropriate levels of mental health treatment
to the incarcerated serious mentally ill inmate in the least restrictive environment. The MHSDS
continues to develop a standardized, automated system of records management and case tracking.

Some key concepts are inherent in the design and administration of these services. These
concepts are:

1. To deliver services that promote mental health, by developing and reinforcing individual
responsibility. A mental disorder does not necessarily excuse individual responsibility and
accountability. The inmate-patient’s ability to achieve their clinical goals is enhanced by a
therapeutic emphasis on responsibility for one’s own behavior.

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2. To promote understanding that mental health treatment is a sensible administrative approach

to managing inmate-patients when behavioral expressions of their mental disorder disrupt
their ability to adequately function and program during confinement.

3. To provide all services with strict observance of Utilization Management guidelines, as a

reminder to fiscal responsibility regarding the use of taxpayer funds, which are a limited
resource.

The MHSDS uses a variety of therapeutic strategies. The goals of treatment in MHSDS are to
help inmates adjust to the prison environment, to optimize appropriate personal functioning, and
to help inmates accept responsibility for their behavior. An inmate’s offense and institutional
behavior, rather than the need for treatment, determine the level of custody placement.

At each institution, the MHSDS operates under the management of the Chief of Mental Health or
the Clinical Director. This individual is typically the Chief Psychiatrist, Chief Psychologist, or
Senior Psychologist. Mental Health staff are under the supervision of the institution’s Health
Care Manager. Success of the MHSDS requires that the mental health staff work cooperatively
with other Health Care units in the institution, including Health Records, Pharmacy, Lab, and
Nursing. It also requires that mental health staff work cooperatively with the institution’s
correctional and institution support staff.

A. REASONABLE ACCOMMODATIONS FOR INMATES

The CDCR provides access to its programs and services to inmates with disabilities, with or
without reasonable accommodation, consistent with legitimate penological interests. No
qualified inmate with a disability as defined in Title 42 of the United States Code,
Section 12102 shall, because of that disability, be excluded from participation in or denied the
benefits of services, programs, or activities of the CDCR or be subjected to discrimination.
All institutions housing inmates with disabilities will ensure that housing and programming
are reasonable and appropriate in a manner consistent with their mission and CDCR policy.

Reasonable accommodations shall be afforded to inmate-patients with disabilities, e.g.,

visually impaired, hearing impaired, speech impaired, learning disabled, and developmentally
disabled, to ensure equally effective communication during contacts of any kind that occur
within the MHSDS. Auxiliary aids that are reasonable, effective, and appropriate to the needs
of the inmate-patient shall be provided when simple written or oral communication is not
effective. Such aids may include qualified sign language interpreters, readers, sound
amplification devices, captioned television/video text displays, Telecommunication Devices
for the Deaf (TDD), audio taped texts, Braille materials, large print materials, and signage.
For developmentally disabled inmate-patients, equally effective communication may require
reviewing the CDCR 128C-2, Developmental Disability Program Screening Results, that
documents the adaptive support services required by the inmate-patient.
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It is the obligation of CDCR staff, including mental health clinicians, to provide effective
communication under all circumstances. The degree of accommodation that is required shall
be determined on a case-by-case basis.

In any case in which a question may arise as to the inmate’s ability to comprehend, staff shall
document the determination that the inmate understood the process during all clinical contacts
and shall record the basis for that determination and how the determination was made. This
shall be recorded on the documentation of the clinical contact, such as the CDCR Form 7230-
MH, Interdisciplinary Progress Note. Examples of documentation of effective
communication include, "the responsive written notes generated by a hearing impaired inmate
indicated that he/she understood the process,” "the sign language interpreter appeared to
communicate effectively with the hearing impaired inmate as indicated by the inmate's
substantive response via sign language,” or, "the inmate was able to summarize instructions
given to him/her." To the extent that written notes are used to effectively communicate with
an inmate-patient, those notes shall be attached to the documentation of that clinical contact
and filed in the Unit Health Record (UHR).

B. PRIMARY COMPONENTS

Crisis Intervention A crisis is defined as a sudden or rapid onset or exacerbation of symptoms

of mental illness, which may include suicidality or other aberrant behavior which requires
immediate intervention. Crisis intervention is provided at all institutions to inmate suffering
from a situational crisis or an acute episode of mental disorder. The first step in providing
crisis intervention is adequate training for all institutional staff in the recognition of mental
health crisis symptoms, a plan for immediate staff response, and procedures for referral to
clinical staff. Custody and clinical staff cooperation is critical to ensure that an inmate in a
mental health crisis is treated as soon as possible.

Comprehensive Services The MHSDS offers comprehensive services and a continuum of

treatment for all required levels of care. In addition to standardized screening and evaluation,
all levels of care found in a county mental health system are represented in the CDCR
MHSDS programs. All levels of care include treatment services provided by multiple clinical
disciplines, and development and update of treatment plans by an Interdisciplinary Treatment
Team (IDTT), which includes appropriate custody staff involvement.

Decentralized Services Mental health services are geographically decentralized by making

basic services widely available. All levels of care, except inpatient hospitalization, are
available at most geographically-defined Service Areas (see Section E). Case management
and crisis intervention are provided at all institutions.

Clinical and Administrative Oversight In coordination with each institution, the CDCR
Division of Correctional Health Care Services (DCHCS) and Division of Adult Institutions
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will continue to update standardized program policy and develop a system for monitoring
delivery of program services. The CDCR shall develop an annual review schedule of the
MHSDS Program Guide, according to the Inmate Medical Services Policies and Procedures,
U U U U

Chapter 8, Implementation and Review of Health Care Policies and Procedures. A system-
wide automated tracking and records system continues to evolve to support administrative and
clinical oversight.

Standardized Screening Access to mental health services is enhanced for all inmates through
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standardized screening of all admissions at Reception Centers. Standardized screening

ensures that all inmates have equal and reliable access to services. The data generated by
standardized screening provides the CDCR with necessary information to improve the
assessment of mental health service needs. If screening reveals indicators of mental disorder,
such as prior psychiatric hospitalization, current psychotropic medication, suicidality or
seriously maladaptive behaviors, follow-up evaluation by a clinician shall determine the
immediate treatment needs of the inmate. Early identification of an inmate’s mental health
needs will provide an appropriate level of treatment and promote individual functioning
within the clinically least restrictive environment consistent with the safety and security needs
of both the inmate-patient and the institution. Avoiding the utilization of more expensive
services will aid in budget containment.

Pre-Release Planning This component of service, in conjunction with the Correctional

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Counselor’s preparation of the CDCR 611, Release Program Study, focuses on preparing the
seriously mentally disordered inmate-patient for parole. Its objective is to maximize the
individual's potential for successful linkage and transition to the Parole Outpatient Clinic, or,
if required, to inpatient services in the community or the Mentally Disordered Offender
Program operated at the DMH facilities. In the case of paroling inmate-patients, this includes
facilitating the work of the Parole and Community Services Division’s Transitional Case
Management Program.

C. REFERRALS TO MENTAL HEALTH

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Any inmate can be referred for mental health services at any time. Inmates who are not
identified at Reception or upon arrival at an institution as needing mental health services,
may develop such needs later. Any staff members that have concerns about an inmate’s
mental stability are encouraged to refer that inmate for evaluation by a qualified mental
health clinician (psychiatrist, psychologist, or clinical social worker). Under certain
circumstances, referral to mental health may be mandatory. A referral to mental health
should be made whenever:

• An inmate demonstrates possible symptoms of mental illness or a worsening of

symptoms.

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• An inmate verbalizes thoughts of suicide or self-harm behavior.

• Upon return from court when an inmate has received bad news such as a new sentence
that may extend their time.

• An inmate has been identified as a possible victim per the Prison Rape Elimination Act.

• An inmate demonstrates sexually inappropriate behavior as per the Exhibitionism policy.

• An inmate who is written up for a disciplinary infraction was demonstrating bizarre,

unusual, or uncharacteristic behavior when committing the infraction.

• An inmate placed into Administrative Segregation indicates suicidal potential on the pre-
screening, or rates positive on the mental health screening, or gives staff any reason to be
concerned about the inmate’s mental stability, such as displaying excessive anxiety.

• Upon arrival to an institution when the inmate indicates prior mental health treatment and
medications, especially if not previously documented.

Referrals to mental health may be made on an Emergent, Urgent, or Routine Basis. An

inmate deemed to require an Emergent (immediate) referral shall be maintained under
continuous staff observation until evaluated by a licensed mental health clinician. An Urgent
referral is to be seen within 24 hours. A Routine referral should be seen within five working
days.

Referrals are made on the CDCR-MH5, Mental Health Referral Chrono, and forwarded to
the mental health office. Emergent and Urgent referrals should also be made by phone to
facilitate a timely response. The referral chronos, when received at the mental health office,
are logged, entered into the data tracking system, and scheduled for follow-up with the
appropriate clinician.

Inmates may also self-refer for a clinical interview to discuss their mental health needs.
Inmate self-referrals shall be collected daily from each housing unit, and processed the same
way as staff referrals.

D. TREATMENT CRITERIA FOR THE LEVELS OF CARE

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Overall Treatment Criteria

8BU

Overall treatment criteria have been developed for the MHSDS. An inmate must meet the
criteria in 1, 2, or 3 below, in order to receive MHSDS treatment at any level of care:

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1. Treatment and monitoring are provided to any inmate who has current symptoms and/or
requires treatment for the current Diagnostic and Statistical Manual diagnosed (may be
provisional) Axis I serious mental disorders listed below:

Schizophrenia (all subtypes)

Delusional Disorder
Schizophreniform Disorder
10B

Schizoaffective Disorder
Brief Psychotic Disorder
Substance-Induced Psychotic Disorder (exclude intoxication and withdrawal)
Psychotic Disorder Due To A General Medical Condition
Psychotic Disorder Not Otherwise Specified
Major Depressive Disorders
Bipolar Disorders I and II

2. Medical Necessity Mental health treatment shall be provided as needed. Treatment is

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continued as needed, after review by an IDTT, for all cases in which:

Mental health intervention is necessary to protect life and/or treat significant

disability/dysfunction in an individual diagnosed with or suspected of having a
mental disorder. Treatment is continued for these cases only upon reassessment and
determination by the IDTT that the significant or life threatening
disability/dysfunction continues or regularly recurs.

3. Exhibitionism Treatment is required when an inmate has had at least one episode of
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indecent exposure in the six-month period prior to the IDTT that considers the need for
exhibitionism treatment and the inmate patient is either:

• Diagnosed with Exhibitionism, or

• Meets the alternate criteria. (Alternate Criteria: An inmate who meets all criteria for
the diagnosis of Exhibitionism, except that the victim was not an “unsuspecting
stranger” but was a staff member or inmate who did not consent to or encourage the
behavior.)

(A diagnosis of Exhibitionism is not required for inmates who meet the alternate criteria.)

Specific Treatment Criteria

9BU

In addition to the overall treatment criteria above, an inmate must meet the following specific
treatment criteria to receive treatment at a specific level of care:

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1. Correctional Clinical Case Management System

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• Stable functioning in the general population, Administrative Segregation Unit (ASU)

or Security Housing Unit (SHU); and

• Criteria not met for higher levels of care; and

• Exhibits symptom control, or is in partial remission as a result of treatment.

• These conditions usually result in Global Assessment of Functioning (GAF) scores of

50 and above.

Correctional Clinical Case Management System (CCCMS) is located at all institutions

[except California Conservation Center (CCC), Calipatria State Prison (CAL), Centinela
State Prison (CEN), Chuckwalla Valley State Prison (CVSP), and Ironwood State
Prison (ISP). These prisons provide necessary care until the inmate-patient can be
transferred] to provide care, monitoring and follow-up services to inmate-patients whose
condition is relatively stable and whose symptoms are largely controlled. This may
include a response to symptoms that require only a brief intervention, such as a
psychotherapy session or an adjustment in medications. While mentally disordered, these
inmate-patients can function in the general population and do not require a clinically
structured, therapeutic environment.

All inmates, including those in SHU or ASU, needing crisis intervention and/or continued
treatment also receive services from CCCMS staff. Details for provision of services in
ASU and SHU are found in their respective chapters of the Program Guide.

2. Enhanced Outpatient Program

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• Acute Onset or Significant Decompensation of a serious mental disorder characterized

by increased delusional thinking, hallucinatory experiences, marked changes in affect,
and vegetative signs with definitive impairment of reality testing and/or judgment;
and/or

• Inability to function in General Population based upon:

a. A demonstrated inability to program in work or educational assignments, or other

correctional activities such as religious services, self-help programming, canteen,
recreational activities, visiting, etc. as a consequence of a serious mental disorder;
or

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b. The presence of dysfunctional or disruptive social interaction including

withdrawal, bizarre or disruptive behavior, extreme argumentativeness, inability to
respond to staff directions, provocative behavior toward others, inappropriate
sexual behavior, etc., as a consequence of serious mental disorder; or

c. An impairment in the activities of daily living including eating, grooming and

personal hygiene, maintenance of housing area, and ambulation, as a consequence
of serious mental disorder.

• These conditions usually result in a GAF of less than 50.

Enhanced Outpatient Program (EOP) provides care to mentally disordered inmate-patients

who would benefit from the structure of a therapeutic environment that is less restrictive
than inpatient settings. This may include response to crisis symptoms which require
extensive treatment, but can be managed as outpatient therapy with several psychotherapy
sessions or medication adjustment with follow-up visits.

These inmate-patients do not require continuous nursing care. Often, they are
transitioning from inpatient care in a DMH hospital or the Mental Health Crisis
Bed (MHCB). They may also have a serious mental illness that is of long duration with
moderate to severe and persistent functional impairments. The EOP's structured program
of treatment and supportive activities will, in many cases, build on therapeutic
improvements made in a hospital program or MHCB. EOP will release cases which have
successfully completed treatment to CCCMS. The EOP is located in a designated living
unit at the hub institution.

3. Mental Health Crisis Bed Placement

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• Marked Impairment and Dysfunction in most areas (daily living activities,

communication and social interaction) requiring 24-hour nursing care; and/or:

• Dangerousness to others as a consequence of a serious mental disorder, and/or

dangerousness to self for any reason.

• These conditions usually result in a GAF score of less than 30.

All inmate-patients admitted to a MHCB are discharged within ten days, with scheduled
appropriate clinical follow-up, to outpatient care or the general population or are
transferred to DMH inpatient care. Stays of over ten days must be approved by the Chief
of Mental Health, or designee. The MHCB also provides short-term inpatient care for
seriously mentally disordered inmate-patients awaiting transfer to a hospital program or
being stabilized on medication prior to transfer to a less restrictive level of care. The
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MHCB is a part of a licensed General Acute Care Hospital (GACH), Skilled Nursing
Facility (SNF), or a Correctional Treatment Center (CTC) offering 24-hour basic medical,
nursing, and other health services. A Central Health Services building which houses CTC
services houses the MHCB beds, staff offices and therapy space. In the CTC, the MHCB
runs its short-term crisis care program under the CTC “optional mental health treatment
program” regulations. In a GACH or SNF, the MHCB are under the “distinct part
Psychiatric” licensing regulations.

4. DMH Inpatient Hospital Care

Referral to inpatient programs provided via contract with the DMH is available for
inmate-patients whose conditions cannot be successfully treated in the outpatient setting
or in short-term MHCB placements. Both acute and intermediate care programs are
offered in facilities for both male and female inmate-patients. Specific criteria are noted
in
Chapter 6, Department of Mental Health Inpatient Program.

The IDTT shall generally be responsible for developing and updating treatment plans. This
process shall include input from the inmate-patient and other pertinent clinical information
that may indicate the need for a different level of care. Referrals to higher levels of care shall
be considered when the inmate-patient’s clinical condition has worsened or the inmate-patient
is not benefiting from treatment services available at the current level of care. Consideration
of appropriate level of care shall be documented by the IDTT on a
CDCR 7230-MH, Interdisciplinary Progress Notes, and shall include the justification for
maintaining the current level of care or referral to a different level of care.

E. SERVICE AREAS

The principal infrastructure for service delivery is the Service Area. A mental health Service
Area assumes responsibility for mental health services; a medical Service Area, while it
generally overlaps with that for mental health, is responsible for medical services. Several
Service Areas report to a Regional Administrator.

Each Service Area consists of a group of two or more institutions in relative geographic
proximity that share the full complement of services directly provided by CDCR. These
services include all levels of care, except the Acute and Intermediate inpatient care provided
through DMH. Each mental health Service Area has from one to three MHCB locations and
one EOP located at its hub institution. CCCMS completes the delivery system within a
Service Area. Staff handling CCCMS caseloads are at every institution.

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F. CLINICAL PROGRAM GUIDE

MHSDS Program Guide chapters have been developed for the MHCB, EOP, and CCCMS
levels of care. Each chapter is organized into the following sections: Program Objectives,
Population Served, Treatment Modalities, Staffing, and Patient Assessment and Case Review
Procedures. Although these chapters define essential program content and delineate system-
wide policies, each Service Area is expected to have written policies and specific operational
procedures (derived from the Program Guide) articulated in ways that best address the unique
needs of the specific Service Area and its institutions. Written policies and procedures are
especially necessary for the MHCB to meet health facility licensing requirements.

G. STANDARD PROGRAM STAFFING

Staffing for all programs is based on the Mental Health Staffing Workload Study, completed
June 2007, which allocates both clinical and clerical support staff whom perform duties
related to the provision of mental health services. CDCR may utilize contract staff as
necessary to fulfill staffing requirements. Use of unlicensed psychologists and clinical social
workers during the period they are gaining qualifying experience for licensure is governed by
Section 1277 of the Health and Safety Code, and Section 5068.5 of the Penal Code.

Institutions may use pre-doctoral psychology interns who are trained and supervised by a
licensed psychologist according to regulations in Sections 1287, 1287.1, and 1287.2 of
Title 16, Division 13.1 of the California Code of Regulations. Institutions may also use
social work interns who are currently enrolled in a master’s program in social work
according to regulations in Section 4996.15 of the California Business and Professions Code.

All newly hired psychiatrists must meet minimum credentialing criteria as follows:

1. Current board certification from the American Board of Psychiatry and Neurology or
the American Osteopathic Board of Neurology and Psychiatry.

OR

2. Satisfactorily completed specialized training requirements in psychiatry in programs

that, for a psychiatrist, are accredited by the Accreditation Council for Graduate
Medical Education (ACGME) or Bureau of Osteopathic Education of the American
Osteopathic Association (AOA) or certified by the Royal College of Physicians and
Surgeons of Canada.

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a) Two patterns of training are acceptable:

(i). Training Pattern One: A Three-Year Psychiatry Residency Program

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• A broad-based clinical year of ACGME or Bureau of Osteopathic Education of

the AOA-accredited training in internal medicine, family practice, or pediatrics;
or

• An ACGME or Bureau of Osteopathic Education of the AOA-accredited

transitional year program that included a minimum of four months of primary
care; or

• An AGCME or Bureau of Osteopathic Education of the AOA-accredited

residency in a clinical specialty requiring comprehensive and continuous patient
care.

AND
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Three full years of postgraduate, specialized residency training in a psychiatry

program accredited by the ACGME or Bureau of Osteopathic Education of the
AOA.

OR

(ii) Training Pattern Two: A Four-Year Psychiatry Residency Program

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Four years of training in an ACGME or Bureau of Osteopathic Education of the

AOA-accredited program in psychiatry is acceptable. A psychiatry PGY-1 must
include at least four months of internal medicine, family practice, and/or pediatrics.
This training must be in a clinical setting that provides comprehensive and continuous
patient care. No more than one month of this requirement may be fulfilled by an
emergency medicine rotation, as long as the experience predominantly involves
medical evaluation and treatment, rather than surgical procedure. Neurology
rotations may NOT be used to fulfill this four-month requirement.

(Exception: Any applicant who completed a residency program in psychiatry that was
accredited by the ACGME or Bureau of Osteopathic Education of the AOA or
certified by the Royal College of Physicians and Surgeons of Canada at the time the
applicant completed the residency will qualify under this pattern of training upon
CDCR verification that all residency requirements were successfully completed and if
all other requirements are met.)

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If the candidate’s training program(s) is not currently accredited by the ACGME or

the Bureau of Osteopathic Education of the AOA, CDCR shall research the history of
the program(s) to determine if it was accredited at the time the candidate attended and
completed the training.

All osteopaths hired in the classification of psychiatrist before January, 2006, and presently
in that classification must meet the above criteria or must undergo a court-mandated
evaluation of their clinical competency for employment in the position of psychiatrist with
the CDCR.

H. PARAMETERS OF CONFIDENTIALITY OF INMATE-PATIENT

COMMUNICATIONS AND GUIDELINES FOR DISCLOSURE

CDCR has developed a detailed policy to ensure that confidentiality of inmate-patient

communications with mental health clinicians is protected. This policy, issued in a
memorandum dated April 18, 2007, is Attachment A to the MHSDS Program Guide. The
policy is accompanied by examples for the purpose of staff training. Clinicians, including
psychiatrists, physicians, psychologists, clinical social workers, nurse practitioners,
registered nurses, licensed vocational nurses, licensed psychiatric technicians, and
recreational therapists, shall be trained in this policy. In addition, all staff members who
intentionally, accidentally, or inadvertently overhear confidential communications (arising
from clinical contacts such as cell front visits) are responsible for maintaining confidentiality
of the communication. Custody officers, correctional counselors, and other staff who are
members of an IDTT are bound to not discuss health-related inmate-patient information with
anyone other than the team members.

Clinicians are responsible for informing inmate-patients of the limits of confidentiality, or

ensuring that prior documentation in the UHR indicates that this disclosure has occurred
prior to commencement of a clinical encounter. CDCR 7448, Informed Consent for Mental
Health Care, shall be used for this purpose.

I. CLINICAL INPUT INTO THE DISCIPLINARY PROCESS

Inmate-patients in the Mental Health program or any inmate showing signs of possible mental
illness may require a CDCR 115-MH, Rules Violation Report – Mental Health Assessment,
when they are charged with a disciplinary action.

All inmates in the EOP, MHCB, and DMH programs who receive a CDCR 115-MH, Rules
Violation Report – Mental Health Assessment, shall be referred by the Reviewing Custody
Supervisor to Mental Health Services for a Mental Health Assessment. All inmates in
CCCMS or non-MHSDS inmates who receive a CDCR 115-MH, Rules Violation Report and
who exhibit bizarre, unusual, or uncharacteristic behavior shall be referred for a CDCR 115-
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MH Rules Violation Report: Mental Health Assessment. Inmates who receive a

CDCR 115, Rules Violation Report for Indecent Exposure or Intentionally Sustained
Masturbation Without Exposure shall be referred for a CDCR 115-MH Rules Violation
Report: Mental Health Assessment.

A mental health clinician who is not the inmate’s Primary Clinician shall review the relevant
portions of the inmate’s UHR and any other records deemed appropriate and shall evaluate the
inmate in a non-confidential interview in a private setting. The findings shall be reported on a
CDCR 115-MH, Rules Violation Report: Mental Health Assessment. The report must be
returned to the Reviewing Custody Supervisor within 5 working days for non-MHSDS and
CCCMS inmates (to allow time to assign a Staff Assistant) and within 15 calendar days for
EOP, MHCB and DMH patients. The clinician shall determine the following:

1. Are there any mental health factors that would cause the inmate to experience difficulty in
understanding the disciplinary process and representing his/her interests in the hearing
that would indicate the need for the assignment of a Staff Assistant? Note: All inmates
in the EOP, MHCB, and DMH programs automatically have a Staff Assistant
assigned.

2. Did the inmate’s mental disorder appear to contribute to the behavior that led to the Rules
Violation Report?

3. If the inmate is found guilty of the offense, are there any mental health factors that the
hearing officer should consider in assessing the penalty?

Refer to the “Inmate Disciplinary Process, Mental Health Assessment” manual (See
Attachment B) and CDCR 115-MH, Rules Violation Report: Mental Health Assessment, for
detailed instructions on completing this assessment and utilizing the information in the
hearing process.

J. AUTOMATED TRACKING SYSTEM

The Inmate Mental Health Identifier System (IMHIS) has been designed to track the
movement of all inmate-patients receiving care in the MHSDS. The data entered into the
system will be processed daily, so the system will maintain information regarding MHSDS
inmate-patients current level of care as well as MHSDS inmate-patients transfers, discharges,
and new cases. All institutions are to conduct a reconciliation of the inmate-patients housed
in ASUs who require mental health treatment with the IMHIS codes for this specific
population. It is very important that IMHIS information be as up to date as possible and daily
updates to the IMHIS are mandatory.

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K. MENTAL HEALTH TRACKING SYSTEM

3BU

The Mental Health Tracking System (MHTS) is an automated program designed to track and
record all pertinent mental health information for inmate-patients from the time they enter the
MHSDS until they are released, paroled, or transferred out of the MHSDS and return to the
general population. This institutional information management program is capable of tracking
an inmate-patient’s medication history, level of care changes, mental health staff contacts,
current and previous DSM psychiatric diagnoses, latest Abnormal Involuntary Movement
Scale score, status and information regarding current or past Keyhea orders, as well as other
key data related to an inmate-patient’s mental health treatment history. In addition, the
MHTS is used to produce the Inmate Profile which documents suicide risk data and
accompanies inmates whenever they are transferred between institutions to provide the
receiving institution with suicide risk data and other initial MHTS input data. The MHTS is
designed to track and aggregate data which serves as a basis for quality assurance and
improvement activities at the Institutional and Departmental levels.

L. MENTAL HEALTH PLACEMENT CHRONO

4B U

Each inmate who is assessed as having a serious mental disorder and is accepted into the
MHSDS will have a CDCR 128-MH3, Mental Health Placement Chrono (MHPC) completed
and entered into their UHR and Central File. This chrono indicates the inmate-patient’s LOC,
medication status, any behavioral alerts, and their GAF score. This information is entered
daily into the IMHIS and the MHTS and is a critical component in the overall management of
inmate-patients in the MHSDS. As long as an inmate-patient is in the MHSDS, they shall
have a MHPC that reflects the inmate-patient’s current status.

• At the RC, the MHPC shall be dated within 90 days of the Classification Staff
Representative placement action. As inmate-patients usually spend less than 90 days in
the RC, updates will not normally be required.

• In all other housing situations, no updates of the MHPC will be required unless there is a
change in the level of care, or when the inmate-patient is being referred for transfer to
another institution.

M. LEVEL OF CARE CHANGE /TRANSFER TIMELINES

5BU

The following table summarizes the time frames which CDCR must meet for the transfer of
MHSDS inmate-patients between levels of care, whether within the same institution or to
another institution. More detail on the level of care change/transfer process is provided in the
individual level of care sections of the Program Guide.
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The following definitions apply to the Transfer Timelines Table:

• “Identification:” The date that the inmate-patient is identified as requiring a higher LOC.
The IDTT is responsible for identifying inmate-patients who are appropriate for discharge
to a lower LOC, an increase from CCCMS to EOP LOC, or DMH intermediate care. An
individual clinician may identify an inmate-patient as requiring initial admission into
MHSDS at CCCMS or EOP LOC. A credentialed clinician may admit an inmate-patient
to MHCB care. An individual clinician may refer an inmate-patient for DMH acute
inpatient care.

• “Referral” within CDCR: The date the LOC change is documented on a Mental Health
Placement Chrono, or the time the physician or clinical psychologist orders admission into
a CTC.

• “Referral” to DMH: The date the completed referral packet is received by DMH by
facsimile or overnight mail.

• “Acceptance” at DMH: The date the Clinical Assessment Team at DMH accepts the
inmate-patient for placement at a DMH facility. Some inmate-patients may be placed on a
waitlist pending bed availability after acceptance.

• “Transfer:” The date the inmate-patient is placed into the LOC and program to which
s/he was referred.

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2009 REVISION 12-1-15
Program Guide Overview Mental Health Services Delivery System

From: To:

Setting/Level of care Setting/Level of Care Timeline for Transfer

RC/CCCMS Mainline/ CCCMS Within 90 days of referral; 60 days of
referral if clinically indicated
RC/EOP Mainline/EOP Within 60 days of referral; 30 days of
referral if clinically indicated
Any setting/level of MHCB Within 24 hours of referral
care
Any institution/ level Any Acute DMH Within ten days of referral, if accepted to
of care placement DMH. (Referral must be completed
within two working days of identification.
Transport must be completed within 72
hours of bed assignment)
Any institution/level Any Intermediate Care Within 30 days of referral, if accepted to
of care DMH placement DMH. (Referral must be completed
within five working days of identification
by IDTT if inmate-patient consent is
obtained, and within ten working days of
identification if due process hearing is
required. Transport must be completed
within 72 hours of bed assignment).
Mainline (General Mainline (General Within 60 days of referral; 30 days of
Population)/ Population) /EOP referral if clinically indicated
CCCMS
Desert institutions CCCMS Within 30 days if inappropriately
(CAL, CEN, ISP, transferred; otherwise 90 days of referral
CVSP, or 60 days of referral if clinically
CCC)/CCCMS indicated
Desert institutions EOP Within 21 days if inappropriately
(CAL, CEN, ISP, transferred; otherwise 60 days of referral
CVSP, CCC)/EOP or 30 days of referral if clinically
indicated
EOP ASU EOP ASU Hub Within 30 days of ASU placement or
referral to EOP level of care.
EOP ASU/ EOP ASU PSU Within 60 days of endorsement to PSU
Hub
Outpatient Housing EOP Within 30 days of endorsement to EOP
Unit

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2009 REVISION 12-1-16
Program Guide Overview Mental Health Services Delivery System

N. PROGRAM GUIDE REVISION POLICY AND PROCEDURE

U

The MHSDS Program Guide revisions shall occur annually. The revisions shall be presented
to the Mental Health Program Subcommittee (MHPS) by January 31 of each year. The
MHPS shall forward revisions to the appropriate authorities for approval.

All proposed revisions to the MHSDS Program Guide shall be submitted to the DCHCS
Program Guide Coordinator (PGC). The PGC shall be designated by the DCHCS Chief of
the Mental Health Program.

The PGC shall distribute proposed revisions to the Program Guide Focused Improvement
Team (PG-FIT). The PG-FIT shall include at minimum:

• Program Guide Coordinator

• Chief Psychiatrist, Clinical Policy and Programs, DCHCS

• Chief Psychologist, Clinical Policy and Programs, DCHCS

• Assistant Deputy Director, or designee, DAI

• Supervising Attorney, or designee, Office of Legal Affairs

The PG-FIT shall be responsible for involving appropriate representatives from other CDCR
Divisions and other appropriate consultants (e.g. representatives from field institutions) in
decisions regarding any proposed revisions.

Where revisions may impact resources, the PG-FIT shall initiate evaluation of resource
impact and/or request submission of a budget change proposal.

The PG-FIT shall meet as needed with the MHPS to make recommendations regarding
revisions. The MHPS shall present the proposed revisions to the Quality Management
Committee (QMC). The QMC will approve or disapprove each proposed revision.
Approvals will be forwarded to the DCHCS Governing Body (GB). The PGC will record all
changes approved by the GB.

Memoranda signed by the Deputy Director, DCHCS, shall implement emergent or court-
ordered substantive changes to the MHSDS Program Guide throughout the year. These
memoranda shall be integrated into the annual revision of the MHSDS Program Guide
document.

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Program Guide Overview Mental Health Services Delivery System

The PGC shall maintain a project file to include original input submitted by those persons
who provided review and or revisions of the MHSDS Program Guide, along with a tracking
log of approved revisions of the MHSDS Program Guide. Revised portions of the MHSDS
Program Guide shall be marked “SUPERCEDED” with the date it was superceded, and
revised portions shall be filed by revision date.

This tracking log of approved revisions, along with revised MHSDS Program Guide pages
shall be distributed to the Warden, Health Care Manager, Chief of Mental Health, and
Correctional Health Services Administrator and/or Standards Compliance Coordinator at
each institution no later than 30 days after final approval. The distribution shall include
direction that copies of relevant sections are to be shared with appropriate staff. The Chief of
the Mental Health Program at each institution shall ensure that the revisions are integrated
into ALL existing copies of the MHSDS Program Guide according to Inmate Medical
Services Policies and Procedures Chapter 8 “Implementation and Review of Health Care
Policies and Procedures” section regarding Proof of Practice Documentation. Current
DCHCS Policies and Procedures manuals shall be readily available to all mental health staff
in each program and work area. The Chief of Mental Health shall be responsible to ensure
that all staff are trained regarding revised Program Guide requirements.

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2009 REVISION 12-1-18
Reception Center Mental Health Services Delivery System
Mental Health Assessment

CHAPTER 2
Reception Center Mental Health Assessment

A. INTRODUCTION

The Reception Center (RC) program provides mental health assessment for all inmates
committed to the California Department of Corrections and Rehabilitation (CDCR) and basic
treatment for those inmates identified as having a serious mental disorder while awaiting
transfer.

By enhancing and standardizing screening and evaluation efforts at the entry point into the
institution system, the CDCR can best ensure that all inmates in need of mental health
treatment are identified and provided necessary services at the earliest possible time. Early
and easy access to care has been shown to have both therapeutic as well as fiscal benefits in
managing mental illness at its lowest level of acuity. This is particularly true in the high
stress environment of an institution setting.

This program utilizes clinical and clerical positions to achieve the following objectives:

1. Provide a standardized system for universal screening of all inmates received in the
CDCR for possible symptoms of mental disorder or suicide risk.

2. Conduct in-depth clinical evaluations of individuals identified in the screening process

for diagnosis of serious mental disorder, level of functioning, and necessary level of
care.

3. Through the Inmate Mental Health Identifier System, CDCR is able to track inmate-
patients who have been identified as seriously mentally disordered and enrolled in one
of the Mental Health Services Delivery System (MHSDS) levels of care. This
information provides a management tool and is utilized in program planning.

It is important to emphasize that the population this program seeks to identify is defined as
those inmates who are dysfunctional in the prison environment as a result of a serious mental
disorder. Specifically, these are inmates with a Diagnostic and Statistical Manual (DSM)
Axis I diagnosis, with current symptoms, or evidence of medical necessity. Inmates who are
prescribed psychotropic medications are also included in MHSDS. Inmates suffering suicidal

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2009 REVISION 12-2-1
Reception Center Mental Health Services Delivery System
Mental Health Assessment

ideation shall also receive crisis care to protect life. Mental health intervention is also
provided to treat significant disability/dysfunction in an individual diagnosed with or
suspected of having a mental disorder.

Mental health issues which may be identified in the screening process, but which are not
included in the treatment services provided by the CDCR’s mental health treatment programs,
are sexual and substance abuse disorders and personality disorders. However, if these mental
health issues are also accompanied by an Axis I serious mental disorder or meet the
requirements of medical necessity, treatment is provided by the CDCR’s mental health
treatment programs. While all inmates are screened in the RC for developmental disabilities,
services for inmates with developmental disabilities, although provided by mental health staff
in numerous institutions, are not addressed in this Program Guide, as they fall under the
oversight of the Clark Remedial Plan. Inmates with developmental disabilities who also have
an Axis I serious mental disorder are, of course, included in the MHSDS, and some inmates
with developmental disabilities may be included in MHSDS programs under medical
necessity criteria.

B. POLICIES AND PROCEDURES FOR ASSESSMENT OF MENTAL HEALTH

NEEDS

Goal and Target Population

To identify and assign an appropriate level of care to inmates who are suicidal or are
experiencing impaired functioning as a result of serious mental disorder.

Policies to Achieve Goal

1. All inmates shall receive an Initial Health Screening by nursing staff within 24 hours of
arrival to determine need for continuation of currently prescribed and used psychotropic
medications, need for crisis psychiatric care, or other mental health intervention.

2. All inmates shall receive a Mental Health screening within the first seven calendar days
of arrival to identify mental health concerns that may indicate a need for treatment.

3. All inmates with possible mental health treatment needs shall receive a standardized
mental health evaluation within 18 calendar days of arrival, and prior to any placement
decision.

4. All inmates who request a clinical interview shall receive one.

5. Any RC Staff may refer any inmate for clinical interview at any time.
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Reception Center Mental Health Services Delivery System
Mental Health Assessment

6. All mental health screening and evaluation interviews shall be conducted in a private
setting.

7. All psychological evaluations shall conclude with a provisional diagnosis, level of

functioning, and recommended level of care placement, if required.

8. Mental health services shall be provided to inmates while awaiting transfer.

9. In order to facilitate long range planning, each RC shall accumulate and regularly report
data on all inmates screened, evaluated, and determined to be in need of particular levels
of treatment.

C. PROCEDURES TO IMPLEMENT POLICIES

1. Initial Health Screening of Inmates at Receiving and Release

All inmates arriving at a RC shall be interviewed utilizing a standard set of questions

(CDCR 7277, Initial Health Screening) regarding their medication needs or need for
immediate referral for crisis care under the supervision of a Registered Nurse (RN).
Medical staff or equivalent staff trained in the procedures for the standardized health
screening and mental health referrals, shall review available documentation from
committing jurisdictions regarding mental health treatment. This includes a review of
medications provided at County facilities or observed behavior that may indicate a need
for mental health treatment.

This interview shall be conducted in an environment which is sufficiently private and

confidential to encourage full disclosure and open, candid responses. Inmates who are
unable to speak English shall be provided with necessary interpreters. Where a need for
emergency or urgent psychiatric review is identified, a direct referral to a psychiatrist
shall take place, utilizing a standard CDCR 128-MH5, Mental Health Referral Chrono.
The original 128-MH5, Mental Health Referral Chrono, shall be sent to the psychiatrist
and a copy to the mental health office for data entry and filing. These Chronos should be
hand delivered or this information relayed by telephone, if necessary. Emergency
referrals shall be made and responded to immediately. Urgent referrals, including
medication assessment or review, shall be responded to within 24 hours. Observation of
possible mental health symptoms not requiring emergency attention may also be
documented on a staff referral chrono and forwarded to the mental health office within
the next working day. Clinical evaluation and health transfer information from
committing counties relating to a need for medical or mental health care or assessment
are to be placed in the inmate’s Unit Health Record (UHR).
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Reception Center Mental Health Services Delivery System
Mental Health Assessment

2. Physical Exam

Within three working days of arrival, all inmates shall undergo a physical examination
and evaluation of medical history. Any mental health issues that become apparent in the
interviews by the physician, RN, or Licensed Vocational Nurse (LVN) conducting the
reviews, shall be documented on staff referral chronos for subsequent mental health
evaluation. Emergency or urgent cases requiring crisis care or medication review shall
be immediately referred for psychiatric evaluation.

3. Mental Health Screening

Within seven calendar days of arrival at the RC, all inmates (new commitments and
parole violators) shall receive a screening for possible mental health needs. They shall
be individually interviewed by a psychologist or Clinical Social Worker using the
standardized Mental Health Screening questionnaire. The screening clinician shall
explain the purpose of the screening process, and assess the inmate's ability to complete
the interview. Inmates who are unable to speak English shall be provided with
necessary interpreters. Inmates who refuse to participate in the mental health screening
interview shall be referred for a psychological evaluation to determine if they have a
mental disorder. Individuals who are unable to participate in the screening interview
due to possible acute psychiatric distress shall be immediately referred for crisis care.
This will normally include a referral for an emergency psychiatric evaluation (see
Section 5, Psychiatric Evaluations, below).

If a returning Parole Violator identifies himself or herself as a former MHSDS inmate-

patient, the file review indicates such designation, or Distributed Data Processing
System (DDPS) indicates such designation, he or she shall be automatically referred for
further psychological evaluation.

Following completion of the screening interview, the completed screening form shall be
forwarded to the mental health data processing station for analysis. The results of this
screening shall be documented by mental health staff on a CDCR 128-MH1, Mental
Health Screening Chrono. Refusals to participate and any need for an interpreter shall
also be documented on this Chrono. Each case shall be either cleared for general
population placement, scheduled for a full psychological evaluation within 18 calendar
days, or immediately referred for crisis care, as needed.

Information from the standardized Mental Health Screening shall be retained in the
automated system for future reference and data compilation.

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Reception Center Mental Health Services Delivery System
Mental Health Assessment

4. Psychological Evaluations

Inmates referred for psychological evaluation who have been identified in the initial
mental health screening as having a possible mental health need or who refused the
screening, shall be scheduled for a full psychological evaluation to be completed by the
18 calendar day evaluation period after arrival. Preparatory to the evaluation, the
inmate's UHR and Central Files shall be reviewed when available, by the clinician. The
results of the clinical screening assessment, including working diagnosis, shall be
reviewed, as will any information generated from staff or self-referrals to that point.

If the inmate states that he or she had significant prior treatment or the file review
indicates history of such treatment, the clinician shall request that the inmate sign a
Release of Information in an attempt to obtain previous records. The clinician shall
immediately forward the signed Release of Information form to the Health Record
Services staff. Health Record Services staff shall process all requests for information
from external sources, and shall monitor the receipt of the requested information. All
received health information shall be immediately incorporated into the appropriate UHR
with simultaneous notification to the requesting health care personnel, consistent with
the Health Record Services Policies and Procedures. If the inmate has been moved to
another institution, the Health Record Services staff shall check the Offender Based
Information System/DDPS to determine the inmate’s current location and forward the
information immediately to the Health Record Services supervisor at the current
location.

The psychologist or psychiatrist shall conduct an individual interview with the inmate in
a private and confidential setting. Where possible, the psychologist or psychiatrist will
utilize a computer terminal for reference and input in completing the evaluation.
Identifying information already available in the computer will be verified in the file
review and inmate interview.

The psychological evaluation shall be recorded on the CDCR 7386, Mental Health
Evaluation. The psychologist or psychiatrist shall obtain and input a brief narrative of
the presenting problem and historical information of relevance from the files and
interview. A mental status examination and assessment of level of functioning will be
completed, with the results directly entered into the computer on pre-programmed
screens (or hard copy forms, where automated systems are not available). A provisional

diagnosis shall be noted and, where this includes an Axis I condition, a level of
functioning assessment shall also be provided.

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Reception Center Mental Health Services Delivery System
Mental Health Assessment

After arriving at a diagnosis and functioning assessment, the psychologist or psychiatrist

shall determine need for treatment and recommend a level of care, based upon the level
of acuity and treatment program criteria. The psychologist’s findings shall be
documented on a CDCR 128-MH3, Mental Health Placement Chrono. Where possible
needs for psychotropic medication are present, and no current prescription has been
made, a referral to the psychiatrist shall be made, utilizing a standard CDCR 128 MH5,
Mental Health Referral Chrono. A copy of the completed chrono requesting medication
assessment shall be immediately provided to the psychiatrist. The psychiatrist’s
decision regarding the medication needs shall be documented in CDCR 128-MH6,
Psychiatric Evaluation Chrono and the CDCR 7230-MH, Interdisciplinary Progress
Notes in the inmate’s UHR. Pending transfer of the inmate-patient to an appropriate
level of care, an initial treatment plan shall also be provided by the psychologist or
psychiatrist on a CDCR 7386, Mental Health Evaluation, and by the psychiatrist where
medication or crisis care is necessary. Inmates who are acutely psychotic or suicidal
shall be referred for placement in a mental health crisis bed (MHCB) or emergency
transfer to the Department of Mental Health facility at the California Medical Facility or
to Patton State Hospital for female inmates.

All inmates in a RC who are identified as requiring mental health services shall receive
basic treatment as specified in the initial treatment plan. The initial treatment plan is an
integral part of the psychological evaluation and formulated to meet individual inmate-
patient’s clinical needs while housed in the RC. The level of treatment provided during
the transition period for these inmate-patients varies depending on the clinical needs and
the length of stay in the RC as determined by the commitment status. The initial
treatment plan is tailored to meet individual inmate-patient’s clinical needs on a short-
term basis and specifies the type of services, including orientation, medication needs
assessment, or regular monitoring, crisis intervention as needed, and individual contact
with a treating clinician as often as necessary.

