SOP 508.20: Mental Health Rounds in Restrictive Housing Units

|GEORGIA DEPARTMENT OF CORRECTIONS
Standard Operating Procedures|Col2|Col3|
|---|---|---|
|Policy Name:Mental Health Rounds in Restrictive Housing Units|Policy Name:Mental Health Rounds in Restrictive Housing Units|Policy Name:Mental Health Rounds in Restrictive Housing Units|
|Policy Number: 508.20|Effective Date: 8/2/2022|Page Number: 1 of 8|
|Authority:
Commissioner
|Originating Division:
Health Services Division
(Mental Health)|Access Listing:
Level I: All Access|

I. Introduction and Summary:

It is the policy of the Georgia Department of Corrections (GDC) that a Qualified
Mental Health Professional conduct regular weekly mental health rounds on all
offenders confined in restrictive housing to 1) ensure that offenders previously
identified as having a Serious Mental Illness receive continuous mental health services
while confined in restrictive housing, and 2) ensure that any offender exhibiting signs
of Serious Mental Illness in restrictive housing is detected and treated in a timely
manner. Mental health rounds are conducted primarily for purposes of identification
and referral of offenders with Serious Mental Illness, as opposed to delivering actual
mental health treatment of service. This procedure is applicable to all Georgia
Department of Corrections facilities with a mental health mission.

II. Authority:

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

Screen, 508.15 Mental Health Evaluations, 508.19 Mental Health Referral and
Triage, 507.04.33 Health Evaluation of Offenders in Restrictive Housing, 508.28
Managing Potentially Suicidal, Self-Injurious, and Assaultive Behavior, and
508.25 Psychiatric Hospitalization; and

B. ACA Standards: 5-ACI-4A-10, 5-ACI-4B-01, 5-ACI-4B-10, 5-ACI-4B-28, 5
ACI-4B-30.

III. Definitions:

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

significantly impairs judgment, behavior, or capacity to recognize reality or cope
with the ordinary demands of life within the prison environment and which is
manifested by pain or disability. Serious Mental Illness requires a mental health
diagnosis, prognosis, and treatment by appropriate mental health staff.

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

Psychiatrists, Psychologists, Advanced Practice Registered Nurses (APRN),
Licensed Nurses, Licensed Professional Counselors, Licensed Master and Clinical

|GEORGIA DEPARTMENT OF CORRECTIONS
Standard Operating Procedures|Col2|Col3|
|---|---|---|
|Policy Name:Mental Health Rounds in Restrictive Housing Units|Policy Name:Mental Health Rounds in Restrictive Housing Units|Policy Name:Mental Health Rounds in Restrictive Housing Units|
|Policy Number: 508.20|Effective Date: 8/2/2022|Page Number: 2 of8|
|Authority:
Commissioner
|Originating Division:
Health Services Division
(Mental Health)|Access Listing:
Level I: All Access|

Social Workers, and Licensed Marriage and Family Therapists, Mental Health
Counselors, Mental Health Technicians, and Mental Health Behavioral Specialists.

C. Licensed Health Care Provider - A licensed, registered, or certified health care

employee whose position requires a license and/or credentials that meet state
credentialing laws.

D. Double-Bunking (in Restrictive Housing) - A Mental Health Offender who is on

Protective Custody Status or Administrative Segregation Status and is placed in
the same segregation cell with another Mental Health Offender.

E. Mental Health Offender - An offender who has a current mental health diagnosis

and is assigned as Level II or higher, also referred to as being on the mental health
caseload or receiving mental health services.

IV. Statement of Policy and Applicable Procedures:

A. Evaluation of offenders on the mental health caseload confined in Restrictive

Housing:

1. When offenders receiving mental health services are placed in restrictive

housing, the mental health unit manager or designee will be notified and they,
in turn, will notify the offender’s mental health counselor.

