SOP 508.15: Mental Health Evaluations

|GEORGIA DEPARTMENT OF CORRECTIONS
Standard Operating Procedures|Col2|Col3|
|---|---|---|
|Policy Name:Mental Health Evaluations|Policy Name:Mental Health Evaluations|Policy Name:Mental Health Evaluations|
|Policy Number:
508.15|Effective Date:8/15/2022|Page Number: 1 of 13|
|Authority:
Commissioner
|Originating Division:
Health Services Division
(Mental Health)|Access Listing:
Level II: Required Offender
Access|

I. Introduction and Summary:

It is the policy of the Georgia Department of Corrections (GDC) to ensure that
Qualified Mental Health Professionals thoroughly and properly evaluate offenders
with serious mental illness and other identified mental health needs, for the purpose
of identifying the offender’s need for mental health services and assigning a mental
health classification level.

II. Authority:

A. GDC Standard Operating Procedures (SOPs): 508.14 Mental Health Reception

Screen, 508.19 Mental Health Referral and Triage, 508.21 Treatment Plans,
508.24 Psychotropic Medication Use Management, and 508.33 Transfer of
Seriously Mentally Ill Offenders;

B. NCCHC Standards for Health Services in Prisons 2018: P-E-05 Mental Health

Screening and Evaluation;

C. NCCHC Standards for Health Services in Juvenile Facilities 2014: Y-E-05

Mental Health Screening and Evaluations; and

D. ACA Standards: 2-CO-4E-01, 5-ACI-6A-28 (Mandatory), 5-ACI-6A-33, 5-ACI
6A-37, 5-ACI-6C-04 (Mandatory), 4-ALDF-4C-27 (Mandatory), 4-ALDF-4C28, 4-ALDF-4C-30 (Mandatory), 4-ALDF-4C-31, 4-ALDF-4C-34, and 4-ALDF4D-15.

III. Definitions:

A. Mental Health Reception Screen - A procedure conducted as part of the normal

diagnostic reception and classification process on all offenders entering the
system, designed to identify those offenders with serious mental illness or
offenders in need of further mental health attention or evaluation. A Qualified
Mental Health Professional conducts a mental health screening by utilizing
standard forms and procedures.

|GEORGIA DEPARTMENT OF CORRECTIONS
Standard Operating Procedures|Col2|Col3|
|---|---|---|
|Policy Name:Mental Health Evaluations|Policy Name:Mental Health Evaluations|Policy Name:Mental Health Evaluations|
|Policy Number: 508.15|Effective Date: 8/15/2022|Page Number: 2 of 13|
|Authority:
Commissioner|Originating Division:
Health Services Division
(Mental Health)|Access Listing:
Level II: Required Offender
Access|

B. Mental Health Evaluation - A procedure conducted on all offenders as, 1) part

of the diagnostic reception and classification process based on results from the
mental health reception screen indicating a more comprehensive mental health
assessment is needed, 2) part of a comprehensive mental health assessment when
further diagnostic clarity is needed, or 3) needed when additional information is
necessary for decision-making to assist with treatment planning and other clinical
needs.

C. Serious Mental Illness - A substantial disorder of thought or mood that

significantly impairs judgment, behavior, capacity to recognize reality or coping
with the ordinary demands of life within the correctional environment. Mental
suffering or disability manifests the disorder. Serious mental illness requires a
mental health diagnosis and treatment in accordance with an individualized
treatment plan.

D. Qualified Mental Health Professional - Mental Health Unit Managers,

Psychiatrists, Psychologists, Advance Practice Registered Nurses (APRN),
Licensed Nurses, Licensed Professional Counselors, Licensed Master or Clinical
Social Workers, Licensed Marriage and Family Therapists, Mental Health
Counselors, Mental Health Technicians, Mental Health Behavior Specialists and
Multifunctional Correctional Officers.

E. Mental Health Unit Manager - The Mental Health Unit Manager is the staff

member responsible for the overall operation of the mental health unit and the
provision of mental health services in accordance with Georgia Department of
Corrections Standard Operating Procedures at the assigned mental health
facility/facilities.

IV. Statement of Policy and Applicable Procedures:

This procedure is applicable to all Georgia Department of Corrections facilities with
a mental health mission.

|GEORGIA DEPARTMENT OF CORRECTIONS
Standard Operating Procedures|Col2|Col3|
|---|---|---|
|Policy Name:Mental Health Evaluations|Policy Name:Mental Health Evaluations|Policy Name:Mental Health Evaluations|
|Policy Number: 508.15|Effective Date: 8/15/2022|Page Number: 3 of 13|
|Authority:
Commissioner|Originating Division:
Health Services Division
(Mental Health)|Access Listing:
Level II: Required Offender
Access|

A. General Evaluation Procedures:

1. All mental health referrals derived from the Mental Health Reception

Screening process or through the mental health referral process will go to the
Mental Health Unit Manager for assignment to a qualified mental health
professional to conduct the appropriate assessment.