Inmates who have no diagnosed mental illness, or whose current level of functioning is
adequate without need for treatment (including psychotropic medications), shall be
cleared for general population placement.

Inmates who are seen by the psychologist as a result of a staff or self-referral after the
completed evaluation, shall be assessed for necessary adjustments to the original
evaluation or treatment plan. Where such adjustments are indicated, new documentation
will be generated.
Following entry of all elements of the psychological evaluation into the automated
system, a CDCR 128-MH3, Mental Health Placement Chrono, shall be generated for the
inmate’s UHR. The chrono shall be provided for the Central File with copies to the
Correctional Counselor (CC) and inmate. The 128-MH3, Mental Health Placement
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2009 REVISION 12-2-6
Reception Center Mental Health Services Delivery System
Mental Health Assessment

Chrono, shall be completed whether the inmate requires treatment or is cleared for
general population placement. The original document shall be dated and signed by the
clinician completing the evaluation.

If an inmate refuses to participate in the psychological evaluation interview, the

clinician shall review the Central File, UHR, and reports from housing officers and/or
other staff, and make clinical observation of the inmate. Clinicians shall make an effort
to resolve refusal cases by the end of the 18 calendar day evaluation period. In those
rare situations where these cases cannot be resolved during the 18 calendar day
evaluation period, the clinician shall document this on the inmate’s CDCR 128-MH3,
Mental Health Placement Chrono. The clinician shall include in a CDCR 7230-MH,
Interdisciplinary Progress Note, a description of what efforts were made to complete the
evaluation (e.g., review Central File and UHR, consult with housing officers, etc.) and a
recommendation of how to proceed with the case. The Chief of Mental Health at the
institution reviews all refusals and approves the clinician’s recommendations. The
results of the psychological evaluation shall be documented on a CDCR 128-MH3,
Mental Health Placement Chrono. If the inmate is not transferred out of the RC within
90 days, a new CDCR 128-MH3, Mental Health Placement Chrono, shall be completed.

5. Psychiatric Evaluations

Psychiatric Evaluations will primarily address the issues of need for acute care and
initiation or continuation of psychotropic medications. Review of need for continuation
of medications prescribed prior to commitment to an institution will normally occur
within 24 hours of intake. A medication specific informed consent with signatures of
psychiatrist, inmate-patient, and a witness (health care staff) will be completed
whenever a new medication is ordered. Psychiatric evaluations will be documented on a
CDCR 7230, Interdisciplinary Progress Note, or CDCR 7386, Mental Health
Evaluation, which will be placed in the inmate’s UHR, and completion of a 128-MH6,
Psychiatric Evaluation Chrono, for entry into the Central File. Inmate-patients
requiring follow-up psychiatric care while awaiting transfer will be scheduled for that
purpose, with documentation of clinical contacts recorded in the inmate-patient’s UHR
progress notes. Changes in mental status which impact placement decisions will also be
documented on CDCR 128-MH6, Psychiatric Evaluation Chrono.

Psychiatrists are also responsible to review an inmate-patient’s response to and side

effects of psychiatric medications and to order and review appropriate laboratory testing.
Where staffing permits, psychiatrists may also serve Primary Clinician (PC) functions.

6. Initial Treatment Planning and Treatment

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2009 REVISION 12-2-7
Reception Center Mental Health Services Delivery System
Mental Health Assessment

Initial treatment planning must be developed and regular treatment must be provided for
all inmate-patients who are identified as requiring mental health services. Mental
Health needs of inmate-patients housed in a RC are often greater than those of inmate-
patients in a general population setting, due to a variety of problems related to
incarceration which often precipitate dysfunctional behavior or exacerbate pre-existing
mental conditions. Treatment plans must address basic issues of adjustment, access to
care, monitoring of medication continuity, and clinical pre-release or parole planning.

Without exception, mental health services are extended to all MHSDS designated
inmate-patients while awaiting transfer to a mainline institution. Services include case
management contacts, medication management, and monitoring pertinent to the level of
functionality based on clinical judgment. In addition, crisis intervention, clinical pre-
release or parole planning, and other case management services shall be provided
consistent with the inmate’s clinical needs. Services are provided through staff assigned
to the RC.

Inmate-patients who require Correctional Clinical Case Management System (CCCMS)

level of care shall be seen by the PC within 30 days of placement in CCCMS and at least
every 90 days thereafter while at the RC, or more often if clinically indicated. These
inmate-patients shall also be evaluated by a psychiatrist a minimum of every 90 days
regarding psychiatric medication issues.

Inmate-patients who require Enhanced Outpatient Program (EOP) level of care shall be
seen by the PC weekly and shall be evaluated by a psychiatrist at least monthly
regarding psychiatric medication issues. Institutions that have both a RC and an
established EOP may temporarily house and treat these inmate-patients in their regular
EOP housing units until transfer.

Reception Centers housing inmate-patients requiring EOP level of care shall provide
structured therapeutic activities. At the five reception centers with the preponderance of
inmates (California Institution for Men, Richard J. Donovan Correctional Facility, North
Kern State Prison, Wasco State Prison, and San Quentin State Prison), regularly
scheduled therapy groups will be held on a daily basis. The remaining seven RCs with
smaller populations will provide a less structured treatment array, but all sites will
provide opportunities for a minimum of one hour per day, five days per week, of
out-of-cell therapeutic activities. Inmate-patients will be enrolled into various group
activities based upon PC assessment of individual needs, related to both individual
symptoms as well as commitment status. The treatment activities delineated in the
Program Guide will be augmented with the following options:

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2009 REVISION 12-2-8
Reception Center Mental Health Services Delivery System
Mental Health Assessment

• Orientation to institution living – Individuals with impaired mental abilities who are
placed into the institution environment require assistance in understanding and
adapting to institutional rules and gaining access to available services. These
individuals are also susceptible to being preyed upon by more aggressive inmates.
This therapy group provides an orientation to prison life, offers coping mechanisms
for personal safety, and allows for patients to ask questions and vent frustrations
involved in their adaptation to their new environment.

• Assertiveness Training – Teaches ways to communicate assertively but non-

aggressively. Didactic teaching techniques and practice sessions are utilized.

In addition to providing the above therapeutic activities (and the current provisions
outlined in the EOP Clinical Pre-Release Program in 12-4-13 of the MHSDS Program
Guide), additional clinical staff will provide individuals with imminent (60 to 120 days)
release dates the following pre-release planning:

• Application for federal and state benefit entitlements, such as: Medi-Cal, Medi-
Care, Supplemental Security Income, and Veterans Benefits. This will be
accomplished by referring potentially eligible inmates to the Transitional Case
Management Program under the rubric of the Division of Adult Parole Operations.

• Initiation of Conservatorship proceedings where the inmate-patient meets criteria.

• Liaison with Parole Outpatient Program staff with reporting instructions and
planning for continuity of care.

• Liaison with family members and significant others who may provide living options
to the individual upon release.

• Screening for need for inpatient placement per Penal Code 2962 (Mentally
Disordered Offender).

7. Transfer Timelines
U

Once an inmate-patient is evaluated and placed in the MHSDS program, the inmate-
patient shall be processed by classification staff on a priority basis to ensure timely
transfer to a treatment setting. All EOP designated inmate-patients shall be transferred
to a treatment setting within 60 days of level of care designation, or 30 days of such
designation, if clinically indicated. All CCCMS designated inmate-patients, with the
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2009 REVISION 12-2-9
Reception Center Mental Health Services Delivery System
Mental Health Assessment

exception of parole violators with 90 days or fewer to parole, shall be transferred to a

mainline institution within 90 days of level of care designation or 60 days of such
designation, if clinically indicated. Inmate-patients with fewer than 30 days to parole
shall receive mental health services as described above, consistent with their clinical
needs. Refer to transfer timeline table in MHSDS Program Guide, Chapter 1, Program
Guide Overview.

8. Staff and Self Referrals

At any time during the RC process, an inmate may self-refer, or be referred by any staff
member for a review by a mental health clinician. Referrals will be made on
standardized forms and forwarded to the mental health office. All referrals will be
entered into the data system to ensure responses and facilitate scheduling.

Crisis cases identified by clinical and custody staff will be immediately referred to a
psychologist or psychiatrist. Medication issues identified by clinical staff will be
immediately referred to the psychiatrist.

a) Staff referral: Any staff member who observes possible signs or symptoms of a
serious mental disorder may refer an inmate for clinical evaluation by completing a
CDCR 128-MH5, Mental Health Referral Chrono, and handle as self-referral
process below. Any inmate who is observed to be a suicide risk, or in any other
condition that requires crisis care, shall be immediately screened by a PC to assess
the potential for suicide and, if appropriate, referral to the Mental Health Crisis
Bed (MHCB) for admission. On weekends and holidays, refer to self-referral
process below.

b) Self referral: Inmates may request a clinical interview to discuss their mental
health needs. These requests are made on a CDCR 7362, Health Care Services
Request.

Mondays through Fridays, the following shall occur:

a) A health care staff member shall collect all the CDCR 7362, Health Care Services
Request, and CDCR 128-MH5, Mental Health Referral Chrono, each day from the
designated areas.

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2009 REVISION 12-2-10
Reception Center Mental Health Services Delivery System
Mental Health Assessment

b) Upon receipt of the collected forms, nursing staff shall initial and date each
CDCR 7362, Health Care Services Request, and CDCR 128-MH5, Mental Health
Referral Chrono.

c) The CDCR 7362, Health Care Services Request, and CDCR 128-MH5, Mental
Health Referral Chrono, shall be delivered to the designated program
representative in mental health services, dental services, or pharmacy services for
same-day processing.

On weekends and holidays, the following shall occur:

a) The Triage and Treatment Area RN shall review each mental health staff referral
form and CDCR 7362, Health Care Services Request, for medical, dental, and
mental health services, shall establish priorities on an emergent and non-emergent
basis, and shall refer accordingly.

b) If a mental health clinician is not available, the Medical Officer of the Day
(MOD), physician on call or psychiatrist on call shall be contacted.

Inmates will be seen by a mental health clinician or on weekends by the MOD,

physician or psychiatrist on call within the clinically determined time frame.

a) Emergent – Emergency cases will be seen immediately or escorted to the Triage

and Treatment Area

b) Urgent – Urgent cases shall be seen within 24 hours

c) Other cases will be seen within five working days. Copies of staff referral forms
shall be placed in both the Central File and UHR for future reference. Staff
members initiating referrals may be contacted directly, as necessary. Inmate self-
referral forms shall be kept confidential, and the results of these interviews
documented as deemed appropriate by the clinician.

9. Classification File Review

Correctional Counselors shall conduct a comprehensive Central File review for all
inmates received into the CDCR. This shall include a review of current commitment
offense records and parole violation reports. Other documentation (e.g., Mental Health
Placement Chronos or Probation Officer’s Reports) containing information about prior
mental health issues, placement in mental health treatment programs, or criminal history
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Reception Center Mental Health Services Delivery System
Mental Health Assessment

shall also be reviewed for indications of mental health needs, if applicable. A face-to-
face interview shall also be conducted. The CC shall complete a staff referral when
there are indications of a need for a mental health evaluation. The specific reason(s) for
the mental health evaluation shall be noted on the CDCR 128-MH5, Mental Health
Referral Chrono. Clinical recommendations for treatment shall be utilized in
determining institutional placement.

10. Placement Decisions

The completed case file with results of mental health evaluations will be reviewed by
Classification Staff Representatives for final placement decisions. Where treatment is
required, the decision will necessitate placement in an institution with the availability of
the recommended level of care (inpatient, MHCB, EOP, or CCCMS), consistent with the
CDCR’s policy on placements, based on security requirements.

11. Data Processing

A data processing station within mental health services at each RC will process
screenings and assessments, receive all referrals for evaluation, schedule clinicians to
conduct evaluations, process (type, record, distribute) completed evaluations, track
inmates through the stages of assessment, and submit periodic summaries of required
data to institutional administrative staff and headquarters. It is important to emphasize
that, in order to ensure the accurate collection of data the system will be utilized by
appropriately trained CDCR staff and will provide adequate safeguards to protect the
security and confidentiality of the data. Inmate clerks are banned from having access to
documents or records containing other inmates’ mental health information (California
Codes of Regulations, Title 15, Section 3354, (b), (6)).

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2009 REVISION 12-2-12
 Correctional Clinical Case Mental Health Services Delivery System
Management System

CHAPTER 3
Correctional Clinical Case Management System
A. INTRODUCTION

The California Department of Corrections and Rehabilitation’s (CDCR) Mental Health

Services Delivery System (MHSDS) serves the majority of inmates with serious mental
disorders through the Correctional Clinical Case Management System (CCCMS) available at
all institutions. For General Population (GP) outpatient services to be effective (e.g., sustain
improved functioning and minimize the use of more intensive levels of care), inmates must
know what services are available and how to access them. An effective clinical case
management system ensures timely access to mental health care. Outpatient services
delivered through a well-designed clinical case management system is the most cost-effective
means of maintaining adequate institutional functioning among inmates with serious mental
disorders.

1. The strength of well-coordinated clinical case management is its ability to systematically

monitor the clinical needs and movement of MHSDS inmate-patients within and between
CDCR institutions. With this service delivery mode, CDCR provides the best possible
means of ensuring continuity of care while optimizing the use of available resources.

2. Clinical case management improves the quality of mental health services offered through
timely therapeutic intervention, utilizing the CDCR-approved Mental Health Tracking
System (MHTS). The MHTS fosters information sharing among staff who provide
service to inmate-patients and the optimal utilization of professional time.

The Correctional Clinical Case Management System

Clinical case management facilitates care by linking inmate-patients to needed services and
providing sustained support while accessing such services. Clinical case management adds
to the usual functions of traditional case management a clinical component based on a
therapeutic working relationship between inmate-patient and Primary Clinician (PC). This
therapeutic relationship makes the PC a more effective agent in helping the inmate-patient
achieve individualized treatment goals. The PC provides therapeutic intervention and
coordinates other mental health treatment services required by the inmate-patient. This
relationship ensures continuity of care.

The CCCMS services in CDCR are provided as outpatient services within the GP setting to
promote inmate-patient integration and normalization. Inmate-patients requiring more
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intensive services are referred to a higher level of care and are transferred to an appropriate
institution/facility.

1. Through its universal availability and as the least restrictive level of care, CCCMS forms
the foundation of the CDCR’s MHSDS.

2. Ready access to treatment intervention increases the safety and security of the institution,
and may also contribute to lowering the recidivism rate of inmate-patients released on
parole or discharged to the community.

The CCCMS within the prison system is a different type of case management than one would
find in the community. Within the CDCR, the fact that basic needs of inmate-patients are
already provided allows PCs to concentrate on helping resolve mental health problems.
Adjunct services which help maintain or improve functioning (e.g., education, substance
abuse groups, and work training assignments), are available within the perimeter of the
institution and are thus relatively easy for inmate-patients to physically access.

While the structure of correctional settings is conducive to facilitating clinical case

management responsibilities, other factors including penological concerns that are inherent
in correctional settings pose special problems for clinical practice. Institution inmates
represent a specialized clientele in whom treatment of serious mental disorders are often
complicated by dual diagnoses and behavior problems. Further, security considerations have
to be appropriately considered in treatment plans and service delivery methods.

Psychiatrists, Clinical Social Workers (CSW), and psychologists can function as PCs. All
institutions have clinical case management staff available to inmate-patients.

Using Correctional Counselors (CC), CDCR provides case management for institutional
programming with which CCCMS shall interface. In effect, each CCCMS inmate-patient
shall have both a PC and a CC working within the scope of their designated duties, as
members of an Interdisciplinary Treatment Team (IDTT) to coordinate and deliver services.

CCCMS inmate-patients are a highly diversified population representing a broad spectrum of

functional abilities. Treatment services must be tailored to adequately meet the clinical
needs of each individual inmate-patient considering the functional level, readiness for
treatment, insight into mental illness, and motivation for treatment. Individualized treatment
plans specify measurable treatment goals and objectives, address problems, prescribe
intervention modalities including treatment frequency/duration, and identify the staff
member responsible for providing services. The treatment services are individualized by
clinical need as described below:

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1. For high-functioning inmate-patients, tracking and monitoring is often sufficient to meet

this group’s clinical needs. They are the most likely group to benefit from active
involvement in institutional programming and require minimal contact with the PC. The
primary treatment focus is on symptom management and medication monitoring.

2. For inmate-patients with significant psychological impairment, CCCMS provides, in

addition to regular monitoring, more focused monitoring contacts with the PC, treating
psychiatrist, and custody and correctional counseling staff to promote symptom
management and prevent decompensation. Individual and group psychotherapy and
other supportive services are provided as clinically indicated.

3. Although scheduled at different intervals according to clinical needs, CCCMS inmate-

patient monitoring entails regular assessments and treatment plan updates.

B. PROGRAM OBJECTIVES

The goal of the CCCMS is to maintain and/or improve adequate functioning of mentally
disordered inmate-patients in the least restrictive treatment setting possible within each
correctional setting. Doing so enables CCCMS to prevent the use of more expensive,
intensive level of care treatment services. The array of CCCMS services available to GP
inmates extends to inmates in segregated housing units [Administrative Segregation
Unit (ASU), Security Housing Units (SHU), and Condemned inmates]. The CCCMS also
helps maintain adequate functioning among “nonpatients” by providing crisis intervention to
those experiencing situational crises. To accomplish this goal the program provides:

1. Prompt access to mental health professionals for diagnostic evaluation and treatment.

2. Continuity of care by tracking inmate-patients' progress and by timely referral to

appropriate level of care.

3. Linkage to available adjunct services when clinically and custodially appropriate (e.g.,
work assignments, academic and vocational education programs).

4. Linkage to existing prerelease programs and parole outpatient treatment services for
inmate-patients about to parole.

Treatment in CCCMS

1. Ensures that inmate-patients participating in treatment address the following areas:

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a. Orientation and adjustment to the day-to-day requirements of institutional living.

b. The offense or crime itself and what, for the individual inmate, were precursors or
contributing factors (including cognitive, behavioral, and emotional indicators).

c. The nature of the diagnosed mental disorder including symptom identification, coping
strategies, medication compliance issues, and identification of high-risk situations
that may lead to decompensation.

2. Minimizes crisis episodes and inpatient hospitalization through timely therapeutic

intervention, regular assessments and treatment plan updates.

3. Helps reduce recidivism upon release from CCCMS by providing clinical pre-release
planning and coordinating the follow-up of mental health services with CCs and Parole
Outpatient Clinic (POC Clinic) staff.

C. POPULATION SERVED

Overall Treatment Criteria

Overall treatment criteria have been developed for the MHSDS. An inmate must meet the
criteria of 1, 2, or 3 below in order to receive MHSDS treatment at any level of care:

1. Treatment and monitoring are provided to any inmate who has current symptoms and/or
requires treatment for the current Diagnostic and Statistical Manual diagnosed (may be
provisional) Axis I serious mental disorders listed below:

Schizophrenia (all subtypes)

Delusional Disorder
Schizophreniform Disorder
Schizoaffective Disorder
Brief Psychotic Disorder
Substance-Induced Psychotic Disorder (exclude intoxication and withdrawal)
Psychotic Disorder Due To A General Medical Condition
Psychotic Disorder Not Otherwise Specified
Major Depressive Disorders
Bipolar Disorders I and II
2. Medical Necessity: Mental health treatment shall be provided as needed. Treatment is
continued as needed, after review by an IDTT, for all cases in which:

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Mental health intervention is necessary to protect life and/or treat significant

disability/dysfunction in an individual diagnosed with or suspected of having a
mental disorder. Treatment is continued for these cases only upon reassessment
and determination by the IDTT that the significant or life threatening
disability/dysfunction continues or regularly recurs.

3. Exhibitionism: Treatment is required when an inmate has had at least one episode of
indecent exposure in the six month period prior to the IDTT consideration of the need for
exhibitionism treatment, and the inmate-patient is either:

• Diagnosed with Exhibitionism, or

• Meets the alternate criteria. (Alternate Criteria: An inmate who meets all criteria for
the diagnosis of Exhibitionism, except that the victim was not an “unsuspecting
stranger” but was a staff member or inmate who did not consent to or encourage the
behavior.)

(A diagnosis of Exhibitionism is not required for inmates who meet the alternate criteria.)

Specific Treatment Criteria for CCCMS

U

In addition to the overall treatment criteria above, an inmate must meet the following specific
treatment criteria to receive treatment at the CCCMS level of care:

• Stable functioning in the GP, ASU, or SHU

• Criteria not met for higher levels of care

• Exhibits symptom control, or is in partial remission as a result of treatment

• These conditions usually result in Global Assessment Functioning scores of 50 and

above.

All inmates, including those in SHU or ASU, needing crisis intervention and/or continued
treatment also receive services from CCCMS staff. Details for provision of services in
ASU and SHU are found in their respective chapters of the Program Guide.

Once entered in CCCMS, inmate-patients are tracked using the MHTS.

D. TREATMENT AND ASSESSMENT SERVICES

4BU

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The CDCR’s CCCMS relies on both mental health staff and custody staff, as members of an
IDTT working within the scope of their credentials and job descriptions, to provide the
prescribed services to an inmate-patient suffering from a serious mental disorder. The basic
MHSDS treatment philosophy embraces the concept that mentally disordered inmate-patients
need comprehensive services to maintain adequate functioning in the GP, ASU, or SHU. In
addition to mental health treatment, institutional services such as academic and vocational
education programs are therapeutic and integral elements in a comprehensive treatment plan
for GP inmate-patients. For SHU inmate-patients, treatment plans are modified to take into
account inmate security concerns and status. As noted, this correctional-clinical model of
case management requires custody and clinical staff to work in tandem, from the beginning,
to assess the treatment and programming needs of seriously mentally disordered inmate-
patients and to ensure they receive the mental health and institutional services specified in
their treatment plans.

Referral to CCCMS
9BU

Inmates are referred to the program from a variety of sources. A large percentage come from
Reception Centers (RC), identified as having a serious mental disorder in the routine process
of screening and evaluation. Others are referred from Enhanced Outpatient Program (EOP),
Mental Health Crisis Beds (MHCB) or, less frequently, Department of Mental Health (DMH)
Inpatient Programs. Some may be identified at the time of inter-institutional transfer. Others
are referred by institutional staff or through self-referrals. All referrals to CCCMS are
processed in a timely manner and entered into the MHTS by clerical staff.

Inmates who receive a CDCR 115, Rules Violation Report for Indecent Exposure or
Intentionally Sustained Masturbation Without Exposure shall be referred for all of the
following:

• CDCR 115-MH, Rules Violation Report: Mental Health Assessment;

• A mental health assessment shall be completed within 24 hours to rule-out

decompensation and/or intoxication. The referral shall be made by telephone to the local
Chief of Mental Health who shall arrange this assessment; and,

• For inmate-patients included in the MHSDS, to the inmate-patient’s PC.

1. Referrals are made on one of several forms, depending on referral source:

• Inmate Request for Interview

• CDCR 7362, Health Care Services Request Form

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• Staff Referral on CDCR 128-MH5, Mental Health Referral Chrono

• From RCs and other levels of care on a CDCR 7386, Mental Health Evaluation, and a
corresponding CDCR 128-MH3, Mental Health Placement Chrono

NOTE: When an IDTT determines that an inmate-patient requires treatment of

exhibitionism, that inmate-patient’s level of care shall be changed to CCCMS, Medical
Necessity (or higher if appropriate), bypassing the standard referral process.

2. The CCCMS Clinical Director shall appoint a staff member to coordinate and track
referrals. A Clinical Intake Assessment shall be completed within ten working days of
referral/arrival. If there is an adequate CDCR 7386, Mental Health Evaluation, available
in the Unit Health Record (UHR) the PC may update it with documentation on a CDCR
7230, Interdisciplinary Progress Note, or on a CDCR 7389, Brief Mental Health
Evaluation. If there is no CDCR 7386, Mental Health Evaluation, in the UHR, a new
CDCR 7386, Mental Health Evaluation, must be done. The coordinator shall then
arrange for the inmate to be seen immediately by a Staff Psychiatrist if an emergency
psychiatric evaluation is needed. When disagreement exists between the evaluator at a
reception center and the receiving institution IDTT regarding the need for the CCCMS
services, the receiving institution clinician shall document the justification for removal
from the program and complete a CDCR 128-MH4, Mental Health Removal Chrono,
within 90 days of inmate transfer from that reception center. The CDCR 128-MH4,
Mental Health Removal Chrono, requires approval from the Chief of Mental Health or
designee.

3. Inmate-patients are continued on the same medication(s) without interruption pending

further evaluation of psychotropic medications by a receiving psychiatrist.

4. Clinical case management staff are available for the initial screening of inmates referred
for crisis episodes. In this initial screen the level of required clinical intervention is
assessed and proper action taken.

Clinical Intake Assessment

10BU

While the CDCR’s MHSDS provides screening and assessment upon reception, a more
comprehensive assessment is critical in formulating a treatment plan after placement in
CCCMS. The assessment includes the inmate-patient's personal strengths, achievements and
goals, and past responses to intervention. Inmate-patients placed in CCCMS directly from
RCs have a psychological evaluation (CDCR 7386, Mental Health Evaluation) with at least a
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provisional diagnosis and an initial treatment plan. In all cases, assessments and treatment
plans are updated to include an evaluation of the inmate-patient’s current readiness for
institutional programming (e.g., work, substance abuse counseling, school, prerelease
transition).

The PC completes a clinical intake assessment within ten working days of referral/arrival. If
there is an adequate CDCR 7386, Mental Health Evaluation, available in the UHR the PC
may update it with using page 13 of CDCR 7386, Mental Health Evaluation (Add-A-Page),
or documentation on the CDCR 7230, Progress Note. If there is no CDCR 7386, Mental
Health Evaluation, a new CDCR 7386, Mental Health Evaluation must be done. The clinical
intake assessment shall include:

1. A review of the inmate-patient’s Central File and UHR, a face-to-face interview with the
inmate-patient, and interviews with other institutional staff when possible.

2. A review of previous mental health records. If the inmate-patient states that he or she
had significant prior treatment or if the file review indicates history of such treatment, the
clinician shall request that the inmate-patient sign a Release of Information form to
obtain previous records. The clinician shall forward the signed Release of Information
form to Health Records for immediate processing, in accordance with Health Record
policies and procedures.

3. Evaluation of an inmate-patient’s ability to program based on appropriate educational

and vocational testing instruments that take into account the degree of psychiatric
impairment, physical (medical) limitations, and custody and housing restrictions.
4. Multiaxial diagnoses (Axis I through V) from the current Diagnostic and Statistical
Manual.

5. Evaluation of suicide and violence potential.

Treatment Planning

Interdisciplinary Treatment Team

The responsibilities of overall treatment planning within the CCCMS program rests with an
IDTT.

1. These responsibilities include:

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• Admission decisions for individual cases

• Formulation and approval of individualized treatment plans

• Annual and special case reviews for the continuation or termination of services

• Review of current treatment needs and response to past intervention efforts

2. The IDTT is composed of, at a minimum:

19B

• Assigned Primary Clinician

• Assigned Psychiatrist

• Correctional Counselor

• Inmate-patient

3. Other staff who have direct knowledge of the inmate-patient are encouraged to attend or
provide information:

• Licensed Psychiatric Technicians

• Custody Officers

The IDTT shall generally be responsible for developing and updating treatment plans. This
process shall include input from the inmate-patient and other pertinent clinical information
that may indicate the need for a different level of care. Referrals to higher levels of care
shall be considered when the inmate-patient’s clinical condition has worsened or the inmate-
patient is not benefiting from treatment services available at the current level of care.
Consideration of appropriate level of care shall be documented by the IDTT on a
CDCR 7230-MH, Interdisciplinary Progress Notes, and shall include the justification for
maintaining the current level of care or referral to a different level of care.

In consultation with the IDTT, the PC develops an individualized treatment plan for all
CCCMS inmate-patients. Treatment plans are based on current assessments from all
disciplines and with as much participation from the inmate-patient as possible. The inmate-
patient shall be included in the IDTT, unless the inmate-patient refuses to participate. If the
inmate-patient refuses to participate in the IDTT, the inmate-patient shall indicate the refusal,
the reason for the refusal, and shall sign on the backside of the ducat. Inmate-patients shall
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not be disciplined for not participating in IDTT. If the inmate-patient refuses to

participate, the PC documents the reason for refusal in the CDCR 7230, Interdisciplinary
Progress Notes.

The Treatment Plan specifies mental health and other institutional services that can facilitate
the resolution of identified problems listed in the problem list. All activities including work,
education, and recreation are potentially therapeutic and must be included in the total
treatment plan. When activities are prescribed in the treatment plan, specific target behaviors
that are expected to benefit from these activities must also be identified. The individualized
treatment plan must be completed within 14 working days of referral/arrival by the PC in
consultation with the other IDTT members. CDCR Form 7388, Mental Health Treatment
Plan, is used for this purpose.

1. Selected information from the intake assessment and the treatment plan are shared with
the CCs during IDTT for inclusion in the Classification Committee review.

2. The treatment plan includes:

a. Basic identifying data about the inmate-patient (age, race, committing county,
commitment offense, current Earliest Possible Release Date or Minimum Eligible
Parole Date, classification score/custody level, education, and work history);

b. A diagnosis, identified problems, and treatment objectives measurable in behavioral

terms;

c. Treatment services and other institutional services designed to impact the identified
problems and achieve individual treatment objectives;

d. Frequency and duration of services to be provided;

e. Documentation regarding the completion of appropriate forms such as a signed

Release of Information necessary to obtain prior medical/mental health records,

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signed Medication Informed Consent to medicate, and heat warning forms for those
inmate-patients prescribed psychotropic medication; and

f. Aftercare and clinical pre-release plans.

3. The date of the treatment plan approval shall be entered into the MHTS.

4. At the conclusion of the initial IDTT, if an inmate-patient is determined to be appropriate

for inclusion in the CCCMS program, the PC shall send a CDCR-128 MH3, Mental
Health Placement Chrono, to the appropriate staff to be entered in the Priority Level of
Care List for inputting into the MHTS. That staff person forwards the CDCR 128-MH3,
Mental Health Placement Chrono, to the Classification and Parole Representative.

5. Treatment plans are updated at least annually, whenever a change in level of care occurs,
or when clinical judgment indicates the need for an update.

6. All services to inmate-patients shall be reflected in treatment plan updates.

7. All updates shall be entered in the MHTS and a CDCR 128 MH3, Mental Health
Placement Chrono, shall be produced with every change in level of care (see “Patient
Monitoring and Clinical Case Review” in this section for more details).

Treatment Modalities
12BU

Institutional programming is an essential component of the treatment regimen of most

clinical case management participants. The PCs shall make specific recommendations for
programs such as education, work, and substance abuse counseling and coordinate with CCs
to ensure appropriate linkages to these programs. As noted earlier, a therapeutic working
relationship between the inmate-patient and the PC is essential to the success of the treatment
outcome.

Based on identified needs, treatment modalities may include:

• Orientation and supportive counseling for institutional adjustment

• Medication review and monitoring

• Individual counseling and crisis intervention

• Group therapy such as anger management and relapse prevention

• Social skills training
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• Consultation services, such as to education and work programs

• Clinical discharge or clinical pre-release planning

Medication Evaluation and Management

20BU

1. Each CCCMS inmate-patient on psychiatric medication shall be reevaluated by a

psychiatrist a minimum of every 90 days regarding psychiatric medication issues. The
psychiatrist shall respond to inmate requests and staff referrals for medication issues
according to the time frames established for inmate and staff responses (i.e., Emergent
[immediately], Urgent [within 24 hours], or Routine [5 working days]).

2. Refer to Inmate Medical Services Policies and Procedures, Medication Management

U U

regarding procedures for administration of medication, medication refusals, Directly

Observed Therapy (DOT), and other aspects of medication administration.

3. Refer to Chapter 5, Mental Health Crisis Bed, for information on involuntary medication
administration.

Transfer and Clinical Discharge

13BU

Important functions of PC include:

• Making the clinical determination as to when and how to transfer inmate-patients to

more intensive levels of care,

• Discharging those inmate–patients who no longer need services, and

• Coordinating pre-release planning for inmate-patients being paroled.

Clear and measurable criteria for both transfer to more intensive levels of care and clinical
discharge are important (Chapter 1, Program Guide Overview, Section D). Equally
important is coordination with units or programs which shall take over the care and/or
monitoring of the inmate-patient and coordination of pre-release planning with correctional
counseling staff, Parole and Community Services Division Transitional Case Management
staff, and Parole Outpatient Clinic staff.

1. Prior to CCCMS termination (clinical discharge or program transfer), the PC must

complete a CDCR 128-MH3, Mental Health Placement Chrono, or CDCR 128-MH4,
Mental Health Removal Chrono, to notify custody.
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2. Clinical discharges and/or program transfers shall be documented in the MHTS.

3. The PC shall present a recommendation for transfer to an EOP or clinical discharge in a

clinical case review with the IDTT. If, after consultation, the IDTT approves
recommendation for transfer to an EOP, the PC shall complete a CDCR 7386, Mental
Health Evaluation, and a corresponding CDCR 128 MH3, Mental Health Placement
Chrono. If the team approves recommendation for clinical discharge, the PC shall
complete a CDCR 128 MH4, Mental Health Removal Chrono.

4. Inmate-patients requiring more intensive outpatient services within a structured setting

shall be transferred to an EOP within 60 days of the EOP designation, or within 30 days
if clinically indicated.

5. Inmate-patients awaiting EOP transfer shall have updated treatment plans, (CDCR 7388,
Mental Health Treatment Plan). While awaiting EOP transfer, inmate-patients shall be
seen on a weekly basis by the PC.

6. If a transfer occurs within the same institution, immediately before transfer to EOP the
CCCMS PC shall contact the EOP Clinical Director or designee to ensure continuity of
care and provide the most recent, relevant clinical information regarding the inmate-
patient’s clinical needs.

7. Inmate-patients shall be transferred to MHCB for crisis episodes requiring 24-hour

nursing care. The transfer to a MHCB shall be accomplished within 24 hours of referral.
While awaiting transfer, the inmate-patient shall be housed in a medical facility with at
least an Outpatient Housing Unit (OHU) level of care. A psychiatrist, psychologist, or
CSW shall provide clinically appropriate care, while the inmate-patient is awaiting
transfer. This may include suicide observation, one to one counseling, medication
management, and/or nursing care.

8. Inmate-patients with multiple admissions to MHCB (three or more within a six month
period) shall be evaluated for referral to DMH or EOP.

9. Inmate-patients who:

• attempt suicide,

• currently have significant suicidal ideation or potential, or

• pose a moderate to serious risk for suicide,

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shall be admitted to MHCB and considered for referral to DMH. If an inmate-patient is

accepted to DMH, the inmate-patient shall be transferred to DMH within 72 hours of bed
assignment.

10. Inmate-patients may be clinically discharged from CCCMS if they have been in
continuous remission and are functioning adequately in the mainline without treatment
(including medication) for six-months. Inmates shall be seen for 90-day clinical contacts
throughout the six-month period.

11. Inmate-patients admitted on the basis of medical necessity shall be discharged when the
crisis or problem necessitating treatment is resolved. Discharge of inmate-patients, who
were placed in the CCCMS program on a medical necessity, shall be determined by the
IDTT and shall be approved by the Chief Psychiatrist, Chief Psychologist, Senior
Psychologist or designee.

12. Clinical pre-release plans included as part of the Treatment Plan shall be updated as
appropriate but at least at every annual clinical case review.

13. The Discharge/Transfer Summary shall include the diagnoses (current Diagnostic and
Statistical Manual version), Axis I through Axis V, a brief summary of the inmate-
patient’s course of treatment in CCCMS, recommendations for follow-up care, and
discharge medications (Pre-release planning).

14. The PC shall coordinate with the CC, staff from the Transitional Case Management
program, and clinical staff from the POC Clinic regarding plans for release and follow-up
of the inmate-patient to be paroled. Discharge/Transfer Summaries shall be forwarded to
the POC Clinic or other pertinent clinical pre-release program providers after signed
Releases of Information have been obtained. While necessary for record transactions
with other agencies, a signed release is not needed within CDCR. Patients currently
receiving medication, upon a physician's order, shall be provided a 30-day supply of
essential medications when released on parole or discharged unless clinically
contraindicated.

15. CCCMS inmate-patients who are inappropriately transferred to a non-CCCMS mainline

institution shall be transferred to a defined treatment setting within 30 days of arrival at
the non-CCCMS institution.

16. Inmate-patients who are determined to require CCCMS level of care while in a non-
CCCMS institution shall be transferred to a treatment setting within 90 days of the level
of care designation or 60 days of the level of care designation, if clinically indicated.
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E. INMATE-PATIENT MONITORING AND CLINICAL CASE REVIEW

Monitoring Contacts

Inmate-patient progress is assessed by the PC during regularly scheduled contacts. The

frequency of these contacts shall vary based on clinical needs. The majority of CCCMS
inmate-patients who have been stabilized are capable of functioning adequately in the
mainline while receiving maintenance care. Usually, they can manage the symptoms of their
mental illness and report with little prompting for renewal of medication prescriptions. A
certain percentage of inmate-patients will manifest greater needs and thus require more
frequent contact.

1. Face-to-face individual contacts between the PC and the CCCMS inmate-patients in a GP

setting shall occur as often as clinical needs dictate but at least once every 90 days.

2. Inmate-patients recently released from more intensive levels of care, admitted directly
from RCs, or recently released from segregated housing units may initially require daily
to weekly contacts.

3. Inmate-patients who were admitted to the MHCB for a suicide attempt or ideation, upon
discharge from that program, shall be seen by the PC, or designee, daily for the first five
calendar days following discharge, and as often as required thereafter. Custody staff
shall also observe these inmate-patients a minimum of every hour for the first 24 hours
after the discharge from the MHCB. At the end of the first 24 hours after discharge, the
CCCMS clinical staff shall evaluate an inmate-patient to determine the need for
extending the observation period (not to exceed 24 hours at a time). If the
recommendation for an extension is justified, the inmate-patient shall be observed every
two hours for the following 48 hours and every 4 hours thereafter. If, after a second
evaluation, a mental health clinician feels additional hourly checks are required, the
inmate-patient shall be returned to the MHCB for further stabilization. Custody staff
shall maintain a log of their rounds on inmate-patients. Inmate-patients housed in OHUs
for suicide observation, who do not require MHCB level of care and who were
discharged from the OHU before 24-hours, may be seen by clinicians and custody staff
for follow-up care. The process and timeframes for follow up care may be the same as is
described for MHCB suicide dischargees.

4. Monitoring contacts and attendance at treatment activities shall be entered into the
inmate-patient contact file of the MHTS.

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5. Significant inmate-patient contacts shall be documented on CDCR 7230,

Interdisciplinary Progress Notes, in the UHR on the same day of occurrence. Group
therapy sessions must be recorded in a monthly summary note and include the inmate-
patient’s attendance, behavior in the group, and the progress toward achieving treatment
goals.

Clinical Case Review

In consultation with the IDTT, a full review of outpatient progress, which includes clinical
status and performance in work, educational and vocational training, social, and daily-living
activities, shall be done to ascertain the appropriateness of current level of care placement.
This review may or may not result in modifications of the Treatment Plan.

1. Clinical case reviews shall be done at least annually, prepared prior to, and included as
applicable in Classification Committee hearings reviewing inmate-patient status. The
first annual clinical review shall be scheduled in the month prior to a classification
hearing and annually thereafter.

2. The annual review culminates in a CDCR 7388, Mental Health Treatment Plan,
rejustification. This report shall include a description of current clinical status,
participation in treatment and institutional programming, and reasons for continuation or
termination of CCCMS services.

3. Clinical case reviews shall also be done every time placement in more intensive levels of
care or change to nonpatient status is indicated. These case reviews are documented in
the CDCR 7230, Interdisciplinary Progress Notes, CDCR 7386, Mental Health
Evaluation Form, CDCR 7388, Mental Health Treatment Plan, a CDCR 128-MH-3,
Mental Health Placement Chrono, or a CDCR 128-MH, Mental Health Removal Chrono.
Clinical case review documentation shall include the printed names and signatures or
initials of the clinical and custody staff present in the IDTT. The custody staff who
manages the inmate-patient’s day-to-day routine shall be included whenever possible in
the IDTT. The PCs shall document the presence of the inmate-patient during the review
and indicate reasons for the inmate-patient’s absence.

F. STAFFING

Staffing for CCCMS includes psychologists, CSWs, psychiatrists, and clerical support.
CDCR may utilize contract staff as necessary to fulfill staffing requirements.
Staff training is crucial to the successful operation of the CCCMS. Training is essential
because CCCMS, as a formalized systemwide approach to outpatient treatment in inmate-
patients’ regularly assigned living units, is relatively new, not only to CDCR, but to
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2009 REVISION 12-3-16
Correctional Clinical Case Mental Health Services Delivery System
Management System

correctional settings in general. Many clinical staff hired to work in CCCMS programs are
new, not only to the institution setting, but also to forensic mental health. Training facilitates
standardizing basic elements of CCCMS service delivery.

Clinical Director

A Clinical Director is critical to the success of CCCMS. In addition to direct care

responsibility, the Director takes the lead in developing and implementing local policies and
procedures for clinical case management, oversees the MHTS, makes PC assignments,
facilitates training, provides clinical and administrative supervision, and coordinates system
monitoring functions contained in quality assessment and improvement activities. The
Clinical Director can be any licensed mental health professional with experience running a
complex case management system. In the standard staffing pattern, a Senior Psychologist is
provided to serve as the CCCMS Clinical Director, although in some institutions this role is
performed by the Chief of Mental Health or designee (see description in Chapter 1, Program
Guide Overview).

Primary Clinician

Under the direction of the Clinical Director, the PC performs the necessary case management
functions for all outpatients in their caseloads. This includes assessment, treatment planning
and treatment, clinical monitoring, and clinical case reviews. They coordinate with
institutional services that are considered helpful in maintaining or improving inmate-patient
functioning. The PCs shall screen institution referrals to the CCCMS, including those for
crisis episodes. If an inmate-patient is referred for evaluation of medication related issues,
the referral shall be routed directly to a psychiatrist for evaluation. CSWs, psychologists,
and psychiatrists shall be assigned as PCs.

Clerical Support

Medical Transcribers or Office Technicians shall provide clerical support to clinicians.

Clerical support includes: record keeping; assisting with scheduling; transcribing and typing
reports and forms used in referral, assessment, treatment planning, patient contacts, and
clinical case reviews. Responsibilities of this position also include computer data entry, e.g.
MATS.

G. MENTAL HEALTH QUALITY MANAGEMENT SYSTEM

Ongoing assessment of the quality of clinical services shall follow the Mental Health Quality
Management System procedures.

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Enhanced Outpatient Program Mental Health Services Delivery System

CHAPTER 4
Enhanced Outpatient Program

A. INTRODUCTION

The Enhanced Outpatient Program (EOP) provides the most intensive level of outpatient
mental health care within the Mental Health Services Delivery System (MHSDS). The
program is characterized by a separate housing unit and structured activities for mentally ill
inmate-patients who, because of their illness, experience adjustment difficulties in a General
Population (GP) setting, yet are not so impaired as to require 24-hour inpatient care. Inmate-
patients who, because of a mental disorder, do not function well in EOP may be referred for
higher levels of care including: Mental Health Crisis Bed (MHCB); or Department of Mental
Health (DMH) Day Treatment Program, Intermediate Care Program, or Acute Psychiatric
Program.