2. Any offender who is receiving mental health services and has been placed in

Restrictive Housing, must receive a mental health screen (See SOP 508.14
Mental Health Reception Screen) by a Qualified Mental Health Professional
within two (2) working days of placement in order to assess for contraindications to restrictive housing. This evaluation will be documented on
Attachment 2, 48 Hour/Weekly Progress Note (form M40-01-03) that is placed
in the offender’s mental health record.

3. A Qualified Mental Health Professional will meet weekly with each offender

who is receiving mental health services and is housed in Restrictive Housing.
The offender contact will be documented in the offender’s mental health record

|GEORGIA DEPARTMENT OF CORRECTIONS
Standard Operating Procedures|Col2|Col3|
|---|---|---|
|Policy Name:Mental Health Rounds in Restrictive Housing Units|Policy Name:Mental Health Rounds in Restrictive Housing Units|Policy Name:Mental Health Rounds in Restrictive Housing Units|
|Policy Number: 508.20|Effective Date: 8/2/2022|Page Number: 3 of8|
|Authority:
Commissioner
|Originating Division:
Health Services Division
(Mental Health)|Access Listing:
Level I: All Access|

using Attachment 2, 48 Hour/Weekly Progress Note (form M40-01-03) that is
placed in section 1 of the offender’s mental health record or section 5 of the
medical record if mental health records are kept in the medical record (e.g., at
probation detention centers).

4. Once a month, Level II mental health offenders will have an individual

counseling session with their mental health counselor. Level III and IV
offenders will have a minimum of two (2) individual counseling sessions a
month. These counseling contacts are expected to occur out of cell. The
session will be based on treatment plan needs and documented on Attachment
2, Mental Health Progress Note (form M20-02-02) from SOP 508.10
Confidentiality of Mental Health Records.

B. Evaluation of offenders confined in restrictive housing units (Segregation,

Isolation, Protective Custody):

1. At facilities with mental health services, a mental health professional

privileged to perform such evaluations shall conduct on-site weekly rounds in
the institution’s restrictive housing unit(s) using Attachment 1, Restrictive
Housing Rounds Log (form M40-01-01).

2. At facilities with mental health services, the mental health unit manager will

be responsible for maintaining Attachment 1, Restrictive Housing Rounds Log
(form M40-01-01). The following information must be tracked:

a. Segregation unit;

b. Date;

c. Staff person conducting rounds;

d. Time in;

e. Time out;

|GEORGIA DEPARTMENT OF CORRECTIONS
Standard Operating Procedures|Col2|Col3|
|---|---|---|
|Policy Name:Mental Health Rounds in Restrictive Housing Units|Policy Name:Mental Health Rounds in Restrictive Housing Units|Policy Name:Mental Health Rounds in Restrictive Housing Units|
|Policy Number: 508.20|Effective Date: 8/2/2022|Page Number: 4 of8|
|Authority:
Commissioner
|Originating Division:
Health Services Division
(Mental Health)|Access Listing:
Level I: All Access|

f. Officer(s) on duty;

g. Offenders in need of mental health services; and

h. A brief description of clinical concerns for each offender in need of mental

health services.

3. Mental health rounds in restrictive housing units conducted by a Qualified

Mental Health Professional consist of:

a. A collaborative inquiry with the unit correctional officer into any

problematic offender behaviors,

b. A brief conversation with each offender and a mental health screen when

clinically indicated, and

c. The person conducting rounds will document any clinical concerns on

Attachment 1, Referral Form from SOP 508.19 (form M35-01-01).
Referrals for a mental health evaluation will be handled in accordance with
SOP 508.19 Mental Health Referral and Triage.