2. The assignment of the mental health classification or level is determined by

the outcome of an evaluation. The Mental Health Unit Manager will ensure
that mental health classification levels are entered into the appropriate
computer tracking system (Scribe) and processed appropriately based on the
offender’s status (i.e., diagnostic vs. permanent).

3. Under no circumstances should an offender determined to need mental health

services be returned to a facility without on-site mental health services. It is
the responsibility of the Mental Health Unit Manager at the evaluating site, to
ensure the arrangement of appropriate housing and the implementation of any
orders for special precautions.

4. It is the responsibility of the evaluator to get appropriate Consent to Mental

Health Evaluation or Treatment (SOP 508.10, Confidentiality of Mental
Health Records, Attachment 1, form M20-02-01) signed at the time of the
evaluation. In section five of the mental health record, the original consent
form will be filed, and a copy given to the offender.

B. Request for Records Procedures:

1. For all offenders determined to be in need of any level of mental health

services obtain the consent from the offender, for routinely requesting their
hospitalization and recent mental health treatment records.

2. When records are requested, it is the responsibility of the evaluator to get

appropriate Authorization for Release of Information (Attachment 3, form

|GEORGIA DEPARTMENT OF CORRECTIONS
Standard Operating Procedures|Col2|Col3|
|---|---|---|
|Policy Name:Mental Health Evaluations|Policy Name:Mental Health Evaluations|Policy Name:Mental Health Evaluations|
|Policy Number: 508.15|Effective Date: 8/15/2022|Page Number: 4 of 13|
|Authority:
Commissioner|Originating Division:
Health Services Division
(Mental Health)|Access Listing:
Level II: Required Offender
Access|

M31-01-03) signed at the time of the evaluation. File a copy of the
authorization form in the mental health record (section 5).

3. Each mental health unit will establish a Requested Records Log (Attachment

5, form M31-01-05) to track requests for records. The following information
will be logged:

a. The offender’s name, number, and social security number;

b. All places from which records were requested;

c. Date request for records was mailed or faxed;

d. Date records were received; and

e. If records were not received, all follow-up actions to attempt to obtain the
records.

C. Specific Evaluation Procedures:

1. Emergency Evaluations:

a. Offenders meeting the following criteria will be referred for emergency
evaluations:

i. Offenders identified as posing a danger to self or others or as being

actively psychotic by the Qualified Mental Health Professional during
the Mental Health Reception Screen or by the Mental Health Unit
Manager while triaging mental health referrals;

ii. Any situation where a clear need for immediate intervention is

present; and

|GEORGIA DEPARTMENT OF CORRECTIONS
Standard Operating Procedures|Col2|Col3|
|---|---|---|
|Policy Name:Mental Health Evaluations|Policy Name:Mental Health Evaluations|Policy Name:Mental Health Evaluations|
|Policy Number: 508.15|Effective Date: 8/15/2022|Page Number: 5 of 13|
|Authority:
Commissioner|Originating Division:
Health Services Division
(Mental Health)|Access Listing:
Level II: Required Offender
Access|

iii. A psychiatrist, psychologist or APRN will conduct emergency

evaluations.

2. Mental Health Services Screening/Evaluation:

a. All referrals received through the reception screening (diagnostic) process

will receive a full Mental Health Evaluation for Services (Attachment 1,
form M31-01-01) within 5 business days and may be supplemented with
the Mental Status Evaluation (Attachment 2, form M31-01-02).

b. Upon receipt of a self or staff referral other than through the Mental

Health Reception Screening process, a Qualified Mental Health
Professional will perform an assessment consisting of a review of records
and a brief clinical interview.