Critical components include:

1. A comprehensive array of mental health services delivered within the framework of an

Interdisciplinary Treatment Team (IDTT), which is composed of representatives from a
cross-section of clinical disciplines as well as prison custodial and counseling staff.
Treatment is focused on resolution of institutional adjustment problems which impede
functioning within the GP. Services include management of activities of daily living,
group and individual psychotherapy, medication management, recreational therapy, and
clinical pre-release planning.

2. A designated housing unit with restricted access and alternative educational, work, and
recreational opportunities specifically provided for inmate-patients whose mental illness
precludes their placement and participation in the GP programs.

3. Active interface with custodial staff, including Correctional Counselors (CC), which
enhances the assessment and treatment process and optimizes the inmate-patient
functioning within the prison environment.

B. PROGRAM OBJECTIVES

The goal of the EOP is to provide focused evaluation and treatment of mental health
conditions which are limiting an inmate's ability to adjust to a GP placement. The overall
objective is to provide clinical intervention to return the individual to the least restrictive
clinical and custodial environment.
More specific objectives include:
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2009 REVISION 12-4-1
Enhanced Outpatient Program Mental Health Services Delivery System

1. Provide short to intermediate term (a range of 3 to 12 months for most cases) focused
care for inmate-patients who do not require 24-hour inpatient care. Short term treatment
goals are primarily directed at developing constructive coping mechanisms, achieving
treatment compliance, and further stabilization of psychiatric symptoms that are
necessary for transition to the Correctional Clinical Case Management System (CCCMS)
level of care.

2. Provide longer-term placement for inmate-patients with chronic mental illness whose
symptoms have stabilized but whose level of functioning is insufficient to allow GP
placement. Supportive care, assistance with activities of daily living, recreational
therapy, anger management, reality therapy, and programs related to symptom
management and clinical pre-release planning are offered.

3. Provide short-term secure custodial placements with clinical resources which address
behavioral problems for mentally ill EOP inmate-patients who are transitioning from
Security Housing Units or Psychiatric Services Units (PSU). Treatment for these inmate-
patients focuses on achieving behavioral control and the development of socially
acceptable behavior within the institution.

C. POPULATION SERVED

Overall Treatment Criteria

Overall treatment criteria have been developed for the MHSDS. An inmate must meet the
criteria in 1, 2, or 3 below in order to receive MHSDS treatment at any level of care:

1. Treatment and monitoring are provided to any inmate-patient who has current symptoms
and/or requires treatment for the current Diagnostic and Statistical Manual diagnosed
(may be provisional) Axis I serious mental disorders listed below:

Schizophrenia (all subtypes)

Delusional Disorder
Schizophreniform Disorder
Schizoaffective Disorder
Brief Psychotic Disorder
Substance-Induced Psychotic Disorder (exclude intoxication and withdrawal)
Psychotic Disorder Due To A General Medical Condition
Psychotic Disorder Not Otherwise Specified
Major Depressive Disorders
Bipolar Disorders I and II

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Enhanced Outpatient Program Mental Health Services Delivery System

2. Medical Necessity: Mental health treatment shall be provided as needed. Treatment is

continued as needed, after review by an IDTT, for all cases in which:

Mental health intervention is necessary to protect life and/or treat significant

disability/dysfunction in an individual diagnosed with or suspected of having a
mental disorder. Treatment is continued for these cases only upon reassessment
and determination by the IDTT committee that the significant or life threatening
disability/dysfunction continues or regularly recurs.

3. Exhibitionism: Treatment is required when an inmate has had at least one episode of
indecent exposure in the six-month period prior to the IDTT that considers the need for
exhibitionism treatment, and the inmate-patient is either:

• Diagnosed with Exhibitionism, or

• Meets the alternate criteria (Alternate Criteria: An inmate who meets all criteria for
the diagnosis of Exhibitionism, except that the victim was not an “unsuspecting
stranger” but was a staff member or inmate who did not consent to or encourage the
behavior.)

(A diagnosis of Exhibitionism is not required for inmates who meet the alternate criteria.)

Specific Treatment Criteria for EOP

16BU

In addition to the overall treatment criteria above, an inmate must meet the following
specific treatment criteria to receive treatment at the EOP level of care:

• Acute Onset or Significant Decompensation of a serious mental disorder

characterized by symptoms such as increased delusional thinking, hallucinatory
experiences, marked changes in affect, and vegetative signs with definitive
impairment of reality testing and/or judgment; and/or

• Inability to Function in General Population Based Upon:

a. A demonstrated inability to program in work or educational assignments, or

other correctional activities such as religious services, self-help programming,
canteen, recreational activities, visiting, etc. as a consequence of a serious
mental disorder; or

b. The presence of dysfunctional or disruptive social interaction including

withdrawal, bizarre or disruptive behavior, extreme argumentativeness, inability

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Enhanced Outpatient Program Mental Health Services Delivery System

to respond to staff directions, provocative behavior toward others, inappropriate

sexual behavior, etc., as a consequence of a serious mental disorder; or

c. An impairment in the activities of daily living including eating, grooming and

personal hygiene, maintenance of housing area, and ambulation, as a
consequence of a serious mental disorder.

• These conditions usually result in Global Assessment Functioning (GAF) Scores of

less than 50.

Enhanced Outpatient Care (Designated Housing Unit)

U

Participants in the MHSDS EOP are placed in designated housing units that provide
increased clinical and custodial support and limit contact with members of the institution’s
GP inmates.

D. ADMISSION TO PROGRAM
U

Referral Process
U

1. Mental Health clinicians may initiate an EOP referral. This referral decision is
documented on a CDCR 128-MH3, Mental Health Placement Chrono, and clinically
supported in an original or updated CDCR 7386, Mental Health Evaluation. Both forms
are placed in the Unit Health Record (UHR) and the CDCR 128-MH-3, Mental Health
Placement Chrono, is placed in the Central File.

2. If the referral is generated for an inmate-patient at a GP institution without an EOP, the

clinician at the referring institution may consult with the Chief of Mental Health at the
closest EOP site regarding the need for EOP level of care, prior to initiating the referral
process. In situations where there is a disagreement between the conferring clinicians,
the inmate-patient will be referred to an EOP treatment setting for further onsite
evaluation.

3. EOP placements do not require prior clinical approval from the receiving institution.

4. Referral documentation is prepared by the referring clinician. The documentation

includes the chronological CDCR 7230, Interdisciplinary Progress Note, containing
circumstances, symptoms, and behaviors justifying the need for EOP level of care. This
document is placed in the UHR. The documentation also includes a CDCR 128-MH3,
Mental Health Placement Chrono, containing a brief description of behavioral alerts.
The original of this document is forwarded to classification staff for processing and

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Enhanced Outpatient Program Mental Health Services Delivery System

Classification Staff Representative (CSR) endorsement for institutional placement. A

copy of the CDCR 128-MH3, Mental Health Placement Chrono, is placed in the UHR.
5. EOP placements from within the same institution are accomplished with the approval of
the IDTT, placed in an available EOP bed, and documented on a CDCR 128-MH3,
Mental Health Placement Chrono. For inmates not currently participating in the
MHSDS program, the classification committee will refer the case to the CSR for EOP
endorsement. For those currently participating in the MHSDS program, the classification
committee will refer the case to the Classification and Parole Representative (C&PR) for
EOP endorsement. Subsequent placements of the same individual into the EOP require
only C&PR approval. A weekly count of filled and vacant EOP beds is provided to
Division of Correctional Health Care Services (DCHCS) and Division of Adult
Institutions to facilitate the use of available beds by population management staff.

6. The classification and transportation systems are designed to ensure placement within 60
days of level of care designation, or 30 days of level of care designation, if clinically
indicated. Transfers within the same institution of inmate-patients previously identified
and treated as EOP or from the institution’s MHCB should occur on the same day, or
within 24 hours of referral.

7. EOP inmate-patients who are inappropriately transferred via CSR endorsement action to
a non-EOP institution shall be transferred to an EOP institution within 21 days of arrival.

8. Inmate-patients who are determined to require EOP level of care while in a non-EOP
institution, shall be transferred to an appropriate EOP treatment setting within 60 days of
the EOP designation, or 30 days of the designation, if clinically indicated.

9. Inmates who receive a CDCR 115, Rules Violation Report for Indecent Exposure or
Intentionally Sustained Masturbation Without Exposure shall be referred for all of the
following:

• CDCR 115-MH Rules Violation Report: Mental Health Assessment;

• A mental health assessment shall be completed within 24 hours to rule-out

decompensation and/or intoxication. The referral shall be made by telephone to the
local Chief of Mental Health who shall arrange this assessment; and,

• For inmate-patients included in the MHSDS, to the inmate-patient’s Primary

Clinician (PC)

NOTE: When an IDTT determines that an inmate requires treatment of exhibitionism,

that inmate’s level of care shall be changed to CCCMS, Medical Necessity (or higher if
appropriate), bypassing the standard referral process.
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Enhanced Outpatient Program Mental Health Services Delivery System

Interdisciplinary Treatment Team

9BU

The responsibilities for overall treatment planning within the EOP rest with the IDTT.
These responsibilities include:

• Program admission decisions for individual case

• Formulation and approval of initial and updated individual treatment plans

• Periodic case reviews and re-justifications of treatment

• Discharge decisions

• Overall utilization review of available beds

• Overall program quality improvement

The IDTT is composed of, at a minimum:

• Assigned Primary Clinician (PC)

• Assigned Psychiatrist

• Correctional Counselor

• Inmate-patient

Other staff who have direct knowledge of the inmate-patient are encouraged to attend or
provide information:

• Licensed Psychiatric Technicians (LPT)

• Custody Officers

Recreation Therapists (RT), Registered Nurses (RN), Licensed Vocational Nurses, LPT,
and the housing custody officer will also normally participate. Each member of the team
will provide input into the overall treatment plan. Input from additional staff, including
vocational and educational personnel, is strongly encouraged. A representative from the
IDTT (the assigned PC or designee) should be present in all classification hearings
regarding inmate-patients in treatment to provide mental health input into the
classification decision-making process. The inmate-patient shall be included in the
IDTT, unless the inmate-patient refuses to participate. If the inmate-patient refuses to
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Enhanced Outpatient Program Mental Health Services Delivery System

participate in the IDTT, the inmate-patient shall indicate the refusal and the reason for the
refusal. The PC shall document this information on the treatment plan, CDCR 7388,
Mental Health Treatment Plan, and in the progress notes, CDCR 7230-MH, Mental
Health Progress Note. Inmate-patients shall not be disciplined for not participating in
IDTT. The PC is responsible for presenting the inmate-patient’s concerns to the IDTT.

The Chief of Mental Health shall designate the IDTT leader.

Initial Evaluation Process

The initial clinical assessment involves an interview with the inmate-patient and a review
of available clinical records, the Central File, the evaluation of the referring clinician, and
records from prior institutional placements. A review of these evaluations and an
observation period are utilized to establish a functional baseline and working clinical
diagnosis. This process shall be completed within 14 calendar days from arrival at the
EOP.

If the inmate-patient states that he or she had significant prior treatment or the file review
indicates history of such treatment, the clinician shall obtain a signed Release of
Information and forward it to the Institutional Health Record Services to obtain previous
records. The referring clinician, custodial staff, work supervisors, teachers, chaplains,
and family members are excellent sources of patient collateral information and should be
utilized whenever possible (with appropriate release of information when required).

At the conclusion of the evaluation process and within 14 calendar days from arrival at
the EOP, the IDTT will review all relevant clinical, institutional, and criminal history
data, interview the inmate-patient and make one of the following determinations:

1. Admit to the program and develop a treatment plan on the CDCR 7388, Mental
Health Treatment Plan.

2. Decline admission (indicate clinical options).

3. Extend evaluation process for an additional 14 calendar days.

All decisions regarding change of treatment level made by the IDTT shall be documented
with a CDCR 128-MH3, Mental Health Placement Chrono. This chrono shall be
forwarded to classification for review and central file update. One copy of the chrono is
placed in the UHR and another copy forwarded for entry into the MHTS. An
individualized treatment plan, CDCR 7388, Mental Health Treatment Plan, shall include
the recommendations of the IDTT and specifics such as type of therapeutic activities
(schedule, duration, outcome expectations) and anticipated length of stay. The
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2009 REVISION 12-4-7
Enhanced Outpatient Program Mental Health Services Delivery System

prescription of treatment activities should consider the commitment offenses and current
institutional maladjustment.

Inmate-patients who are released from Administrative Segregation Unit (ASU) or the
PSU to a GP EOP for continuing mental health treatment may require mental health
services related to adjustment to the GP environment. The ASU or PSU PC shall
document recommendations regarding the inmate-patient’s specific treatment needs,
including any concerns about facilitating the inmate-patient’s successful transition to GP.
The receiving EOP IDTT will consider documentation by the ASU or PSU clinician in
developing the inmate-patient’s treatment plan. The treatment plan for inmate-patients
transferred from ASU or PSU to GP-EOP shall include services provided to aid in the
transition to the GP environment. Inmate-patients referred from the ASU or PSU to a
GP-EOP Unit shall be retained at EOP level of care for a minimum of 90 days.

Release after Initial Evaluation

If, at the conclusion of the initial evaluation process, the IDTT determines that EOP
placement is inappropriate, documentation to this effect is placed in the UHR using
CDCR 7388, Mental Health Treatment Plan. A CDCR 128-MH3, Mental Health
Placement Chrono, noting the decision and recommending more appropriate placement
shall be prepared for classification processing and transfer (if appropriate). If inpatient
care is indicated, the assigned PC is responsible for initiating and completing the
placement process.

E. EOP INMATE-PATIENT TREATMENT SERVICES

Each EOP inmate-patient will have an individualized treatment plan that provides for
treatment consistent with the inmate-patient’s clinical needs. The treatment plan shall be
documented on a CDCR 7388, Mental Health Treatment Plan. Each inmate-patient shall be
offered at least ten hours per week of scheduled structured therapeutic activities as approved
by the IDTT. It is recognized that not all inmate-patients can participate in and/or benefit
from ten hours per week of treatment services. For some inmate-patients, ten hours per week
may be clinically contraindicated. For those inmate-patients scheduled for less than ten
hours per week of treatment services, the PC shall present the case and recommended
treatment program to the IDTT for approval. The CDCR 7388, Mental Health Treatment
Plan, must include a detailed description of the diagnosis, problems, level of functioning,
medication compliance, and rationale for scheduling less than ten hours. For inmate-patients
who are scheduled for less than ten hours of treatment activities per week, the IDTT shall
meet at least monthly and be responsible to review and increase the treatment activities or
refer to a higher level of care as clinically indicated.

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Enhanced Outpatient Program Mental Health Services Delivery System

Categories of Treatment Services

REQUIRED TREATMENT

1. Individual Treatment Planning involves a meeting of the IDTT and the inmate-patient at
least every 90 days for the purpose of identifying treatment needs, developing treatment
plans, assessing treatment progress, and updating/revising individual treatment plans in
accordance with the inmate-patient’s needs and progress.

2. Weekly clinical contact with PC either individually or in group psychotherapy; individual

clinical contact at least every other week.

3. Medication Evaluation and Management

a) A psychiatrist shall evaluate each EOP inmate-patient at least monthly to address

psychiatric medication issues.

b) Refer to Inmate Medical Services Policies and Procedures, Volume 4, Chapter 11,
Medication Management, regarding procedures for administration of medication,
medication refusals, Directly Observed Therapy, and other aspects of medication
administration.
c) Refer to MHSDS Program Guide, Chapter 5, Mental Health Crisis Bed, for
information on involuntary medication administration.

4. Ten hours per week of scheduled structured therapeutic activities. See below for list of
treatment activities.

OTHER TREATMENT ACTIVITIES

1. Group therapy and psycho-educational groups provide inmate-patients with an

opportunity to express, explore, and resolve issues with the assistance of clinical staff and
other inmate-patient group participants who have similar problems or experiences.
Psycho-educational groups focus on cognitive/behavioral skill building as a means of
improving inmate-patient interpersonal skills and problem solving abilities.

2. Individual therapy provides inmate-patients with the opportunity to discuss personal

problems that may not be adequately addressed in a group setting.

3. Recreational and occupational therapies provide inmate-patients with supervised

recreational activities or exercise programs designed to reduce stress, improve self-
esteem and physical health, foster positive interpersonal interactions, and promote the
constructive use of leisure time. Occupational or recreational therapy is counted as

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2009 REVISION 12-4-9
Enhanced Outpatient Program Mental Health Services Delivery System

structured activity only if an appropriate clinician (an occupational therapist, recreational

therapist, LPT, or other qualified professional) is present and supervising the activity.
Unsupervised routine exercise is available for all inmate-patients and is not counted as a
therapeutic activity.

4. Work and educational programs may provide rehabilitative services through institutional
programming designed to help inmate-patients improve vocational and educational
functioning. Work and education assignments can constitute up to four hours of
structured activity per week if they are identified as such in the inmate-patient’s
treatment plan. The treatment plan must indicate how it is believed the inmate-patient
benefits from particular vocational and/or educational activities.

Examples of Treatment Activities

The EOP may offer some or all of the following treatment activities, depending on the needs
of the inmate-patient population and the resources available.

1. Daily Living Skills - train and assist inmate-patients in developing or improving skills in
maintaining appropriate personal hygiene and grooming habits. These activities include
demonstrating and prompting inmate-patients in bathing, dressing, and the maintenance
of a clean living environment. These activities promote personal responsibility and
initiative for self-care, enhance self-esteem, and provide a predictable daily routine.

2. Medication Education - educate inmate-patients regarding the importance and benefits of

regularly taking their prescribed medications. It discusses medication, interaction with
alcohol and drugs, and teaches how to correctly take medication. It explains side effects
and when they need to be brought to the attention of clinical staff. It stresses the
importance of effective doctor/patient communication in obtaining and maintaining
medication compliance.

3. Symptom Management - help inmate-patients with chronic mental disorders become

more effective in managing their psychiatric symptoms by teaching them how to identify
warning signs of relapse, persistent symptoms, and medication side effects. Inmates
learn how to cope with symptoms and seek professional help.

4. Specific Mental Health Issues - provides focused clinical support for inmate-patients
experiencing specific mental health issues, such as depression, or who have a history of
being a victim.

5. Social Skills/Communication - focus on activities which allow inmate-patients to interact

in a positive manner with other individuals, both staff and inmates. It promotes the
development of communication skills that are appropriate and socially acceptable.
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2009 REVISION 12-4-10
Enhanced Outpatient Program Mental Health Services Delivery System

6. Anger Management - teaches inmate-patients the socially acceptable and appropriate

ways of handling anger and expressing feelings. This module is geared towards reducing
aggressive/assaultive behavior toward self or others or by developing self-control skills.
It teaches inmate-patients processes that can be used within the institution setting to
resolve conflicts and handle problems appropriately without resorting to violence.

7. Stress Management - teaches inmate-patients how to identify recurring prison stressors

and provides specific stress reduction techniques to minimize the negative effects of
stress on their behavior and mental health.

8. Substance Abuse Group - teaches inmate-patients about the relationship between

substance abuse and criminality and emphasizes the effects of chemical abuse on inmate-
patients with mental illness. The group offers supportive interactions and explores issues
of chronic abuse and the development of alternatives.

9. Health Issues - provides education regarding basic physical, emotional, and mental health
issues, including human sexuality and sexually transmitted diseases.

10. Offense Specific Therapy - provides clinical support for insight-oriented treatment
related to causative factors in criminal behavior, emphasizing the development of
alternative courses of conduct.

11. Rational Behavior/Reality and Decision-making - emphasizes the assumption of

responsibility for one's actions, accepting the reality of their living environment, the
development of more productive and pragmatic life scripts, as well as developing
strategies to identify and achieve attainable goals.

12. Family Issues - focus on stressful experiences associated with spousal abuse, childhood
physical and sexual abuse, separation from offspring and loved ones, dysfunctional
relationships, pregnancy issues, etc.

13. Therapeutic Community Meeting - all inmate-patients in the program are involved in
regularly scheduled community meetings to discuss issues that commonly affect their
treatment and living environment. Inmate-patients learn through active interaction with
peers and staff how to build a therapeutic community.

14. Clinical Pre-Release group - inmate-patients nearing parole to the community are seen
weekly in group and discuss issues related to community living arrangements, continued
outpatient care, financial, educational, and vocational needs. The skills necessary to
successfully meet the general conditions of parole in the community are discussed.
Clinical Pre-Release groups involve coordination with the Parole and Community

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Services Division Transitional Case Management Program (TCMP) staff and Parole
Outpatient Clinic (POC) clinical staff.

Daily Activity Schedules

Utilizing the above treatment descriptions (and additional optional activities as may be
developed at the institutional level), each inmate-patient has a weekly activity schedule
incorporated into the individual treatment plan drawn from a schedule of treatment activities
available on the unit. Development of, and adherence to, the schedule is the joint
responsibility of the inmate-patient and PC. The establishment of additional unit activities,
available to all inmate-patients, is the responsibility of EOP staff.

Nursing and Supportive Care

1B

Although 24-hour nursing care is not required for inmate-patients within the EOP, services
expanded from those offered to GP inmate-patients are provided by RNs and/or LPTs. These
services include:

1. Administration of all medications. Refer to the Inmate Medical Services Policies and
U

Procedures, Volume 4, Chapter 11, Medication Management.

U

2. Regular monitoring of medication compliance, and notification of medication non-

compliance to treating psychiatrist, consistent with DCHCS policy.

3. Provision of nursing services as ordered by a physician.

4. Supervision and assistance in the activities of daily living, including maintenance of

living quarters, personal hygiene, and eating habits.

5. Coordination and support of out-of-cell activities with program staff.

Documentation
12B

Clinical staff shall document the progress of an inmate-patient on a CDCR 7230,

Interdisciplinary Progress Note, at least monthly. Additionally, individual clinical contacts
and significant changes in the inmate-patient’s level of functioning shall be documented.
The monthly progress note shall include:

• Record of attendance at treatment activities.

• Description of participation in treatment activities.

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Enhanced Outpatient Program Mental Health Services Delivery System

• Progress in resolving identified problems and symptoms.

• Current mental status.

Aftercare Planning and Referral

3B

Planning for follow-up services is a critical component of care that inmate-patients need
upon release from the EOP. The PC or the IDTT leader is responsible for ensuring that this
is accomplished prior to an inmate-patient's discharge from the program. Such planning
includes referrals to other levels of care, other programs, or other appropriate therapeutic
placement to ensure continuity of care. Inmate-patients whose level of functioning has
improved shall be referred to the CCCMS. Inmate-patients who require a higher level of
care are referred to the MHCB or the DMH Inpatient Program.

Aftercare plans should describe:

1. The inmate-patient’s diagnosis and the psychiatric problems continuing to require

treatment.

2. Any other pertinent mental health or medical conditions (e.g., allergies, special dietary
needs, chronic diseases), criminal and legal history, and cognitive or functional
impairment (e.g., developmental problems, insufficient education and/or language
barriers) that could affect adjustment and treatment.

3. Recommendations for follow-up treatment, including medications and recommendations

for specific scheduled structured therapeutic activities.

4. Referrals to appropriate programs and other institutional services, including chaplain

services, substance abuse programs, education, and job programs.

Clinical Pre-Release Program

4B

This is designed to provide systematic planning, support and education to inmate-patients

who are approaching their date of release/parole to the community and who are not expected
to transition to another level of care before departure. This service is designed to maximize
the inmate-patient's opportunities for successful transition into community living. The
service coordinates its activities with the TCMP and POC staff to facilitate community
outpatient care and support services. The PC shall prepare a discharge summary, which
includes a diagnosis, current medications, and placement needs. The discharge summary
shall be sent to the regional POC office prior to release.

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F. STAFFING AND CASE MANAGEMENT

U

The EOP staffing structure is based on clinical needs for this level of care and the staffing
ratios developed to meet these needs. EOP staff includes psychiatrists, psychologists,
clinical social workers (CSW), RNs, LPTs, and RTs. In addition to interdisciplinary clinical
staff, the EOP staffing provides enhanced correctional officer support.

Chief of Mental Health

5B

The Chief of Mental Health (or designee) assigns the IDTT leaders and PCs, and reviews the
overall quality of assessment and treatment plans, including aftercare plans for each inmate-
patient.

Primary Clinician
7B

One clinical staff member of the team (a psychiatrist, a psychologist, or a CSW) is identified
as the PC for each inmate-patient. This individual assumes overall responsibilities for the
treatment services provided to inmate-patients by maintaining active therapeutic involvement
with the inmate-patient and coordinating services provided by other treatment providers
involved in implementing the treatment plan. Specific responsibilities of the PC include:

1. Completion of initial clinical intake assessment (CDCR 7386, Mental Health

Evaluation).

2. Documentation of:

• All individual PC contacts;

• Initial and updated treatment plans (CDCR 7388, Mental Health Treatment Plan);

• Treatment progress or lack thereof, at least monthly (CDCR 7230-MH, Mental

Health Progress Note);

• Specific reasons when the inmate-patient is unable to attend or participate in group

therapy;

• Reasons for weekly individual PC contact when indicated;

• Degree of participation in treatment activities;

• Contact log for MHTS input.

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3. Weekly clinical contacts (either individual or group psychotherapy) with assigned

inmate-patients. Individual clinical contacts must occur at least every other week.
Individual clinical contacts shall be held in a private setting out of cell, or cell-front if an
inmate-patient refuses.

4. Provision of group therapy.

5. Scheduling for regular and special IDTT reviews. (Special IDTT reviews are held for
inmate-patients who require a change in level of care or if otherwise clinically indicated.)

6. Response to inquiries regarding clinical status of inmate-patient.

7. When an inmate-patient is discharged to the CCCMS, notification to the PC at the

receiving program/institution.

G. CASE REVIEW

The IDTT is responsible for conducting a structured process of case review. The review
occurs quarterly or more often if clinically indicated. The purpose of the review is to ensure
optimal progress toward achieving resolution of symptomatology sufficient for placement in
the least restrictive clinical and custodial environment. Proper case review maximizes the
utilization of the limited beds available for EOP placements.

The IDTT shall generally be responsible for developing and updating treatment plans. This
process shall include input from the inmate-patient and other pertinent clinical information
that may indicate the need for a different level of care. Referrals to higher levels of care
shall be considered when the inmate-patient’s clinical condition has worsened or the inmate-
patient is not benefiting from treatment services available at the current level of care.
Consideration of appropriate level of care shall be documented by the IDTT on a
CDCR 7230-MH, Interdisciplinary Progress Note, and shall include the justification for
maintaining the current level of care or referral to a different level of care.

The PC for each inmate-patient shall prepare a case summary on a CDCR 7230-MH, Mental
Health Progress Note, for quarterly IDTT review, which will consist of the following:

1. Clinical diagnosis and brief history of previous clinical interventions with emphasis on
interventions implemented since the last team review.

2. Current length of stay in EOP.

3. Assessment of current status and progress or lack of progress in achieving treatment

goals.
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4. Assessment of willingness and ability to participate in the program and description of

attempts to improve treatment participation.

5. Recommendations for modifications to treatment plan, including diagnosis, level of care,

problems, medications, and treatment intervention.

6. If applicable, input from the previous CCCMS PC when a reduction in level of care is
considered.

7. Discharge planning, including a tentative discharge date, anticipated level of care,

specific follow-up recommendations, and perceived impediments to discharge.

Pertinent information from IDTT reviews shall be documented on a CDCR 7230-MH,

Mental Health Progress Note, and filed in the UHR. Any modifications to the individualized
treatment plan shall be documented on an updated CDCR Form 7388, Mental Health
Treatment Plan, and also filed in the UHR. A full case summary, with a recommendation for
either continued placement or transfer to an alternative level of care, shall be completed on
an annual basis, for placement in the UHR. If there is a change in the level of care, formal
notification will be provided to the inmate-patient’s Correctional Counselor via a CDCR
128-MH3, Mental Health Placement Chrono.

H. DISCHARGE

Discharge from the EOP will be based upon a decision utilizing the IDTT process when the
inmate-patient satisfies any of the following conditions:

1. Is able to function in a GP setting with CCCMS support.

2. Has clinically decompensated to the extent that placement into 24-hour inpatient care
(either MHCB or DMH hospitalization) is required.

3. Has reached his/her parole date, and clinical services will be transferred to a POC.

Note: Inmate-patients who are placed in ASU or SHU and continue to require EOP level of
care shall not be discharged, but shall be transferred to the appropriate setting (see Chapters
7 and 9).

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Enhanced Outpatient Program Mental Health Services Delivery System

I. ENHANCED OUTPATIENT PROGRAM FOR CONDEMNED INMATE-PATIENTS

1. EOP Housing for Condemned Inmate-Patients

Per Penal Code Section 3600, male inmates who have received a death sentence are
incarcerated at California State Prison - San Quentin (SQ). Female inmates who have
received a death sentence are incarcerated at Central California Women’s Facility
(CCWF). Therefore, these two institutions are charged with the responsibility to provide
mental health treatment services at the EOP level of care to condemned inmate-patients
identified as needing this level of care.

Housing for condemned inmates is determined by the inmate’s behavioral adaptation to

the correctional setting. Upon arrival, each condemned inmate completes an orientation
period. At SQ, the orientation period is generally completed in the Adjustment Center
housing unit. During the orientation period, inmate-patients are identified as either a
Grade A Condemned (housing and program closely related to a GP setting), or Grade B
Condemned (housing and program closely related to an administrative segregation
setting). Additionally, the initial medical evaluation identifies the inmate-patient’s
medical needs including any serious mental health needs that require treatment.
Therefore, Grade A or Grade B Condemned inmates identified as requiring EOP level of
care are housed according to institutional custody determination, and appropriate mental
health treatment services are then provided. A condemned inmate’s grade level
determination is subject to review and change on an annual basis or more often if
determined appropriate.

At CCWF, due to the few female inmates sentenced to the death penalty, all female
condemned inmates are housed and programmed in a designated housing unit, separate
from other GP inmates. The female condemned program at CCWF does currently
classify condemned inmates into “grades” as referenced above. All programs including
any required mental health treatment services for EOP female condemned inmate-
patients are provided within this housing unit.

2. Condemned EOP Inmate-Patient Treatment Plan

All condemned EOP inmate-patients housed at SQ or CCWF shall have an individual

treatment plan documented on a CDCR 7388, Mental Health Treatment Plan, that
provides for treatment consistent with the inmate-patient’s clinical needs.

The development of the individual treatment plan by the assigned IDTT must take into
account the unique security operations and procedures necessary to effectively manage
this condemned population during a period when the institution is locked down for an
execution. At SQ, programs and services (excluding delivery of medication and
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emergency services) are curtailed prior to, during, and after the actual execution of a
condemned inmate, as determined by the Warden. Out-of-cell activities do not occur
during the period that the institution is locked down pending or following an execution;
however, LPTs shall continue daily rounds. These procedures are mandatory and are
required due to the sensitive and potentially volatile atmosphere at the institution when
carrying out an imposed death penalty.

Additionally, the recommended individualized treatment plan for Grade B Condemned

EOP inmate-patients at SQ may require modification due to the heightened safety
concerns associated with this population’s required placement in the Adjustment Center.
Out-of-cell activities for this population specifically require intensive staff resources to
ensure the safety and security for all involved: inmates, clinical staff, as well as,
correctional staff.

The individualized treatment plan for the condemned EOP inmate-patient, as for all EOP
inmate-patients, provides the “blue print” for the course of mental health treatment that is
intended to address the diagnosed condition. The initial plan provides the treatment
foundation by prescribing services, activities, and medication that will be attempted and
monitored. Frequent clinical and custody staff involvement provide ongoing assessment
of progress and effectiveness of the applied plan. The ongoing assessment provides the
impetus for the modification and/or change for the treatment services contained in the
individualized treatment plan.

3. EOP Condemned Inmate-Patient Treatment Services

The Condemned EOP Inmate-patient will receive treatment services commensurate with
their demonstrated ability to safely participate in the offered services. All condemned
EOP inmate-patients will be offered ten hours per week of scheduled structured
therapeutic activities identified and approved by the IDTT as part of the individualized
treatment plan. It is recognized that not all condemned EOP inmate-patients can or will
participate in and/or would benefit from this amount of treatment time. The ten hours per
week for certain diagnosed condemned EOP inmate-patients may be clinically
contraindicated. However, for condemned EOP inmate-patients scheduled for less than
ten hours, the PC shall present the case to the IDTT for approval. The CDCR 7388,
Mental Health Treatment Plan, shall include a detailed description of the diagnoses,
inmate-patient’s problem list, level of functioning, medication compliance, and clinical
reasons for scheduling less than ten hours. For inmate-patients who are scheduled for
less than ten hours of treatment activities per week, the IDTT shall meet at least monthly
to review and increase the treatment activities or refer to a higher level of care, as
clinically indicated.

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REQUIRED TREATMENT ACTIVITIES

The Condemned EOP inmate-patient shall be offered the following treatment services:

1. Individual Treatment Planning involves a meeting of the IDTT and the inmate-patient for
the purpose of identifying treatment needs, developing treatment plans, assessing
treatment progress, and updating/revising individual treatment plans in accordance with
the inmate-patient’s needs and progress. Refer to Section D. Admission to Program,
Interdisciplinary Treatment Team, of this document for a complete description of the
functions of the EOP IDTT and membership.

2. Weekly PC contact (either individual or group psychotherapy) with assigned inmate-

patients. Individual clinical contacts must occur at least every other week.

3. Daily LPT contact for Grade B Condemned EOP inmate-patients.

4. Medication Evaluation and Management

a) A psychiatrist shall evaluate each Condemned EOP inmate-patient at least monthly

to address psychiatric medication issues.

b) Refer to Inmate Medical Services Policies and Procedures, Volume 4, Chapter 11,
Medication Management, regarding procedures for administration of medication,
medication refusals, Directly Observed Therapy, and other aspects of medication
administration.

c) Refer to MHSDS Program Guides, Chapter 5, Mental Health Crisis Bed, for
information on involuntary medication administration.

5. Crisis Intervention

6. Ten hours per week of scheduled structured therapeutic activities. See below for list of
treatment activities.

TREATMENT ACTIVITIES

Specific treatment services offered include the following:

1. Group Therapy provides inmate-patients with an opportunity to express, explore, and

resolve issues with the assistance of clinical staff, as well as supportive interactions with
inmate-patients who have similar problems or experiences.

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2. Individual Therapy provides inmate-patients with the opportunity to discuss personal

problems that may not be adequately addressed in a group setting.

3. Recreational Therapy provides inmate-patients with supervised recreational activities or

exercise programs designed to reduce stress, improve self-esteem and physical health,
foster positive interpersonal interactions, and promote constructive use of leisure time.
Recreational therapy is counted as structured activity only if a recreational therapist is
present and supervising the activity. Unsupervised routine exercise is available for all
inmate-patients and is not counted as a therapeutic activity. No inmate-patient in SQ's
Adjustment Center will be permitted out of his cell for the purposes of recreational
therapy, but in-cell treatment activities (therapy) may be permitted, subject to the
heightened safety and security concerns present in the Adjustment Center.

4. Monitoring and Assistance with daily living skills.

5. Nursing and Supportive Care: Although 24-hour nursing care is not required for inmate-
patients within the EOP, expanded services from those offered to non-EOP Condemned
inmate-patients are provided by RN and/or LPTs. These services include:

a) Administration of all medications. Refer to the Inmate Medical Services Policies and
Procedures, Volume 4, Chapter 11, Medication Management.

b) Regular monitoring of medication compliance and notification of medication non-

compliance to treating psychiatrist, consistent with DCHCS policy.

c) Provision of nursing procedures as ordered by a physician.

d) Supervision and assistance of activities of daily living, including maintenance of

living quarters, personal hygiene, and eating habits.

e) Coordination and support of activities with recreational therapy staff.

f) Provision of clinical escorts, when needed.

6. Aftercare Planning and Referral: Planning for follow-up services is a critical component
of care that inmate-patients need upon release from the EOP. The PC or the IDTT
Leader is responsible for ensuring that this is accomplished prior to an inmate-patient’s
discharge from the program. It includes referrals to other levels of care, programs, or
other appropriate therapeutic placement to ensure continuity of care. Inmate-patients
whose level of functioning has improved significantly to the point where the structure of
the EOP therapeutic and housing environment is no longer needed shall be referred to the
CCCMS services available in Condemned Housing. Condemned male inmate-patients
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who experience decompensation in the form of crisis shall be referred to the DMH
Inpatient Program at CMF for a MHCB level of care or DMH inpatient level of care.
Female inmate-patients shall be referred to Patton State Hospital.

J. MENTAL HEALTH QUALITY MANAGEMENT SYSTEM

Ongoing assessment of the quality of clinical services will follow the Mental Health Quality
Management System procedures.

K. TRACKING ATTENDANCE AT TREATMENT ACTIVITIES

Attendance at treatment activities, psychiatrist and PC appointments, and scheduling of

IDTTs, among other information, will be tracked by the MHTS.

L. GROUP/PRIVILEGE GROUP A1A DESIGNATION

All EOP inmate-patients who are actively participating in structured therapeutic activities as
determined by the IDTT shall be assigned to work Group/Privilege Group A-1-A.

EOP inmates-patients may be assigned to established work or education programs if

participation will be therapeutically beneficial. In these situations, a job description and
timekeeping log shall be maintained by the work supervisor.

Inmates-patients not assigned to a credit qualifying work or education assignment, who

refuse to participate in therapeutic activities and are returned to CCCMS level of care, shall
be reassigned to Work Group/Privilege Group A-2-B.

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Mental Health Crisis Bed Mental Health Services Delivery System

CHAPTER 5
Mental Health Crisis Bed

A. INTRODUCTION

The goal of the Mental Health Crisis Bed (MHCB) program is to provide services for
conditions which require an inpatient setting to ameliorate mental health symptoms in the
least restrictive environment. MHCB programs are located in California Department of
Corrections and Rehabilitation (CDCR) institutions with facilities licensed as a Correctional
Treatment Center (CTC) [California Code of Regulations (CCR), Title XXII, Division 5,
Chapter 12, Article 4, Section 79739, Mental Health Treatment Program], General Acute
Care Hospital (GACH), or Skilled Nursing Facility (SNF). The MHCB program operates 24
hours a day, 7 days a week. An inmate-patient admitted to the MHCB for mental health
treatment may have acute symptoms of a serious mental disorder or may be suffering from a
significant or life threatening disability. Refer also to the Correctional Treatment Center
Policy and Procedure Manual, Volume VIII, Mental Health, for more detailed procedures.

Many conditions may precipitate a mental health crisis during institution confinement. At
reception, the loss of the existing support system the individual had on the outside and/or the
stress of initial imprisonment may lead to suicidal behavior, self-harm, or other symptoms.
In mainline settings within institutions, stress factors unique to imprisonment may cause a
pronounced degree of emotional strain and/or physical and interactive tension, and often
compound existing stress factors inherent in everyday life. Such factors as the restrictions of
confinement, pressures to conform to the prison lifestyle, and fear of more predatory inmates
may disrupt an inmate's coping abilities. An inmate with no known mental health history
may suffer acute symptoms, while another with mental illness in remission may have
recurring symptoms. Prior to release, fears of delayed release or inability to cope with the
outside world or loss of the institution support system of food, shelter, clothing, and structure
of time may lead to crisis reactions.

The MHCB has a length of stay of up to ten days. The Chief Psychiatrist or designee, must
approve exceptions to the length of stay. Not all crises require admission to the MHCB.
Crisis episodes for some inmate-patients may be handled on an outpatient basis. Other
inmate-patients, even if stabilized on medications, may require placement in a structured
therapeutic environment for ongoing treatment and monitoring. This may necessitate a
referral to an Enhanced Outpatient Program (EOP), or if longer-term intensive care is
needed, to an inpatient facility operated by the Department of Mental Health (DMH).

Presenting problems may require continuous observation or monitoring before an inmate-

patient's treatment needs can be fully assessed or the crisis brought under control. Where 24-
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Mental Health Crisis Bed Mental Health Services Delivery System

hour care is needed, an inmate-patient shall be placed in a MHCB for continuous nursing
care.

B. PROGRAM OBJECTIVES

The primary objective of the MHCB is to evaluate the symptoms associated with the crisis
and provide initial stabilization and recommendations for follow-up care, post discharge.
More specific objectives include:

1. To observe, monitor, and provide continuous nursing assistance to inmate-patients whose

condition requires 24 hours or more to achieve stabilization.

2. To assess the inmate-patient’s symptoms, formulate a provisional or differential

diagnosis, and develop an initial treatment plan. This may include a
medical/neurological evaluation or an initiation of referral for such.

3. To control symptoms of serious mental illness, using emergency medication when

necessary.

4. To alleviate psychiatric distress with appropriate therapy or counseling.

5. To refer the inmate-patient for placement in an appropriate level of care.

6. To provide an alternative to hospitalization for inmate-patients whose condition allows

placement within ten calendar days to a less intensive level of care.

C. POPULATION SERVED

Overall Treatment Criteria

Overall treatment criteria have been developed for the Mental Health Services Delivery
System (MHSDS). An inmate must meet the criteria in either 1 or 2 below in order to
receive MHSDS treatment at any level of care:

1. Treatment and monitoring are provided to any inmate who has current symptoms and/or
requires treatment for the current Diagnostic and Statistical Manual (DSM) diagnosed
(may be provisional) Axis I serious mental disorders listed below:

Schizophrenia (all subtypes)

Delusional Disorder
Schizophreniform Disorder
Schizoaffective Disorder

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Brief Psychotic Disorder

Substance-Induced Psychotic Disorder (exclude intoxication and withdrawal)
Psychotic Disorder Due To A General Medical Condition
Psychotic Disorder Not Otherwise Specified
Major Depressive Disorders
Bipolar Disorders I and II

2. Medical Necessity: Mental health treatment shall be provided as needed. Treatment is

U U

continued as needed, after review by the Interdisciplinary Treatment Team (IDTT), for
all cases in which:

Mental health intervention is necessary to protect life and/or treat significant

9B

disability/dysfunction in an individual diagnosed with, or suspected of having, a

mental disorder. Treatment is continued for these cases only upon reassessment
and determination by the IDTT that the significant or life threatening
disability/dysfunction continues or regularly recurs.

Specific Treatment Criteria for MHCB

In addition to the overall treatment criteria above, an inmate must meet the following specific
criteria to receive treatment at the MHCB level of care:

• Marked impairment and dysfunction in most areas (daily living activities, communication
and social interaction) requiring 24-hour nursing care; and/or

• Dangerousness to Others as a consequence of a serious mental disorder/Dangerousness to

Self.

• These conditions usually result in a Global Assessment of Functioning (GAF) score of

less than 30.

D. REFERRAL AND TRANSFER

U

Referrals

An inmate-patient suffering from an acute, serious mental disorder resulting in serious

6B

functional disabilities, or who is dangerous to self or others, shall be referred to a MHCB.

MHCB Transfer

If the institution does not have a MHCB or there are no MHCB beds available in the
institution where the inmate-patient is currently housed, the inmate-patient shall be
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Mental Health Crisis Bed Mental Health Services Delivery System

transferred to a designated MHCB institution. The inmate-patient shall be transferred within

24 hours of referral.

(See Inmate Medical Services Policies and Procedures, Volume 4, Chapter 3, Health Care
Transfer Process and Volume 6, Chapter 18, Transfer of Patient Health Records Within
CDCR; Institution to Institution, for specific requirements concerning transfers and Unit
Health Records)

If the MHCB beds are not available at the designated hub institution, the inmate-patient shall
be taken to an available MHCB bed that is able to provide MHCB care while simultaneously
providing the commensurate level of custody and security. In most cases, movement from an
institution to a MHCB bed shall be completed by institutional transportation staff via special
transport within 24 hours. On weekends and after normal business hours, the mental health
clinician on call or the physician on call at the referring institution shall contact the mental
health clinician on call or the physician on call at other institutions to locate a vacant MHCB
bed. The Health Care Placement Oversight Program (HCPOP) may be contacted seven
days a week to assist in locating a vacant MHCB bed.