~~4.~~ The mental health vendor is responsible for ensuring that at facilities without

mental health services, each offender in restrictive housing shall receive a
weekly visit from mental health staff to ensure that offenders have access to
the behavioral health system. The minimum expectation of clinical
documentation will include an entry of the offender’s name and GDC
identification number, restrictive housing unit identifier and officer on duty,
time of entry and exit, and a brief description of any mental health concerns in
the Restrictive Housing Rounds Log (Attachment 1, form M40-01-01). Mental
health staff will also provide a signature on the cell door sheet. The presence
of a mental health staff member in restrictive housing is announced to security
staff and recorded in the restricted sign-in log provided by security staff. The
above procedures entail a minimum expected standard.

|GEORGIA DEPARTMENT OF CORRECTIONS
Standard Operating Procedures|Col2|Col3|
|---|---|---|
|Policy Name:Mental Health Rounds in Restrictive Housing Units|Policy Name:Mental Health Rounds in Restrictive Housing Units|Policy Name:Mental Health Rounds in Restrictive Housing Units|
|Policy Number: 508.20|Effective Date: 8/2/2022|Page Number: 5 of8|
|Authority:
Commissioner
|Originating Division:
Health Services Division
(Mental Health)|Access Listing:
Level I: All Access|

5. Mental health staff assigned to conduct on-site weekly restricted housing

rounds at facilities without mental health services shall use Attachment 1,
Restrictive Housing Rounds Log (form M40-01-01).

6. Mental health rounds in restrictive housing units conducted at facilities without

mental health services consist of:

a. A collaborative inquiry with the unit correctional officer into any

problematic offender behaviors,

b. A brief conversation with each offender and a mental health screen when

clinically indicated, and

c. The mental health staff member conducting rounds in restrictive housing

units at facilities without mental health services will document any clinical
concerns on Attachment 1, Referral Form from SOP 508.19 (form M3501-01). Referrals for a mental health evaluation will be handled in
accordance with SOP 508.19, Mental Health Referral and Triage.

7. At facilities without mental health services, a Licensed Health Care Provider

will conduct on-site rounds at least once a week (See SOP 507.04.33 Health
Evaluation of Offenders in Restrictive Housing).

8. If an offender is placed in restrictive housing after release from the Acute Care

Unit/Crisis Stabilization Unit, a mental health assessment will be conducted by
the Qualified Mental Health Professional on that offender within the first 10 12 hours of placement in restrictive housing.

9. Whenever an offender not receiving mental health services remains in

restrictive housing for more than 30 days, they will be examined by a Qualified
Mental Health Professional to determine if there is a need for mental health
services. This initial evaluation shall be conducted after the first 30 days of
confinement and every three (3) months thereafter unless signs of psychiatric
decompensation warrant a mental health evaluation to occur earlier than

|GEORGIA DEPARTMENT OF CORRECTIONS
Standard Operating Procedures|Col2|Col3|
|---|---|---|
|Policy Name:Mental Health Rounds in Restrictive Housing Units|Policy Name:Mental Health Rounds in Restrictive Housing Units|Policy Name:Mental Health Rounds in Restrictive Housing Units|
|Policy Number: 508.20|Effective Date: 8/2/2022|Page Number: 6 of8|
|Authority:
Commissioner
|Originating Division:
Health Services Division
(Mental Health)|Access Listing:
Level I: All Access|

clinically indicated. The evaluator will write a brief note addressing any
mental health needs, conduct a mental status evaluation, and document the
impact of restrictive housing on the offender using Attachment 3, 30/90 Day
Progress Note (form M40-01-04). This note will be placed in the mental health
section of the medical record. If the offender requires mental health
intervention, they will be referred for further evaluation and treatment as
needed.

a. The staff person conducting rounds shall notify the mental health unit

manager, or designated staff at facilities with no mental health units, of
offenders in restrictive housing who present with a need for non-emergency
mental health services for purposes of scheduling a routine mental health
services evaluation.

b. Staff referrals and self-referrals for a mental health evaluation will be

handled in accordance with SOP 508.19 Mental Health Referral and
Triage.

C. Offenders found to be in need of immediate mental health attention will be referred

to the mental health unit manager or designated medical personnel for further
action that includes, but is not limited to:

1. Scheduling an emergency mental health evaluation to be conducted in

accordance with SOP 508.15 Mental Health Evaluations within 24 hours or on
the next working day.