c. Within 14 calendar days of a routine referral request date, the Mental

Health Evaluation for Services (Attachment 1, form M31-01-01) will be
completed and include at least the following:

i. [Review of the mental health screening and appraisal data;](javascript:standardsMaster.SelectTreeNode(3507766);)

ii. Direct observations of behavior;

iii. Collection and review of additional data from individual diagnostic

interviews and tests (assessing personality, intellect, and coping
abilities);

iv. Compilation of the individuals' mental health history; and

v. Development of an overall [treatment/management](javascript:standardsMaster.SelectTreeNode(3509755);) plan with
[appropriate referral.](javascript:standardsMaster.SelectTreeNode(3505111);)

|GEORGIA DEPARTMENT OF CORRECTIONS
Standard Operating Procedures|Col2|Col3|
|---|---|---|
|Policy Name:Mental Health Evaluations|Policy Name:Mental Health Evaluations|Policy Name:Mental Health Evaluations|
|Policy Number: 508.15|Effective Date: 8/15/2022|Page Number: 6 of 13|
|Authority:
Commissioner|Originating Division:
Health Services Division
(Mental Health)|Access Listing:
Level II: Required Offender
Access|

d. The information obtained will be documented on the Mental Health

Evaluation for Services form (Attachment 1, form M31-01-01), Mental
Status Evaluation (Attachment 2, form M31-01-02) and the lower portion
of the referral form (SOP 508.19 Mental Health Referral and Triage,
(Attachment 1, form M35-01-01) will be reviewed and signed by an
upper-level provider. If it is determined, the offender is not in need of
services, the evaluation process will terminate at this point and the mental
health level will remain level 1. Place the level 1 offender’s Mental
Health Referral Form and the Mental Health Evaluation form in the
offender’s Medical Record (section 5).

e. Once the Mental Health Evaluation for Services (Attachment 1, form

M31-01-01) is completed, possible outcomes include:

i. The offender is not in need of mental health services;

ii. The offender is in need of mental health services and will be given a

mental health classification level based on the level of care that is
clinically indicated; or

iii. The offender needs further evaluation before determining their mental

health classification level.

f. The Mental Health Evaluation for Services (Attachment 1, form M31-01
01) and Mental Status Evaluation (Attachment 2, form M31-01-02) will
be filed in the medical record (section 5), and a copy of the evaluations
will be placed in the mental health record (section 4) on all offenders
placed on the mental health caseload.

g. A clinical psychologist or other upper-level provider will review and sign

all Mental Health Evaluation for Services (Attachment 1, form M31-0101) conducted by unlicensed mental health personnel.

|GEORGIA DEPARTMENT OF CORRECTIONS
Standard Operating Procedures|Col2|Col3|
|---|---|---|
|Policy Name:Mental Health Evaluations|Policy Name:Mental Health Evaluations|Policy Name:Mental Health Evaluations|
|Policy Number: 508.15|Effective Date: 8/15/2022|Page Number: 7 of 13|
|Authority:
Commissioner|Originating Division:
Health Services Division
(Mental Health)|Access Listing:
Level II: Required Offender
Access|

h. Once the mental health classification level is determined, the level will be

entered in the appropriate computer tracking system (SCRIBE) and will
be made a part of the diagnostic package for offenders referred through
the reception screening process.

i. The Mental Health Unit Manager will enter the mental health

classification level in the appropriate computer tracking system
(SCRIBE) for offenders referred from other facilities or from general
population. In addition, the Mental Health Unit Manager may arrange for
transfer as necessary in accordance with mental health standard operating
procedures SOP 508.33, Transfer of Offenders with Serious Mental
Illness.

j. As part of the treatment planning process, any offender will be scheduled

for an Initial Psychiatric/Psychological Evaluation (SOP 508.24,
Psychotropic Medication Use Management, Attachment 6, form M60-0106) if classified as mental health level II or higher. In general, to address
questions regarding the need of medication, a psychiatrist or APRN will
conduct an initial psychiatric evaluation and the psychologist will conduct
an initial psychological evaluation on those offenders where medication is
not an issue.

3. Psychiatric/Psychological Evaluations:

a. Refer offenders for an initial psychiatric evaluation if they meet the

following criteria:

i. Offenders entering the Georgia Department of Corrections with an

active prescription for psychotropic medication (NOTE: When
indicated, prescriptions will be rewritten by a physical health
physician until the offender is evaluated by a psychiatrist or APRN);
and

|GEORGIA DEPARTMENT OF CORRECTIONS
Standard Operating Procedures|Col2|Col3|
|---|---|---|
|Policy Name:Mental Health Evaluations|Policy Name:Mental Health Evaluations|Policy Name:Mental Health Evaluations|
|Policy Number: 508.15|Effective Date: 8/15/2022|Page Number: 8 of 13|
|Authority:
Commissioner|Originating Division:
Health Services Division
(Mental Health)|Access Listing:
Level II: Required Offender
Access|

ii. Offenders referred by a physical health physician to a psychiatrist or

APRN for a psychiatric evaluation.