MHCB transfers shall be done under authority as “Emergency Medical Transfers”

(Department Operations Manual [DOM] 62080.17). Since MHCB transfers are typically
viewed as emergency moves, they do not require classification committee action or
Classification Staff Representative (CSR) endorsement. MHCB transfers shall be done on a
“Psychiatric and Return” basis.

Generally, the transfer process shall be initiated by the inmate-patient's psychiatrist,

psychologist, or the Chief of Mental Health.

The transferring psychiatrist, psychologist, or Chief of Mental Health shall determine

whether the inmate-patient is "medically cleared" to transfer. State law provides that, before
a patient may be transferred to a health facility, the patient must be sufficiently stabilized to
be safely transported. The transferring physician is responsible for determining whether the
inmate-patient's condition will allow transfer. The CCR provides, in part, that a transfer or
discharge may not be carried out if, in the opinion of the inmate-patient's physician, such
transfer or discharge would create a medical hazard. The transferring physician must
initially evaluate the relative benefits and risks associated with transporting the inmate-
patient. The determination of whether the transfer creates an unacceptable risk or a "medical
hazard" will depend upon the inmate-patient's condition, the expected benefits to the inmate-
patient if he or she is transferred, and whether the risks to the inmate-patient's health are
outweighed by the benefits.

The receiving facility must consent to the transfer. CCR, Title XXII, licensing standards
provide that a patient shall not be transferred unless and until the receiving facility has

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consented to accept the patient. Specifically, the CCR provides, in part, that no patient shall
be transferred, or discharged for purposes of transferring, unless arrangements have been
made in advance for admission to a health facility. Therefore, the transferring clinician must
secure the receiving health facility's approval in advance for the inmate-patient's admission.
The transferring clinician shall document in the inmate-patient's Unit Health Record (UHR)
that approval was obtained and from whom.

Appropriate housing of inmate-patients pending MHCB transfer shall be determined by the

sending institution and in the following order of preferred locations:

1. Inpatient beds

2. Outpatient Housing Unit

3. Outpatient Housing Unit overflow cells

4. Large holding cells with water/toilets including, but not limited to, “ZZ cells,” “wet
cells,” and/or “clinic cells.” Many CTC buildings have holding cells located outside of
the entrance to the licensed bed area. These are typically located in the Specialty Care
Clinic area. These cells are permissible for temporary housing pending transfer without
violating licensing restrictions of the licensed bed area of the CTC building.

5. Large holding cells without water/toilets such as “Contraband Cells” (not in a CTC
licensed area)

6. Triage and Treatment Area or other clinic physical examining room

7. Other unit-housing where complete and constant visibility can be maintained

8. When none of the above are available, small holding cells (not in a CTC licensed bed
area) that are designed for the inmate-patient to sit or stand may be used for up to four
hours by which time consideration of a rotation to one of the above listed options shall
have been considered and the outcome of such consideration documented. Inmate-
patients shall be retained in sit/stand cells only with approval of the watch commander
and notification of on-call clinical staff.

9. Holding cells within the licensed bed area of the CTC building (notification to
Department of Health Services of an unusual occurrence is required)

All inmates-patients housed in one of the above sites while pending transfer to a MHCB shall
be provided, at minimum, with a safety (no-tear) mattress, safety (no-tear) blanket, and safety
(no-tear) smock. If the inmate-patient subsequently attempts to use any or all of these items

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to harm him or herself, a clinician may then order that one or more of these items be
removed. Inmate-patients who are subsequently returned to their housing units shall receive
appropriate clinical follow-up, which may include five-day custody and clinical wellness
checks.

When an inmate-patient, identified as requiring MHCB care, is housed in an Outpatient

Housing Unit, Administrative Segregation Unit, or any of the above sites, the HCPOP shall
be notified of the need for MHCB placement.

Procedure

The Chief of Mental Health or designee at the sending institution shall contact the MHCB
Clinical Director or designee at the receiving institution to obtain approval for the transfer.

In cases where the Clinical Director or designee at the receiving institution does not agree to
the transfer, and the Chief of Mental Health at the sending institution believes the clinical
need for transfer remains, the case shall be referred to the HCPOP and/or Mental Health
Services at headquarters central office for assistance. If an agreement cannot be reached, the
inmate shall be admitted and evaluated.

Upon receipt of approval to transfer, from the MHCB Clinical Director or designee at the
receiving institution, the Chief of Mental Health or designee at the sending institution shall
complete a CDCR 128-C, Chrono – Medical/Psychiatric/Dental, indicating acceptance.
Copies of the completed CDCR 128-C, Chrono – Medical/Psychiatric/Dental, shall be
forwarded to the MHCB Clinical Director or designee at the receiving institution and the
Classification & Parole Representative (C&PR) at the sending institution.

The C&PR at the sending institution shall forward a copy of the completed CDCR 128-C,
Chrono – Medical/Psychiatric/Dental, to the C&PR at the receiving institution.

The Chief of Mental Health or designee, MHCB Clinical Director or designee, and the
C&PRs at both the sending and receiving institutions shall communicate to ensure all health
care/classification/transportation aspects are addressed. The escort needs for each transport
are different given the variation of custody and health care concerns that may arise. At
times, the transportation may be accomplished with just custody staff. However, occasions
do arise when a combination of custody and clinical staff are needed to accompany an escort.
This may occur when the inmate-patient has highly sensitive and varying medication needs
or when the presence of a clinical staff member may substantially reduce decompensating or
disruptive inmate-patient behavior during transportation.

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The C&PR at the receiving institution shall contact the Classification Services Unit (CSU)
for teletype transfer approval. The transfer approval shall be obtained from a CSR if
available on site.

Documentation and classification of inmate-patients accepted for transfer to another

institution shall be consistent with procedures outlined in the DOM. The sending institution
shall clearly indicate on CDCR 135, Inmate Transfer Record, that the purpose of the transfer
is for psychiatric treatment.
The inmate-patient shall be informed of the reasons for and destination of the transfer.

The Receiving and Release sergeant at the receiving institution shall notify the MHCB when
the inmate-patient arrives. An inmate-patient who arrives by special transport because of
urgent acuity shall be screened by a physician. If immediate admission is not possible, an
inmate-patient shall be housed in an appropriate medical setting until a bed is available
(CCR, Title XXII, Section 79789).

E. ADMISSION

Pre-admission Screening

All inmate-patients referred to the MHCB shall receive a pre-admission screening for the
purpose of determining the appropriateness of the admission to the MHCB program. During
regular working hours, the screening shall be performed by a psychiatrist or a licensed
psychologist privileged to practice in the MHCB, and documented in the Progress Notes.
During weekends, holidays, and after normal business hours, the screening shall be
performed by an on-site physician on duty or any other licensed health care staff. The pre-
admission screening may be performed via telephone prior to transfer when the inmate-
patient is at an institution without an available MHCB. An inmate-patient in crisis may be
screened where the crisis occurs (such as in the cell), or in the emergency service area of the
CTC/GACH/SNF, prior to admission to the MHCB.

All inmates attempting suicide and those having suicidal ideation or showing signs and
symptoms of suicide potential will be evaluated by a mental health clinician (psychiatrist,
psychologist, or Clinical Social Worker) on an emergency basis. Inmates referred to health
care by custody because of suicide concerns, shall be immediately evaluated for suicide risk
by a mental health clinician, which shall include a Suicide Risk Assessment Checklist
(SRAC). On weekends, evenings, and holidays, the SRAC shall be performed by the
Physician on Call (POC), Medical Officer of the Day (MOD), or Registered Nurse (RN)
trained to administer the SRAC if mental health clinicians are not available. It is the
responsibility of the Health Care Manager to establish procedures for suicide risk assessment
by clinical staff outside of normal work hours. All SRACs shall be filed in the inmate-
patient’s UHR whether or not the inmate-patient is admitted to the MHCB. An inmate

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showing suicidal potential cannot be refused admission until there is a face-to-face

evaluation and SRAC completed by a clinician trained to conduct suicide risk assessments.

All inmates who are screened positive for possible admission to the MHCB on a weekend,
holiday, or after normal business hours shall be referred to a MHCB psychiatrist or
psychologist with admitting privileges (On Call or On Duty) for admission. The clinician
facilitates the admission based on the admission criteria indicated in Section C above. The
actual admission may be done by the MOD or POC in consultation with the psychiatrist or
psychologist (On Call or On Duty). For all inmates not admitted, the psychiatrist or
psychologist (On Call or On Duty) shall prepare a detailed Progress Note explaining the
reason for the decision. A log shall be kept by the referring institution, and shall include the
following information for all inmates referred to the MHCB and evaluated but not admitted:

• Date of referral

• Inmate-patient identification

• Reason for referral

• Reason for not being admitted

• Referring clinician

Admission/Transfer Log

Each mental health program with a MHCB unit shall develop and maintain a log of all
MHCB admissions/transfers. This log shall include at least the following information:

• Date of referral

• Inmate identification

• Reason for referral to MHCB

• Current level of care

• Date of Admission to MHCB

• Whether a suicide risk assessment (including a SRAC) was performed upon admission
(for suicidal inmates)

• Discharge diagnosis

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• Whether a suicide risk assessment (including a SRAC) was performed upon discharge
(for suicidal inmates)

• Date of clinical discharge from the MHCB

• Date of physical discharge from the MHCB

• Date of referral to new location/program

• Date of transfer to new location/program

• Location/program to which the inmate-patient has been transferred

All inmate-patients who receive a pre-admission evaluation for suicide potential, but who are
not admitted, will be tracked in a separate log. The log shall be kept by the MHCB that did
not admit the inmate-patient, and will include at least the following information:

• Date of referral

• Inmate-patient identification

• Reason for referral

• Reason for not being admitted

• Deciding clinician

Procedure

The MHCB shall accept inmates who meet the criteria for care and treatment and shall
continue to house only those inmates for whom care is appropriate. No inmate shall be
admitted to the MHCB until a provisional diagnosis or valid reason for admission has been
stated and the appropriateness determined. When clinical differences of opinion exist
regarding the appropriateness for admission and the clinicians involved cannot reach an
agreement at the institutional level, the cases shall be referred to the HCPOP and/or Mental
Health Services at headquarters central office for assistance.
Admissions to the MHCB shall be made on a “Psychiatric and Return” basis. A psychiatrist
or a psychologist with admitting privileges in the MHCB may admit an inmate to the MHCB.
Inmates shall be admitted only upon the written or verbal order of a MHCB psychiatrist or a
psychologist.

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2009 REVISION 12-5-9
Mental Health Crisis Bed Mental Health Services Delivery System

Occasionally, crisis referrals require emergency and involuntary admission to the MHCB.
An inmate-patient may, because of a psychotic episode, be confused, disoriented,
disorganized and/or gravely disabled, or because of acute depression, may be dangerously
suicidal. An inmate-patient in crisis who is explosive and assaultive may also be admitted
involuntarily if a serious mental disorder also exists. Assaultiveness that is assessed by the
clinician as resulting from an antisocial behavior, and not as a result of a serious mental
disorder, is more appropriately dealt with by custody staff, per general institution policies.

Any inmate-patient admitted to the MHCB program because of suicidal threats or behavior
shall receive a suicide risk assessment (including a SRAC) from a clinician, upon admission
and prior to discharge.

After hours, weekends, and holidays, the Administrative Officers of the Day, MODs, POCs,
and Watch Commanders shall be notified of an inmate who makes a serious suicide attempt
or engages in self-injurious behavior requiring medical treatment.

Inmate-patients with multiple admissions to MHCB (three or more within a six-month

period) shall be evaluated for referral to DMH.

An admission note shall be completed within 24 hours of admission to the MHCB by the
admitting clinician and shall include the inmate-patient’s condition at the time of admission,
provisional diagnosis, and an initial treatment plan. This shall be documented on a
CDCR 7230, Interdisciplinary Progress Notes, and filed in the UHR.

MHCB Nursing Evaluation

The nurse shall:

a. Interview and give an orientation to the inmate-patient.

b. Assess the inmate-patient and take vital signs.

c. Notify the physician of admission status including any admission problems.

d. Assemble the chart.

e. Initiate the Patient Care Plan.

f. Note and implement any admission orders, such as laboratory tests (for details refer to
the Correctional Treatment Center Policy and Procedure Manual, Volume VIII, Mental
Health), X-rays, medications, etc.

Physical Examination

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2009 REVISION 12-5-10
Mental Health Crisis Bed Mental Health Services Delivery System

For immediate care planning, a history and physical examination, including neurological
screening, shall be completed, to the extent clinically possible, immediately before or within
24 hours of admission. If the inmate-patient is uncooperative or otherwise cannot be fully
examined, a description of all possible observations and findings of the physical examination
shall be documented. The complete physical examination shall be conducted as soon as
clinically possible and documented in the UHR.

F. ASSESSMENT AND TREATMENT SERVICES

U

Intake Assessment

Upon admission to the MHCB unit, an assessment shall immediately be made on how best to
meet the critical needs of the seriously mentally disordered inmate-patient. This is
accomplished by reviewing and updating the CDCR 7386, Mental Health Evaluation,
completed by the referring clinician at the time of referral. At a minimum, a provisional
diagnosis is determined and an initial plan in the “Recommended Follow Up/Initial
Treatment Plan” section of the CDCR 7386, Mental Health Evaluation, shall be formulated
within 24 hours for immediate care planning and to rule out medical conditions that may be a
cause of presenting symptoms. Serious medical conditions that are a significant cause of the
crisis may warrant acute care medical hospitalization.

Interdisciplinary Treatment Team and Individualized Treatment Planning

The IDTT is composed of, at a minimum:

• Assigned MHCB psychiatrist

• Assigned MHCB Primary Clinician (PC)

• Nursing staff

• Correctional Counselor
• Inmate-patient (if clinically and custodially appropriate)

Other staff who have direct knowledge of the inmate-patient are encouraged to attend or
provide information, such as:
• Custody officers

• RNs

• Licensed Vocational Nurses (LVN)

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2009 REVISION 12-5-11
Mental Health Crisis Bed Mental Health Services Delivery System

• Recreational Therapists

The IDTT is chaired by a licensed mental health clinician. The inmate-patient shall be
included in the IDTT, if clinically and custodially appropriate as determined by the IDTT,
unless the inmate-patient refuses to participate. If the inmate-patient refuses to participate,
the PC shall document the reason for refusal on the CDCR 7230, Interdisciplinary Progress
Notes. Inmate-patients shall not be disciplined for refusing to participate in IDTT. Attempts
shall be made to gather input from the inmate-patient, such as talking to and observing the
inmate-patient at the cell door.

The IDTT shall meet within 72 hours of an inmate-patient’s admission and at least weekly
thereafter. The IDTT shall begin discharge planning at the initial IDTT meeting.

An individual treatment plan shall be developed and implemented at the initial IDTT
meeting. The treatment plan, which is to be filed in the inmate-patient's UHR, shall be
individualized and based on a comprehensive assessment, including, at a minimum, a mental
status exam and the inmate-patient's legal, criminal, psychiatric, medical, and developmental
history, and psychosocial evaluations. Psychosocial evaluations shall include personal and
family history, inmate-patient’s strengths and weaknesses, and evaluation of support system.

The individualized treatment plan shall:

1. Provide a primary diagnosis and identify the main presenting problems targeted for
treatment. The diagnosis may be provisional.

2. For every identified target problem, document the goals, interventions, and measurable
objectives of treatment.

3. Specify the types, frequencies and providers of prescribed therapies and adjunct
activities.

4. Document the success or failure in achieving stated objectives

5. Evaluate the factors contributing to the inmate-patient’s progress or lack of progress
toward recovery.

6. Document prescribed medication, dosage, and frequency of administration, as well as

medication compliance.
7. Be reviewed at each IDTT meeting, at least weekly, and updated accordingly.

8. Designate appropriate medications, therapies, and custody follow-up in an aftercare plan

to be followed after the inmate-patient's release from the MHCB. See MHSDS Program
U

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2009 REVISION 12-5-12
Mental Health Crisis Bed Mental Health Services Delivery System

Guide, Chapter 10, Suicide Prevention and Response, for specific follow-up
requirements for inmate-patients admitted for suicide prevention.

Case Reviews And Treatment Plan Update (CCR, Title XXII, Section 79747)

An inmate-patient's condition shall be assessed and monitored daily by the treating clinician,
either a psychiatrist or psychologist. On weekends or holidays, a mental health clinician on
call or the MOD shall make daily rounds. The Chief of Mental Health is responsible to
ensure that all physicians serving as MOD or POC are trained in the use of the SRAC.

Documentation of daily contacts shall be made within 24 hours in the UHR by the updating
clinician.

The IDTT shall review each crisis case as often as necessary, but at least every seven days,
and update the treatment plan accordingly. Each treatment plan update shall include the
following:

1. Documentation of the inmate-patient's response to treatment and his/her progress or lack

of progress towards the goals of treatment.

2. Evaluation of factors that hinder progress and the interventions planned by the team to
facilitate progress.

3. The most recent diagnoses and descriptions of the main presenting problems.

4. Evaluation of risk factors.

5. Review of release or discharge plans.

Treatment Services

The MHCB Clinical Director or designee shall be responsible for the prompt care and
treatment of each inmate-patient admitted to the MHCB, development and implementation of
a treatment plan, completeness and accuracy of the UHR, necessary special instructions, and
transmitting reports of the inmate-patient's condition. Whenever these responsibilities are
delegated to another staff member, continuity shall be ensured [CCR, Title XXII, Section
79741 (b)] by the MHCB Clinical Director.

An inmate-patient admitted to the MHCB shall be provided the following services and
treatment:

Medication Evaluation and Management

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2009 REVISION 12-5-13
Mental Health Crisis Bed Mental Health Services Delivery System

The assigned psychiatrist shall evaluate each MHCB inmate-patient individually at least
twice weekly to address psychiatric medication issues.

Refer to Inmate Medical Services Policies and Procedures, Volume 4, Chapter 11,
Medication Management, regarding procedures for administration of medication, medication
refusals, Directly Observed Therapy, and other aspects of medication administration.

Nursing Care

Twenty-four hour nursing care is provided in the MHCB to administer and supervise
medication, provide assistance for activities of daily living, observe and monitor inmate-
patients, obtain all physician-ordered laboratory studies, and provide counseling or inmate-
patient supervision as needed.

Therapy and Counseling

One-to-one intervention is often necessary in a crisis case. Usually, brief, intensive therapy
is helpful if it focuses on issues that precipitated the admission and explores changes in
behaviors, perceptions and expectations that facilitate coping with the crisis. Group therapy
may be provided to MHCB inmate-patients, consistent with clinical needs.

Rehabilitation Therapy

Inmate-patients may participate in rehabilitation therapy activities, consistent with clinical

needs. Rehabilitation therapy may include activities such as indoor or outdoor recreation.
These activities provide a setting for additional observation of inmate-patients, allowing for
the evaluation of exaggerated symptoms or severe symptoms that are masked [see CCR, Title
XXII, Section 79749 (c) (1) for Rehabilitation Treatment Plan requirements].

Inmate-patients who are awaiting transfer to DMH and remain in a MHCB beyond ten days,
shall be offered additional rehabilitation therapy and other treatment activities, as clinically
indicated.

Aftercare Planning and Referral

Planning for follow-up services is a critical component of the care an inmate-patient needs
upon release from the MHCB. This planning may lead to a referral to a program or other
appropriate placement to ensure continuity of care. An inmate-patient who clearly requires
longer-term hospital care may be referred and transferred to an inpatient hospital program
operated by the DMH. Aftercare plans shall include:

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2009 REVISION 12-5-14
Mental Health Crisis Bed Mental Health Services Delivery System

1. The diagnosis and psychiatric problems continuing to require treatment.

2. Any other unique mental health or physical conditions that could affect treatment (e.g.,
allergies, special dietary needs, chronic diseases).

3. Recommendations for follow-up treatment, including medications and specific

psychotherapies.

4. Referrals to other treatment programs and institutional services, including vocational or

educational programs, substance abuse programs and job programs (CCR, Title XXII,
Section 79749 [d]).

5. The aftercare plan shall consider the inmate-patient’s potential in-custody housing,
proximity to release from incarceration, probable need for community treatment and
social services, and the need for continued mental health care. If an inmate-patient
requires continued care upon paroling, the Parole Outpatient Clinic shall be contacted.

G. INVOLUNTARY TREATMENT
U

An inmate-patient in crisis who does not consent for treatment with medication may be
involuntarily treated to control symptoms which constitute:

• A danger to self, or

• A danger to others, or

• Grave disability on the basis of a serious mental disorder.

Involuntary medication administration refers to the administration of any psychotropic or

antipsychotic medication or drug by use of force, or restraint.
The reasoning for the determination that an inmate-patient is a danger to self or others, or is
gravely disabled, and is incompetent to render an informed consent shall be documented in
the inmate-patient’s UHR.

If in the clinical judgment of a psychiatrist or other physician, an emergency exists, the

physician or psychiatrist may order involuntary medication for a period not to exceed 72
hours. An emergency exists when there is a sudden marked change in the inmate-patient's
condition so that action is immediately necessary for the preservation of life or the
prevention of serious bodily harm to the inmate-patient or others and it is impractical to first
obtain consent.
An inmate-patient shall be afforded due process rights if involuntary treatment is necessary
beyond 72 hours.
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2009 REVISION 12-5-15
Mental Health Crisis Bed Mental Health Services Delivery System

Refer to Correctional Treatment Center Policy Manual, Volume VIII, Section 16,
Involuntary Treatment, for detailed procedures.

H. CLINICAL RESTRAINT AND SECLUSION

Restraint and/or seclusion are special treatment procedures used to protect the safety of
inmate-patients who pose an immediate danger to themselves or others, by restricting their
ability to inflict injury by limiting body movement or by containing them in a safe
environment. While utilization of restraint and/or seclusion is clearly effective in saving
lives and preventing serious injury, it is also a procedure with inherent risks. In rare cases
inmate-patients who have been restrained or secluded have suffered injury or death as a
result of improper procedure or monitoring.

Restraints and/or seclusion shall be used only as a last resort and in response to an
emergency to protect the inmate-patient and/or others from imminent harm, after less-
intrusive and non-physical interventions have been attempted or ruled out. Staff shall strive
to minimize or eliminate the use of seclusion or restraint whenever possible, through proper
training, thorough assessment, effective treatment planning, and continuous quality
improvement efforts. This policy restricts the use of restraints for mental health purposes
generally to MHCBs. The use of restraints, for mental health purposes, in areas other than a
MHCB unit shall be restricted to the amount of time required for transfer to a MHCB unit.
Inmate-patients in need of restraints shall be transferred, in an expedited timeframe, to a
MHCB unit.

The form of restraint and/or seclusion selected shall be the least restrictive level necessary to
contain the emerging crisis/dangerous behavior. The determination of the presence of an
emergent situation rests upon the clinical judgment of staff. It does not require the staff to
defer restraint or seclusion until dangerous behavior occurs but may be based upon
knowledge of the inmate-patient and its predictive value.

Restraint and/or seclusion shall never be used as punishment or for the convenience of staff.
Threatening inmate-patients with restraint and/or seclusion is considered psychological abuse
and is prohibited. It may be appropriate to inform an inmate-patient when behavior may
necessitate the use of restraints or placement into seclusion.

This policy expressly prohibits any form of as needed (PRN) or standing order for restraint
or seclusion.
For the purpose of this policy, authorized clinician means a psychiatrist, licensed
psychologist, (and at Pelican Bay State Prison only, a psychiatric nurse practitioner) or (on
weekends or after normal business hours) the POC or psychiatrist on call, or the POD or
MOD.

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2009 REVISION 12-5-16
Mental Health Crisis Bed Mental Health Services Delivery System

Per Title 22 Regulations, a “qualified RN” is a RN who has received training in the
administration of restraints and placement into seclusion, and who has passed a competency
examination, which includes assessment of clinical issues relevant to the use of restraint
and/or seclusion.

RESTRAINT

Initial and Subsequent Orders

Restraints shall only be used on a written or verbal order of an authorized clinician. When an
authorized clinician is present, the authorized clinician shall evaluate the need for restraints,
and if appropriate, write an order and provide sufficient and adequate justification in the
inmate-patient’s UHR.

In an emergency circumstance, when no authorized clinician is available, a qualified RN may

authorize initiation of restraints. An emergency circumstance exists when there is a sudden
marked change in the inmate-patient’s behavior so that action is immediately necessary for
the preservation of life or the prevention of serious bodily harm to self or others, and it is
impractical to first obtain an order from an authorized clinician.

When no authorized clinician is present, a qualified RN shall evaluate the need for restraints
and implement restraints if appropriate. If a RN is not present, a RN shall be notified
immediately and shall respond within 15 minutes of notification to evaluate the need for
restraints and initiate restraints, if appropriate. When a RN initiates restraints, an authorized
clinician shall immediately be notified. Within one hour of notification, an authorized
clinician shall give a verbal or written orders (with justification) to either continue or
discontinue restraints.

If the authorized clinician is not available for the initial assessment, a phone order will be
secured to cover the restraint use and the nurse will do an initial assessment within one hour.

The initial order for restraint shall not exceed four hours. Subsequent orders for continuation
of restraint shall not exceed four hours. Each order must specify the behavioral conduct
requiring restraint and the type of restraint used. While a restraint order is valid for four
hours, no inmate-patient shall be in restraint for longer than the time necessary to contain the
dangerous behavior. Removal from restraints is an authorized clinician or RN determination,
and does not require a physician’s order unless otherwise specified.
Assessment by Authorized Clinicians and Qualified RNs

Prior to expiration of the initial order, an authorized clinician or qualified RN shall conduct a
face-to-face evaluation to determine whether continued placement into restraints is clinically

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2009 REVISION 12-5-17
Mental Health Crisis Bed Mental Health Services Delivery System

justified. If the clinician performing the initial face-to-face assessment is not a

psychiatrist/physician, within four hours of the initial order a psychiatrist/physician shall be
contacted/consulted by the RN to review current medications and any contraindications to
continued restraint.

An authorized clinician or a qualified RN shall conduct a face-to-face evaluation at least

every 8 hours during the period an inmate-patient is in restraints. An authorized clinician
shall evaluate the inmate-patient face-to-face at least every 24 after the first four hours. If
the authorized clinician is not a physician, the authorized clinician should consult with a
physician after the face-to-face assessment. A psychiatrist shall conduct a face-to face
evaluation at least every 24 hours while the inmate-patient is in clinical restraint.

A physician or nurse practitioner shall perform a brief physical examination of the inmate-
patient as soon as possible but no more than four hours after the initiation of restraint use and
document the evaluation on a progress note in the UHR. The physician/nurse practitioner’s
assessment will include inquiring into any history of physical disability or any other
condition which would place the inmate-patient at greater physical or psychological risk
during the restraint procedure. If the use of restraints is discontinued prior to the physician’s
arrival, the physician shall conduct a brief physical examination no more than 24 hours after
the episode of restraint use.

Documentation

Documentation of an order for the use of restraints shall include the name of the authorized
clinician giving the order, the time the order was received, the duration of the order, which is
not to exceed four hours, the type of restraint to be used, and the name and signature of the
RN receiving the order.

The Initial Telephone orders for restraint shall be received only by licensed nursing staff,
who shall record them immediately. The ordering authorized clinician shall sign them within
24 hours. Likewise, subsequent telephone orders for restraint shall be signed within 24 hours
of the time the orders were given.

This policy requires the clinician ordering the restraint to provide a written order authorizing
the use of restraint even if such use is discontinued prior to the authorized clinician’s arrival.

Each time a verbal order for restraint is written, the nurse shall complete a CDCR 7230,
Interdisciplinary Progress Note, documenting the need for initiation/continuation of restraint
and shall specify the elements for the emergency that necessitated the use of restraint and
behavior changes that may indicate the inmate-patient no longer presents a danger to self or
others. The note shall describe any less restrictive measures that were implemented prior to
this order.

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2009 REVISION 12-5-18
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Results of face-to-face evaluations shall be documented on CDCR 7316, Restraints/Seclusion

Record.

When a qualified RN initiates restraint, the RN shall document the need for the initiation of
restraint on a CDCR 7316, Restraint/Seclusion Record. The documentation shall include a
description of the inmate-patient’s behavior including any precursor/antecedent behaviors
and other relevant factors upon which the inmate-patient was determined to be a danger to
self or others, staff actions taken to utilize alternatives to restraint, information given to the
inmate-patient about the reasons for restraint, the conditions of release, the inmate-patient’s
response, and injuries to the inmate-patient.

The use of restraints requires the inmate-patient’s treatment plan be modified to include a
sufficiently detailed description of the emergency and the rationale for the use of the specific
degree of restraint. The inmate-patient’s nursing care plan shall be modified to provide for
the special needs of the inmate-patient while in restraint and/or seclusion. The criteria for
establishing termination should be described in operational, objective terms comprehensible
to the inmate-patient.

Types of Restraint
3BU

• Five-point: All four extremities and waist (note below on use of five-point restraints)

• Four-point: All four extremities

• Two-point: Upper extremities only

Application
4BU

The inmate-patient shall be protected from injury during restraint application and use. Staff
shall use the least physical force necessary to protect inmate-patient and yet exercise
sufficient force to control the inmate-patient.

The dignity and well-being of the inmate-patient shall be preserved at all times during the
period of restraint.

Inmate-patients shall be placed on their backs when restraints are applied unless clinically
contraindicated. When an inmate-patient is medically compromised or disabled, all
necessary steps to safeguard the inmate-patient during the procedure need to be taken.
Inmate-patients who are considered medically compromised/disabled consist of, but are not
limited to, the following: morbidly obese, known history of cardiac or respiratory disease,
history of spinal injury, amputee, fractured or injured extremity, recent history of emesis,
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2009 REVISION 12-5-19
Mental Health Crisis Bed Mental Health Services Delivery System

pregnancy, or seizure disorder. RNs must contact a physician either prior to, or immediately
after, the placement of a medically compromised inmate-patient in restraints to notify the
physician of the restraint and the inmate-patient’s medical condition. Upon notification of
the restraint of a medically compromised/disabled inmate-patient, the physician will either
order the RN to discontinue the restraint or order the restraint as well as any special
measures/treatments that need to be taken to safeguard the inmate-patient’s medical
condition. If the inmate-patient is an amputee or otherwise lacks one or more limbs, two or
three point restraints should be used. Generally, restraints should be applied to the upper
extremities first.

Four-, five-, or two-point leather restraints shall be used by clinical staff when ordered by an
authorized clinician. Inmate-patients shall only be restrained with the least amount of
restraints necessary to contain the unsafe behavior. Each period of restraint must be assessed
individually to determine the level of restraint required at the time of the application of the
restraint. Five-point restraints will only be used after the inmate-patient has been
unsuccessfully restrained in four-point restraints or a determination is made by the RN that a
fifth restraint is needed to ensure the safety of the inmate-patient. The physician on-call and
the Nursing Supervisor must be notified anytime five-point restraints are utilized. The
restraint key shall be carried by nursing staff after restraints have been applied to an inmate-
patient until the procedure is discontinued.

Generally, four-point restraints should be used unless there are compelling reasons to the
contrary.

A soft cloth or bandage shall be applied to the extremity before applying the leather restraints
to protect the skin.

Nursing staff shall notify the watch commander and Chief Psychiatrist or designee of an
order to place an inmate-patient in restraints. When restraints are applied to an inmate-
patient, CTC staff shall have at least three custody personnel present for the application of
these restraints, but the RN shall be in charge of the actual application of restraints. The RN
is responsible to ensure that the restraints are applied properly, and are not restricting the
inmate-patient’s circulation.

In emergency situations, custody staff may use metal restraints (handcuffs) on inmates in
order to gain control. Metal restraints shall be replaced with leather restraints by the RN as
soon as possible.

Monitoring and Evaluation by Nursing Staff

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2009 REVISION 12-5-20
Mental Health Crisis Bed Mental Health Services Delivery System

All inmate-patients placed into restraint shall remain under constant direct, in-person visual
observation by trained nursing staff (CNA, psychiatric technician, LVN, or RN) until
restraint is discontinued.

Immediate Nursing Evaluation

A RN shall perform a mental status and physical assessment of the inmate-patient

immediately upon the initiation of restraint use. The RN assessment will include the
identification of techniques, methods and tools which can help the inmate-patient control
their behavior, and will identify pre-existing medical conditions and physical disabilities that
place the inmate-patient at greater risk during the restraint procedure.

Assessment at 15 minute Intervals

In order to continue adequate circulation, nursing staff monitoring the inmate-patient shall
physically check each extremity every 15 minutes. Each 15 minute assessment period shall
be documented on the CDCR 7316, Restraint/Seclusion Record.

The nursing staff shall provide fluids and nourishments every 15 minutes as needed and as
practicable except during hours of sleep. The inmate-patient’s head and shoulders shall be
elevated, if needed, while being fed or receiving fluids to reduce the risk of aspiration. The
nurse shall document meals and fluids on CDCR 7316, Restrain/Seclusion Record.

Hourly Assessments

The RN will conduct hourly assessments of the inmate-patient during the entire period of
restraints. Subsequent to the initial assessment conducted by the RN, the hourly assessments
will document current physical, mental, and behavioral status of the inmate-patient, any
indicated interventions performed, and the inmate-patient’s readiness for release from
restraints. The assessment includes noting the condition of skin and circulation, need for
toileting, personal hygiene procedures, and proper application of restraint. Documentation of
the one hour evaluations shall summarize the inmate-patient’s overall physical condition,
general behavior, and response to counseling/interviews.

Every hour the nursing staff, with the assistance of custody staff, shall perform 2 minute
range of motion exercises on each limb unless the inmate-patient is too agitated or assaultive
to safely remove the restraints. For range of motion exercises, restraints on each extremity
shall be removed, one at a time. Performance of range of motion exercises shall be clearly
documented on the CDCR 7316, Restraint/Seclusion Record, and shall include the inmate-
patient’s behavior, respiration, and responsiveness. If range of motion exercises are not
performed, nursing staff shall clearly document the reason on the CDCR 7316,
Restraint/Seclusion Record.

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2009 REVISION 12-5-21
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A RN may suspend restraints for short periods of time in order to transfer inmate-patients
from place to place to attend to necessary or personal needs (i.e., feeding, bathing, or other
treatment needs as necessary). A RN shall decide whether release from restraint is necessary
in order to attend to necessary nursing or personal needs. Custody staff shall provide
adequate security to prevent assaults or self-injurious behavior during suspension of
restraints. If an inmate-patient has been released from restraints for more than one hour, a
new order shall be obtained. Inmate-patients shall not be returned to the previous, or any
state of restraint without continuing evidence of dangerousness to self or others.

Restraint Renewal

The RN shall contact an authorized clinician and provide a description of current behavior,
attitudes, or other indicators of present dangerousness; PRN/emergency medication usage;
change in vital signs, including pain assessment; changes in mental or physical status; and
side effects (e.g., confusion, akathisia, or extrapyramidal) at least every four hours. The
authorized clinician shall then either give an order to discontinue restraint or give an order to
continue or modify restraint for a period not to exceed four hours.

Termination

Restraint shall be terminated when:

1. The emergency or dangerous behavior no longer exists based on previously established

criteria for release; or

2. The inmate-patient’s identified precursor behaviors indicating imminent danger to self or

others are not longer present; or

3. Due to the presence of medical contraindications, it would be harmful for the inmate-
patient to remain in restraints.

Removal from restraints is an authorized clinician or RN determination that the inmate-

patient has reached the behavioral criteria for release and no longer presents an imminent
danger. Release does not require a physician’s order unless otherwise specified.

Upon termination of the restraint use, an entry shall be made in the CDCR 7230,
Interdisciplinary Progress Note, describing the condition and response of the inmate-patient.

In accordance with Health and Safety Code 1180, a clinical and quality review shall be
conducted for each episode of the use of restraints.

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Mental Health Crisis Bed Mental Health Services Delivery System

Seclusion

Seclusion is a behavioral treatment procedure used to prevent injury to self or others by

containment of the inmate-patient in a specially designed room. Seclusion will typically take
place in safety cells in a MHCB facility. Seclusion rooms shall be designed or modified to:
provide for sufficient space for freedom of movement of staff; be free from hazardous objects
or fixtures; have adequate light and ventilation; be maintained at an appropriate temperature;
have secure, lockable doors; and have windows that permit visual observation of the inmate-
patient by staff. Each MHCB facility shall set aside and equip a specific room to be used for
the purpose of seclusion.

Placement of inmate-patients in single cells located in housing units, CTC’s, or MHCB’s for
custodial reasons does not constitute seclusion for the purposes of this section.

Initial and Subsequent Orders

Seclusion shall only be used on a written or verbal order of an authorized clinician. When an
authorized clinician is present, the authorized clinician shall evaluate the need for seclusion
and if appropriate, write an order and provide sufficient and adequate justification in the
inmate-patient’s UHR. The initial order for seclusion shall not exceed four hours.

In an emergency circumstance when there is no authorized clinician present, a qualified RN

may authorize initiation of seclusion after evaluating the need for seclusion. An emergency
circumstance exists when there is a sudden marked change in the inmate-patient’s behavior
so that action is immediately necessary for the preservation of life or the prevention of
serious bodily harm to self or others, and it is impractical to first obtain an order from an
authorized clinician. If a RN is not present, a RN shall be notified immediately and shall
respond within 15 minutes of notification to evaluate the need for seclusion and initiate
seclusion, if appropriate. When a RN initiates seclusion, an authorized clinician shall
immediately be notified, and within one hour of notification write or give a verbal order with
justification to either continue or discontinue seclusion.

Subsequent orders for continuation of seclusion shall not exceed four hours.

Documentation

Documentation of an order for seclusion shall include the name of the authorized clinician
giving the order, the time the order was received, the duration of the order, and the name and
signature of the RN receiving the order.
Telephone orders for seclusion shall be received only by licensed nursing staff, shall be
recorded immediately, and shall be signed within 24 hours. Initial telephone orders for
seclusion shall be followed with written orders within 24 hours of the time the seclusion was

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2009 REVISION 12-5-23
Mental Health Crisis Bed Mental Health Services Delivery System

first ordered. The ordering clinician will follow subsequent telephone orders for seclusion
with written orders within 24 hours.

A written order authorizing the use of seclusion is required even if such use is discontinued
prior to the authorized clinician’s arrival.

Each time an order for seclusion is written, the authorized clinician or RN shall complete a
CDCR 7230, Interdisciplinary Progress Note, documenting the need for
initiation/continuation of seclusion and shall specify the elements of the emergency that
necessitated the use of seclusion and behavior changes that may indicate the inmate-patient
no longer presents a danger to self or others. The note shall describe what least restrictive
measures were tried prior to this order.

Results of face-to-face evaluations shall be documented on CDCR 7316, Restraint/Seclusion

Record.

When a qualified RN initiates seclusion, the RN shall document the need for the initiation of
seclusion on a CDCR 7316, Restraint/Seclusion Record. The documentation shall include a
description of the inmate-patient’s behavior including any precursor/antecedent behaviors
and other relevant factors upon which the inmate-patient was determined to be a danger to
self or others, staff actions taken to utilize alternatives to seclusion, information given to the
inmate-patient about the reasons for seclusion, the conditions of release, the inmate-patient’s
response, and injuries to the inmate-patient.

The inmate-patient’s treatment plan must be modified to include a sufficiently detailed

description of the emergency and the rationale for the use of seclusion. The inmate-patient’s
nursing care plan shall be modified to provide for the special needs of the inmate-patient
while in seclusion. The criteria for establishing termination should be described in
operational, objective terms comprehensible to the inmate-patient.

Monitoring and Evaluation by Nursing Staff

During the entire period of seclusion, the inmate-patient shall remain on direct one on one
nursing observation. Nursing staff will document their observations at least every 15
minutes on a CDCR 7316, Restraints/Seclusion Record. Nursing staff shall ensure that the
inmate-patient is safely secluded. The direct one on one nursing observation shall also
include verbal interaction when the inmate-patient is awake.

A RN shall perform a mental status and physical assessment of the inmate-patient

within 15 minutes of the initiation of seclusion. A physician or nurse practitioner shall
perform a brief physical examination of the inmate-patient as soon as possible but no more
than four hours after the initiation of seclusion and document the evaluation in the patient’s

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Mental Health Crisis Bed Mental Health Services Delivery System

UHR. If seclusion is discontinued prior to the physician’s arrival, the physician shall
conduct a brief physical examination no more than 24 hours after the episode of seclusion.

Prior to the expiration of the initial order an authorized clinician or qualified RN shall
conduct a face-to-face evaluation to determine whether continued placement in seclusion is
clinically justified. If the clinician performing the initial face-to-face assessment is not a
psychiatrist/physician, within four hours of the initial order a psychiatrist/physician shall be
consulted by the RN to review current medications and any contraindications to continued
seclusion. The authorized clinician shall either give an order to discontinue seclusion or give
an order to continue seclusion for a period not to exceed four hours.

After the initial face-to-face evaluation, an authorized clinician or a qualified RN shall

conduct a face-to-face evaluation at least every eight hours during the period an inmate-
patient is in seclusion and evaluated for continued dangerousness by an authorized clinician
at least daily. The authorized clinician shall then either give an order to discontinue
seclusion or give an order to continue seclusion for a period not to exceed four hours.

An authorized clinician shall evaluate the inmate-patient face-to-face at least every 24 after
the first four hours. If the authorized clinician is not a physician, the authorized clinician
should consult with a physician after the face-to-face assessment. A psychiatrist shall
conduct a face-to-face evaluation at least every 24 hours while the inmate-patient is in
clinical seclusion.

Every hour the RN will perform an assessment of the inmate-patient including need for
toileting; exercise; personal hygiene procedures; and room environment, temperature, and
cleanliness. Fluids and nourishment shall be offered every 15 minutes by the nursing staff
assigned to the direct observation of the inmate-patient, except during hours of sleep. In
documentation of hourly evaluations, the nurse shall summarize the inmate-patient’s overall
physical condition, general behavior, and response to counseling/interviews.

A RN may suspend seclusion for short periods of time in order to transfer inmate-patients
from place to place to attend to necessary nursing or personal needs (i.e., feeding, bathing, or
other treatment needs as necessary). A RN shall decide whether release from seclusion is
necessary in order to attend to necessary nursing or personal needs. Custody staff shall
provide adequate security to prevent assaults or self-injurious behavior during suspension of
seclusion. If an inmate-patient has been released from seclusion for more than one hour, a
new order shall be obtained. Inmate-patients shall not be returned to the previous, or any
state of seclusion without continuing evidence of dangerousness to self or others.
Termination

Seclusion shall be terminated when:

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1. The emergency or dangerous behavior no longer exists based on previously established

criteria for release; or

2. The inmate-patient’s identified precursor behaviors indicating imminent danger to self or

others are no longer present; or

3. Due to the presence of medical contraindications, it would be harmful for the inmate-
patient to remain in restraints.

Removal from the seclusion is an authorized clinician or RN determination that the inmate-
patient has reached the behavioral criteria for release and no longer presents an imminent
danger. Release does not require a physician’s order unless otherwise specified.

Upon termination of the seclusion use, an entry shall be made on a CDCR 7230,
Interdisciplinary Progress Note, describing the condition and response of the inmate-patient.

In accordance with Health and Safety Code 1180, a clinical and quality review shall be
conducted for each episode of the use of seclusion.

I. DISCHARGE

It is the responsibility of the MHCB to provide for continuity of inmate-patient care upon
discharge to another level of care, another facility, or self-care.