2. Immediate transfer of the offender to mental health observation, acute care

unit, crisis stabilization unit, supportive living unit, or arrange for a higher level
of psychiatric care based on the offender’s mental status and level of care
needed in accordance with SOPs 508.28 Managing Potentially Suicidal, SelfInjurious and Assaultive Behavior, and 508.25 Psychiatric Hospitalization.
This should be documented on a mental health referral form in accordance with
SOP 508.19 Mental Health Referral and Triage.

|GEORGIA DEPARTMENT OF CORRECTIONS
Standard Operating Procedures|Col2|Col3|
|---|---|---|
|Policy Name:Mental Health Rounds in Restrictive Housing Units|Policy Name:Mental Health Rounds in Restrictive Housing Units|Policy Name:Mental Health Rounds in Restrictive Housing Units|
|Policy Number: 508.20|Effective Date: 8/2/2022|Page Number: 7 of8|
|Authority:
Commissioner
|Originating Division:
Health Services Division
(Mental Health)|Access Listing:
Level I: All Access|

D. Double-Bunking in Restrictive Housing for Mental Health Offenders:

1. Mental Health Offenders who are Double-Bunked in protective custody or

administrative segregation should be paired with an offender of similar mental
health level. Upon notification, and if deemed clinically appropriate, a Level
II offender may be housed with a Level I offender. If Levels are mixed, mental
health staff will document on a mental health progress note that the offender is
clinically appropriate for Double-Bunking with an offender of a different
Level. Level III offenders may only Double-Bunk with other Level III
offenders. Level IV offenders should always be housed in a single cell. (See
paragraph IV. D. 3. below for exceptions to the above “housing” assignments).

2. The facility classification committee will notify the mental health unit manager

or his/her designee of the need to Double-Bunk offenders of different Levels.
Security will be notified by mental health staff of any modifications or contraindications to the housing assignment. The mental health duty officer will log
the Double-Bunked offenders with different levels in the mental health duty
officer logbook.

3. Special consideration should be given to the following three (3) circumstances:

a. Offenders on the mental health caseload charged with assault are to be

“housed” alone. In cases when there are extenuating circumstances,
security/officer in charge will contact the mental health counselor/duty
officer to determine if Double-Bunking is deemed appropriate. The mental
health counselor/duty officer will in turn notify the facility classification
committee of any modifications or contra-indications to the housing
assignment.

b. Offenders on the mental health caseload who are alleged victims of sexual

abuse are to be “housed” alone. In cases when there are extenuating
circumstances, security/officer in charge will contact the mental health
counselor/duty officer to determine if Double-Bunking is deemed
appropriate. The mental health counselor/duty officer will in turn notify the

|GEORGIA DEPARTMENT OF CORRECTIONS
Standard Operating Procedures|Col2|Col3|
|---|---|---|
|Policy Name:Mental Health Rounds in Restrictive Housing Units|Policy Name:Mental Health Rounds in Restrictive Housing Units|Policy Name:Mental Health Rounds in Restrictive Housing Units|
|Policy Number: 508.20|Effective Date: 8/2/2022|Page Number: 8 of8|
|Authority:
Commissioner
|Originating Division:
Health Services Division
(Mental Health)|Access Listing:
Level I: All Access|

facility classification committee of any modifications or contra-indications
to the housing assignment.

c. Offenders on the mental health caseload with a physical or sexual assault

history are to be “housed” alone. In cases when there are extenuating
circumstances, security/officer in charge will contact the mental health
counselor/duty officer to determine if Double-Bunking is deemed
appropriate. The mental health counselor/duty officer will in turn notify
the facility classification committee of any modifications or contraindications to the housing assignment.

V. Attachments:

Attachment 1: Restrictive Housing Rounds Log (M40-01-01)
Attachment 2: 48 Hour/Weekly Progress Note (M40-01-03)
Attachment 3: 30/90 Day Progress Note (M40-01-04)

VI. Record Retention of Forms Relevant to this Policy:

Upon completion, Attachment 1 will remain in the mental health area for three (3)
years, then destroyed. Upon completion, Attachments 2 and 3 will be placed in the
offender’s mental health file. 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 ten (10) years.