b. Refer offenders for an initial psychological evaluation if they meet the

following criteria:

i. Offenders entering the Georgia Department of Corrections that do not

have an active prescription for psychotropic medication; and

ii. Offenders referred by the Mental Health Unit Manager for an initial
psychological evaluation prior to receiving an initial psychiatric
evaluation to consider pharmacological interventions.

c. The Mental Health Unit Manager/designee will schedule initial

psychiatric/psychological evaluations in accordance with SOP 508.14,
Mental Health Reception Screen and SOP 508.19, Mental Health Referral
and Triage.

d. Psychiatric/psychological evaluations will be completed and documented

in accordance with SOP 508.24, Psychotropic Medication Use
Management.

e. Base any psychiatric/psychological follow-up on the clinical judgment of

the psychiatrist, APRN or psychologist and in accordance with SOP
508.24, Psychotropic Medication Use Management.

f. After the initial psychiatric/psychological evaluation is completed, the

psychiatrist or psychologist will complete a diagnosis list (SOP 508.09,
Mental Health Records, Attachment 5, form M20-01-05) using the most
current diagnostic statistical manual (DSM) criteria and make a final
determination regarding mental health level of care.

|GEORGIA DEPARTMENT OF CORRECTIONS
Standard Operating Procedures|Col2|Col3|
|---|---|---|
|Policy Name:Mental Health Evaluations|Policy Name:Mental Health Evaluations|Policy Name:Mental Health Evaluations|
|Policy Number: 508.15|Effective Date: 8/15/2022|Page Number: 9 of 13|
|Authority:
Commissioner|Originating Division:
Health Services Division
(Mental Health)|Access Listing:
Level II: Required Offender
Access|

g. After determining the level of care, the Mental Health Unit Manager will

assign the offender to a mental health counselor/technician or behavior
specialist who will see the offender within 48 hours.

h. The mental health counselor/technician or behavior specialist will develop

a treatment plan in accordance with SOP 508.21, Treatment Plan, which
includes any special housing or program needs requiring placement at
specific facilities.

i. The Mental Health Unit Manager/designee will inform inmate

classification of the mental health classification level and special
housing/program needs. If necessary, a transfer will occur to a facility or
unit specifically designated for handling this type of individual.

4. Transfer Evaluations:

a. If there is documented evidence of a mental health evaluation within the

previous 90 days, a new mental health evaluation is not required,
except as determined by the designated mental health authority.

b. If offender is on medication, a psychiatric consultation will occur within

fourteen (14) days of arrival at the new facility and must be documented
on a Psychiatry/Psychology Transfer Evaluation (SOP 508.24,
Psychotropic Medication Use Management, Attachment 5, form M60-0105).

c. If offender is not on medication, a psychological consultation or

psychiatric consultation will occur within fourteen (14) days of arrival at
the new facility and documented on a Psychiatry/Psychology Transfer
Evaluation (SOP 508.24, Psychotropic Medication Use Management,
Attachment 5, form M60-01-05).

|GEORGIA DEPARTMENT OF CORRECTIONS
Standard Operating Procedures|Col2|Col3|
|---|---|---|
|Policy Name:Mental Health Evaluations|Policy Name:Mental Health Evaluations|Policy Name:Mental Health Evaluations|
|Policy Number: 508.15|Effective Date: 8/15/2022|Page Number: 10 of 13|
|Authority:
Commissioner|Originating Division:
Health Services Division
(Mental Health)|Access Listing:
Level II: Required Offender
Access|

5. Psychological Testing and Evaluation:

a. Offenders will be referred for psychological testing based on, but not

limited to the following criteria:

i. Need for diagnostic clarification;

ii. The offender has been referred previously and not found to need

Mental Health Services but continues to experience problems in
general population;

iii. Need for the facilitation and development of a treatment plan by

identifying strengths and weaknesses;

iv. Need to assess treatment efficacy; and

v. To assist in the development of a behavior management plan.

b. Before administering any psychological test, the Psychologist will review

the referral and determine which tests to administer, to address the
questions asked.

c. Under the direction of the Psychologist, the Mental Health Behavior

Specialist, Mental Health Counselor or Mental Health Technician
privileged in test administration, may be assigned to administer, and score
assessments.

d. The Psychologist will write a psychological assessment report within

fourteen (14) working days of receiving the referral, answering the
specific questions asked in the mental health referral and making
appropriate recommendations.

|GEORGIA DEPARTMENT OF CORRECTIONS
Standard Operating Procedures|Col2|Col3|
|---|---|---|
|Policy Name:Mental Health Evaluations|Policy Name:Mental Health Evaluations|Policy Name:Mental Health Evaluations|
|Policy Number: 508.15|Effective Date: 8/15/2022|Page Number: 11 of 13|
|Authority:
Commissioner|Originating Division:
Health Services Division
(Mental Health)|Access Listing:
Level II: Required Offender
Access|

e. All tests will be maintained on file in the mental health record (section 4)

or, if no mental health record exists, in the medical record (section 5).