The inmate-patient has a right to information regarding discharge on an ongoing basis during
his or her stay in the MHCB.
Discharge Plan

a. The discharge plan is initiated at the time of admission.

b. The IDTT shall assess the inmate-patient’s need for further medical, psychiatric,
psychological, social work, and rehabilitative services; nursing services; education
services; and transportation when developing the discharge plan. The plan ensures that
needed services are available at the appropriate level of care.

c. The plan shall include participation by the inmate-patient to facilitate inmate-patient

responsibility for his or her care and treatment.

d. The plan reflects appropriate coordination with and utilization of MHCB custody staff.
e. The plan includes documentation of contact with the Chief of Mental Health at the
institution where the inmate-patient is being transferred.

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f. Once the discharge plan is completed, referrals for appropriate aftercare placement shall
be documented by an MHCB clinical staff member in the inmate-patient's treatment plan.

g. The assigned CCM or PC at the institution where the inmate-patient is being transferred
is responsible for implementing the discharge plan.

h. Treatment shall continue for all inmate-patients clinically discharged until transferred.

Discharge Criteria

Criteria for discharge from the MHCB to an EOP or CCCMS program include:

• stabilization of the crisis behavior; and

• the ability to function in a less clinically structured environment.

Discharge criteria do not necessarily include complete resolution of symptoms but a

U U U U

resolution sufficient to allow continuation of treatment at a less intensive level of care.

Discharge to DMH inpatient care requires the clinical need for inpatient services of a
duration greater than ten days.

Procedure

a. Upon completion of MHCB inpatient treatment, cases transferred to the MHCB as

“Psychiatric and Return” shall be returned to the sending institution, unless the sending
institution does not provide the level of care that the inmate-patient currently requires or
the inmate-patient has any other case factor(s) that preclude return to the sending
institution. In those cases, the MHCB will transfer the inmate-patient to an institution
that provides the appropriate level of care and security.

b. The MHCB discharge summary shall be completed by the attending psychiatrist or

psychologist prior to release from the MHCB. This should include specific
recommendations regarding follow-up visits with the CCM or PC and custody staff. The
discharge summary, either handwritten or dictated, includes, but is not limited to, the
MHCB course of treatment, current medications, response to treatment, condition at time
of discharge, and detailed information regarding follow-up care needs. The inmate-
patient’s participation, which supports inmate-patient responsibility, shall also be
included.
c. An inmate-patient shall be discharged only on the written order of the MHCB
psychiatrist or psychologist.

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2009 REVISION 12-5-27
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d. Each institution with an MHCB shall appoint a Discharge Coordinator who is responsible
for notifying the Chief of Mental Health or designee at the institution where the inmate-
patient is being transferred of the pending discharge. The notification shall occur prior to
discharge and shall include the inmate-patient’s discharge summary, custody level,
treatment needs, and any significant medical conditions. The Discharge Coordinator
shall document the notification in the inmate-patient’s discharge plan.

e. The Chief of Mental Health or designee at the institution where the inmate-patient is
being transferred shall notify the assigned CCM or PC. If the inmate-patient does not
have an assigned CCM or PC, one shall be assigned. If the inmate-patient was admitted
to the MHCB for Suicide Precaution or Watch, the Chief of Mental Health shall also
notify the mental health clerical staff responsible for the tracking system, clinical staff
responsible for weekend or holiday coverage, and the Facility Captain of the housing unit
to which the inmate-patient is being transferred so that the required clinical and custody
evaluation can be scheduled.

f. No inmate-patient shall be discharged from the MHCB without an IDTT review, or in the
event a new IDTT cannot be convened, a consultation with an IDTT member, such as a
nurse.

g. At the time of discharge, the original inpatient record is retained at the MHCB institution.
The inmate-patient's UHR shall be transferred to the receiving institution at the time of
discharge. Certain documents from the Inpatient Record are copied and filed in the
Inpatient section of the UHR. This includes copies of the Admission Record, History and
Physical, Operative Reports, Physician Orders, Discharge Summary, Consultations,
Progress Notes, and Diagnostic Reports.

h. Prior to discharge from the MHCB, a nurse shall advise the inmate-patient regarding
medications and follow-up visits, and clear the inmate-patient for MHCB discharge.

i. Any inmate-patient admitted to the MHCB program because of suicidal threats or

behavior shall not be discharged to their housing unit until a Suicide Risk Assessment
Checklist has been completed and a follow-up plan developed.

• The PC shall provide follow-up treatment on an outpatient basis. This shall include
daily contact with the inmate-patient for five consecutive days following discharge.
On weekends and holidays, a Licensed Psychiatric Technician or mental health
clinician other than the PC may conduct the daily contact; however, the PC is
responsible for ensuring the contacts occur. The daily contact shall be documented
on a CDCR 7230, Interdisciplinary Progress Note, or a CDCR 7230B-MH, Follow
Up to MHCB/MH-OHU Discharge for Suicidal Issues template. The note shall
include the inmate-patient’s current mental status and suicide risk.

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• The contact shall occur in the inmate-patient’s regular housing unit.

• Custody staff shall conduct an hourly check of inmate-patients admitted to the

MHCB for suicidality for the first 24 hours after discharge. A mental health clinician
shall then discuss the inmate-patient’s behavior with the custody staff and evaluate
the inmate-patient to determine if the custody checks should be continued or
discontinued. If the custody checks are retained, the mental health clinician shall
determine whether the checks are to be every hour, every 2 hours, or every 4 hours
for the next 24 - 48 hours. Custody staff shall maintain a log of checks on inmates.

• If after any evaluation the mental health clinician believes the inmate-patient has not
stabilized, the inmate-patient shall be returned to the MHCB for further treatment.
Careful consideration by the IDTT should be given to releasing inmates on a Friday,
during the weekend, or the day before a holiday. The mental status and stability of
the inmate-patient should be documented in detail on a CDCR 7230, Interdisciplinary
Progress Note. A mental health clinician must be available every day (including
weekends and holidays), either on duty or on call, to monitor inmate-patients who are
discharged from a MHCB.

Quality Management for Implementation of Discharge Planning

Concurrent with the implementation of the discharge plan or within 21 days of the
inmate-patient’s discharge from the MHCB, the Chief of Mental Health at the institution
where the inmate-patient was transferred will audit the implementation of the discharge plan
and follow-up care.

For inmate-patients who were admitted to the MHCB for Suicide Precaution or Watch, the
Chief of Mental Health shall review the SRAC that was completed prior to discharge from
the MHCB to ensure the discharge plan is appropriate. The Chief of Mental Health shall
document the review in the UHR and forward a copy of the SRAC to the local Suicide
Prevention Committee. A copy will also be retained by the mental health clerical staff.

J. MENTAL HEALTH PATIENTS IN OUTPATIENT HOUSING UNITS

U

When an inmate-patient requires observation and evaluation of behaviors that may be

indicative of mental illness, a licensed mental health professional may document the need for
placement of the inmate-patient into an Outpatient Housing Unit (OHU).

A physician, psychiatrist, or licensed psychologist shall order placement and release

of inmate-patients into and out of the OHU for mental health care and shall be in charge of

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the inmate-patients’ care while housed there. The placement into the OHU shall be made
using the CDCR 7221, Physician’s Order.

Psychologists ordering placement of inmate-patients into the OHU shall refer the inmate-
patient to a physician for a physical examination and to a psychiatrist for a medication
evaluation.

The physician’s or psychologist’s placement orders may be transmitted verbally or by

telephone to the RN or LVN. The ordering physician or psychologist shall sign all verbal
placement orders within 24 hours.

A physician or psychologist shall document the need for placement on a CDCR 7230,
Interdisciplinary Progress Note, within 24 hours of placement. Within 24 hours after
placement each inmate-patient shall have an evaluation, including admission history and
physical examination, for immediate care planning. The Mental Health Evaluation shall be
documented on a CDCR 7386, Mental Heath Evaluation.

The patient shall receive an additional face-to-face evaluation by a mental health clinician or
other qualified medical staff within 48 hours. This contact shall be documented on a
CDCR 7230, Interdisciplinary Progress Note. If at any time during this
observation/evaluation period it is determined that the inmate-patient requires inpatient care,
arrangements shall be made to transfer the inmate-patient within 24 hours of the
determination to a MHCB. If evaluation of the inmate-patient’s mental health need
continues beyond 48 hours, arrangements shall be made to transfer the inmate-patient to a
MHCB or inpatient facility. Inmate-patients shall not remain in OHU for more than 72
hours.

The only exception to this 72-hour limit shall occur, on a case-by-case basis, only if both of
the following criteria are met:

1. The inmate-patient has been determined to need EOP level of care and is awaiting
placement, and

2. An IDTT determines that the inmate-patient may be at risk if returned to any of the
housing units available at that institution while awaiting transfer.

When both of the above criteria are met, the inmate-patient may be held in OHU until
transferred to an EOP level of care program. The timeline for transfer from OHU to EOP
shall not exceed 30 days from EOP endorsement. This timeline for transfer shall include
any days that the inmate-patient is in a MHCB following endorsement, and shall not be
restarted if the inmate-patient returns to the OHU.

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Mental Health Crisis Bed Mental Health Services Delivery System

When it is determined that inpatient care is necessary and the institution staff are unable to
expeditiously find a MHCB, they will contact the HCPOP for assistance to ensure placement
within the required timelines. If it is determined that an order for Suicide Precaution or
Watch is necessary, observation by clinical and/or custody staff, consistent with the MHSDS
Suicide Prevention policy (see Chapter 10 for details), shall be provided.

When an inmate is placed in the OHU for being potentially suicidal, a mental health clinician
shall administer a SRAC at the times of placement and release. On weekends, holidays, or
after hours, the SRAC shall be administered by the MOD, POD, or RN trained on
administration of the SRAC. Inmate-patients housed in OHU for suicide observation, who
do not require MHCB level of care and who were discharged from the OHU before 24-hours,
may be seen by clinicians and custody staff for follow-up care utilizing the process and
timeframes described for MHCB suicide discharges, if clinically indicated.

When emergency circumstances exist, clinical restraint or clinical seclusion may be applied
in OHU, subject to the requirements for clinical restraint or clinical seclusion in the MHCB.
Emergency circumstances exist when there is a sudden marked change in the inmate-patient's
condition so that action is immediately necessary for the preservation of life or the
prevention of serious bodily harm to the inmate-patient or others, and it is impractical to first
transfer the inmate-patient to a MHCB. The MHCB transfer process (See Section D,
Referral and Transfer, MHCB Transfer) shall be immediately initiated upon determination
that an
inmate-patient requires clinical restraint or clinical seclusion, and transported when clinically
safe to do so.

HCPOP shall be notified when an inmate-patient has been placed in clinical restraint or
clinical seclusion. HCPOP shall expedite MHCB placement of inmate-patients in clinical
restraint or clinical seclusion.

Mental Health Conditions Appropriate for Placement into an OHU

1. Observation for Suicide Precaution or Suicide Watch consistent with the CDCR
Suicide Prevention and Response Project.

2. Inmates who engage in behaviors that might be indicative of a mental disorder that
interferes with daily living and requires further observation and evaluation.

3. Inmate-patients who have been referred to an EOP or MHCB who are too ill or too
vulnerable to be placed in the general population while waiting for transfer.

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Mental Health Crisis Bed Mental Health Services Delivery System

If at any time the mental health clinician determines that the inmate-patient has improved and
does not require a higher level of care, the clinician may discharge the inmate-patient back to
the General Population at the appropriate level of care.
K. STAFFING

The MHCB is designed to provide 24-hour care and is subject to State licensing requirements
(CCR, Title XXII, Section 79739). Consequently, it must comply with the staffing standards
of the CTC license under which it operates. MHCB staff shall provide acute mental health
services for inmate-patients admitted to MHCB. In programs with six or fewer beds, acute
mental health services may be provided by the MHCB Clinical Director. Through contracts
or temporary reassignment of mental health staff from other program areas, staffing shall be
augmented as needed.

The MHCB shall have a Clinical Director who shall direct the clinical program and be
responsible for the quality of clinical services (CCR, Title XXII, Section 79741 (b)). The
Clinical Director shall be a psychiatrist, licensed clinical psychologist, licensed clinical
social worker, or a psychiatric mental health nurse operating within his or her scope of
licensure with at least three years of direct clinical experience with seriously mentally
disordered individuals after completion of his or her last year of graduate education (CCR,
Title XXII, Section 79755 (a)). Each inmate-patient admitted as a patient to the MHCB is
under the treatment of Staff Psychiatrists, Psychologists and/or Licensed Clinical Social
Workers. Nursing services are provided by RN, LVN, Recreational or Occupational
Therapists or Licensed Psychiatric Technicians. Clerical services are provided by an Office
Technician and a Medical Transcriber.

Administrative Staff

The MHCB is subject to the same medical staff organization, bylaws, and policies and
procedures that govern the other licensed beds of the facility (CCR, Title XXII,
Sections 79775, 79777). Staff serving in these positions shall meet the minimum
qualifications specified in the CCR, Title XXII. All MHCB staff are responsible to the
Clinical Director.

Clinical Staff

Individual therapy or counseling, aftercare planning and referral services, and the clinical
lead role in treatment plan development and modification shall be performed by the Staff
Psychiatrist, Staff Psychologist, or Licensed Clinical Social Worker. A Chief or Senior
Psychiatrist or a Chief or Senior Psychologist may also provide these clinical services in
addition to his or her other supervisory or management responsibilities, as directed.
Supervising clinical staff may assist in these services if required by workload, staffing
considerations or unusual complexity of an individual case. Staff Psychiatrists, Staff

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Psychologists, Licensed Clinical Social Workers, Senior Psychiatrists and Senior

Psychologists serve as PCs and report to the Clinical Director.

Nursing Staff (CCR, Title XXII, Section 79629)

Two Supervising RNs positions oversee all nursing services delivered in the CTC: one for
medical services and one for mental health services (CCR, Title XXII, Section 79755 (d)).
Although the latter includes the MHCB, the use of one Supervising RN per shift may mean
that MHCB nursing functions may be supervised by the medical Supervising RN for part of
each 24-hour day.

Supervising RN are responsible for functional supervision of CTC line nursing staff and
nursing administration, which includes the MHCB. Twenty-four hour registered nursing
coverage and availability of a Supervising Psychiatric RN forty hours a week are necessary
in the MHCB. There are sufficient nurses within a 24-hour period to provide at least 2.5
hours per inmate-patient (CCR, Title XXII, Section 79759). An inmate-patient with higher
acuity needs receives additional nursing and professional care as symptoms require. RNs
may co-manage selected inmate-patients assisting PCs with group therapies but will not
function independently as PCs.

Mental Health Rehabilitation Services Staff

Mental health rehabilitation therapy services shall evaluate social, recreational, and
vocational needs in accordance with the interests, abilities and needs of the inmate-patient;
shall develop and prepare related therapies; and shall include such evaluation, and
documentation of therapy development and preparation, in the inmate-patient's treatment
plan (CCR, Title XXII, Section 79749).

Mental health rehabilitation therapy services shall be designed by and provided under the
direction of a licensed mental health professional, a Recreational Therapist, an Occupational
Therapist, or a Licensed Psychiatric Technician (CCR, Title XXII, Section 79749 (c) (2)).

In the Department, appropriately trained Correctional Officers (COs) and Correctional

Counselors may be counted to meet licensing ratios. COs also assist in managing, observing
and escorting the assaultive or suicidal inmate-patients.

Clerical Staff

Clerical support in the MHCB is provided by an Office Technician, who reports to the
Clinical Director, and a Medical Transcriber, who is placed in the institutional transcriber
pool and reports to the pool's Supervising Medical Transcriber.

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Mental Health Crisis Bed Mental Health Services Delivery System

L. UNIT HEALTH RECORDS

1. Confidentiality

Mental health records generally have a higher standard of confidentiality than other
medical records. All staff with possible access to such records shall sign an oath of
confidentiality to keep any information they learn from the records strictly confidential
(CCR, Title XXII, Section 79807).

2. Access

All MHCB clinicians and nursing staff must have access to the inmate-patient's records
24 hours per day. Records shall be brought as needed from the records storage area, kept
in the MHCB treatment area or clinician offices while needed, and returned to the storage
area when no longer needed. If records are required outside the MHCB treatment area or
clinician's offices, the records shall be hand carried by escorting staff and returned to the
MHCB with escorting staff as soon as the outside business is completed (CCR, Title
XXII, Section 79807).

3. The Clinical Director shall:

a. Ensure the History and Physical is transcribed and delivered to the MHCB as soon as
possible.

b. Ensure that previous medical records are provided to the MHCB [Title XXII,
Section 79803 (d)].

M. MENTAL HEALTH QUALITY MANAGEMENT SYSTEM

Ongoing assessment of the quality of clinical services will follow the Mental Health Quality
Management System procedures.

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Department of Mental Health Mental Health Services Delivery System
Inpatient Program

CHAPTER 6
Department of Mental Health Inpatient Program
A. INTRODUCTION

The California Department of Corrections and Rehabilitation (CDCR) is responsible for

providing acute and intermediate inpatient care, in a timely manner, to those CDCR inmates
clinically determined to be in need of such care. CDCR currently maintains a contract with
the California Department of Mental Health (DMH) to provide acute and long-term
intermediate inpatient mental health care to inmate-patients. Referrals to a DMH facility
may be made by CDCR clinicians for inmate-patients who are so severely disturbed or
suicidal that their treatment needs cannot be met in a CDCR treatment program or who may
require a comprehensive psychiatric assessment.

1. Inmate-patients who have had repeated admissions to a CDCR Mental Health Crisis Bed
(MHCB) or have been in an MHCB for longer than ten days shall be considered for such
a referral.

2. The following DMH institutions are available for referrals for the indicated level of care:

Acute Psychiatric Care: Vacaville Psychiatric Program (VPP), Acute Psychiatric

Program (APP) (males only);

Emergency Acute Psychiatric care: (Mental Health Crisis Beds) ASH and VPP under the
conditions prescribed in the acute Memorandum of Understanding (MOU);

Intermediate Care: Atascadero State Hospital (ASH) (males only); Coalinga State
Hospital (CSH) (males only); Patton State Hospital (PSH), (females only); Salinas Valley
Psychiatric Program (SVPP), (high security males only); Vacaville Psychiatric Program
(VPP); and

Day Treatment: Vacaville Psychiatric Program, Day Treatment Program (DTP) (males
only).

B. OVERALL TREATMENT CRITERIA

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Department of Mental Health Mental Health Services Delivery System
Inpatient Program

Inpatient Placement General Requirements

2BU

The inmate-patient to be referred must have a Serious Mental Disorder (See Mental Health
Services Delivery System [MHSDS] Program Guides, Chapter 1, Program Guide Overview)
and:

1. Have marked impairment and dysfunction in most areas (daily living activities,
communication and social interaction) requiring 24-hour inpatient care, or

2. Is a danger to self or others as a consequence of a serious mental disorder, or

3. Meets admission criteria for any of the DMH programs.

C. DMH ACUTE PSYCHIATRIC PROGRAM (APP)

3BU

The APP is a short-term, intensive-treatment program with stays usually up to 30 calendar

days to 45 calendar days provided. Actual length of stay shall be determined by the
Interdisciplinary Treatment Team on a case-by-case basis. Inmate-patients in the APP who
are determined to need long-term mental health inpatient care shall be referred to an
appropriate DMH intermediate care program.

Referral to the APP is considered when, in the judgment of the CDCR treating clinician, the
inmate-patient meets the following DMH admission criteria:

Admission Criteria
5BU

1. Any inmate-patient (age 18 or older) who suffers impairment of functioning with signs
and symptoms that may be attributed to either an acute major mental disorder or an acute
exacerbation of a chronic major mental illness, as defined by the current Diagnostic and
Statistical Manual of Mental Disorders (DSM). Such signs and symptoms of illness may
render the inmate-patient:

• Unable to carry out adequately the normal routines of the institution,

• Unable to provide for his basic needs or use the supportive treatment resources
available to him, or

• A significant risk of harming himself or others.

2. Any inmate-patient who has been assessed as a severe suicidal risk.

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Department of Mental Health Mental Health Services Delivery System
Inpatient Program

3. Additional factors that justify consideration for referring an inmate to the APP include:

• The inmate-patient has symptoms or secondary conditions that require inpatient

mental health treatment.

• The inmate-patient engages in self-injurious behavior that has not responded to

treatment in a CDCR facility. Without mental health treatment, the inmate is likely to
develop serious medical complications or present a threat to his life.

4. Each inmate-patient referred from another CDCR institution who is not accepted for
direct placement-evaluation to the APP due to lack of an available bed shall be retained
at the sending institution until a bed is available.

5. Inmate-patients admitted to the APP shall be inmates anticipated to be stabilized

sufficiently for release from DMH within 30 to 45 days.

Referral Procedure
U

1. Each referral to the APP is the responsibility of CDCR clinical staff. Referrals shall be
made whenever in the judgment of the treating clinician the
inmate-patient’s condition warrants inpatient care and meets the admission criteria for
APP. Referrals generally are made by a clinician working in a CDCR MHCB Program
or Enhanced Outpatient Program (EOP). Referrals must be completed within two
working days of identification.

2. CDCR shall transmit standardized referral information to the appropriate DMH program
on the DMH Referral Form/Acute Psychiatric Care. The referral packet shall be sent to
the APP Admission and Discharge Coordinator.

3. DMH shall review the referral packet within one working day of receipt. DMH staff
shall immediately notify the referring institution on the DMH Referral Decision Form by
fax of their decision. The decision shall provide the detailed reasons for any rejections.

4. An inmate-patient considered for transfer to the APP must sign a consent to treatment at
DMH or is entitled to a hearing in accordance with Title 15, Section 3369.1 (a) unless the
inmate waives the hearing. Documentation of the hearing shall be processed in
accordance with Department Operations Manual Section 62030.4.2. Written consent
shall be obtained, or the hearing shall be conducted by the prison prior to transfer.

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Inpatient Program

5. The referral packet shall be completed fully and include all required information as
follows:

• If the inmate-patient is referred from a Mental Health Crisis Bed (MHCB), then the
referral packet shall only include the following three items with their sub-
components:

a. Written consent OR documentation of the required due process hearing, or a valid

waiver of the due process hearing if the inmate-patient refuses to sign consent to
transfer;

b. Custody Case Factor Sheet; and

c. Mental Health Crisis Bed Inpatient Record including but not limited to:

Admission summary
Progress Notes
Orders and lab orders
Interdisciplinary treatment plan
Interdisciplinary Treatment Team notes
Discharge summary

• If the inmate-patient is referred from any other level of care (EOP, Correctional
Clinical Case Management System [CCCMS]) or other location, then the referral
packet shall include:

a. Written consent OR documentation of the required due process hearing

(CDCR 128-MH6), or a valid waiver of the due process hearing if the inmate-
patient refuses to sign consent to transfer;

b. Custody Case Factor Sheet;

c. CDCR suicide risk assessment including a Suicide Risk Assessment Checklist

(SRAC);

d. Current Treatment Plan – CDCR 7388-MH, Mental Health Treatment Plan

e. Transfer Medical Summary or Health and Physical (H&P);

f. Pharmacy Profile or Medication Administration Record (MAR);

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Department of Mental Health Mental Health Services Delivery System
Inpatient Program

g. Supporting Keyhea documentation or Keyhea Order (when relevant for

involuntary medications); and

h. TB chrono from the referring institution.

Admission Procedure

1. The APP shall notify the referring institution in writing of the decision on a referral
(accept, deny, defer) within one (1) calendar day of the referral including, if accepted, the
APP bed number. Inter-institutional endorsements for transfer of inmate-patients
accepted into the APP are processed by the Classification and Parole Representative
(C&PR) at California Medical Facility (CMF).

2. Inmate-patients who have been accepted shall be moved via special transport to DMH
within 72 hours of bed assignment. In any event all transfers shall be accomplished
within 10 days of the date of the referral.

3. Referred inmate-patients who are accepted into the APP are transferred from the referring
institution as “psych and return” cases (i.e., in most circumstances the inmate-patient will
be returned to the referring institution provided that institution can provide appropriate
treatment and custody). Inmate-patients referred to the APP, who are accepted but are
deferred for lack of bed availability, are retained at the referring institution pending a bed
assignment.

4. APP staff and the CMF Chief Deputy, Clinical Services, or designees, shall prioritize, on
a daily basis, any inmate-patient awaiting transfer into the APP. Prioritization for
admission is based upon the clinical acuity of the inmate-patient, the length of time the
inmate-patient has been on the waiting list, and the availability of mental health staff at
the referring institution. APP staff shall separately review, on a weekly basis, APP
inmate-patients who are clinically ready to be discharged to a CDCR institution.

5. DMH is responsible for completing any referral of an APP inmate-patient to any other
DMH program.

Discharge Procedures

1. The APP will contact the receiving institution’s designated “DMH Contact” and fax the
clinical discharge summary with continuing care recommendations to the designated
clinician at the institution. The discharging clinician shall also telephone the designated
clinician at the receiving institution to notify that institution of the impending discharge
of the inmate-patient and describe the inmate-patient’s recommended aftercare plan.

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2009 REVISION 12-6-5
Department of Mental Health Mental Health Services Delivery System
Inpatient Program

2. For each inmate-patient returning to CDCR from the APP the following documents shall
be transferred with the inmate-patient to the respective CDCR institution:

• Psychiatric Discharge Summary or Recommended Continuing Care Plan (RCCP);

• Nursing Assessment or Discharge Summary;

• Current physician’s orders and/or MAR;

• Current Treatment Plan; and

• Keyhea Order (if applicable).

The inmate-patient shall not be placed in the transport vehicle without the above
documents.

In addition, a discharge packet will be faxed by DMH within two weeks of discharge.
The discharge packet shall include:

• Interdisciplinary Notes for past 15 days;

• Physician Progress Notes for past 15 days;

• Relevant Consults; and

• If applicable, forms specific to psych and return, mental health placement and transfer
information for parolees.

All DMH programs shall provide written copies of the aforementioned cited materials.
Due to its proximity to CMF, VPP shall provide the entire Inpatient Medical Record for
review by the CMF Chief of Mental Health instead of the materials cited above.

D. DMH INTERMEDIATE CARE FACILITIES: ASH, CSH, PSH, SVPP, and VPP
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The Intermediate Care Programs (ICF) at ASH, CSH, SVPP and VPP are for male inmate-
patients; the program at PSH is for female inmate-patients. These programs provide longer-
term mental health intermediate and non-acute inpatient treatment for inmate-patients who
have a serious mental disorder requiring treatment that is not available within CDCR. There
will not be direct admissions from CDCR to CSH at this time.

Male inmate-patients who require close or high custody shall be referred only to SVPP.
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2009 REVISION 12-6-6
Department of Mental Health Mental Health Services Delivery System
Inpatient Program

Custody Level IV male inmates that do not require close or high custody may be referred to
ASH or VPP.

The ICF programs have a full complement of mental health staff including psychiatrists,
psychologists, clinical social workers, rehabilitation therapists, psychiatric technicians, and
registered nurses. Most housing is dormitory-type rooms. The inmate-patients have access
to the day room, supervised yard access and are fed in a dining room. The inmate-patients
receive a multidisciplinary assessment. From this information an individualized treatment
program is developed from a wide variety of treatment modalities including group and
individual psychotherapy, medication management, depression and crisis management,
training in daily living skills and interpersonal skills, substance abuse, management of
assaultive behavior, supportive counseling, modification of maladaptive behaviors, and
educational and vocational programs.

Admission Criteria
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Referral to an ICF is considered when in the judgment of the CDCR treating clinician the
inmate-patient meets the following DMH admission criteria:

1. An Axis I major (serious) mental disorder with active symptoms and any one of the
following:

• As a result of the major mental disorder, the inmate-patient is unable to adequately

function within the structure of the CDCR EOP level of care.

• The inmate-patient requires highly structured inpatient psychiatric care with 24-hour
nursing supervision due to a major mental disorder, serious to major impairment of
functioning in most life areas, stabilization or elimination of ritualistic or repetitive
self-injurious/suicidal behavior, or stabilization of refractory psychiatric symptoms.

• The inmate-patient requires a neurological/neuropsychological consultation.

• The inmate-patient requires an inpatient diagnostic evaluation.

• The inmate-patient would benefit from a comprehensive treatment program with an

emphasis on skill (i.e., coping, daily living, medication compliance) development
with increased programming and structured treatment environment.

• The inmate-patient’s psychiatric medication history indicates that a clozapine trial

might be useful.
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2009 REVISION 12-6-7
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Inpatient Program

• Inmate-patients, who are deemed a significant assault risk, have a history of

victimizing other inmate-patients (including inciting others to act in a dangerous
manner) or present a high escape risk, shall be referred to the SVPP Intermediate
Program. CDCR refers to these inmate-patients as high custody inmate-patients.

• The inmate-patient’s Global Assessment of Functioning indicates behavior that is

considerably influenced by psychotic symptoms; OR serious impairment in
communication or judgment; OR inability to function in almost all areas.

• For SVPP only, the inmate-patient is medically appropriate as determined by the

receiving prison medical staff. The program psychiatrist will determine mental health
suitability. If agreement is not reached refer to the Coordinated Clinical Assessment
Team (CCAT) process in Section VI. Any denial for medical reasons will be
immediately referred to the, Assistant Deputy Director, CDCR, Division of
Correctional Health Care Services (DCHCS).

2. In addition to a primary Axis I disorder, admission to VPP and SVPP shall be considered
when:

• The patient engages in ritualistic or repetitive self-injurious/suicidal behavior that has

not responded to treatment in a CDCR facility. Without inpatient mental health
treatment, the inmate-patient is likely to develop serious medical complications or
present a threat to his life.

• The patient is chronically suicidal and has had repeated admissions to a Mental
Health Crisis Bed (MHCB).

3. Inmate-patient committed to DMH by the courts as being incompetent to stand trial per
6B

Penal Code, Section 1370.

Inmate-patients who commit an offense while in CDCR, are referred to the District
Attorney for prosecution, and are found by the court to be incompetent to stand trial per
Penal Code, Section 1370 will first be considered for the SVPP. If there are no custodial
or clinical reasons for admission to SVPP, they will then be considered for other DMH
programs.

4. Whenever the CDCR institution referring clinician is in doubt concerning the

appropriateness of referring a particular patient, or the appropriate DMH program to meet
the inmate-patient’s custody needs, the referring clinician will discuss the case with the

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2009 REVISION 12-6-8
Department of Mental Health Mental Health Services Delivery System
Inpatient Program

interdisciplinary treatment team (IDTT). If the IDTT does not reach consensus, or does
not agree regarding the appropriate DMH program, a case conference shall be scheduled
with a clinical facilitator from the headquarters DCHCS office. Case conference calls
can be requested by calling the Mental Health Program Specialist at DCHCS
headquarters.

5. Inmate-patients shall be eligible for admission to a DMH program regardless of parole

date. CDCR will provide all discharge and community planning. CDCR will transfer the
inmate-patient from the DMH program to a CDCR institution for release at least one
calendar day prior to the release date.

6. Inmate-patients who are serving a Security Housing Unit (SHU) term and are clinically
appropriate for placement in an ICF, shall be referred to the sending institution’s
Institutional Classification Committee (ICC). The IDTT/ICC shall consider suspension
of the SHU term.

• When the sending institution’s IDTT/ICC decides to suspended the SHU term, the
inmate-patient shall be eligible to participate in the entire ICF program upon arrival at
the receiving institution.

• It is not necessary for the sending institution’s ICC to suspend a determinate or

indeterminate SHU term prior to transferring the inmate-patient if the ICC is
disinclined to take such action due to safety and/or security concerns. The
inmate-patient shall be transferred to DMH with the SHU term in place

• In cases where the sending institution’s IDTT/ICC elects not to suspend the SHU
term, the inmate-patient may participate in only Phase I of the ICF program. The
inmate-patient will be evaluated in Phase I and a decision regarding suspension of the
SHU term will be made by the receiving institution’s IDTT/ICC.

Referral Procedure
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Referrals must be completed within five working days of identification by IDTT if inmate-
patient consent is obtained and within ten working days of identification if due process
hearing is required.

The following CDCR institutions retain Unit Health Records (UHR) for inmate-patients
referred to ASH/PSH. California Men’s Colony (CMC) shall retain records of inmate-
patients referred to ASH. California Institution for Women (CIW) shall retain records for
female inmate-patients referred to PSH.
1. All referrals shall be made on the required referral form – Department of Mental Health
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2009 REVISION 12-6-9
Department of Mental Health Mental Health Services Delivery System
Inpatient Program

Referral Form-Intermediate Care Program. The referral packet shall be sent to the DMH
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Forensic Coordinator or the Admission and Discharge Coordinator. The form shall be
fully completed and include all required information as follows:

• Transfer Medical Summary or History & Physical for Transfer to DMH. The H&P is
required for SVPP and must have been completed within the last 30 days;

Current Treatment Plan – CDCR 7388-MH, Mental Health Treatment Plan;

• Due Process documentation of the hearing OR Written consent (Use CDCR 128C
until CDCR 128-MH6 is implemented), or a valid waiver of the due process hearing
is required for referral if the patient refuses to sign consent to transfer;

Pharmacy Profile;
Supporting Keyhea documentation or a Keyhea Order (when relevant);
Interdisciplinary Progress Notes for past 15 days (May be less for new arrival to
reception center);
TB chrono from the referring institution;
Abstract of Judgment (For State Hospitals only);
Legal Status Summary (For State Hospitals only);
Chrono History (For State Hospitals only);
Custody Case Factor Sheet;
CDCR Suicide Risk Assessment.

2. Any CDCR clinical concerns regarding the referral shall be discussed with the Chief of
Mental Health, or designee, at DCHCS, prior to completion of the referral form.
Questions regarding the transfer process shall be discussed with Health Care Placement
Oversight Program (HCPOP), or designated Central Office Staff. (See also CCAT
below).

3. DMH shall review the referral packet within three working days of receipt, and shall
immediately notify the referring institution by fax of the decision to accept or reject. The
decision shall provide detailed reasons for any rejections.

Transfer Procedure
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1. The CDCR institution shall provide for transportation of a patient between a DMH
program and a CDCR institution or DMH psychiatric program. The parole unit or region
shall provide for transportation of a parolee between a DMH program and a local
detention facility or community placement. Transfer must take place within 30 days of
referral if accepted at DMH.
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2009 REVISION 12-6-10
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Inpatient Program

2. A transfer schedule shall be established by the CDCR referring institution and the
respective DMH program.

3. Inmate-patients who have been accepted shall be transported to DMH within 72 hours of
bed assignment.

4. Each patient or parolee admitted to a DMH program shall have with him/her, unless
already sent, all documentation listed in Section V. B. 4. If, following the patient's
admission, it is determined by assessments of the DMH staff that the patient does not
meet admission criteria for the inpatient mental health program CDCR will transport the
inmate-patient back to an institution on expedited basis but no more than 72 hours.

If the admission was based on a 5150 evaluation by the state hospital and the patient does
not meet criteria for continued hospitalization or conservatorship. CDCR/Parole will
transport the patient back to prison or the inmate-patients county of residence
within 24 hours. The state hospital cannot retain a patient beyond 24 hours and if the
inmate-patient is not picked up within this time period, it may become necessary for the
state hospital to discharge the inmate-patient to the street.

5. A patient who has been found to pose an unusual and severe security risk to the DMH
program in which he/she is housed shall be transferred by CDCR to a CDCR institution
within 24 hours. However, if the security risk is on the basis of mental disorder rather
than criminality or personality disorder, DMH shall make every effort to retain and treat
the patient or parolee in the DMH hospital.

6. A patient or parolee's personal property and funds are to accompany him/her at the time
of delivery to and from the DMH hospital.

• Property, other than legal materials, shall be limited to no more than can be stored
within six cubic feet.

• The property box from CDCR shall be inventoried and sealed. Any Board of Control
Claim resulting from items missing from a patient or parolee's property upon
admission to the DMH hospital is the responsibility of CDCR.

• CDCR shall ensure that items on the DMH Hospital Contraband List (see Attachment
# 1-Contraband List) are not transferred to a DMH hospital with the patient or
parolee's personal property.
7. Each patient or parolee shall be subject to TB evaluation by DMH upon admittance.

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2009 REVISION 12-6-11
Department of Mental Health Mental Health Services Delivery System
Inpatient Program

Utilization Management (UM)

1. CDCR reserves the right to inspect, monitor, and perform utilization reviews
prospectively, concurrently, or retrospectively regarding the courses of treatment or
inpatient care provided to CDCR’s inmate-patient. Such reviews shall be undertaken to
determine whether the course of treatment or services was prior authorized, medically
necessary and performed in accordance with CDCR rules and guidelines. DMH agrees to
make available, upon request by CDCR, for purposes of utilization review, an individual
patient’s medical record and any committee reviews and recommendations related to a
CDCR patient.

2. DMH acknowledges and agrees that concurrent utilization management review shall not
operate to prevent or delay the delivery of emergency treatment.

3. DMH acknowledges that the care of a patient at DMH shall be reviewed by CDCR
Utilization Management (UM) nurses or designated party and by a Joint CDCR/DMH
Review Process.

4. CDCR UM nurses or designated party will gather data and review cases of CDCR
inmate-patients in DMH programs. CDCR UM nurses or designated party will report
their findings and make recommendations to the CDCR Health Care Manager and CDCR
Chief Psychiatrist or their designee(s). CDCR and DMH managers or their designees
will meet monthly to review the data. Each DMH program also will have a joint
CDCR/DMH UM process that will review individual cases.

If there is a disagreement about discharge, the UM nurse will review the patient’s record
and forward a recommendation to the Joint CDCR/DMH UM Review Process. If there
continues to be disagreement, the recommendation will be conveyed to the CCAT.

Discharge Criteria

1. The inmate-patient has improved to a degree that further hospitalization is unnecessary,

or the primary illness or problem for which hospitalization was required is in substantial
remission, and the remaining symptoms are those of a disorder for which continued
DMH inpatient care is not necessary, the inmate-patient will be returned to CDCR for
ongoing treatment; or

2. Evaluation during hospitalization has resulted in a change of diagnoses such that

continued hospitalization is not appropriate or necessary.
3. If requested by DMH, an inmate-patient who has withdrawn informed consent for mental
health treatment or psychiatric medication, but for whom continued treatment is

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2009 REVISION 12-6-12
Department of Mental Health Mental Health Services Delivery System
Inpatient Program

otherwise recommended, may be returned to CDCR after all other clinical and legal
avenues to obtain authorization to treat have been exhausted, if the following two criteria
have been met:

• Withdrawal of informed consent shall be demonstrated by seven calendar days of

continuous refusal to take oral medication or 30 calendar days of continuous refusal
to accept scheduled depo-injectable medication, and documentation of discussions
between treating DMH psychiatrists and other team members and the patient
regarding the risks and benefits of continuing medication.

• Documentation that the patient has not met criteria for involuntary treatment for at
least the last seven calendar days.

Discharge Procedure
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1. Inmate-patients will be returned to the institution from which they came per the “psych
and return” policy provided that institution can meet the level of care and security needs
of the inmate-patient. Generally most inmate-patients will be returned to an institution
that has an EOP. The EOP IDTT may decide to discharge the inmate-patient to a lower
level of care after the initial 14-28 day evaluation period.

2. Inmates who are paroling and require ongoing treatment will be referred to the Parole and
Community Services Division (P&CSD) Transition Case Management Program and to a
Parole Outpatient Clinic or to a State hospital per Penal Code 2974.

3. DMH shall fax a copy of the Discharge Summary to the designated “DMH contact”, of
the receiving institution at the time of notification of discharge. DMH shall also call the
receiving institution. The inmate-patient shall then be returned to the CDCR institution
within five working days after the time of notification, or resolution of any appeal,
whichever occurs later.

4. Appeals for denial of return to CDCR will be reviewed by the Coordinated Clinical
Assessment Team (CCAT), Part V of this document.

5. Emergency returns to CDCR, shall be accomplished within twenty-four hours. Such

returns will be with prior notification and approval by telephone of the CDCR
institution’s C&PR staff and Mental Health Program Director, or designee. DMH shall
call the receiving institution to provide continuity of care including medication.

A dictated, typed discharge summary shall follow as soon as practicable, but not more
than fourteen days after return.

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2009 REVISION 12-6-13
Department of Mental Health Mental Health Services Delivery System
Inpatient Program

6. Discharge Information: For each inmate-patient returning to CDCR from a DMH

program, DMH shall ensure that the following documents be shall be transferred with the
inmate-patient to the respective CDCR institution:

• Psychiatric Discharge Summary;

• Nursing Assessment or Discharge Summary;

• Current Physicians orders and/or MAR;

• Current Treatment Plan;

• Keyhea Order (if applicable).

The inmate-patient shall not be placed in the transport vehicle without the above
documents. For each parolee returning to (P&CSD) supervision, DMH shall ensure that
the parolee’s documents shall be forwarded to the Chief Psychiatrist of the respective
Parole Region.

In addition, a DMH discharge packet will be faxed within two weeks of discharge. The
discharge packet shall include but not be limited to (see Attachment #2-DMH Discharge
Checklist:

• Interdisciplinary Notes for past 15 days;

• Physician Progress Notes for past 15 days;

• Relevant Consults;

• If applicable, forms specific to psych and return, mental health placement and transfer
information for parolees.

The DMH psychiatric programs will include in their discharge packets, the forms specific
to psych and return, mental health placement and transfer information for parolees.

All DMH programs shall provide written copies of the aforementioned cited materials.
For VPP and SVPP, due to their close proximity to CMF and SVSP, shall provide the
entire UHR for review by the CMF and SVSP Chief of Mental Health instead of the
above.

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2009 REVISION 12-6-14
Department of Mental Health Mental Health Services Delivery System
Inpatient Program

7. When an inmate returns to a prison from DMH, the Receiving & Release nurse shall
notify Mental Health Service upon arrival. The inmate shall be evaluated by a mental
health clinician within 24 hours of arrival. Medications shall be continued according to
Inmate Medical Services Policies and Procedures, Volume 4, Chapter 11, Medication
Management.

E. DMH DAY TREATMENT PROGRAM (DTP) at CMF

The DTP is a comprehensive treatment program with an emphasis on skill development.

This program provides treatment for inmate-patients who require a higher LEVEL OF CARE
than is provided in EOP but do not require 24-hour nursing care. The program includes
increased programming and supervision to improve level-of-functioning, reduce further need
for inpatient treatment and promote successful adjustment to the EOP, CCCMS, GP or parole
environment.

Admission Criteria

To be accepted the inmate-patient:

1. Has an Axis I major (serious) mental disorder with active symptoms.

2. Does not require 24-hour nursing supervision.

3. Suffers from mild to moderate impairment of functioning in most life areas that would
benefit from focused and comprehensive skill development to improve functioning
within the prison setting or in preparation for parole, and/or requires continuing
stabilization of psychiatric symptoms in a more structured setting.

4. Is able to function in a structured therapeutic setting with minimal staff prompting.

5. Is able to participate in own treatment planning.

6. Has had no serious suicide attempts in the past 30 days.

7. Has no acute medical issues.

Referral Process

All referrals shall include a completed DTP referral form and a referral packet, which
consists of:

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2009 REVISION 12-6-15
Department of Mental Health Mental Health Services Delivery System
Inpatient Program

1. Medical H&P for Transfer to DMH;

2. Current Treatment Plan – CDCR 7388;

3. Due process or written consent;

4. Pharmacy profile;

5. Interdisciplinary Progress Notes for past 15 days;

6. TB chrono from the referring institution;

7. Custody Case Factor Sheet; and

8. CDCR Suicide Risk Assessment (including a SRAC).

DMH psychiatric programs (VPP and SVPP) shall require only a transfer form
(see Attachment #3-DMH Referral/Transfer Form) and case factor sheet for DMH-to-DMH
transfers.

All male CDCR institutions shall provide written copies of the aforementioned
cited materials except for CMF where due to their proximity they shall provide the entire
UHR for review by the DTP Admission and Discharge Coordinator or designee.

Discharge Process

DTP options for return to CDCR:

1. Return to the sending institution provided that institution can meet the treatment needs.

2. If the inmate-patient requires continued mental health care, transfer to an appropriate

LEVEL OF CARE (see Chapter 3, CCCMS, and Chapter 4, EOP, for inclusion criteria).

3. Discharge to parole with a referral to a Parole Outpatient Clinic as needed.

4. The inmate-patient shall be returned to the CDCR institution on an expedited basis but no
later than 5 working days after the time of notification.

Discharge Procedure

1. For each inmate-patient returning to CDCR from the DTP, the DTP shall ensure that the

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2009 REVISION 12-6-16
Department of Mental Health Mental Health Services Delivery System
Inpatient Program

following documents be shall be transferred with the inmate-patient to the CDCR

institution (see Attachment #2-DMH Discharge Checklist):

• Psychiatric Discharge Summary;

• Nursing Assessment or Discharge Summary;

• Current Physicians orders and/or MAR;

• Current Treatment Plan; and

• Keyhea Order (if applicable).

The inmate-patient shall not be placed in the transport vehicle without the above
documents. For each parolee returning to P&CSD supervision, the DTP shall ensure that
the parolee’s documents shall be forwarded to the Chief Psychiatrist of the Parole
Region.

In addition, a discharge packet will be faxed within two weeks of discharge. The
discharge packet shall include but not be limited to:

• Interdisciplinary Notes for past 15 days;

• Physician Progress Notes for past 15 days;

• Relevant Consults;

• If applicable, forms specific to psych and return, mental health placement and transfer
information for parolees.

The DTP shall provide written copies of the aforementioned cited materials except for
CMF where due to their proximity; they shall provide the entire UHR for review by the
CMF Chief of Mental Health or designee.

F. PROCESS FOR CENTRALIZED DECISION MAKING FOR REJECTIONS AND

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INCOMPLETE PACKETS-CCAT

The Coordinated Clinical Assessment Team (CCAT) shall review referrals of CDCR inmate-
patients that were rejected by DMH, and referrals where incomplete items were not resolved
within two working days. Conducted by members of both the DMH and CDCR DCHCS,
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2009 REVISION 12-6-17
Department of Mental Health Mental Health Services Delivery System
Inpatient Program

CCAT provides a centralized approach to expedite the review and decision making process
for inmate-patients referred to DMH.
When any DMH program rejects an inmate-patient for admission, or is unable to resolve
incomplete referral items within two days after referral, a designee from DMH Long Term
Care shall contact a designee from CDCR DCHCS to initiate the CCAT process. The
CDCR, DCHCS designee shall facilitate a telephone or videoconference to discuss the case
with involved clinical and custody staff.

The CCAT shall include (but not be limited to):

• Senior mental health clinician(s) from DCHCS

• CDCR HCPOP representative(s)

• CDCR Classifications Services Unit representative(s)

• The referring clinician and supervising clinician(s) from the referring CDCR institution,
and

• Senior clinician(s) from the relevant DMH programs.

When reviewing a rejection, a senior clinician from each potentially relevant DMH program
shall participate in the review. When reviewing an incomplete packet, only the DMH senior
clinician from the affected state hospital or psychiatric program shall be required to
participate.

Case Conferences: The CDCR, DCHCS designee shall schedule case conferences upon
request by DMH and/or CDCR clinicians regarding a difficult or perplexing inmate-patient
case, including repeated admissions of the same inmate-patient in a short time frame.

G. HEALTH CARE PLACEMENT OVERSIGHT PROGRAM

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The HCPOP shall assist institution staff in referring and placing an inmate-patient in a DMH
facility in the following ways:

1. Assist field staff with DMH intermediate or acute LEVEL OF CARE referrals

• Coordinate with mental health staff at DCHCS headquarters for proper determination
of appropriate DMH LEVEL OF CARE and subsequent placement determination.

• Assist field staff concerning the referral process for the different DMH placement
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2009 REVISION 12-6-18
Department of Mental Health Mental Health Services Delivery System
Inpatient Program

settings.
• Assist field staff regarding Program Guide and MOU placement requirements such as
timelines and means of transportation.

2. HCPOP staff shall assist field staff with appeals of referrals denied by DMH for clinical
and custody reasons

• Assist field staff regarding the DMH appeal process as appropriate (e.g., DMH
contact persons, obtain written denial).

• Coordinate with headquarters DCHCS mental health staff for determination of

appealing referrals denied by DMH for clinical and/or custody reasons.

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2009 REVISION 12-6-19
Administrative Segregation Mental Health Services Delivery System

CHAPTER 7
Administrative Segregation

A. INTRODUCTION

The Administrative Segregation Unit (ASU) Mental Health Services (MHS) program is part
of the California Department of Corrections and Rehabilitation (CDCR) Mental Health
Services Delivery System (MHSDS). This Program Guide outlines program policies and
provides basic institutional operational procedures to ensure the effective delivery of clinical
services to inmates with serious mental disorders who, for custodial reasons, require housing
in ASU.

B. RESPONSIBILITY

1. Overall institutional responsibility for the program shall rest jointly with the Health Care
Manager and the Warden.

2. Institutional operational oversight of the ASU MHS shall be the responsibility of the
Chief of Mental Health at each institution.

3. Custodial responsibilities, including initial placement, disciplinary actions, correctional

counseling services, classification, inmate-patient movement, and daily management
shall rest with the Warden or designee. The assigned psychiatrist or Primary Clinician
(PC) shall attend all Institutional Classification Committee (ICC) meetings to provide
mental health input.

4. Individual clinical case management, including treatment planning, level of care

determination and placement recommendations, are performed by the assigned PC and
approved by the institution Interdisciplinary Treatment Team (IDTT).

C. PROGRAM GOALS AND OBJECTIVES

The goal of the ASU MHS program is to provide necessary mental health services for the
population of seriously mentally disordered inmates who, for custodial reasons outlined in
California Code of Regulations Title 15, Section 3335, require placement in ASU.

Specific program objectives include:

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Administrative Segregation Mental Health Services Delivery System

1. Continuation of care for inmate-patients with identified mental health treatment needs
through regular case management activities and medication monitoring to enable
inmate-patients to maintain adequate levels of functioning and avoid decompensation.

2. Daily clinical rounds of ALL inmates.

3. Mental Health screening of inmates who are not currently in the MHSDS caseload to
identify mental health needs, and referral for further mental health evaluation as
indicated.

4. Referral to a more intensive level of care for inmate-patients whose mental health needs
cannot be met in the ASU, including expeditious placement into Mental Health Crisis
Beds (MHCB) for inmate-patients requiring inpatient mental health care.

5. Mental health assessments and input into the classification decision-making process
during ICC meetings, including the inmate-patient’s current participation in treatment,
medication compliance, suitability of single celling or double celling, risk assessment of
self-injurious or assaultive behavior, status of Activities of Daily Living (ADL), ability to
understand Due Process proceedings, likelihood of decompensation if retained in ASU,
recommendations for alternative placement, and any other custodial and clinical issues
that have impact on inmate-patients’ mental health treatment.

6. Mental health assessments and input into the adjudication of Rules Violation Report
(RVR) hearing proceedings involving MHSDS inmate-patients. Mental health
information includes the quality of the inmate-patients’ participation in their current
MHSDS treatment plan, mental condition that may have been a contributing factor in the
alleged misbehavior, and the ability to comprehend the nature of the charges or
participate meaningfully in the disciplinary process. Final housing decisions are made by
the ICC after considering all relevant clinical and custody factors.

D. TREATMENT POPULATION

Refer to the Treatment Criteria for the level of care in the MHSDS, Chapter 1, Overview
Program Guide.

Referral for Mental Health Services

1. Pre-placement mental health screening: All inmates are screened by medical personnel
for possible suicide risk, safety concerns, and mental health problems before placement
in ASU (see Inmate Medical Services Policy and Procedure, Volume 4, Chapter 14:
CDCR 7219). If an inmate screens positive on the CDCR 128-MH7, ASU Pre-Placement
Chrono, they are referred for a mental health evaluation on an Emergent, Urgent, or
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Administrative Segregation Mental Health Services Delivery System

Routine basis, depending on their answers to the screening questions. After completion,
the CDCR Form 128-MH7, ASU Pre-Placement Chrono, shall be placed in the mental
health chrono section of the Unit Health Record (UHR). For Urgent and Routine
referrals, the medical staff conducting the screening shall complete a CDCR 128-MH5,
Mental Health Referral Chrono, and follow the referral process below.

2. Current MHSDS inmate-patients: All inmates placed into ASU shall be reviewed for
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identification of current MHSDS treatment status by the time of the initial CDCR-114D,
Order and Hearing on Segregated Housing, review. This shall occur on the first work
day following an inmate's placement. Current MHSDS inmate-patients are identified by
checking the ASU placements reported on the Institutional Daily Movement Sheet with
the treatment identifier code in the Distributed Data Processing System (DDPS) or the
Mental Health Tracking System (MHTS) for inmate-patient treatment cases. During the
initial review, mental health staff will ensure the continuity of mental health care,
including the delivery of prescribed medications. Upon inmate's placement into ASU,
nursing staff shall transfer the inmate's Medication Administration Record to ASU,
consistent with the post orders.

3. Staff referral: Any staff member who observes possible signs or symptoms of a serious
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mental disorder shall refer an inmate for clinical evaluation by completing a CDCR 128-
MH5, Mental Health Referral Chrono. The Referral Chrono shall be processed by
following the referral process below. Any inmate who is observed to be a suicide risk, or
in any other condition that requires crisis care, shall be immediately screened by the PC
to assess the potential for suicide and, if appropriate, referral to the MHCB for admission.

4. Inmates who receive a CDCR 115, Rules Violation Report, for Indecent Exposure or
Intentionally Sustained Masturbation Without Exposure shall be referred for all of the
following:

• CDCR 115-MH Rules Violation Report: Mental Health Assessment;

• A mental health assessment shall be completed within 24 hours to rule-out

decompensation and/or intoxication. The referral shall be made by telephone
to the local Chief of Mental Health who shall arrange this assessment; and,

• For inmate-patients included in the MHSDS, to the inmate-patient’s Primary

Clinician

5. Self referral: Inmates in ASU may request a clinical interview to discuss their mental
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health needs. These requests are made on a CDCR 7362, Health Care Services Request.
Inmates shall receive the attached pamphlet, “Administrative Segregation Inmate

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2009 REVISION 12-7-3
Administrative Segregation Mental Health Services Delivery System

Orientation Mental Health Guide” (available in Spanish), within 24 hours of placement

into ASU.

NOTE: When an IDTT determines that an inmate-patient requires treatment of

exhibitionism, that inmate-patient’s level of care shall be changed to CCCMS, Medical
Necessity (or higher if appropriate), bypassing the standard referral process.

Referral process
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Mondays through Fridays, the following shall occur:

1. A health care staff member shall collect the CDCR 7362, Health Care Services Request,
and staff referral forms each day from the designated areas.

2. Upon receipt of the collected forms, a Registered Nurse (RN)/Licensed Vocational Nurse
shall initial and date each CDCR 7362, Health Care Services Request, and the CDCR
128-MH5, Mental Health Referral Chrono.

3. The CDCR 7362, Health Care Services Request, and the CDCR 128-MH5, Mental
Health Staff Referral, shall be delivered to the designated program representative in
mental health services, dental services, or pharmacy services for same-day processing.

On weekends and holidays, the following shall occur:

1. The Triage and Treatment Area RN shall review each CDCR 128-MH5, Mental Health
Staff Referral, and CDCR 7362, Health Care Services Request, for medical, dental, and
mental health services, shall establish priorities on an emergent and non-emergent basis,
and shall refer accordingly.

2. If a mental health clinician is not available, the medical officer of the day (MOD),
physician on call or psychiatrist on call shall be contacted.

Inmates will be seen by a mental health clinician, or on weekends, by the MOD, physician,
or psychiatrist on-call within the clinically determined time frame.

• Emergent: Emergency cases will be seen immediately or escorted to the Triage and
Treatment area

• Urgent: Urgent cases will be seen within 24 hours

• Routine: Other cases will be seen within five working days

E. CLINICAL ROUNDS AND SCREENING

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Administrative Segregation Mental Health Services Delivery System

Clinical rounds

A mental health staff member, usually a Licensed Psychiatric Technician (LPT), shall
conduct rounds seven days per week in all ASUs to attend to the mental health needs of all
inmates. The LPT shall make initial contact with each inmate placed into ASU within 24
hours of placement.

A morning “check-in” meeting between custody and clinical staff shall be held each day. At
minimum, an ASU Sergeant and an assigned ASU Mental Health clinician (psychologist or
social worker) shall attend the morning meeting. During the meeting, involved personnel
shall identify new arrivals, discuss current behavioral issues and concerns, and share any
pertinent information regarding new arrivals and/or at-risk inmates. Pertinent suicide risk
information from the MHTS Suicide Tracking Report will be discussed. This meeting shall
be documented in the ASU Log book and salient clinical information shall be documented in
the UHR and, if necessary, a referral for mental health services shall be made at the
appropriate level of urgency.

In order to establish contact and provide information, mental health staff shall attend to
developing rapport with new inmates on the first day of mental health rounds.

Each institution is to ensure that effective communication is observed when inmates have
limited ability to speak English or are hearing impaired. Interpreter services information
shall be posted in all areas where phones may be used for that purpose, and all staff assigned
to ASU shall be provided documented training regarding access and use of services and
available translation equipment.

Those inmates not previously identified as having mental health treatment needs who exhibit
possible signs and symptoms of serious mental disorders are referred, via CDCR 128-MH5,
Mental Health Staff Referral, for clinical evaluation. Interaction shall be sufficient to
ascertain the inmate’s mental condition particularly during the first ten days. The LPT shall
maintain an individual record of clinical rounds on both MHSDS and non-patients by
initialing next to the inmate's name on the CDCR 114, Isolation Log Book, each time the
inmate is seen. Any unusual findings that may require closer observation by custody shall be
documented on the CDCR 114-A, Daily Log, on the same day of occurrence. For identified
MHSDS inmate-patients, the LPT shall document a summary of daily clinical rounds on a
CDCR 7230, Interdisciplinary Progress Notes, in the UHR on a weekly basis. Notes will be

clearly labeled as “Weekly Summary of LPT Clinical Rounds.” If clinically indicated, the
LPT may provide additional documentation.

Screening Questionnaire

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Administrative Segregation Mental Health Services Delivery System

All inmates who are not in the MHSDS and who are retained in ASU shall receive, within 72
hours of placement in ASU, a mental health screening interview utilizing the 31-question
mental health screening questionnaire also used in the Reception Centers. The interview
shall be conducted by a mental health clinician or trained nursing staff in private and
confidential settings that afford confidentiality of sight and sound from other inmates, and
confidentiality of sound from staff. Screening interview appointments shall be announced by
custody staff as “health appointments” to avoid stigmatization and possible retribution by
other inmates. Every effort shall be made to encourage inmates to attend these appointments.

The results of the questionnaire are evaluated either by hand-scoring or on an approved

automated scoring system to determine the need for further evaluation. The scoring sheet
shall be filed in the UHR. All inmates scoring positive on the questionnaire shall be referred
to a mental health clinician to be seen within the clinically appropriate time frame. Emergent
cases shall be seen immediately, Urgent cases shall be seen within 24 hours, all others shall
be seen within 5 working days.

All referrals and results of evaluations are documented in individual inmates’ UHR on
approved forms and entered into the institutional MHTS. Decisions to provide treatment via
placement into an outpatient program or MHCB shall be entered into DDPS.

F. CLINICAL EVALUATION

Referral evaluations will be completed within the time frames listed above and consist of the
following:

1. A review of the UHR and, if necessary, the Central File, shall be completed and
documented on approved forms as a part of the assessment process. Past treatment
needs, medications, and program placements shall be noted.

2. An individual clinical interview to determine the nature of the problem and a full mental
status examination. The examination is documented on a CDCR 7386, Mental Health
Evaluation, and placed into the UHR.

3. When necessary, as determined by the evaluating clinician in consultation with the IDTT,
psychological and neuropsychological testing may be conducted as a part of the
diagnostic assessment of all cases not previously identified as having mental health
treatment needs (testing is discretionary for inmate-patients currently receiving care who
have not previously undergone such testing). When suicidality is an issue, a suicide risk
assessment shall be conducted using the Suicide Risk Assessment Checklist (SRAC).

4. All assessments shall conclude with a five axis Diagnostic and Statistical Manual clinical
diagnosis, be documented on CDCR approved forms, and placed in the inmate’s UHR.

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Administrative Segregation Mental Health Services Delivery System

5. Inmates who are identified as a result of the above process as meeting the clinical criteria
for MHSDS placement may be referred to a psychiatrist for possible medication needs
and other interventions as deemed appropriate (including placement into a MHCB for
initiation of involuntary medication). These referrals shall be made on a CDCR 128-
MH5, Mental Health Referral.

G. CORRECTIONAL CLINICAL CASE MANAGEMENT SYSTEM (CCCMS) CARE

Inmate-patients who were receiving treatment at the CCCMS level of care prior to ASU
placement and those who are newly identified as requiring treatment at this level of care are
assigned a PC. The IDTT shall include the inmate-patient’s Correctional Counselor who
shall present case factors of the ASU placement for consideration in development of the
treatment plan and initiation of an aftercare plan.

The treatment intervention shall meet the guidelines set forth in the MHSDS Program Guide,
CCCMS, Chapter 3, and may include the following:

Required Treatment

1. Regular monitoring of symptoms by LPTs through daily rounds.

2. Individual contact every week by the PC, or more frequently as clinically indicated.

3. Medication treatment and monitoring of compliance by psychiatric and nursing staff

Other Treatment Activities

1. Group therapy when deemed clinically appropriate

2. Self-help therapeutic activities such as reading and writing

3. When necessary, supportive care for Activities of Daily Living.

H. ENHANCED OUTPATIENT PROGRAM CARE

1. The Chief of Mental Health or designee, or the Health Care Manager or designee, shall
present the IDTT's recommendation for the Enhanced Outpatient Program (EOP) level of
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Administrative Segregation Mental Health Services Delivery System

care to the ICC and provide clinical input regarding mental health placement options
based on the inmate-patient’s clinical needs. Placement options include:

a. Referral to an EOP for inmate-patients who are involved in non-violent incidents and
determined to not be a risk to others.

b. Transfer to an appropriate ASU EOP hub institution treatment setting within 30 days
of placement at the EOP level of care designation. Inmate-patients who are involved
in serious rule violations and whose propensity for threat to others and/or the security
of the institution is so high that no other alternative placement is considered
appropriate shall be retained in ASU. These inmate-patients shall receive the EOP
level of care as described below.

c. Referral to a Psychiatric Services Unit for inmate-patients who are serving an

established and endorsed SHU term (placement of these cases requires ICC referral
and Classification Staff Representative endorsement).

2. Once identified as requiring EOP level of care, an inmate-patient shall be processed

through investigations and disciplinary hearings on a priority basis. Where court
proceedings are required, staff will make every effort to expeditiously support the
Court’s adjudicative process. In no event shall a pending CDCR 115, Rules Violation
Report, impede or delay the transfer of these inmate-patients to a hub ASU institution.

3. Intake Assessment
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a. Within a maximum of five calendar days of the time of placement, an ASU Primary
Clinician (PC) will be assigned who shall complete a brief evaluation of the inmate-
patient including a review of the inmate-patient’s mental health history and interview.

b. A comprehensive mental health clinical assessment shall be done by the PC and other
IDTT members prior to the initial IDTT. If this evaluation is completed within five
days, the brief evaluation referenced above need not be completed. This assessment
shall include at minimum:

• Comprehensive review of Central File and UHR of mental health treatment needs,
including prior placements and medications.

• Current mental status examination, including diagnosis and level of functioning.

• Daily observation by mental health and custody staff to assess ADL and social
interactions.

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• Review of medication history and adjustments to current prescriptions (including

involuntary medications as necessary) by staff psychiatrist.

• The assigned Correctional Counselor shall be prepared to discuss significant

disciplinary history and custodial placements.

• Review with inmate-patient specific risk factors for violence toward self and
others.

4. Interdisciplinary Treatment Team

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a. All EOP inmate-patients will appear at the initial IDTT.

b. All inmate-patients referred for EOP will be seen by the IDTT prior to the initial ICC
or within 14 calendar days.

c. The IDTT will develop a treatment plan on CDCR 7388, Mental Health Treatment
Plan.

5. Length of Stay More Than 90 Days

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a. Inmate-patients housed in ASU for more than 90 days shall be reviewed every 30
days outside of the ICC process, by the Facility Captain and Correctional Counselor
II. The status of each case, with detailed information regarding reasons for delays in
the referral, disciplinary, classification, and/or transfer process, shall be compiled and
reviewed by the Warden or designee (Chief Deputy Warden, or Associate Warden for
Health Care). The Warden shall ensure that reviewers take action to resolve any
issues that impact length of stay in ASU.

b. Inmate-patients housed in ASU for more than 90 days who postpone a RVR hearing
pending referral to the District Attorney, shall be reviewed for alternate housing. If
the time housed in ASU is equivalent to the projected SHU term (if the inmate-patient
has been found guilty of the RVR), the inmate-patient shall be released to a general
population setting. The Warden or designee shall contact the District Attorney to
discuss expediting pending cases.

6. EOP Treatment in ASU Hubs

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Administrative Segregation Mental Health Services Delivery System

To avoid premature returns of inmate-patients and provide adequate time for observation
and evaluation, inmate-patients transferred to EOP ASU hub institutions for treatment
shall be held at the hub institution for no less than 60 days from the date of reception.
Inmate-patients placed into general population housing during the initial 60-days after
transfer to an ASU EOP hub shall be maintained at the EOP level of care for the duration
of the 60-day period

Inmate-patients housed in ASU EOP hubs hall be provided care consistent with their
clinical needs. Each inmate-patient shall have an individualized treatment plan for ten
hours per week of scheduled structured therapeutic activities, using standardized
therapeutic materials, with the following services:

REQUIRED TREATMENT

a. Medication Management including a psychiatric evaluation by the psychiatrist at

least every 30 days

b. Daily LPT rounds seven days per week

c. Weekly PC contact
d. Crisis intervention

OTHER TREATMENT ACTIVITIES

a. Medication Education

b. Group Therapy including Anger Management, Stress Management, Substance Abuse

(where clinically appropriate)

c. Monitoring and assistance with daily living skills

d. Recreation therapy both within cell and out of cell; this may include music therapy,
art therapy, current events

Inmate-patients who are released from ASU to a general population EOP for continuing
mental health treatment may require mental health services related to adjustment to
the general population environment. The ASU primary clinician shall document
recommendations regarding the inmate-patient’s specific treatment needs, including any
concerns about facilitating the inmate-patient’s successful transition to general population.
The receiving EOP IDTT will consider documentation by the ASU clinician in developing
the inmate-patient’s treatment plan. The treatment plan for inmate-patients transferred from
ASU to general population-EOP shall include services provided to aid in the transition to the
general population environment.
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Administrative Segregation Mental Health Services Delivery System

7. Treatment Refusals
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For inmate-patients who refuse more than 50% of offered treatment during a one-week
period, the PC shall:

• Interact with these inmate-patients daily on scheduled work days (instead of weekly)

• Include in the treatment plan efforts to reduce resistance to participation in group

therapy

• Discuss these inmate-patients during the ASU morning meeting with custody

• Consider referral of inmate-patients to higher levels of care and document the results
of this consideration.

I. INPATIENT PLACEMENT
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Inmates who are found to meet the clinical criteria for referral to the MHCB for inpatient
care shall immediately be transferred for such treatment, upon authorization by the Chief of
Mental Health of the sending institution. (Refer to Section 5, Mental Health Crisis Bed, for
transfer procedure)

If an ASU inmate-patient in an MHCB is determined to meet the clinical criteria for referral
to the Department of Mental Health (DMH) program, the Chief of Mental Health or
designee, of the sending institution shall initiate the referral process following established
procedures to facilitate the admission to a DMH program.

J. STAND-ALONE ADMINISTRATIVE SEGREGATION UNITS

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1. No participant in the MHSDS shall be housed in a stand-alone ASU. Any inmate-patient

included in the MHSDS, who is inadvertently placed in a stand-alone ASU, shall be
transferred out within 24 hours.

2. LPTs shall make rounds seven days a week.

3. A mental health clinician shall conduct an assessment of any inmate in a stand-alone

ASU identified and referred by the LPT or any staff immediately or within 24 hours,
depending on urgency of the referral. Any inmate who meets criteria for MHSDS shall
be transferred to another ASU as soon as possible but no longer than 24 hours following
identification.

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Administrative Segregation Mental Health Services Delivery System

K. PLACEMENT REVIEW AND CLINICAL INPUT IN CLASSIFICATION

COMMITTEE

1. The initial IDTT is held prior to the initial ICC and as often as needed thereafter, at a
minimum, once every 90 days. The PC and the Correctional Counselor assigned to the
case shall present relevant clinical and custody case factors with recommendations
concerning treatment and placement needs. The PC shall document the results of the
IDTT reviews and decisions on the CDCR 7388, Mental Health Treatment Plan.

A CDCR 128-MH3, Mental Health Placement Chrono, shall be completed by the PC and
forwarded to correctional counseling staff for necessary classification actions when there
is a change in the level of care.

2. The Chief of Mental Health or designee, or in institutions without such a position, the
Health Care Manager or designee, shall attend the ICC to provide clinical input at the
committee meeting.

L. INTERDISCIPLINARY TREATMENT TEAM

The responsibilities for overall treatment planning within the ASU rest with the IDTT.
These responsibilities include:

1. Placement decisions for individual cases.

2. Review of relevant clinical data for diagnostic formulation.

3. Review of relevant case factors.

4. Formulation and approval of treatment plans.

5. Annual and special reviews for continuation or termination of services

6. Review of treatment response.

7. Discharge planning.

The IDTT shall generally be responsible for developing and updating treatment plans. This
process shall include input from the inmate-patient and other pertinent clinical information that
may indicate the need for a different level of care. Referrals to higher levels of care shall be
considered when the inmate-patient’s clinical condition has worsened or the inmate-patient is
not benefiting from treatment services available at the current level of care. Consideration of
appropriate level of care shall be documented by the IDTT on a

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2009 REVISION 12-7-12
Administrative Segregation Mental Health Services Delivery System

CDCR 7230-MH, Interdisciplinary Progress Note, and shall include the justification for
maintaining the current level of care or referral to a different level of care

The ASU MHS IDTT is composed of, at a minimum:

The assigned PC

The assigned psychiatrist

The LPT

The assigned Correctional Counselor

Correctional housing officer or any other mental health and custodial staff members who
have specific information or knowledge relevant to cases under review are encouraged to
attend. The inmate-patient shall be included in the IDTT, if clinically and custodially
appropriate, unless the inmate-patient refuses to participate. If the inmate-patient refuses to
participate, the clinician must document the reason for refusal on a CDCR 7230-MH, Mental
Health Progress Notes.

M. DUTIES OF CLINICAL CASE MANAGER OR PRIMARY CLINICIAN

Each inmate-patient within the treatment component of the ASU MHS shall be assigned a PC
or PC, typically a Clinical Social Worker (CSW) or psychologist. This individual shall
maintain clinical involvement with the inmate-patient, as well as performing casework
functions, including the following:

1. Documentation of initial and updates to the Mental Health Assessment.

2. In consultation with the IDTT, develop and document initial and updated treatment plans
that also address security concerns and status.

3. Weekly individual contact for CCCMS and EOP inmate-patients.

4. Scheduling for regular or special IDTT reviews.

5. Response to inquiries regarding clinical status of the inmate-patient.

6. Attendance at initial IDTT reviews of the inmate-patient, prior to the initial ICC, and at
subsequent IDTTs, at least every 90 days.

7. Participation in ICC to provide mental health input.

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Administrative Segregation Mental Health Services Delivery System

8. Liaison with custody and correctional counseling staff regarding overall management of
inmate-patients.

9. Group therapy as defined in the inmate-patient’s treatment plan.

10. Crisis intervention and referral for inpatient care as needed.

11. Review of the weekly summary of clinical rounds and documentation of this review in the
UHR.

N. UNIT HEALTH RECORD

1. A current record of all treatment plans and progress notes shall be maintained on
departmentally approved forms within the individual UHR. Only designated staff shall
have access to this record. All staff shall adhere to the confidentiality requirements.

2. There are many legitimate exceptions to confidentiality requirements (e.g., institutional

security). However, every member of the ASU MHS, including correctional staff, shall
treat all clinical information with professional discretion. No information shall be
divulged without clinical or correctional necessity.

O. AUTOMATED TRACKING SYSTEM

The Inmate Mental Health Identifier System (IMHIS) has been designed to track the
movement of all inmate-patients receiving care in the MHSDS. The data entered into the
system will be processed daily, so the system will maintain current information regarding
MHSDS inmate-patients’ current level of care, as well as MHSDS transfers, discharges and
new cases. All institutions are to conduct a reconciliation of the inmate-patients housed in
ASU who require mental health treatment with the IMHIS codes for this specific
population. Daily updates to the IMHIS are mandatory for every ASU.

All mental health contacts shall be tracked in the MHTS.

P. CUSTODIAL OPERATIONS

Inmate-patients within the ASU MHS are subject to all rules, custodial requirements,
activities, and privileges of other ASU inmates.
Q. PHYSICAL PLANT

Interviews of inmates will be held in a private setting unless the security of the institution or
the safety of staff will be compromised. Screening and evaluation interviews and treatment
activities are accomplished in existing interview rooms and exercise areas within
current ASU units. The IDTT interviews may require inmate-patient escorts to
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classification/interview rooms. Clinical monitoring and routine interviews, including clinical

staff daily rounds, may be provided through cell-front contacts as clinically appropriate and
depending on the cooperation of the inmate. While some therapeutic activities may take
place within the cell, whenever possible treatment activities should take place out of cell.

Mental health treatment in ASU may be provided using mental health programming booths.
All mental health programming booths procured after March 2007, shall conform to design
specifications available through the Prison Industry Authority. Booths are available through
the Prison Industry Authority’s online product catalog at: http://catalog.pia.ca.gov/ using the
search term “Mental Health Programming Booth.”.

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Security Housing Unit Mental Health Services Delivery System

CHAPTER 8
4B

Security Housing Unit

0B

A. INTRODUCTION
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It is the policy of the Department of Corrections and Rehabilitation (CDCR) to provide

inmates in a prison setting with prompt access to mental health services, regardless of their
housing designation. Provision of mental health services within a Security Housing Unit
(SHU) is part of the Mental Health Services Delivery System (MHSDS). Mental health
services within a SHU are provided to all SHU inmate-patients in accordance with the
inmate-patient’s treatment needs and level of care. Services are designed to achieve
symptom management through regular case management activities, medication
administration and monitoring, crisis intervention, continuous monitoring for signs or
symptoms of a serious mental disorder, and referral to a more intensive as needed.

The CDCR currently has four SHUs located at the institutions listed below. Inmates in the
MHSDS receive services as indicated.

• Valley State Prison for Women (females only) – Inmates in this unit receive mental
health services in conjunction with inmates in the Administrative Segregation Unit
(ASU).

• California Correctional Institution – Inmates are provided Correctional Clinical Case

Management Services (CCCMS). Inmates requiring the Enhanced Outpatient Program
(EOP) are referred to a Psychiatric Services Unit (PSU) and transferred to an ASU EOP
hub while awaiting PSU placement.

• California State Prison, Corcoran – Inmates are provided CCCMS in the SHU. Inmates
requiring EOP services are referred to a PSU and transferred to the ASU EOP hub while
awaiting PSU placement.

• California State Prison, Sacramento – Inmates are provided CCCMS in the SHU.
Inmates requiring EOP services are referred to a PSU.

• Pelican Bay State Prison (PBSP) – Per exclusionary criteria from the federal court,
inmates with one of the conditions listed below shall not be admitted to the PBSP SHU.

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Security Housing Unit Mental Health Services Delivery System

1. Documented diagnosis or evidence of any of the following Diagnostic and Statistical

Manual IV – Axis 1 conditions currently in existence or within the preceding three
months:

Schizophrenia (all sub-types);

Delusional Disorder;
Schizophreniform Disorder;
Schizoaffective Disorder;
Brief Psychotic Disorder
Substance-Induced Psychotic Disorder (excluding intoxication and
withdrawal);
Psychotic Disorder Not Otherwise Specified;
Major Depressive Disorders;
Bipolar Disorder I and II

2. A diagnosed mental disorder that includes being actively suicidal.

3. A diagnosis of a serious mental illness that is frequently characterized by breaks with

reality, or perceptions of reality that leads to significant functional impairment.

4. A diagnosis of “organic brain syndrome” that results in a significant functional

impairment if not treated.

5. A diagnosis of a severe personality disorder that is manifested by frequent episodes

of psychosis or depression and results in significant functional impairment.

6. A diagnosis of mental retardation.

7. A prior history, which suggests that the inmate will do poorly in the SHU. This
includes inmates who have experienced psychotic symptoms that appear to be
attributable to incarcerations in a SHU environment. These inmates are those for
whom evidence exists of a deterioration in mental health which correlates with
placement in SHU or SHU-like environments. Such diagnoses as “Brief Psychotic
Episode,” “Psychosis NOS,” and “Major Depression” which have been assigned
during periods of placement in SHU may, for example, be indicative of deterioration
of mental health which accompanies SHU placement. Inmates whose history
suggests such a causal relationship should be excluded from SHU.

8. A history which includes any of the following within the preceding three months:

a. Medication prescribed to address any of the “at risk” mental health categories
listed above.
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b. Therapy and/or supportive services to address any of the “at risk” mental health
categories listed above.

c. Frequent (e.g. at least weekly) monitoring for deterioration in mental health

condition. This does not include situations in which repeated visits by mental
health staff are attributable to repeated referral from the inmate or from custody
staff but where no mental health condition is noted.

d. A history which includes a recurrent or “cyclic” mental health condition (e.g.

Bipolar Disorder) where the inmate has not currently been symptom free for a
period of time that is at least twice as long as the longest known period of active
symptoms or known to demonstrate recurrent symptoms at intervals of
approximately 6 months, would be considered as “positive” on this indicator until
they had been symptom free for a continuous period of at least 12 months.

Where the results of the Unit Health Record (UHR) review reveal that any of the above
conditions exist, the inmate must be removed from SHU within 96 hours of his arrival on
that unit.

Where the results of the UHR review do not reveal the existence of any of the above
conditions and there is evidence that the inmate has been evaluated with the existing 31
item mental health screen or other evaluation (documented on a CDCR 7386, Mental
Health Evaluation) within the preceding 12 month period, the inmate may be housed in
SHU.

Where the results of the UHR are equivocal (as where no clear diagnosis is established
but where mental health contact and observations have suggested that symptoms
consistent with one or more of the above conditions have been observed) or when no
mental health evaluation (a 31 item mental health screen or completion of an evaluation
documented on a CDCR 7386, Mental Health Evaluation) has occurred the preceding 12
month period, a mental health evaluation shall be conducted.

B. PURPOSE

This chapter outlines program policies and provides institutional operational procedures to
assure the effective delivery of mental health services to inmate-patients with serious mental
disorders who, for custodial reasons, require housing in a SHU, according to California Code
of Regulations, Title 15.

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C. RESPONSIBILITY

1. Overall institutional responsibility for the program shall rest jointly with the Health Care
Manager and the Warden.

2. Institutional operational oversight of the Mental Health Services in a SHU shall be the
responsibility of the Chief of Mental Health. The assigned Psychiatrist or Primary
Clinician (PC) shall attend all Institutional Classification Committee (ICC) meetings in
the SHU to provide mental health input.

3. Custodial responsibilities, including initial placement, correctional counseling services,

classification, inmate movement, and daily management shall rest with the Warden or
designee.

4. Clinical case management, including treatment planning and placement

recommendations, shall be performed by an assigned PC and approved by the SHU
Interdisciplinary Treatment Team (IDTT).

D. PROGRAM GOALS AND OBJECTIVES

The goal of the mental health services in the SHU is to provide evaluation and treatment of
serious mental disorders that are limiting the ability of inmates with high security needs to
adjust to appropriate institutional placements. Inmate-patients with clinical needs that cannot
be met within the SHU mental health program, as determined by the IDTT, shall be referred
to the SHU ICC for consideration of alternative treatment programs.

The program objectives are to:

1. Provide regular case management, treatment activities, and medication monitoring, to

enable inmate-patients to maintain their current level of functioning and avoid
decompensation.

2. Ensure that inmate-patients whose clinical mental health needs cannot be met in SHU and
require a change in level of care are referred for alternative treatment programs by mental
health clinicians.

3. Provide clinical rounds every other week by Licensed Psychiatric Technicians (LPT) or
other clinicians to identify mental health needs for all inmates who are not currently in
MHSDS. Rounds are provided by PCs at PBSP and by LPTs in other SHUs.

4. Provide weekly clinical rounds by LPTs or other clinicians of inmates in the MHSDS.

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Security Housing Unit Mental Health Services Delivery System

5. Conduct mental health assessments to provide input into ICC proceedings concerning the
inmate-patients’ current participation in the MHSDS program. This includes medication
compliance, suitability for single or double celling, risk assessment for self injurious or
assaultive behavior, status of Activities of Daily Living (ADL), ability to understand Due
Process, likelihood of decompensation if retained in SHU, and recommendations for
alternative placement.

6. Conduct mental health assessments to provide input into the adjudication of Rules
Violation Reports (RVR) hearing proceedings on MHSDS caseload inmate-patients
according to current policy. Mental health information includes the inmate-patient’s
participation in the current MHSDS level of care, any mental condition that may have
been a contributing factor in the alleged behavior, the inmate-patient’s ability to
comprehend the nature of the charges or the disciplinary process, and any mental health
factor that the hearing officer should consider in assessing the penalty. Final decisions
are made in ICC meetings or hearings after considering all relevant clinical and custody
factors, consistent with Department Operations Manual, Section 62050.13.23
(ICC/Suspension of SHU terms).

E. TREATMENT POPULATION

Refer to the Treatment Criteria for the levels of care in the MHSDS Program Guide,
Chapter 1, Program Guide Overview .

F. SOURCES OF REFERRAL FOR MENTAL HEALTH SERVICES

1. Current MHSDS treatment cases: Current MHSDS inmate-patients are identified by

checking the SHU placements reported on the Institutional Daily Movement Sheet to
ensure the continuity of mental health care including prescribed medications. Upon an
inmate-patient’s placement into the SHU, the nursing staff from the originating unit shall
transfer the inmate-patient’s Medication Administration Record (MAR) to the SHU,
consistent with their post orders.

2. Staff referral: Any staff member who observes possible signs or symptoms of a serious
mental disorder may refer an inmate for clinical evaluation by completing a CDCR 128-
MH5, Mental Health Referral Chrono, and follow the self-referral process below. Any
inmate who is observed to be a suicide risk, or in any other condition that requires crisis
care, shall be immediately screened by a PC to assess their potential for suicide and, if
appropriate, referred to the MHCB for admission. On weekends and holidays, follow the
self-referral process below.

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Security Housing Unit Mental Health Services Delivery System

3. Inmates who receive a CDCR 115, Rules Violation Report, for Indecent Exposure or
Intentionally Sustained Masturbation Without Exposure shall be referred for all of the
following:

• CDCR 115-MH Rules Violation Report: Mental Health Assessment;

• A mental health assessment shall be completed within 24 hours to rule-out

decompensation and/or intoxication. The referral shall be made by telephone to the
local Chief of Mental Health who shall arrange this assessment; and,
• For inmate-patients included in the MHSDS, to the inmate-patient’s PC.

4. Self referral: Inmates in SHU may request a clinical interview to discuss their mental
U U

health needs. These requests are made on a CDCR 7362, Health Care Services Request.
Mondays through Fridays, the following shall occur:

a. A health care staff member shall collect the CDCR 7362, Health Care Services
Request, and staff referral forms, 128-MH5, Mental Health Referral Chrono, each
day from the designated areas.

b. Upon receipt of the collected forms, an nursing staff shall initial and date each CDCR
Form 7362, Health Care Services Request, and/or staff referral forms, 128-MH5,
Mental Health Referral Chrono.

c. The CDCR Forms 7362, Health Care Services Request, and/or mental health staff
referrals forms, 128-MH5, Mental Health Referral Chrono, shall be delivered to the
designated program representative in mental health services for same-day processing.

On weekends and holidays, the following shall occur:

a. The Treatment and Triage Area (TTA) registered nurse (RN) shall review each
mental health staff referral form, 128-MH5, Mental Health Referral Chrono, and
each CDCR 7362, Health Care Services Request, for the need for medical, dental,
and mental health services, establish priorities on an emergent and non-emergent
basis, and refer accordingly.

b. If a mental health clinician is not available, the medical officer of the day (MOD),
physician on call or psychiatrist on call shall be contacted.

5. Inmates will be seen by a mental health clinician, or on weekends by the physician or

psychiatrist on call within the clinically determined time frame.

• Emergent: Emergency cases will be seen immediately or escorted to the TTA

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• Urgent: Urgent cases will be seen within 24 hours

• Other: Other cases will be seen within five working days

6. Clinical rounds: A mental health staff member, usually a LPT or at PBSP, a PC, shall
U U

conduct rounds weekly unless clinically needed more often in the SHU to attend to the
mental health needs of all MHSDS inmates. The LPT shall make rounds of non-
MHSDS inmates every other week. If an inmate refuses to talk to the LPTs, the LPT
will discuss the inmate’s functioning with custody staff. The LPT shall maintain an
individual record of clinical rounds by making a check mark next to the inmate’s name
on the SHU Inmate Roster each time they are checked. Those inmates who have not
been previously identified as having mental health treatment needs but exhibit possible
signs and symptoms of a serious mental disorder shall be referred, via CDCR 128-MH5,
Mental Health Referral Chrono, to a PC for clinical evaluation. Any unusual findings
that may require closer observation by custody shall be documented on the 114-A,
Isolation Log, on the same day of occurrence. The LPT shall document a summary of
the status of MHSDS inmate-patients in a weekly progress note in the UHR.

7. All referrals and evaluations shall be documented on approved forms, filed in individual
inmate UHR, and entered into the Mental Health Tracking System.

NOTE: When an IDTT determines that an inmate-patient requires treatment of

exhibitionism, that inmate-patient’s level of care shall be changed to CCCMS (or higher if
appropriate), bypassing the standard referral process.

G. CORRECTIONAL CLINICAL CASE MANAGEMENT SYSTEM (CCCMS)

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The mental health staff shall continue to provide mental health services to inmate-patients
with the CCCMS level of care designation after they are placed in SHU. Inmate-patients
who meet the clinical criteria of MHSDS resulting from staff referrals, self-referrals, or
clinical rounds shall also receive mental health evaluation and ongoing services, if
determined appropriate. Each MHSDS inmate-patient is assigned a PC.

1. Interdisciplinary Treatment Team

a. The responsibilities for overall treatment planning within the CCCMS program rest
with an IDTT. These responsibilities include:

• Placement decisions for individual cases

• Review of relevant clinical data for diagnostic formulation

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Security Housing Unit Mental Health Services Delivery System

• Review of relevant case factors

• Formulation and approval of treatment plans

• Annual and special reviews for continuation or termination of services

• Review of treatment response

• Discharge planning

b. The IDTT is composed of, at a minimum:

• The assigned PC (either a psychologist or a Clinical Social Worker).