6. Evaluation for Neurodevelopmental Disorder Services:

a. All offenders scoring 70 or below on the culture fair intelligence tests and

offenders with a history of special education services for deficits or
impairments in intellectual or adaptive functioning will be referred to the
Mental Health Behavior Specialist, Mental Health Counselor or Mental
Health Technician for further screening and evaluation.

b. The Mental Health Behavior Specialist, Mental Health Counselor or

Mental Health Technician privileged in testing will administer a
standardized intelligence test approved by the state mental health
director/designee.

c. All offenders scoring 70 or below on that test will be further assessed for

deficits in adaptive functioning through a clinical interview to assess
activities of daily living (ADLs), and a review of records.

d. A Psychologist will review and sign all test results/reports and determine

if a diagnosis of a neurodevelopmental disability is in order.

7. Parole Board Requests for Parole Psychological Evaluations:

a. The Board of Pardons and Parole will send requests for Parole

Psychological Evaluations (Attachment 6, form M31-01-06) to the
Mental Health Unit Manager; and

b. The Mental Health Unit Manager will be responsible for scheduling these

evaluations, conducted by a Qualified Mental Health Professional.

|GEORGIA DEPARTMENT OF CORRECTIONS
Standard Operating Procedures|Col2|Col3|
|---|---|---|
|Policy Name:Mental Health Evaluations|Policy Name:Mental Health Evaluations|Policy Name:Mental Health Evaluations|
|Policy Number: 508.15|Effective Date: 8/15/2022|Page Number: 12 of 13|
|Authority:
Commissioner|Originating Division:
Health Services Division
(Mental Health)|Access Listing:
Level II: Required Offender
Access|

c. Unless otherwise requested by the Parole Board, pages 1 and 2 of this

evaluation may be completed by, a licensed masters-level mental health
counselor, mental health technician or behavior specialist, who is or is not
assigned as counselor to the offender.

d. A Psychologist who has a doctoral degree and currently licensed by the

Georgia Board of Examiners as an applied psychologist, will evaluate
offenders serving a life sentence or a sentence due to a sexual abuse
charge.

e. The Mental Health Unit Manager will ensure the Parole Board receives

the report within 30 days of the receipt of the request for a Parole Board
Evaluation.

f. A Parole Evaluation Log (Attachment 4, form M31-01-04) will be

established at each mental health unit to track Parole Psychological
Evaluations (Attachment 6, form M31-01-06). The following information
will be logged:

i. The offender’s name and number;

ii. Date of Receipt of request for evaluation;

iii. Name and Title of the evaluator;

iv. Date evaluation conducted; and

v. Date the submitted Parole Board Evaluation report is sent to the

Parole Board.

V. Attachments:

Attachment 1: Mental Health Evaluation for Services (M31-01-01)
Attachment 2: Mental Status Evaluation (M31-01-02)

|GEORGIA DEPARTMENT OF CORRECTIONS
Standard Operating Procedures|Col2|Col3|
|---|---|---|
|Policy Name:Mental Health Evaluations|Policy Name:Mental Health Evaluations|Policy Name:Mental Health Evaluations|
|Policy Number: 508.15|Effective Date: 8/15/2022|Page Number: 13 of 13|
|Authority:
Commissioner|Originating Division:
Health Services Division
(Mental Health)|Access Listing:
Level II: Required Offender
Access|

Attachment 3: Authorization for Release of Information (M31-01-03)
Attachment 4: Parole Evaluation Log (M31-01-04)
Attachment 5: Requested Records Log (M31-01-05)
Attachment 6: Parole Board Evaluations (M31-01-06)

VI. Record Retention of Forms Relevant to this Policy:

Upon completion, Attachments 1, 2, and 6 will be placed in the offender’s mental
health file, section four (4). Attachment 3 will be placed in the offender’s mental
health file, section five (5). At the end of the offender’s need for mental health
services and/or sentence, the mental health file will be placed within the offender’s
health record and retained for 10 years. Attachments 4 and 5 will be maintained in
the mental health area for four (4) years, then destroyed or archived.