• The LPT

• The SHU Senior Psychologist or designee

• The assigned psychiatrist

• The assigned Correctional Counselor

• The inmate-patient (if clinically and custodially appropriate). The inmate-patient

shall be included in the IDTT, unless the inmate-patient refuses to participate. If
the inmate-patient refuses to participate, the clinician must document the reason
for refusal in the CDCR 7230, Mental Health Progress Notes. Inmate-patients
shall not be disciplined for not participating in IDTT.

• The housing custody officer or any other staff member who has direct knowledge
of the inmate-patient under review is encouraged to attend. As the staff involved
in day-to-day interactions with inmate-patients, custody officers can provide input
in assessing clinical status and continuing needs, and support in implementing
treatment programs.

c. All CCCMS inmate-patients are seen in the initial IDTT that is held prior to the initial
ICC hearing (within 14 calendar days of arrival in SHU) and quarterly thereafter.
Some inmate-patients may be seen more frequently by the IDTT in special reviews at
the request of the assigned PC or psychiatrist whenever changes in the level of care or
treatment plans are indicated. The results of the IDTT reviews and decisions shall be
documented by the PC in the interdisciplinary progress notes and filed in the UHR.
These notes shall include the following:

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Security Housing Unit Mental Health Services Delivery System

• Names of all IDTT members present

• Inmate-patient’s participation

• Inmate-patient’s suitability for single or double celling

• Risk assessment for self injurious or assaultive behavior

• Current medication regimen

• Compliance with treatment, including medication

• Status of ADL

• Treatment goals and objectives, progress or lack of progress in treatment

• Recommendations for placement options

• Need for staff assistance

• ICC action

d. CDCR 128-MH3, Mental Health Placement Chrono, shall be completed by the PC

and forwarded to correctional counseling staff for necessary classification actions
when there is a change in the level of care.

2. Functions of the PC in SHU may include the following:

a. Complete mental health evaluation on new cases. If an inmate-patient is an active

CCCMS case and the Mental Health Assessment has been completed by a previous
clinician, the PC shall update the assessment.

b. In consultation with the IDTT, develop and document initial and updated
CDCR 7388, Treatment Plans, that also address security concerns and status.

c. Provide individual monitoring contact once every 30 days at a minimum for CCCMS
inmate-patients, or more frequently as clinically indicated.

d. Participate in IDTT meetings.

e. Participate in ICC to provide mental health input.

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f. Provide crisis intervention and referral for a more intensive level of care as needed.

g. Perform as liaison with custody and correctional counseling staff regarding overall
management of inmates.

3. Treatment Modalities: Based on identified needs, the following treatment modalities are
available:

REQUIRED TREATMENT
U

• Individual meeting with PC at least every 30 days or more frequently as clinically

indicated.

• Quarterly IDTT update of treatment plan.

• Medication evaluation, review, and monitoring of compliance by psychiatric and

nursing staff for those inmate-patients receiving medication.

• Regular monitoring of symptoms by LPTs through weekly rounds of all MHSDS

inmate-patients and rounds every other week of all non-MHSDS inmates.

OTHER TREATMENT ACTIVITIES

7BU

• Orientation and supportive counseling for institutional adjustment

• Individual counseling and crisis intervention

• Group therapy such as anger management and relapse prevention

• Social skills training

• Consultation services, such as to education and work programs

• Clinical discharge or clinical pre-release planning

H. ENHANCED OUTPATIENT PROGRAM

3BU

Inmate-patients who are serving an established and approved SHU term and require an EOP
level of care shall be referred to a PSU. While awaiting placement for a PSU, these inmate-
patients shall be transferred to an EOP ASU hub within 30 days of being designated as
requiring EOP care. EOP mental health services shall be provided in the EOP ASU Hubs.
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I. PLACEMENT REVIEW AND CLINICAL INPUT INTO ICC

1. The appropriateness of an inmate-patient’s placement in SHU shall be reviewed in

regularly scheduled ICC meetings. The Chief of Mental Health or designee, is a member
of the ICC. In that capacity, he/she shall present the IDTT's recommendations regarding
placement recommendations, based on the inmate-patient’s clinical needs. Designees
shall be a psychiatrist, a licensed psychologist, or a Licensed Clinical Social Worker.

2. All identified CCCMS and EOP inmate-patients in SHU shall receive continued mental
health services managed by the assigned PC. An exception to this policy will occur at
PBSP when an inmate-patient meets the exclusionary criteria at which time the inmate-
patient shall be transferred to an appropriate treatment setting such as the PSU for EOPs
or a SHU with CCCMS care. Any inmate in the PBSP SHU who is identified as having
one of these diagnoses and requiring EOP level of care shall be transferred within 96
hours out of the PBSP SHU to the PSU, EOP or Correctional Treatment Center (CTC).

3. Inmate-patients in the PBSP PSU recommended by the IDTT for CCCMS are scheduled
for the next available ICC and referred for transfer to the COR SHU. They are housed in
ASU pending transfer.

4. An inmate-patient whose clinical needs cannot be adequately met through regular case
management activities shall be referred to ICC for consideration of alternative clinical
placement, including placement in a Level IV EOP. Inmate-patients who are determined
to meet the clinical criteria for referral to the MHCB shall immediately be transferred to
MHCB. Upon approval by the Chief of Mental Health, or designee, the PC shall initiate
such referrals, based on the direct observation and assessment.

5. The ICC shall review all referrals for alternative placement and may recommend one of
the following placement options, based on the clinician’s input and Correctional
Counselor review of case factors:

a. Transfer to the MHCB program. This option is for inmate-patients who require 24-
hour crisis care and do not require ICC review.

b. Transfer to an appropriate inpatient program through Department of Mental Health

(DMH).

c. Transfer to a PSU. This option is for male inmate-patients who require both
maximum custodial controls and EOP level of care. Female inmate-patients will
continue to be treated in SHU, consistent with updated individualized treatment plans
and LOC, until a PSU for female inmate-patients is established.
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d. Suspension of SHU term and placement in the Level IV EOP: This option is for
inmate-patients who are determined by the ICC to no longer require the maximum
custodial controls of SHU.

e. All inmate-patients requiring EOP care shall be transferred to either a PSU or EOP,
as determined by the ICC, within 60 days or 30 days, if clinically indicated.

J. UNIT HEALTH RECORD

A current record of all CDCR 7386, Mental Health Evaluations, CDCR 7388, Treatment
Plans, and CDCR 7230, Interdisciplinary Progress Notes, shall be maintained in the UHR.
Records shall include documentation regarding modifications to an inmate-patient’s
treatment plan for developmental and other disabilities. Only designated staff shall have
access to this record. All staff shall adhere to the confidentiality requirements. No
information shall be divulged without clinical or correctional necessity.

K. AUTOMATED TRACKING SYSTEM

The Inmate Mental Health Identifier System (IMHIS) has been designed to track the
movement of all inmate-patients receiving care in the MHSDS. The data entered into the
system shall be processed daily, so the system will maintain current information regarding
MHSDS inmate-patients’ current level of care as well as MHSDS inmate-patient transfers,
discharges, and new cases. All institutions shall conduct a reconciliation of the inmate-
patients housed in ASU and SHU who require mental health treatment with the IMHIS codes
for this specific population. Daily updates to the IMHIS are mandatory for every SHU.

Inmate-patients clinical contacts shall be tracked in the Mental Health Tracking System .

L. CUSTODIAL OPERATIONS

Inmate-patients with a serious mental disorder within the SHU are subject to all rules,
custodial requirements, activities, and privileges of other SHU inmates.

M. PHYSICAL PLANT

Screening and evaluation interviews and treatment of inmates shall be held in a private
setting unless the security of the institution or the safety of staff will be compromised. The
IDTT interviews may require inmate-patient escorts to classification/interview rooms.
Clinical monitoring and routine interviews, including clinical staff rounds, may be provided
through cell-front contacts as clinically appropriate and depending on the cooperation of the
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Security Housing Unit Mental Health Services Delivery System

inmate. While some therapeutic activities may take place within the cell, whenever possible
treatment activities should take place out of cell.

Mental health treatment in SHU may be provided using mental health programming booths.
All mental health programming booths procured after March 2007, shall conform to design
specifications available through the Prison Industry Authority. Booths are available through
the Prison Industry Authority’s online product catalog at: http://catalog.pia.ca.gov/ using the
search term “Mental Health Programming Booth.”

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Psychiatric Services Unit Mental Health Services Delivery System

CHAPTER 9
Psychiatric Services Unit
A. INTRODUCTION

The Psychiatric Services Units (PSU) were developed to deliver mental health services to
inmates who have been diagnosed as having a serious mental disorder and are serving a
Security Housing Unit (SHU) term. The purpose of the PSU is to assure the effective
delivery of Enhanced Outpatient Program (EOP) services to inmate-patients in a maximum-
security setting. The PSUs are currently located at the Pelican Bay State Prison, California
State Prison, Sacramento, and for female inmates at the California Institute for Women.

B. PROGRAM GOALS AND OBJECTIVES

1. The goal of the PSU is to provide evaluation and treatment of serious mental disorders
that are limiting the ability of inmates with high security needs to adjust to appropriate
institutional placements. The overall objective is to provide clinical intervention to
return the individual to the least restrictive clinical and custodial environment.

2. More specific program objectives for individual cases may include:

a. Providing comprehensive mental health assessment of inmates to determine their

need for treatment and appropriate clinical placement.

b. Providing alternative housing for inmate-patients whose mental health needs limit
their ability to adjust to placement within the SHU.

c. Providing clinical interventions that reduce the inmate-patients’ behavioral problems

and allow re-integration into less restrictive clinical and custodial placements, or, for
inmate-patients approaching release dates, transition to parole status.

d. Assisting inmate-patients in acquiring skills to function more appropriately and

successfully in an institutional setting.

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C. PROGRAM RESPONSIBILITY

1. The overall institutional responsibility for the program rests jointly with the Health Care
Manager (HCM) and the Warden.

2. The coordination of clinical activities within the PSU is the responsibility of the PSU
Senior Psychologist. The PSU Senior Psychologist is responsible for ensuring that the
PSU Mental Health Program is in compliance with the Mental Health Services Delivery
System (MHSDS).

3. The PSU Facility Captain will oversee custodial responsibilities, correctional counseling
services, and classification actions.

4. Decisions on inmate-patient treatment plans, individual inmate-patient program activities,

and level of care are made by the Interdisciplinary Treatment Team (IDTT).

D. POPULATION TO BE SERVED

Any California Department of Corrections and Rehabilitation (CDCR) inmate-patient with a

SHU classification who requires an EOP level of care will be housed in the PSU. Refer to
the Treatment Criteria for the levels of care in the MHSDS Program Guide, Chapter 1,
Overview Program Guide.

E. REFERRAL AND ENDORSEMENT

SHU inmates shall be placed into PSU when a mental health evaluation determines that EOP
level of care is indicated or when an EOP inmate receives an established and approved SHU
term. Staff shall not postpone a referral to the Classification Services Representative (CSR)
for any unresolved disciplinary infractions or District Attorney referral determinations. In
cases where restrictions may apply (e.g., parole violators returned to custody who are
awaiting a parole revocation extension hearing), the inmate-patient will be referred to the
CSR for PSU endorsement and retained at the ASU hub until the revocation process is
complete, then transferred to the PSU if still appropriate.

1. When an inmate-patient has both an active SHU Term and EOP level of care, he will be
referred for placement in a PSU. The referring source must complete a CDCR 128-MH3,
MHSDS Placement Chrono, outlining the need for PSU placement. This CDCR 128-
MH3, MHSDS Placement Chrono, must be signed by the referring institution’s Chief of
Mental Health or designee.

2. The Institutional Classification Committee (ICC) at the referring institution shall make a
referral to the CSR for endorsement.
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3. Once endorsement is obtained, the inmate-patient shall be transferred to a PSU.

4. EOP inmate-patients with an established and approved SHU term shall be transferred
within 30 days of designation to an EOP ASU hub and will be provided EOP care while
awaiting PSU placement.

5. Per exclusionary criteria from the federal court, inmate-patients with one of the diagnoses
listed below shall not be admitted to the PBSP SHU. SHU EOP inmate-patients with one
of the diagnoses shall be placed in a PSU. Any inmate already in a SHU who is
identified as having one of these diagnoses and requiring EOP level of care shall be
transferred within 96 hours out of the PBSP SHU to the PSU, EOP or Correctional
Treatment Center (CTC).

6. If an inmate in the PBSP SHU is diagnosed with one of the exclusionary diagnoses and
requires Correctional Clinical Case Management System (CCCMS) level of care, he shall
be moved within 96 hours to ASU, the PSU, or the CTC. The inmate shall be reviewed
by the ICC and referred for transfer to the California State Prison, Corcoran SHU. If the
inmate-patient’s diagnosis does not meet exclusion criteria, he shall be retained in the
SHU and reviewed weekly by clinical staff. The exclusionary diagnostic criteria are:

• Schizophrenia (any • Major Depressive Disorder

subtype)
• Delusional Disorder • Bipolar Disorder I or II
• Schizophreniform Disorder • Brief Psychotic Disorder
• Schizoaffective Disorder • Mental retardation
• Substance Induced Psychotic • Any mental disorder which
Disorder (excluding intoxication includes inmate being
and withdrawal) actively suicidal
• Psychotic Disorder Not Otherwise • Organic Brain Syndrome
Specified consistent with significant
functional impairment
• Any mental illness characterized by • Severe personality disorder
breaks with reality or perceptions manifested by frequent episodes of
of reality leading to significant psychosis or depression and
functional impairment resulting in significant functional
impairment

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Psychiatric Services Unit Mental Health Services Delivery System

F. CLINICAL SERVICES

Intake Assessment

1. The Senior Psychologist or designee shall appoint a Primary Clinician (PC) for each
inmate-patient admitted to the PSU. The PC shall complete a brief evaluation of the
inmate-patient including a review of the inmate-patient’s mental health history and an
interview in a timeframe clinically determined appropriate but not more than five
calendar days after arrival in the PSU.

2. All inmate-patients will be evaluated by the IDTT prior to the initial ICC but not later
than 14 calendar days after arrival in the PSU.

3. A comprehensive mental health clinical assessment shall be done by the PC and other
IDTT members prior to the initial IDTT. This assessment shall include at minimum:

a. Comprehensive review of the central file and unit health record (UHR) of mental
health treatment needs, including prior placements and medications.

b. Current mental status examination, including diagnosis and level of functioning.

c. Daily observation by mental health and custody staff to assess Activities of Daily
Living and social interactions.

d. Review of medication history and adjustments to current prescriptions (including

involuntary medications as necessary) by staff psychiatrist.

e. Review of disciplinary history and custodial placements by the assigned Correctional

Counselor or Lieutenant.

f. Review specific risk factors for violence toward self and others. This includes a
suicide risk assessment if indicated.

4. The IDTT will make a decision regarding appropriate placement. This decision includes
the following options:

a. Retention for an additional 14 calendar days to determine the

inmate-patient’s appropriateness for PSU placement.

b. Referral to the Department of Mental Health (DMH) for inpatient care. Inmate-
patients shall be referred to the DMH Acute Psychiatric Program (APP) at the
California Medical Facility (CMF) for acute care.

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Psychiatric Services Unit Mental Health Services Delivery System

Inmate-patients requiring intermediate care shall be referred to the DMH Salinas

Valley Psychiatric Program. All female inmate-patients requiring Department of
Mental Health level of care shall be referred to Patton State Hospital.

c. Placement in Mental Health Crisis Beds (short term crisis stabilization, including
initiation of involuntary medications when required).

d. Retention in the PSU Treatment Program if the inmate-patient requires EOP level of
care.

e. Referral to classification committee recommending SHU placement if the inmate

qualifies for CCCMS care or has been discharged from the MHSDS. Inmate-patients
with any of the exclusionary diagnoses listed in Section E, Referral and
Endorsement, Paragraph 6 above, shall not be placed in the PBSP SHU.

f. If the SHU term has been served, general population placement at the appropriate
level of care including EOP.

Interdisciplinary Treatment Team

1. The PSU IDTT shall be chaired by the PSU Senior Psychologist. All clinical decisions
regarding intake, treatment planning, re-justification of level of care, and discharge, are
made by the PSU IDTT. The IDTT is composed of, at minimum:

• Senior Psychologist

• Assigned Psychiatrist

• PSU Facility Captain

• Correctional Counselor II

• Assigned Primary Clinician

• Inmate-patient

Other PSU staff such as a Recreation Therapist (RT), Nursing staff, Licensed Psychiatric
Technician (LPT), Sergeant and Correctional Officers, and/or custody representatives
may attend. A representative from the IDTT (the assigned PC or designee) shall be
present in all classification hearings regarding inmate-patients to provide mental health
input into the classification decision-making process. The inmate-patient shall be
included in the IDTT, unless the inmate-patient refuses to participate. Inmate-patients
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Psychiatric Services Unit Mental Health Services Delivery System

shall not receive a CDCR 115, Rules Violation Report, for not participating in IDTT.
The PC documents the reason for refusal on the CDCR 7230-MH, Mental Health
Progress Notes, in the UHR. The PC is responsible for presenting the inmate-patient’s
concerns to the IDTT.

2. After the initial IDTT, inmate-patients will be evaluated by the IDTT minimally at 60
and 120 days after admission and at least every 90 days thereafter or sooner, whenever
there is a significant change in level of functioning. The IDTT will evaluate treatment
progress, update the treatment plan and review the discharge goals. The PC assigned to
the case will present a case summary with recommendations for continued treatment or
discharge. The results of all IDTT reviews, decisions and recommendations will be
documented in the UHR. Initial and level of care changes are documented on a
CDCR 128-MH-3, Mental Health Placement Chrono, and forwarded to the Correctional
Counselor II.

3. The responsibility for mental health treatment planning for inmate-patients in the PSU
rests with the IDTT. These responsibilities include:

a. Admission decisions

b. Treatment planning

c. Periodic case reviews and re-justifications of treatment at 60, 120 and at least
every 90 days thereafter, or whenever there is a significant change in the inmate-
patient’s functioning that requires a change in the treatment plan.

d. Discharge recommendations – The initial treatment plan and all subsequent treatment
plans shall include a discharge plan and behavioral goals to discharge the inmate-
patient from the PSU to a less intensive level of care.

Primary Clinician

Each inmate-patient in the PSU shall be assigned a PC, usually a Clinical Social Worker
(CSW) or psychologist, although other clinicians may be assigned to cases with special
needs. The PC will maintain active clinical involvement with the inmate-patient, as well as
performing casework functions, including the following:

• Documentation of initial treatment plan and updates

• Regular clinical contacts with assigned inmate-patients

• Ensuring scheduling of periodic IDTT reviews

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Psychiatric Services Unit Mental Health Services Delivery System

• Attendance at IDTT reviews of the inmate-patient

• Referral to, and coordination with, the assigned staff psychiatrist

• Response to CDCR inquiries regarding clinical status of the inmate-patient

G. TREATMENT PROGRAM

1. Each PSU shall have an Operational Plan that describes its treatment program. Each PSU
shall have a behavioral incentive program with criteria for achieving and retaining each
level. Every level has certain privileges. See the Operational Plan at each institution for
a complete description.

2. Treatment Plan

a. Each inmate-patient in the PSU shall have a current individual treatment plan on
CDCR 7388, Mental Health Treatment Plan.

b. The treatment plan shall be reviewed by the IDTT at 60 and 120 days after admission,
at least every 90 days thereafter, or whenever there is a significant change in the
inmate-patient’s functioning requiring a change in the treatment plan.

c. There shall be a CDCR 7230-MH, Mental Health Progress Note, documenting the
IDTT meeting that includes a list of members in attendance.

d. Each treatment intervention shall be directed to a problem on the inmate-patient’s

Problem List.

e. Each treatment intervention shall indicate the provider, type of intervention (e.g.
individual or group therapy), frequency of intervention, outcome objectives, and
specific measurable behavioral goals.

f. Discharge from the EOP or transfer to another level of care will be documented on a
CDCR 128-MH3, Mental Health Placement Chrono.

3. Within the PSU, each inmate-patient shall have an individualized treatment plan that
provides for treatment consistent with the inmate-patient’s clinical needs. Each inmate-
patient will be offered at least ten hours per week of scheduled structured therapeutic
activities as approved by the IDTT. It is recognized that not all inmate-patients can
participate in and/or benefit from ten hours per week of treatment services. For some
inmate-patients, ten hours per week may be clinically contraindicated. For those inmate-
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2009 REVISION 12-9-7
Psychiatric Services Unit Mental Health Services Delivery System

patients scheduled for fewer than ten hours per week of treatment services, the PC shall
present the case and recommended treatment program to the IDTT for approval. The
CDCR 7388, Mental Health Treatment Plan ,must include a detailed description of the
diagnosis, problems, level of functioning, medication compliance, and rationale for
scheduling fewer than ten hours. For inmate-patients who are scheduled for fewer than
ten hours of treatment activities per week, the IDTT shall meet at least monthly and be
responsible to review and increase the treatment activities, and consider higher level of
care as appropriate.

REQUIRED TREATMENT

• Individual treatment planning involves a meeting of the IDTT and the

inmate-patient at least every 90 days for the purpose of identifying treatment needs,
developing treatment plans, assessing treatment progress, and updating/revising
individual treatment plans in accordance with the inmate-patient’s needs and progress.

• Weekly PC contact (either individually or in group psychotherapy) with assigned inmate-

patients. Individual clinical contacts shall occur at least every other week.

• Medication evaluation and management

• A psychiatrist shall evaluate each EOP inmate-patient at least monthly to address

psychiatric medication issues.

• Refer to Inmate Medical Services Policies and Procedures, Volume 4, Chapter 11,
Medication Management, regarding procedures for administration of medication,
medication refusals, Directly Observed Therapy, and other aspects of medication
administration.

• Refer to MHSDS Program Guide, Chapter 5, Mental Health Crisis Bed, for information
on involuntary medication administration (Keyhea).

OTHER TREATMENT ACTIVITIES

• Individual psychotherapy

• Group therapy such as Anger Management, Stress Management, Offense-related Issues,

Current Events

• Medication education

• Crisis intervention
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2009 REVISION 12-9-8
Psychiatric Services Unit Mental Health Services Delivery System

• Pre-release planning

• Monitoring and assistance with daily living skills

• Cognitive Behavioral Therapy directed to specific behaviors or symptoms

• Recreational activities

• Vocational and pre-vocational training as available

• Education as available

• 12-Step Program and other substance abuse treatment

4. CCCMS – Pelican Bay State Prison

PSU inmate-patients identified as requiring CCCMS level of care shall be transferred as

soon as possible to a SHU that provides CCCMS care. Inmate-patients with any of the
exclusionary diagnoses listed in Section E, Referral and Endorsement, Paragraph 6
above, shall not be placed in the PBSP SHU. Pending transfer, inmate-patients will
receive the following services within the PSU:

a. Assignment of a PC for the purposes of regular monitoring and program review. The
PC shall see the inmate-patient at least every other week or more often if clinically
indicated.

b. Monitoring of symptoms by clinical staff

c. Development or review of an individualized treatment plan

d. Medication, treatment and monitoring

e. Monitoring of daily living skills

f. Pre-release planning

g. Consultation regarding behavior deterioration or other contingency management

procedures

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2009 REVISION 12-9-9
Psychiatric Services Unit Mental Health Services Delivery System

H. DOCUMENTATION

1. Clinical documentation will occur as required. This includes but is not limited to:

a. Initial assessment on CDCR 7386, Mental Health Evaluation, and initial treatment
plan and updates on CDCR 7388, Mental Health Treatment Plan, by the PC.

b. CDCR 7230-MH, Mental Health Progress Notes, documenting weekly contacts and
any other treatment interventions done by all staff. Group therapy shall be
documented monthly. This documentation shall include time attended and a
description of the inmate-patient’s level of participation.

c. Completion of CDCR 128 MH3, Mental Health Placement Chrono, whenever there
is a change in level of care.

Documentation on CDCR 114-A, Detention/Segregation Record

The CDCR 114-A, Detention/Segregation Record (commonly referred to as the Isolation

Log), is a daily record of the inmate-patient’s activities and is used to note the inmate-
patient’s behavior as well as to document services provided. The activities report shall
record the inmate-patient’s daily activities such as showers, yard, meals, visits, clothing/linen
exchange and supplies. This form shall be used to record attendance at treatment activities
such as individual and group therapy, and recreational therapy. The CDCR 114-A,
Detention/Segregation Record, shall also include a list of approved scheduled structured
therapeutic activities. All relevant chronos shall be attached. Staff may also document their
observations and comments regarding the inmate-patient and his program. Significant events
affecting the inmate-patient’s treatment program should be recorded on this form such as
those listed below.

1. Unit staff shall initiate a CDCR 114-A, Detention/Segregation Record, for all inmate-
patients housed in the unit.

2. Unit officers on every shift shall fill out the CDCR 114A, Detention/Segregation Record,
noting the inmate-patient’s activities during their shift. The correct date and time are
critical factors. When a CDCR 114-A, Detention/Segregation Record, is completely
filled out, the last officer making the entry will prepare and begin a new form.

3. A daily chronological report of each PSU inmate-patient will be kept on the CDCR 114A
Detention/Segregation Record, which will include meals, showers, yard, visits, law
library, supplies, clothing and linen issue, or other pertinent information.

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2009 REVISION 12-9-10
Psychiatric Services Unit Mental Health Services Delivery System

4. When an inmate-patient is escorted to a CDCR 115, Rules Violation Report disciplinary

hearing, the CDCR 114-A, Detention/Segregation Record, will be taken to the hearing.
The Hearing Officer or Senior Hearing Officer, will note the CDCR 115, Rules Violation
Report log number, findings, and disposition on the CDCR 114-A, Detention/Segregation
Record.

5. When an inmate-patient is seen or his/her case is heard by ICC, the CDCR 114-A Form
will be taken with the inmate-patient and given to the Committee. The Correctional
Counselor II will note on the CDCR 114-A, Detention/Segregation Record, whether the
inmate-patient attended or refused to attend the Classification meeting and the action
taken.

6. A classification disposition such as “Confined to Quarters”, loss of privileges, or a

restriction, will be noted on the CDCR 114-A, Detention/Segregation Record, and
continued on successive CDCR 114-A, Detention/Segregation Record, until the action
has expired.

7. Other possible entries may include canteen, legal mail, packages, and issuance of
property or cell moves/searches.

8. Staff making the entry on the CDCR 114-A, Detention/Segregation Record, will clearly
and legibly sign their first initial and last name.

9. All of the CDCR 114-A, Detention/Segregation Record, are to be kept in a folder(s) that
are maintained within the housing unit and are available to all staff who interact with the
inmate-patient. On Sunday of each week, First Watch staff will perform an audit of each
inmate-patient’s CDCR 114-A, Detention/Segregation Record, and prepare a unit
compliance report. These reports will be forwarded to the PSU Facility Captain for
review and retention.

Unit Activity Log

Custody staff must record and share with the clinical staff any observations that may impact
an inmate-patient’s treatment plan or provide insight into the success or ineffectiveness of
the current treatment plan. This is particularly critical for First Watch staff. Each housing
unit shall maintain a logbook reflecting daily activities and information of interest to all staff.
All unusual activities will be recorded in the logbook. Observations of unusual or aberrant
behavior shall be recorded via a CDCR 128-B, Informational Chrono. Behavior that
constitutes an infraction of institutional rules or policies may be recorded via a CDCR 115,
Rules Violation Report.

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2009 REVISION 12-9-11
Psychiatric Services Unit Mental Health Services Delivery System

I. CUSTODIAL OPERATIONS

Classification

The Operational Plan of each PSU will contain a detailed description of applicable custody
procedures. These procedures shall be in compliance with relevant California Code of
Regulations, Title 15, and Department Operational Manual requirements.

Removal from a Cell

1. Escorts – Inmate-patients housed in the PSU shall be assigned escorts and program status
at the ICC review. All inmate-patients shall be escorted at all times when they are
outside their respective housing unit sections. Individual escorts shall be performed by a
minimum of two custody officers, and the inmate-patient shall be secured with
mechanical wrist restraints at all times during the escort.

2. The inmate-patient may be recommended for additional escort status by the IDTT or
through the disciplinary process. This shall be approved by the PSU Facility Captain.

Out-of-Cell Exercise

All inmate-patients assigned to the PSU shall be offered a minimum of ten hours of out-of-
cell exercise each week, which may include supervised recreational therapy. An inmate-
patient’s yard designation shall be established by the ICC with input from the IDTT as part
of the individual treatment plan.

J. PHYSICAL PLANT

Mental health treatment in Psychiatric Services Units may be provided using secure modular
treatment units. All modular treatment units procured after March 2007, shall conform to
design specifications available through the Prison Industry Authority (See Attachment 7:
Mental Health Modular Treatment Unit Schematic Design and Photo)

K. SICK AND DENTAL CALL AND MENTAL HEALTH REFERRALS

1. The PSU shall have mental health staff on duty during Second Watch. Each day, the
assigned physician, Registered Nurse (RN) or LPT will tour the unit and assess any
inmate-patient with medical/dental needs.
2. During Second Watch, inmate-patients requiring medical attention will be referred to the
PSU RN.

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2009 REVISION 12-9-12
Psychiatric Services Unit Mental Health Services Delivery System

3. Staff Referral: Referrals may be made on CDCR 128 MH5, Mental Health Referral
Chrono.

4. Inmates who receive a CDCR 115, Rules Violation Report for Indecent Exposure or
Intentionally Sustained Masturbation Without Exposure shall be referred for all of the
following:

• CDCR 115-MH Rules Violation Report: Mental Health Assessment;

• A mental health assessment shall be completed within 24 hours to rule-out

decompensation and/or intoxication. The referral shall be made by telephone to the
local Chief of Mental Health who shall arrange this assessment; and,

• To the inmate-patient’s PC.

5. Self referral: These requests are made on a CDCR 7362, Health Care Services Request.
Mondays through Fridays, the following shall occur:

a. A health care staff member shall collect all the CDCR 7362, Health Care Services
Request, each day from the designated areas.

b. Upon receipt of the collected forms, nursing staff shall initial and date each
CDCR 7362, Health Care Services Request.

c. The CDCR 7362, Health Care Services Requests, shall be delivered to the designated
program representative in mental health services, dental services, or pharmacy
services for same-day processing.

6. On weekends and holidays, the following shall occur:

a. The Triage and Treatment Area (TTA) RN shall review each CDCR 7362, Health
Care Services Request, for medical, dental, and mental health services, shall establish
priorities on an emergent and non-emergent basis, and shall refer accordingly.

b. If a physician, mental health clinician, or dentist is not available, the physician on call
or psychiatrist on call shall be contacted.

7. Inmates shall be seen by a mental health clinician or on weekends by the physician or

psychiatrist on call within the clinically determined time frame.

• Emergent: Emergency cases shall be seen immediately or escorted to TTA.

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Psychiatric Services Unit Mental Health Services Delivery System

• Urgent: Urgent cases shall be seen within 24 hours.

• Routine: Other cases shall be seen within five calendar days.

NOTE: When an IDTT determines that an inmate-patient requires treatment of

exhibitionism, that inmate-patient’s level of care shall be changed to CCCMS (or higher if
appropriate), bypassing the standard referral process.

L. DISCHARGE PROCEDURES

1. At the time of admission to the PSU, a preliminary discharge plan shall be developed
based on the clinical and security needs of the inmate-patient as well as the
inmate-patient’s SHU term.
2. Inmate-patients admitted to the PSU may be discharged to the SHU to complete their
term when they no longer require an EOP level of care. They will be transferred to a
CCCMS level of care in a SHU for at least six months if they no longer require EOP
level of care. Inmate-patients with one of the exclusionary diagnoses listed in Section E,
Referral and Endorsement, Paragraph 6 above, shall not be placed in the PBSP SHU.
Inmate-patients in the PBSP PSU recommended by the IDTT for CCCMS are scheduled
for the next available ICC and referred for transfer to the COR SHU. Pending transfer,
inmate-patients are housed in the ASU.

3. Inmate-patients who complete their SHU term and still require EOP care will be
discharged to a general population EOP for continuing mental health treatment. The PSU
primary clinician will document recommendations regarding the inmate-patient’s specific
treatment needs, including any concerns about facilitating the inmate-patient’s successful
transition to general population. The receiving EOP IDTT will consider documentation
by the PSU clinician in developing the inmate-patient’s treatment plan. The treatment
plan for inmate-patients transferred from PSU to GP-EOP shall include services provided
to aid in the transition to the general population environment.

4. Inmate-patients may be referred to a DMH program as clinically indicated. Generally,

given the security requirements of PSU inmate-patients, this will be to the Salinas Valley
Psychiatric Program for intermediate inpatient care for inmate-patients with a history of
being highly assaultive, predatory, or a high escape risk. Inmate-patients who do not
present these security risks may be referred to Atascadero State Hospital. Inmate-
patients requiring acute inpatient care should be referred to the DMH APP at CMF.

5. Treatment recommendations upon discharge from the PSU shall be made by the IDTT
and documented on a CDCR 128 MH3, Mental Health Placement Chrono.

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2009 REVISION 12-9-14
Psychiatric Services Unit Mental Health Services Delivery System

6. The ICC shall review the discharge recommendations of the IDTT with the PSU Senior
Psychologist or designee present considering both the clinical and custody needs of the
inmate-patient. The decision of the ICC shall be documented on a CDCR 128-G Chrono.

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2009 REVISION 12-9-15
Suicide Prevention and Response Mental Health Services Delivery System

CHAPTER 10
3B

Suicide Prevention and Response

0B

A. INTRODUCTION
7BU

It is the goal of the California Department of Corrections and Rehabilitation (CDCR) Suicide
Prevention and Response Focused Improvement Team (SPR FIT) to prevent inmate deaths
due to suicide. Suicide is defined as an intentional self-injurious behavior that causes or leads
to one’s own death. CDCR recognizes that prevention of suicide involves a team effort by
every employee regardless of professional discipline or job title.

To accomplish this goal, each institution shall implement CDCR Division of Correctional
Health Care Services (DCHCS) policies, described herein, regarding suicide prevention and
response, via written operating procedures. The purpose of the policies is to:

• Establish standards of intervention and care

• Establish ongoing education and training for clinical, custodial, and administrative staff.

• Provide instructions and guidance for establishment and maintenance of the SPR FIT.

• Review suicide deaths regarding systems issues, clinical care issues, and custody
response.

• Ensure that quality improvement (also known as corrective action) plans are drafted and
implemented, when indicated, to reduce the incidence of preventable suicides, improve
the delivery of quality care, improve the involvement of non-healthcare staff, and
contribute to the ongoing education and training.

This chapter of the Mental Health Services Delivery System (MHSDS) Program Guide is
divided into the following subsections:

B. Suicide Prevention and Response Project

C. Training for Staff

D. Clinical Care Services

1. Suicide Risk Assessment

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Suicide Prevention and Response Mental Health Services Delivery System

2. Interventions for Suicidal Ideation and Threats, Self-Injurious Behaviors and Suicide
Attempts

a. Procedures for Suicide Precautions

b. Procedures for Suicide Watch

c. Response to Self-Injurious Behaviors and Suicide Attempts

E. Suicide Reporting

F. Suicide Death Review

G. Mental Health Evaluation Component for a Rules Violation Report

B. SUICIDE PREVENTION AND RESPONSE PROJECT

Policy

CDCR DCHCS

The CDCR DCHCS Quality Management Committee (QMC) shall maintain a DCHCS
Mental Health Program (MHP) Subcommittee that provides oversight to and coordination of
the statewide mental health program to achieve statewide strategic objectives. The DCHCS
MHP Subcommittee shall plan, develop, manage and improve timely access to and
effectiveness of clinical services related to the mental health program. The DCHCS MHP
Subcommittee shall also cooperate with, and respond in a timely manner to, any requests from
the DCHCS Emergency Response & Death Review (ERDR) Subcommittee following a
suicide.

The DCHCS MHP Subcommittee shall establish and maintain a statewide SPR FIT. The
DCHCS MHP Subcommittee shall appoint a DCHCS SPR FIT Coordinator. The Coordinator
shall be a licensed physician, psychologist, social worker, nurse practitioner, or registered
nurse (RN).

Local Institutions

Each Local QMC shall maintain a Local MHP Subcommittee that provides oversight to and
coordination of the local mental health program to achieve statewide strategic objectives.
Each Local MHP Subcommittee shall plan, develop, manage and improve timely access to
and effectiveness of clinical services related to the mental health program. Each Local MHP
Subcommittee shall also cooperate with, and respond in a timely manner to, any requests from
the Local ERDR Subcommittee following a suicide.
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2009 REVISION 12-10-2
Suicide Prevention and Response Mental Health Services Delivery System

Each Local MHP Subcommittee shall establish and maintain a Local SPR FIT. Each Local
MHP Subcommittee shall appoint a Local SPR FIT Coordinator. The Coordinator shall be a
licensed physician, psychologist, social worker, nurse practitioner, or RN.

Purpose

The DCHCS SPR FIT and each Local SPR FIT shall provide employees with training and
guidance with regard to suicide prevention, response, reporting, and review for the purpose of
reducing the risk of inmate suicides.

Procedure

1. Reporting Relationships
8B

The DCHCS SPR FIT shall:

• Send a management report, at least once a month, to the DCHCS MHP

Subcommittee.
• Receive formal communication, at least once a month, from the DCHCS MHP
Subcommittee.
• Each local SPR FIT shall:
• Send a management report, at least once a month, to the local MHP Subcommittee.
• Receive formal communication, at least once a month, from the local MHP
Subcommittee.

2. Responsibilities
9B

a. The DCHCS SPR FIT shall:

1). Provide oversight and guidance for each Local SPR FIT regarding time
sensitive due dates.
2). Monitor implementation and compliance with all CDCR policies and
procedures relating to suicide prevention and response.
3). Provide for the planning, development, and implementation of statewide
training, in collaboration with the DCHCS Training Department, regarding the
issue of suicide prevention and response.
4). Monitor and track all suicides statewide.
5). Provide for the selection and dispatch of a mental health suicide reviewer
(MHSR) after a suicide occurs.

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2009 REVISION 12-10-3
Suicide Prevention and Response Mental Health Services Delivery System

6). Provide oversight, assistance, coordination, and supervision of MHSR activities

and reports.
7). Track and analyze demographic and clinical information received from the
DCHCS ERDR Subcommittee for improving suicide prevention and response
processes.
b. Each Local SPR FIT shall:

1). Ensure implementation and compliance with all CDCR policies and procedures,
relating to suicide prevention and response, at their institution.
2). Be responsible for updating local operating procedures (LOP) to ensure
consistency with DCHCS policies regarding suicide prevention and response.
The institution’s Suicide Prevention and Response LOP shall be updated at least
annually and sent to the DCHCS through the standard Quality Management
process for review and approval.
3). Implement training, in collaboration with the local In-Service Training (IST)
unit, regarding the issue of suicide prevention and response.
4). Review Suicide Watch and precaution procedures, including use of video
cameras (used as a supplement to direct visual observation), to ensure they are
being carried out consistent with operating procedures.
5). Work with the Local ERDR Subcommittee to review all suicides and those
suicide attempts, in which Cardiopulmonary Resuscitation (CPR) and/or other
medical procedures were performed, as well as custody cell entry and cut-down
procedures.
6). Monitor and track all suicide gestures, suicide attempts, self-mutilations, and
deaths. Monitoring and tracking of suicide attempts should include a review of
the appropriateness of treatment plans and five-day follow-ups.
7). Review and track all 5-day clinical follow-up treatment plans and custody
wellness check procedures. The Mental Health Tracking System (MHTS) shall
be used to track all clinical five-day follow-ups.
8). Ensure all required documentation for suicide death reporting is forwarded to
DCHCS in adherence with time-sensitive due dates.
9). Provide assistance for the activities of the visiting MHSR.
10). Provide oversight for the implementation of DCHCS-issued quality
improvement plans (QIP) with input and assistance from the Local MHP and
Local ERDR Subcommittees.
3. SPR FIT Membership
DCHCS shall include: Local shall include:

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2009 REVISION 12-10-4
Suicide Prevention and Response Mental Health Services Delivery System

• SPR FIT Coordinator (Chairperson) • SPR FIT Coordinator (Chairperson)

• Chief Psychiatrist • Chief Psychiatrist*
• Chief Psychologist • Chief Psychologist*
• Nurse Consultant • Supervising RN
• Designated Facility Captain • Sr. Licensed Psychiatric Technician
(LPT) or LPT (preferably from
Administrative Segregated Unit (ASU)
• Health Program Coordinator
• Correctional Health Services
Administrator
• DMH Coordinator

DCHCS may also include, but is not

U Local may also include, but is not
U

limited to:
U limited to:
U U

Senior Psychiatrist Senior Psychiatrist

• Senior Psychologist • Senior Psychologists
• Administrative/Clerical Support • Staff Psychiatrist: Mental Health Crisis
Bed (MHCB)/Outpatient Housing Unit
(OHU)
• Analyst Support • Staff Psychologist: MHCB/OHU
• Standards and Compliance Coordinator
• Litigation Coordinator
• Facility Captain
• ASU Lieutenant/Sergeant
• Reception Center Lieutenant/Sergeant
• Classification and Parole
Representative
• In Service Training Lieutenant
• Administrative/Clerical Support
• Keyhea Coordinator

*Senior Psychiatrist/Senior Psychologist attendance shall meet quorum requirement in

institutions without Chief Psychiatrist/Chief Psychologist positions.

4. Frequency of Meetings
1B

The DCHCS SPR FIT shall meet at least, but is not limited to, once a month.

Each Local SPR FIT shall meet at least, but is not limited to, once a month.
5. Attendance Requirements
12B

A quorum consists of the above listed mandatory members.

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2009 REVISION 12-10-5
Suicide Prevention and Response Mental Health Services Delivery System

6. Management Reports

The DCHCS SPR FIT shall submit a complete, standardized management report to the
DCHCS MHP Subcommittee by the 5th day of each month.

Each Local SPR FIT shall submit a complete, standardized management report to the
Local MHP Subcommittee by the 5th day of each month.

C. TRAINING FOR STAFF

Definitions

Suicidal ideation: Thoughts of suicide or death, which can be specific or vague, and can
include active thoughts of committing suicide or the passive desire to
be dead.
Suicidal intent: The intention to deliberately end one’s own life.
Self-injurious A behavior that causes, or is likely to cause, physical self-injury.
behavior:
Self-mutilation: An intentional self-injurious behavior without suicidal intent. The
purpose of the behavior may be to gain attention, relieve stress, or
experience pain. Self-mutilation can result in serious injury or
accidental death.
Suicide gesture: An intentional self-injurious behavior, accompanied by suicidal
ideation and/or intent, which is unlikely to cause death. The purpose
of the behavior may be to gain attention and/or experiment with the
possibility of suicide. Suicide gestures may indicate increased suicide
risk.

Suicide attempt: An intentional self-injurious behavior, which is apparently designed to

deliberately end one’s life, and may require medical and/or custody
intervention to reduce the likelihood of death or serious injury.
Suicide: An intentional self-injurious behavior that causes or leads to one’s
own death.
All CDCR health care and custodial employees at the local institutions shall attend updated
training on suicide prevention and response at least once annually. Suicide Prevention and
Response training shall be part of the new employee orientation provided by mental health

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2009 REVISION 12-10-6
Suicide Prevention and Response Mental Health Services Delivery System

staff in collaboration with the IST unit at each local institution. New correctional officers
shall receive this training at the Basic Correctional Officer Academy.

The suicide prevention and response training shall include the following elements:

• Suicide risk assessment

• Suicide methods awareness
• Interventions for suicidal ideation, threats, gestures, and attempts
• Suicide reporting and reviews
• Mental health evaluations for rules violation reports

Clinical and custody staff shall receive specialized training with respect to their particular
4B

roles in responding to self-injurious behaviors, suicide attempts, and suicides.

D. CLINICAL CARE SERVICES

U

This subsection addresses the various clinical care services for inmates regarding suicide
prevention and response. Included are the assessment of risk for suicide, the utilization of a
form for documenting the risk factors, and clinical interventions such as procedures for
Suicide Precaution and Suicide Watch, and responses to suicide attempts and to suicide.

Education regarding the methods utilized by inmates when attempting suicide shall be taught
as part of the suicide prevention and response training.

Employee strategies for maintaining a safe environment, and for ensuring that other policies
and procedures relative to suicide prevention and response, such as regarding medication
distribution and inmate-patient compliance, are detailed in the relevant chapters and sections
of the complete Inmate Medical Services Program Policies & Procedures.
U U

Any CDCR employee who becomes aware of an inmate’s current suicidal ideation,
threats, gestures, self-injurious behaviors or suicide attempts shall immediately notify a
member of the health care staff. The inmate shall be placed under direct observation,
per local custody operating procedure, until a clinician trained to perform a suicide risk
assessment (psychiatrist, psychologist, clinical social worker, primary care physician,
nurse practitioner, or RN) conducts a face-to-face evaluation.

1. Suicide Risk Assessment

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2009 REVISION 12-10-7
Suicide Prevention and Response Mental Health Services Delivery System

All inmates are observed for suicide risk. Suicide risk assessment is critical to successful
suicide prevention. Inmate-patients enrolled in the MHSDS shall be regularly monitored
for risk of suicide as clinically appropriate. When an inmate expresses current suicidal
ideation, or makes threats or attempts, a suicide risk assessment shall be made by
collecting, analyzing, and documenting data. Documentation is achieved by utilizing the
CDCR standardized Suicide Risk Assessment Checklist (SRAC) and by clinician notation
in the Unit Health Record (UHR). When an inmate expresses chronic suicidal ideation
without intent or plan, the clinician may document that no change in suicide risk has
occurred since completion of the prior SRAC, instead of completing a new SRAC.

These clinicians shall be trained to perform a suicide risk assessment and complete
the SRAC:

• psychiatrists • primary care physicians

• psychologists • nurse practitioners
• clinical social workers • RNs

This shall occur during the specialized training provided for clinical staff who are
receiving either the new employee orientation or completing the required annual training
module, or when determined necessary by supervisory and/or management staff.

When a primary clinician is scheduled to be available on-site, he or she shall be

responsible for completing a SRAC. When a mental health clinician is not available, any
other staff member who has been trained by CDCR in suicide risk assessment may
complete the SRAC.

A RN completing the SRAC shall collect data related to suicide risk and protective factors
and refer the patient and data collected to a mental health clinician for further evaluation
to determine level of risk.

At a minimum, a written suicide risk assessment using a SRAC shall be completed:

• Every time an inmate has an initial face-to-face evaluation for suicidal ideation,
gestures, threats, or attempts, by a clinician trained to complete the SRAC.
• By the referring clinician prior to placement of an inmate-patient into an OHU for
continued suicide risk assessment or into a MHCB for suicidal ideation, threats, or
attempt.
• After hours, on weekends and holidays, on call clinicians shall conduct a
face-to-face assessment of suicide risk prior to releasing an inmate to any housing
without suicide watch or precaution.

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2009 REVISION 12-10-8
Suicide Prevention and Response Mental Health Services Delivery System

• After hours, on weekends and holidays, when the referring clinician has not completed
an SRAC, by the clinician providing coverage, by the next day, for those inmate-
patients placed into an OHU or MHCB.
• By the associated Interdisciplinary Treatment Team (IDTT) and/or clinician for all
inmate-patients placed into an OHU, for mental health reasons, or MHCB, for any
reason, upon decision to release or discharge.
• Subsequent to release from an OHU placement that was for the purpose of continued
suicide risk assessment, or a MHCB placement for the reason of suicidal ideation,
threats, or attempts, at a minimum of every 90 days for a twelve month period, by a
mental health clinician.
• Within 72 hours of return from a Department of Mental Health (DMH) facility, or
within 24 hours if clinically indicated based on new arrival screening.
• Any time the medical and mental health screening of a new arrival to an institution
indicates a current or significant history, over the past year, of suicide risk factors,
ideation, threats, or attempts.
• Pursuant to Department Operating Manual (DOM), Article 41, Prison Rape
Elimination Act Policy, for victims of sexual assault, within four hours after the
required sexual assault forensic examination.

The clinician shall use the SRAC when documenting a suicide risk assessment, in
addition to making a notation in the UHR. At a minimum, the following categories
shall be used to assess potential risk:

a. Static Risk Factors (unchanging, historical):

U

• Ethnicity
• History of lewd and lascivious acts with a child and/or killed a child
• History of violence
• History of substance abuse
• Suicide ideation and/or threats in past (when and method)
• Previous suicide attempts (when and method)
• Family history of suicide
• History of mental illness with Axis I diagnosis
• High profile case

b. Slowly Changing Risk Factors (long-term risk factors):

U

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2009 REVISION 12-10-9
Suicide Prevention and Response Mental Health Services Delivery System

• First prison term

• Long or life sentence; three strikes
• History of poor impulse control and/or poor coping skills
• Early in prison term
• Known new court proceedings and/or disciplinary actions
• Current term in ASU, Security Housing Unit, or Psychiatric Services Unit
• Level IV custody score
• Chronic, serious or terminal illness

c. Dynamic Risk Factors (short-term risk factors that require ongoing assessment):
U

• Recent suicidal ideation - acute or • Recent rejection and/or loss

chronic
• Recent release from psychiatric • Single-cell placement
hospital
• Sudden calm following ideation or • Significant current impulsivity
attempt
• Anxious and/or agitated and/or fearful • Recent suicide attempt or self-injury
• Disturbance of mood (depression or • Well-planned, highly lethal, attempt
mania) or ideation
• Unstable or labile affect • Hoarding and/or cheeking
medication
• Current insomnia and/or poor appetite • Poor compliance with treatment
and/or medication
• Lack of perceived support system • Recent trauma and/or threat to self-
esteem
• Hopelessness and/or helplessness • Recently assaultive or violent
• Feelings of guilt and/or worthlessness • Pre-death behavior: note, gives
things away

• Fearful for safety • Disclosure of adverse court hearings

• Anniversary of important loss

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2009 REVISION 12-10-10
Suicide Prevention and Response Mental Health Services Delivery System

d. Protective Factors:
U

• Family support • Adequate insight

• Children at home • Realistic life plan

• Religious support • Exercises regularly
• Spousal support • Group activities
• Supportive friends • Job assignment
• Helping others • Other noted protective factors

Clinicians shall utilize their best clinical judgment and make a summary of the relative
risk for suicide via an appropriate descriptor, such as “No apparent significant risk, Low
Risk, Moderate Risk, High Risk, or Conditional Risk” based on a combination of the
above factors, an interview of the inmate, and all other relevant information available to
them. Peer consultation is encouraged when information collected for making a suicide
risk assessment is ambiguous. The clinician shall then make a recommendation regarding
the appropriate level of care required. They shall document their summary,
recommendations, and plan on the SRAC and with appropriate notation in UHR.
Treatment recommendations should be as specific as possible, leaving as little room as
possible for misinterpretation or confusion. A brief rationale for each recommendation
shall be provided. They shall also address how the treatment plan will be implemented
and any required follow-up procedures.

Peer Consultation
U

Peer consultation can be one of the most important clinical and legal safeguards a
practitioner has at his or her disposal, especially when dealing with ambiguous cases.

Sources of peer consultation include, but are not limited to:

• Other clinical members of an IDTT

• Other colleagues working at the institution
• Clinical supervisors

When evaluating for suicide risk, peer consultation is not always necessary. However, in
those cases where there is clinical uncertainty about ambiguous issues, it can be of benefit
for validating or challenging ideas and assumptions. Another clinician’s opinion may also
uncover important additional information. Peer consultation does not absolve a clinician
of responsibility for any decision that he or she ultimately makes, nor does it require the

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2009 REVISION 12-10-11
Suicide Prevention and Response Mental Health Services Delivery System

clinician to change his or her initial opinion. It is to the clinician’s advantage to consult
with peers. It demonstrates that the clinician cared enough about the case to seek another
opinion and that he or she utilized prudent and reasonable judgment.

Suicide History Tracking

In order to ensure quality and continuity of care for high-risk mental health inmate-
patients, all institutions shall track the suicidal history of inmate-patients using MHTS.

2. Interventions for Suicidal Ideation, Threats, and Attempts

Any CDCR employee who becomes aware of inmate suicidal ideation, threats, or attempt
shall immediately notify a member of the health care staff. The inmate shall be placed
under direct observation, per local custody operating procedure, until a clinician trained to
perform a suicide risk assessment (psychiatrist, psychologist, clinical social worker,
primary care physician, nurse practitioner, or RN) conducts a face-to-face evaluation.

Recommendation for placement or admission

Health care staff who assess a patient as a significant suicide risk shall initiate procedures
to admit the patient into a MHCB.

A physician, licensed psychologist, or nurse practitioner may place an inmate-patient into

an OHU for continued suicide risk assessment. Custody staff shall inspect the cell to
ensure that there are no known or obvious safety hazards present. When an inmate-patient
in the OHU is determined to require MHCB level of care, including Suicide Precaution
and/or Watch, he or she shall be recommended for admission to that higher level of care.
The established timeframe for MHCB transfers is 24 hours from the time a physician or
licensed psychologist determines the need for a MHCB.

When an inmate-patient verbalizes suicidal ideation without other signs and symptoms of
increased risk of suicide, the mental health clinician is responsible for evaluating any
contributing environmental stressors and communicating with custody staff and
supervisors regarding any potentially solvable custody issues.

Pending transfer out of the OHU direct observation by clinical and/or custody staff shall
be provided, consistent with requirements for Suicide Precaution or Watch, until the
inmate-patient is transferred.

If there is a difference of opinion, between the clinician who makes the recommendation
and the receiving/admitting clinician, regarding admission into a MHCB or placement into
an OHU, then

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2009 REVISION 12-10-12
Suicide Prevention and Response Mental Health Services Delivery System

a. A third opinion and final decision shall be obtained by consultation with a Chief or
Senior Psychiatrist, or a Chief or Senior Psychologist.

b. When a Chief or Senior Psychiatrist, or a Chief or Senior Psychologist is not

available, the third opinion and final decision shall be obtained from Chief Medical
Officer or Chief Physician and Surgeon.

c. The default shall be to place the inmate into the MHCB or OHU in the event that
there is not a Chief, Senior, or Chief Medical Officer (CMO) available to supply the
third opinion and final decision.

Required Documentation
U

The clinician who recommends an inmate for placement into an OHU for continued
suicide risk assessment or into a MHCB for active suicidal ideation, or suicide threats or
attempts, shall provide to the accepting clinician both a completed SRAC, the patient’s
medication administration record, and a written transfer summary that contains:

• Date and time of referral

• Identifying information: inmate name, CDCR number, date of birth, age, and race
• Current level of care and housing location
• Current diagnosis: all five Diagnostic and Statistical Manual (DSM) axes
• Reason for referral: suicidal ideation and/or threat and/or attempt
• History of present illness
• Mental status examination
• Brief psychiatric history including previous OHU, MHCB, or DMH placements
• History of previous suicidal ideation, threats, and/or attempts
• Treatment recommendations
• Contact information for the referring clinician
After hours and on weekends and holidays, the clinician providing coverage shall
complete the required documentation by the next day.

Health Care Cost and Utilization Program

U

As an integral part of the DCHCS, the Health Care Cost and Utilization Program provides
timely and accurate information, and analysis of health care service delivery data to assist
in the provision of cost effective, quality health care. To facilitate this effort, the clinician
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2009 REVISION 12-10-13
Suicide Prevention and Response Mental Health Services Delivery System

who admits an inmate-patient to a MHCB shall record two codes for the diagnosis on the
CDCR 7388, Mental Health Treatment Plan. One code shall be from the most current
edition of the Diagnostic and Statistical Manual of Mental Disorders and the other shall to
be from the most current edition of the World Health Organization's International
Classification of Diseases Code.

Additional Treatment Options

In addition to inpatient care, the clinician may recommend another type of treatment such
as daily or weekly contact by a mental health clinician, intensive individual
psychotherapy, resolution of a stressful environmental issue or interpersonal conflict, or
other clinically appropriate intervention. Other interventions may be considered such as
notifying a correctional counselor of the inmate-patient’s desire or need to contact a
family member. Alternative interventions, such as a housing change, may be considered
in consultation with custody staff. Clinical and custody staff shall work together to
develop an intervention to address the inmate’s concerns and reduce the risk of suicide.

Physical Restraints and Seclusion

Physical restraints or placement in seclusion may be utilized to protect an inmate-patient

from imminent self-harm, if clinically indicated, and other treatment measures are
ineffective. A staff member shall be assigned to provide one-on-one direct visual
observation of all inmate-patients in physical restraints. Refer to MHSDS Program Guide,
Chapter 5, Mental Health Crisis Bed, for complete descriptions of procedures. In
accordance with Health and Safety Code 1180, a clinical and quality review shall be
conducted for each episode of the use of seclusion or restraints.

Inmate and Cell Search

Before placing an inmate-patient in a room for Suicide Precaution or watch, a custody

officer shall conduct a complete body search.

Call-light cords, nightstands, bed frames, and sheets shall be removed, by order of a
clinician, from the room unless the inmate is in physical restraints. Only a safety (no-tear)
mattress, a safety (no-tear) blanket, and a safety (no-tear) smock/gown shall be provided
and placed directly on the floor.

Additional inmate-patient clothing and furnishing items, while on Suicide Watch or

Precaution, shall be allowable by a clinician’s order.

Custody staff shall conduct a complete cell search before placing an inmate in a cell.

Suicide Precaution and Suicide Watch

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2009 REVISION 12-10-14
Suicide Prevention and Response Mental Health Services Delivery System

When clinically indicated, an inmate with active suicidal ideation, threats, or attempt shall
be placed in an MHCB on Suicide Precaution or Suicide Watch. These are methods used
to provide a safe environment and prevent the inmate from harming him or herself or
others. Suicide Watch and Suicide Precaution procedures shall be a joint responsibility of
custody and health care staff. A close working relationship shall be maintained between
custody and health care staff to ensure the safety and security of the inmate.

The preferred location to place an inmate on Suicide Precaution or Watch status is in the
MHCB, or in the OHU pending transfer to MHCB. The use of Suicide Precaution or
Suicide Watch in any non-medical location shall be a temporary, short-term approach
until an inmate can be moved to an OHU or MHCB, and shall require constant direct
visual observation.

A psychiatrist, licensed psychologist, physician, or nurse practitioner shall review,

modify, and/or renew the order for Suicide Precaution and/or Watch at a minimum of
every 24 hours with input from at least one other member of the IDTT, such as the RN on
duty.

Inmate-patients that are placed in an OHU for continued assessment of suicide risk, or in
an MHCB for active suicidal ideation, threats, or attempt, shall have a note regarding
progress toward the treatment plan goals and objectives recorded daily by a treating
clinician in the Interdisciplinary Progress Notes section of the UHR.

a. Suicide Precaution

When an inmate is in an MHCB because of high risk of attempting self-injurious

behavior, but is not in immediate danger, he or she shall be placed on Suicide
Precaution.
These inmate-patient management procedures require an order from a psychiatrist,
licensed psychologist, physician or nurse practitioner. Additional details of
requirements and procedures are located in Chapter 5, Mental Health Crisis Bed.

Guidelines for clinician-ordered Suicide Precaution:

STATUS CLOTHING FURNITURE BEHAVIORAL

AND OTHER CHECKS
MATERIALS
SAFE CELL Safety (no-tear) Remove all Staggered intervals
STATUS smock/gown, no furniture. Safety not to exceed 15-
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2009 REVISION 12-10-15
Suicide Prevention and Response Mental Health Services Delivery System

ID band on wrist (no-tear) mattress, minute staff checks

safety (no-tear)
blanket
PARTIAL Shorts, t-shirt, Remove all Staggered intervals
ISSUE socks furniture. Safety not to exceed 15-
(no-tear) mattress, minute staff checks
safety (no-tear)
blanket, one book
FULL ISSUE Shorts, t-shirt, Safety (no-tear) Staggered intervals
socks mattress or not to exceed 15-
furniture. Reading minute staff checks
and writing
materials.
Toiletries.

A clinician, when writing orders, can utilize these guidelines for furniture and
clothing and/or make modifications based on clinical judgment, with documentation
of justification. The IDTT shall review all decisions regarding furniture, clothing,
and other materials. No modification is allowed for the interval of staff checks for
Suicide Precaution.

b. Suicide Watch
When an inmate is in an MHCB because of suicide risk and is in immediate danger of
self-injurious behavior, he or she shall be placed on Suicide Watch.

These inmate-patient management procedures require an order from a psychiatrist,

licensed psychologist, physician or nurse practitioner. Additional details of
requirements and procedures are located in Chapter 5, Mental Health Crisis Bed.

Guidelines for clinician-ordered Suicide Watch:

STATUS CLOTHING FURNITURE BEHAVIORAL

AND OTHER CHECKS
MATERIALS
SUICIDE Safety (no-tear) Remove all Continuous
WATCH smock/gown, no furniture. Safety observation
ID band on wrist (no-tear) mattress, 15 minute nursing
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2009 REVISION 12-10-16
Suicide Prevention and Response Mental Health Services Delivery System

safety (no-tear) checks

blanket

All institutions shall conduct Suicide Watch observation by direct visual observation.
The staff member shall be stationed at the cell door with direct line-of-sight from the
observer to the patient. One observer may be responsible for observation of two
inmate-patients on Suicide Watch when the staff member can maintain direct line-of-
sight observation of both inmate-patients. The staff-observer to inmate-patient ratio
shall not exceed one-to-two. Video-monitoring shall never be used as the sole
method for observation of any inmate-patient housed on Suicide Watch status, but
may be used to supplement direct visual observation.

Some institutions have been approved via memoranda signed by the Directors of the
Division of Adult Institutions (DAI) and the DCHCS, to provide one-on-two direct
cell-front observation of inmate-patients on Suicide Watch, when the staff member
can maintain direct line-of-sight observation of both inmate-patients, unless one-on-
one monitoring is ordered by the psychiatrist or psychologist. All other institutions
shall provide one-on-one direct cell-front observation.

The assigned observer shall assume a position where continuous direct visual contact
with the inmate-patient can be maintained, including when the inmate uses the
shower, sink, or toilet.

Suicide Watch posts will be filled using the following order of job classifications:

1. Hospital Aide
2. Certified Nursing Assistant
3. Licensed Psychiatric Technician
4. Licensed Vocational Nurse
5. RN
6. Correctional Officer

It is the responsibility of the Health Care Manager and Warden to ensure that all
hiring efforts be exhausted, including offering voluntary overtime and assigning
involuntary overtime of the medical classifications on the list above, prior to filling
these positions with a Correctional Officer.

The employee assigned to provide direct observation shall be appropriately trained

regarding this post and the performance of duties related to Suicide Watch.

Observation Documentation

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2009 REVISION 12-10-17
Suicide Prevention and Response Mental Health Services Delivery System

The custody and/or health care staff employee assigned to provide continuous
observation during Suicide Watch shall document such observation every 15 minutes
on a log sheet.

Custody and health care staff shall document behaviors and activities on a
CDCR 114A, Detention/Segregation Record.
Nursing staff shall document behavioral checks and the inmate-patients’ affect at
least every 15 minutes during both Suicide Precaution and Suicide Watch. Nursing
checks shall always include visual observation and, when the inmate-patient is
awake, shall also include verbal interaction. Nursing staff shall document using
CDCR 7212, Nursing Care Record (for non-acute care settings), or CDCR 7212A,
Nursing Care Record-Acute Hospital, (for acute care settings) in the UHR.

Leaving a Post Assignment

U

• The observer assigned to Suicide Watch shall only vacate the post if immediate
attention or assistance is needed in a life-threatening situation, and no other
alternative exists.
• A life-threatening situation is defined as a situation in which staff’s failure to
immediately respond will likely result in serious morbidity or mortality.
• In the event of a life-threatening situation, the staff shall activate a personal alarm
in order to summon additional staff to the MHCB area.
• If it becomes necessary for staff assigned to Suicide Watch to leave their post due
to a life-threatening situation, they shall request other staff in the vicinity,
whenever possible, to provide direct observation coverage of the inmate-patients
while away. If no other staff is available, and there is sufficient time, the officer
shall contact the Watch Office before responding to the life-threatening situation.
• Any vacating of the post under these circumstances shall be for the minimal time
necessary. Once the life-threatening situation has been contained, or there is
sufficient staff at the scene to handle the situation, the officer shall immediately
return to the Suicide Watch post.
• Upon return to post, the staff shall document his or her departure and return on
the CDCR 114A, Detention/Segregation Record. The officer shall also ensure
that the staff that covered the post in his or her absence also documents that on the
CDCR 114A, Detention/Segregation Record.
• For the purpose of this procedure, a minimum of one custody officer and one
health care professional shall respond to a life-threatening situation involving a
general population or reception center inmate.

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2009 REVISION 12-10-18
Suicide Prevention and Response Mental Health Services Delivery System

• For the purpose of this procedure, a minimum of one peace officer and one
nursing staff member shall respond to a life-threatening situation involving an
ASU inmate. Responding staff shall obtain and wear a protective vest while
responding in the ASU areas. The ASU Sergeant shall also be notified as soon as
possible.
• Staff will use universal precautions when responding to medical emergencies and
utilize Personal Protective Equipment kits, available in the MHCB unit.

Discharge or Return
U

Inmates sent to a MHCB because of active suicidal ideation, threats, or attempt shall
be returned to their housing unit only after the IDTT and/or a clinician has completed
a SRAC and has determined that the inmate-patient is no longer at imminent risk.
The inmate-patient shall be placed on the 5-day clinical follow-up treatment plan and
custody wellness check procedure as detailed below.

Inmates sent to an OHU for continued suicide risk assessment shall be returned to
their housing unit only after the IDTT and/or a clinician has completed a SRAC and
has determined that the inmate-patient is not at significant risk. The inmate-patient
may, depending on clinical determination, be placed on the 5-day clinical follow-up
treatment plan and custody wellness check procedure as detailed below.

MHCB Discharge
U

• A psychiatrist or licensed psychologist, in consultation with the IDTT, shall write

the order to discontinue an inmate-patient from Suicide Precaution or Suicide
Watch when the inmate is no longer in imminent danger of self-harm. After
hours, on weekends and holidays, the Medical Officer of the Day (MOD) or
psychiatrist, licensed psychologist, or primary care physician on call may write an
order to discontinue Suicide Precaution or Suicide Watch.
• A psychiatrist or licensed psychologist shall complete the MHCB discharge
summary.
• Before discharge, the IDTT shall develop a detailed and complete follow-up
treatment plan, which shall be documented in the inmate's UHR on CDCR 7221,
Physician’s Orders. The plan shall include prescribed housing, medication, type
and frequency of outpatient therapy, and an explicit recommendation on 5-day
clinical follow-up treatment plan and custody wellness check procedure.
• The primary clinician (PC) (or in their absence, the senior mental health clinician)
shall be notified person-to-person of the pending discharge of the inmate-patient
and the discharge plan.

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2009 REVISION 12-10-19
Suicide Prevention and Response Mental Health Services Delivery System

• Inmates with multiple MHCB admissions (three or more within a six-month

period) shall be evaluated by the IDTT for referral to the DMH. The results of
this evaluation, decision of the IDTT, and outcome of the referral shall be
documented on a CDCR 7230-MH, Mental Health Progress Note, in the UHR.
• Careful consideration should be given by the IDTT when discharging from an
MHCB an inmate-patient who was admitted for reasons of suicidal ideation,
threats, or attempt, on a Friday, over the weekend, or the day before a holiday.
Inmate-patients will only be released over a weekend if the IDTT has determined
such and only after an updated face-to-face evaluation by a mental health
clinician. That clinician will establish the 5-day clinical follow-up treatment plan
and custody wellness check procedure. The mental status, stability, and risk
factors of the inmate-patient should be documented in detail on a
CDCR 7230-MH, Mental Health Progress Note. A mental health clinician must
be available on weekends and holidays, either on duty or on call. In the event
that there is no mental health clinician on call in an institution, no discharges
shall be accepted by that institution on, or the day before, a weekend or
holiday.
• A mental health clinician, usually the inmate-patient’s PC, shall provide follow
up treatment on an outpatient basis. This shall include daily contact with the
inmate in their housing unit for five consecutive days following discharge. A
psychiatric technician or other mental health clinician may conduct the contacts
on weekends and holidays. The PC is responsible for ensuring that the contacts
occur. The frequency of visits may then be reassessed. Housing unit custody
officers and mental health staff shall communicate regarding the inmate-patient’s
status.
• Custody shall conduct an hourly check of inmate-patients discharged from the
MHCB (admitted for suicidal ideations, threats, or attempt) for the first 24 hours
after discharge. A mental health clinician shall then discuss the inmate-patient’s
behavior with the custody staff and evaluate the inmate-patient to determine if the
custody checks should be continued or discontinued. If the custody checks are
continued, the mental health clinician shall determine whether the checks are to
be every hour, every two hours, or every four hours for the next 24-48 hours. If
after a second evaluation, mental health clinical staff feel additional hourly checks
are required, the inmate shall be readmitted to the MHCB for further stabilization.
Custody staff shall maintain a log on CDCR 114A, Detention/Segregation
Record, of rounds on inmate-patients.
• The local SPR FIT shall regularly audit compliance with the 5-day clinical
follow-up and custody wellness check procedure. Audit findings shall be
forwarded monthly to the Local MHP Subcommittee.

c. Response to Self-Injurious Behaviors and Suicide Attempts

U

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2009 REVISION 12-10-20
Suicide Prevention and Response Mental Health Services Delivery System

Self-injurious behaviors cause, or are likely to cause, physical self-injury. A suicide

attempt is an intentional act that is deliberately designed to end one’s own life. Both
are medical emergencies that require immediate and appropriate responses.

Custody Protocol
1BU

In medical emergencies, the primary objective is to preserve life. All peace

officers who respond to a medical emergency are mandated, pursuant to court order,
to provide immediate life support, if trained to do so, until medical staff arrives to
continue life support measures. All peace officers must carry a personal CPR mouth
shield at all times.

The officer must assess and ensure it is reasonably safe to perform life support by
effecting the following actions:

• Sound an alarm (a personal alarm or, if one is not issued, an alarm based on local
procedures must be used) to summon necessary personnel and/or additional
custody personnel.
• Determine and respond appropriately to any exposed bloodborne pathogens.
• Determine and neutralize any significant security threats to self or others
including any circumstances causing harm to the involved inmate.
• Initiate life saving measures consistent with training.

The responding peace officer will be required to articulate the decision made
regarding immediate life support and actions taken or not taken, including cases
where life support is not initiated consistent with training and/or situations which
pose a significant threat to the officer or others.

Clinical and Custody Combined Efforts

2BU

Upon arrival, responding medical personnel shall relieve the correctional peace
U

officer and assume primary responsibility for the provision of medical attention
and life saving efforts. Custody and medical personnel together are responsible
for the continuance of life saving efforts for as long as necessary.

-----------------------------------
Preservation of life shall take priority over preservation of a crime scene.
-----------------------------------

Emergency Response
U

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2009 REVISION 12-10-21
Suicide Prevention and Response Mental Health Services Delivery System

The following first aid procedures shall be implemented when an inmate attempts
6B

suicide by hanging, laceration, or other methods:

Hanging
14BU

Medical and custodial staff shall be informed of the nature of the emergency by the
most expedient method available. The cut-down kit shall be transported to the
location immediately by custody staff. Clearing the obstruction to the airway as
quickly as possible is critical to saving the life of the inmate who has attempted
suicide by hanging. When it appears safe, a minimum of two staff shall enter the area
where the inmate is located, relieve pressure on the airway by using a stable object
for support of the inmate’s body or by physically lifting the inmate's weight off the
noose. The inmate shall be cut down by cutting above the knot and then loosening
the noose. Custody staff shall preserve any item of evidentiary value.
Once the inmate is cut down, custody staff shall provide immediate life support, if
trained to do so, until medical staff arrives to continue life support measures.

Medical staff, upon arrival, shall assume responsibility for medical care, as outlined
in the institution’s local operating procedures for emergencies, including any
decisions regarding initiating or continuing CPR.
If possible, the inmate shall also be transported to a triage and treatment area.

Laceration
15BU

General guidelines:

• Use impervious latex gloves and/or appropriate, personal protective equipment

• Utilize whatever clean material is available to apply pressure to the wound site
• Elevate extremities if they are bleeding
• Transport to a triage and treatment area or an emergency room
UOther Methods (overdosing, trauma, swallowing dangerous objects):

• Provide assistance to medical staff and obtain as much information as possible.

• Staff shall perform the Heimlich maneuver if choking is evident.

Cut-down Kit Availability

U

Each warden shall ensure that cut-down kits:

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2009 REVISION 12-10-22
Suicide Prevention and Response Mental Health Services Delivery System

• Are maintained within each housing unit

• Are inventoried and inspected on a daily basis with problems immediately
reported to a supervisor
• Consist of a lockable metal box containing:
a. One inventory list affixed to the inside of the box door
b. One emergency cut-down tool
c. One single-patient-use resuscitator (e.g., AMBU Single-Patient-Use
Resuscitator)
d. One CPR mask (e.g., Lardell CPR Mask, for use by CPR-certified staff only)
e. Minimum of ten latex gloves
f. Disposable oral airway

E. SUICIDE REPORTING
U

All reports of death shall be in accordance with DOM, Section 51070, Deaths.

If at any point during the review of the case, questions arise regarding any circumstances
surrounding or leading up to the suicide that may be attributed to employee misconduct, the
MHSR, the Health Care Manager (HCM), or other responsible individuals may request a
misconduct investigation. In this event, the MHSR shall immediately consult with the
DCHCS SPR FIT Coordinator to determine further action. Requests for further misconduct
inquiry and/or investigation shall be referred in accordance with DOM, Chapter 3, Article 14,
Employee Misconduct Investigations/Inquiries. Even if the matter is referred, all other
aspects of the suicide review shall continue.
Local Institution Responsibilities
U

• In the case of an inmate suicide death, the watch commander or senior custody officer
shall be notified immediately, and shall subsequently notify the Warden, or evenings,
weekends and holidays, the Administrative Officer of the Day. Upon notification of a
possible death, the senior custody officer or the watch commander shall determine the
need to secure the death scene and initiate investigation or other custody measures as
indicated in accordance with DOM, Section 51070.7.
• The institution’s CMO or physician designee shall have primary responsibility for
reporting the death within eight hours to the DCHCS Death Notification Coordinator
(DNC).
• The initial reporting procedures and submission of the CDCR 7229 A, Initial Inmate
Death Report, shall be completed and submitted in accordance with the procedures set
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2009 REVISION 12-10-23
Suicide Prevention and Response Mental Health Services Delivery System

forth in DOM, 51070.9, Deaths. The CDCR 7229 B, Initial Inmate Suicide Report, shall
be completed by the Local SPR FIT Coordinator or designee, and shall be reviewed,
signed and dated by the HCM/CMO. It shall be submitted to the DNC at Central Office
by the close of the second business day following the date of death. This form shall
contain relevant information including the method of suicide, mental health level of care,
psychiatric diagnoses (if applicable), behavioral problems observed, recent history of
suicidal ideations or attempts, medication, and recent stressors.

F. SUICIDE DEATH REVIEW

U

• Within one business day of receipt of the initial data including CDCR 7229 A, Initial
Inmate Death Report, and 7229 B, Initial Inmate Suicide Report, the DCHCS Death
Notification Coordinator (DNC) shall forward the death review folder to the DCHCS SPR
FIT Coordinator.
• Within two business days of receipt of the death review folder, the DCHCS SPR FIT
Coordinator shall appoint a MHSR from a pool of qualified mental health staff at
DCHCS, or regionally from an institution other than where the suicide occurred.
• Within one week, seven calendar days, of being appointed, the MHSR shall begin
reviewing the suicide case for compliance with the CDCR SPR FIT policies and
procedures. The MHSR shall also review all related documentation including the UHR;
Central File; Inmate Death Reports, CDCR 7229 A, Initial Inmate Death Report, 7229 B,
Initial Inmate Suicide Report; CDCR 837 A and B, Crime/Incident Report; and any other
appropriate documentation. The MHSR shall have access to the inmate’s cell, visiting
log, recorded telephone conversations, and other information as required. The
institution’s SPR FIT Coordinator may assist the MHSR in his or her efforts. The
assistance may include making available the UHR, the Central File, and any other
appropriate information as well as arranging interviews if required. The MHSR may
conduct interviews with clinical staff, custody staff, and inmates. However, should there
be any indication an employee misconduct investigation may be warranted, the MHSR
shall immediately consult with the DCHCS SPR FIT Coordinator, who shall provide
guidance in proceeding with the review. Generally, the MHSR shall discontinue
interviews with any employees who may be associated with or implicated in the employee
misconduct investigation, but shall continue with all other aspects of the suicide review
process.
• In cases where there are concerns with clinical care, the case shall be referred to the local
Clinical Performance Enhancement and Review Subcommittee.
•
Within 30 calendar days of the inmate suicide, the MHSR shall complete a preliminary
Suicide Report containing the following information: Inmate name, CDCR number, age,
date and time of discovery, time of death, institution, housing, mental health level of care
(if applicable), method, cause of death, findings of coroner (if available), brief summary
and preliminary findings including recommendations for quality improvement. The report
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2009 REVISION 12-10-24
Suicide Prevention and Response Mental Health Services Delivery System

shall also indicate whether further investigation/inquiry is recommended (if one has not
already been initiated). This report shall be immediately forwarded to the DCHCS SPR
FIT Coordinator who will then schedule discussion of the report at the DCHCS Suicide
Case Review (SCR) Subcommittee. The MHSR will present the case to the SCR
Subcommittee.
• The DCHCS SCR Subcommittee is the body that reviews the documentation and reports
submitted by the institution and MHSR, determines compliance with the statewide SPR
FIT policies and procedures, reviews the QIP (also known as corrective action), and
continues its review, in collaboration with the DCHCS MHP Subcommittee, until the
QIPs are completed and the cases are closed.
• Within 45 days from the date of death, the DCHCS ERDR Subcommittee shall complete
its review of the preliminary suicide report, review the QIP on the preliminary suicide
report, and forward the report to the MHSR for completion of the Suicide Report and the
accompanying Executive Summary.

Quality Improvement Plan

U

When warranted, the MHSR shall recommend a QIP (also known as corrective action), based
on the findings from the review of the case, which shall address and make recommendations
to improve identified problems with clinical care and compliance with policy and procedure.
The QIP shall address problems identified, recommended actions, due dates for recommended
actions, and supporting documents required from the institution.
The DCHCS SCR Subcommittee shall review the QIP and may take the following actions:

• Ensure consistency with policy and procedure

• Recommend remedial action, documentation, and monitoring
• Refer for further action in accordance with DOM, Chapter 3, Article 14, Employee
Misconduct Investigations/Inquiries, when appropriate. When individual conduct of
custody staff requires further investigation, a memorandum shall be forwarded to the
Director, Adult Institutions Division, who shall initiate a CDCR 989, Request for
Investigation, to the Office of Internal Affairs.
• Prepare a memorandum to refer the case to the DCHCS Professional Practice Executive
Committee (PPEC) for review of individual practice of licensed psychologists, psychiatrist,
and/or physicians when appropriate. The DCHCS PPEC shall report to the appropriate
professional licensing board for investigation, when appropriate

When approved by the DCHCS SCR Subcommittee, the Suicide Report shall be signed by the
Director, DCHCS, or designee.

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2009 REVISION 12-10-25
Suicide Prevention and Response Mental Health Services Delivery System

The Suicide Report by the MHSR shall incorporate the QIP approved by the DCHCS SCR
Subcommittee. The DCHCS SPR FIT Coordinator shall include with this report the Inmate
Death Reports, CDCR 7229 A, Initial Inmate Death Report, and CDCR 7229 B, Initial
Inmate Suicide Report, CDCR 837 A and B, Crime/Incident Report , Movement History and
Offense History, and the Executive Summary serving as the cover page to complete the Final
Suicide Report. The report shall then be forwarded to the Director of the CDCR DCHCS and
the Director, DAI. The report shall be signed by both Directors, and copied to Regional
Administrators of DCHCS and DAI; Legal Affairs Division; and to the reporting institutions’
Warden; Health Care Manager/Chief Medical Officer; Mental Health Program Manager,
Chief/Senior Psychiatrist and Chief/Senior Psychologist; and, other appropriate interested and
legally designated persons within 60 days of date of death.

When an investigation is required, the Office of Internal Affairs (OIA) shall track progress
until the investigation is complete. The OIA shall forward a memorandum with a summary
description of the methods and outcome of the investigation to the DCHCS SPR FIT
Coordinator, who shall forward the results to the Coleman Special Master through DCHCS
routing procedures.

For QIP items focused on institutional compliance, the Warden and HCM/CMO are
responsible for ensuring the implementation of the QIP within the specified time frame, which
is not greater than 60 days of receipt of the finalized Executive Summary of the Suicide
Report with signature approval from the Director, DCHCS (120 days following the date of
death). QIP items focused on system-wide policy or training shall be referred to the SPR FIT
at DCHCS. The SPR FIT Coordinator shall maintain a master list of QIP problems, corrective
action, supporting documentation required, and completion dates. A proof-of-practice binder
shall be maintained by the SPR FIT coordinator in order to track and record the progress of
policy revisions and system-wide training.

The QIP shall be monitored by the Warden, HCM/CMO, Mental Health Program Manager,
Chief Psychiatrist, Chief Psychologist, and SPR FIT Coordinator at the institution of
occurrence. DCHCS may require ongoing documentation of compliance.

The Local SPR FIT Coordinator shall prepare a follow up report of implementation
addressing action taken on the recommendations of the QIP. All appropriate supporting
documentation confirming that these actions have been taken shall be attached to this report.
See table below for list of suggested supporting documentation. The Warden and
HCM/CMO, or institution Mental Health Program Manager shall sign this report. The
institution shall retain a copy of the report and forward the original to the DCHCS ERDR for
review. The report is due
within 30 days following the implementation of the QIP (90 days following receipt of the
Executive Suicide Report). Additional follow up monitoring shall occur as necessary as
dictated in the QIP.

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2009 REVISION 12-10-26
Suicide Prevention and Response Mental Health Services Delivery System

Action, Documentation, & Monitoring for Suicide Quality Improvement Plans

ACTION DOCUMENTATION/MONITORING
Training Copy of training agenda and sign-in sheet
Required appointments with clinicians are List of appointments from MHTS
held
Changes in operating procedure Copy of procedure or memos
Develop Quality Improvement Team Copy of recommendations or change in
procedures
Missing medication due to transfer to a Ongoing monitoring of Medication
different housing unit Administration Records in the UHR
Provide sample audit
Proper Documentation Provide plan to audit UHR and a sample
audit
Five Day Follow-up of suicidal inmates Audit of documentation in UHR; provide
released from MHCB a sample audit
Rounds and evaluations done in ASU by Audit UHR, CDCR 114 Isolation log and
psychiatric technicians CDCR 114-A, Daily Log; provide sample
audit
Inmates on Keyhea are identified Review UHR
Conduct suicide risk assessment Review UHR
Statewide policy issues Review new policy
Investigation of individual practitioners Provide status or completion date of
investigation
Audit of records per specified length of Periodic reports of audit findings to
time to be sure that quality improvement DCHCS SPR FIT and DCHCS MHP
is being consistently followed

The DCHCS SCR Subcommittee shall continue to review all open suicide cases until the QIP
is approved and each case is closed. The QIP shall be incorporated into the final Suicide
Report. All decisions made by the DCHCS SPR FIT regarding compliance and quality
improvement shall be documented in the final Suicide Report.
The follow-up report on implementation of the QIP shall be reviewed by the DCHCS SPR
FIT Coordinator. In cases where the QIP is not sufficiently completed by the institution
within the required time frame, the SPR FIT coordinator shall send a memorandum indicating
non-compliance to the institution and to the Regional Administrator at DCHCS and DAI.
Appropriate follow-up shall be conducted by the Regional Administrator in order to ensure
the completion of the QIP item. In cases where a system-wide QIP is not sufficiently
completed by the SPR FIT within the required time frame, a report of progress and any
barriers to completion shall be forwarded from the SPR FIT to the Director of the appropriate
CDCR division. The CDCR Division Director shall take appropriate action to ensure

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2009 REVISION 12-10-27
Suicide Prevention and Response Mental Health Services Delivery System

completion of the QIP. When complete, the QIP shall be distributed by the SPR FIT
Coordinator according to legal mandates.

If, during the suicide review process, other death related information arrives, such as
CDCR 837 C, CDCR 7229 C, or Coroner’s report, the DNC will locate the death review
folder and place these documents inside. The DNC shall update the routing sheet and notify
the SPR FIT Coordinator of the new information. Upon completion of the suicide review, the
death review folder containing the Suicide Report and other related information shall be
returned to the DNC for final data entry. The DNC shall ensure that all documentation is
complete and then return the folder for final storage in a designated locked cabinet at DCHCS.

The DCHCS SPR FIT Coordinator appointed to oversee suicide-related activities shall
coordinate analysis and review of each suicide, and compile and forward annual suicide
statistics to: Secretary, Youth and Adult Correctional Agency; Director, DAI; Director,
DCHCS; Deputy Director, DCHCS; Chief of Clinical Policies and Programs, DCHCS;
Institution Wardens; Institution HCM/CMOs; and, other appropriate senior DCHCS staff.

G. MENTAL HEALTH EVALUATION COMPONENT FOR A RULES VIOLATION

REPORT

Per California Code of Regulations, Title 15, Section 3317 “An inmate shall be referred for a
mental health evaluation prior to documenting misbehavior on a CDCR 115, in any case
where the inmate is suspected of self-mutilation or attempted suicide.”

Staff are to utilize the Request for CDCR 128B, when requesting this mental health
evaluation.

Subsequent to the mental health evaluation, the mental health clinician’s determination will be
documented on a CDCR 128C. A copy of this CDCR 128C shall be forwarded to the custody
staff who requested the mental health evaluation.

In order to preserve an inmate’s due process rights, any decision that a suicide attempt was
not genuine must be supported by the following:
1. A thorough review of the UHR and Central File
2. A complete mental health evaluation including a complete history, current mental status
examination, and current Diagnostic and Statistical Manual diagnosis
3. Appropriate psychological testing to include both objective and projective testing
4. A detailed summary supporting the conclusion that the suicide attempt was not genuine
5. The clinician’s summary must be approved and co-signed by the institution’s Chief of
Mental Health before issuance of a CDCR 115.

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2009 REVISION 12-10-28
Suicide Prevention and Response Mental Health Services Delivery System

If the mental health clinician determines the inmate’s actions were an attempt to manipulate
staff, the inmate may be charged under CCR Section 3005(a) for the specific act of
“Attempted Manipulation of Staff.” The specific act of “Attempted Suicide” or “Self
Mutilation” is not an appropriate charge for a CDCR 115 and shall not be used. In cases
where a self-injurious behavior is found to be intended to manipulate staff, a copy of the
completed mental health evaluation shall be sent to the local SPR FIT coordinator and the
mental health program director.

If a mental health clinician determines that, the inmate’s action was an “actual suicide
attempt,” or cannot make a clear determination that the inmate’s action was an actual suicide
attempt, a CDCR 115 shall not be written. In both these instances the behavior and/or the
inability of mental health staff to make a clear determination shall be documented by custody
staff on a CDCR 128B, Mental Health Services Staff Referral, General Chrono, for inclusion
in the inmate’s Central File and UHR.

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2009 REVISION 12-10-29