Florida Department of Corrections s1

FLORIDA DEPARTMENT OF CORRECTIONS OFFICE OF HEALTH SERVICES

TECHNICAL INSTRUCTION NO. 15.05.18 Page 1 of 16

SUBJECT: OUTPATIENT MENTAL HEALTH SERVICES

EFFECTIVE DATE: 4/19/01

I. PURPOSE:

The purpose of this technical instruction is to define the goals and scope of outpatient mental health services.

II. POLICY:

The department provides a comprehensive range of outpatient mental health services including (but not limited to) evaluation, brief supportive counseling, case management, and referral to S-I/II institutions, chemotherapy, and psychiatric follow-up at S-I/II/III institutions.

The department arranges for continuity of care after expiration of sentence (EOS) for inmates with a diagnosis of mental retardation, those who show evidence of disabling symptoms of borderline or schizotypal personality disorder, or disabling symptoms of an Axis I mental disorder.

III. DEFINITIONS:

A. Psychiatric evaluation: A complete clinical interview, patient history, family mental health history, mental status exams, diagnoses, and relevant biological factors.

B. Psychiatric follow-up: An abbreviated evaluation for ongoing treatment focused upon target symptom medication response and progress towards treatment goals.

C. Psychiatric update: An abbreviated evaluation most similar to a psychiatric evaluation (A above), but focused on changes occurring over the past year. Psychiatric update includes diagnoses, mental status exam, medication changes, family mental health changes, progress towards goals, and medical status changes. In addition, psychiatric updates require a complete review of all psychiatric follow-ups, case management summaries, and diagnostic testing for the previous year.

D. S-I/II Institution: An institution within the department which is authorized to receive and house inmates who are classified as 1, 2, or 2P on category S (mental health) of the health profile. Mental health staff at S-I/II institutions are comprised of psychology personnel, who provide such services as evaluation, crisis intervention, brief supportive counseling, case management, and referral of TECHNICAL INSTRUCTION NO. 15.05.18 Page 2 of 16

inmates who need more intensive intervention to an S-I/II/III institution, transitional care unit, or crisis stabilization unit.

E. S-I/II/III Institution: An institution within the department which is authorized to receive and house inmates who are classified as 1, 2, 2P or 3 on category S (mental health) of the health profile. Both psychology and psychiatry staff are allocated to these institutions in order to provide a higher level of outpatient care than what is available at S-I/II institutions.

F. S Grade 1: The mental health classification used to indicate the absence of an Axis I disorder, the presence of a schizotypal personality disorder or borderline personality disorder, or when such conditions are present, there is a lack of associated impairment in ability to meet the normal demands of an institutional environment.

Note that this definition allows an inmate to be diagnosed with an Axis I disorder and still be properly classified as S-1 due to the absence of any significant impairment in the inmate's ability to adjust within an institutional setting. For example, the diagnoses of pedophilia, vaginismus, and the several psychoactive substance use disorders will not usually be accompanied by impairment in adaptive behavior, at least within an institutional setting. The S-1 classification may be assigned by a psychological specialist, psychologist, psychiatrist, psychiatric nurse, or in their absence, by a nonpsychiatric physician.

G. S Grade 2: The mental health classification denoting mild impairment in adaptive functioning within general inmate housing, which is associated with an Axis I disorder or symptoms thereof, schizotypal personality disorder, borderline personality disorder, or mental retardation. The impairment in functioning is not so severe as to prevent satisfactory adjustment in general inmate housing, with psychological assistance. The S-2 classification may be assigned or reduced by a psychologist or psychiatrist, or in their absence, by a nonpsychiatric physician based upon a recommendation by a psychological specialist.

H. S Grade 2P: The mental health classification denoting mild impairment in adaptive functioning within general inmate housing and the inmate meets the following criteria:

1. The patient has mental health impairment that is limited to the following Axis I disorders: adjustment disorders, dysthymic disorder, cyclothymic disorder, depressive disorder, not otherwise specified (NOS) (mild), and phobias, anxiety disorders, bipolar II and bipolar I.

2. Clinical management of the disorder requires at least periodic administration of psychotropic medication. The patient may exercise the right to refuse such medication. The patient's medication is limited to the TECHNICAL INSTRUCTION NO. 15.05.18 Page 3 of 16

following medications: Amoxapine, Bupropion HCl, Clomimipramine, Desipramine, Doxepin, Imipramine HCl, Nefazodone HCl, Nortriptyline, Protriptyline, Trazodone HCl, Fluoxetine, Paroxetine, Sertraline, Buspirone, Hydroxyzine, and Promethazine HCl.

3. The patient has a medical grade that is limited to 1 or 2.

4. Based upon a review of the complete health record, the current mental status, and institutional adjustment, the patient has a satisfactory level of functioning within the general inmate population.

5. The patient has a satisfactory security status assessment based on adjustment history, escape risk, special review, and security rating.

6. The patients excluded from this category are those who have the following:

a. History suggestive of a more serious mental illness than those listed in IIIE1 above. b. Suicide attempt or gesture within the past two (2) years (excluding behavior for secondary gain). c. Poor impulse control as indicated by poor institutional adjustment. d. Poor compliance with the Individualized Service Plan. e. Poor medication compliance.

7. The impairment in functioning is not so severe as to prevent satisfactory adjustment in general inmate housing with psychological assistance and psychotropic medication.

8. The S-2P classification may only be assigned or reduced by a psychiatrist.

I. S Grade 3: The mental health classification denoting moderate impairment in adaptive functioning due to the presence of an Axis I disorder, borderline personality disorder, or schizotypal personality disorder. The impairment in functioning is not so severe as to prevent satisfactory adjustment in general inmate housing with psychological and psychiatric assistance. Clinical management of the disorder may require at least periodic administration of psychotropic medication. The patient may exercise the right to refuse such medication. The S-3 classification may only be assigned or reduced by a psychiatrist.

J. S Grade 4: The mental health classification denoting assignment to inpatient mental health care at a transitional care unit (TCU). The S-4 classification may only be assigned or changed by a physician at a TCU. TECHNICAL INSTRUCTION NO. 15.05.18 Page 4 of 16

K. S Grade 5: The mental health classification denoting assignment to inpatient mental health care at a crisis stabilization unit (CSU), or at the Corrections Mental Health Institution. The S-5 classification may only be assigned or changed by a physician at a CSU or at CMHI.

IV. TARGET POPULATION FOR ONGOING OUTPATIENT CARE:

A. Any inmate may receive an interview with mental health staff by self or staff referral. Inmate-initiated requests will be responded to within ten (10) working days. Inmate-declared emergencies will be responded to within four (4) hours. Mental health staff or (in their absence) medical staff will respond to routine staff referrals within three working days and to urgent/emergent referrals within four hours. At institutions where 24-hour health care coverage is not available, security staff will coordinate with available health care staff at the nearest institution to ensure response to urgent/emergent referrals.

B. Mental health evaluations will be performed by qualified mental health professionals who are privileged to perform psychiatric or psychological evaluations. These evaluations include the following, as appropriate: mental status exam, psychological testing, suicide and psychosis assessments, crisis intervention, and biopsychosocial assessment (BPSA).

C. Ongoing mental health care (e.g., group and individual therapy, case management, and psychotropic medication) shall be reserved for inmates who have, or are at, significant risk for developing one of the following clinical syndromes listed in the Diagnostic and Statistical Manual of Mental Disorders:

1. Any Axis I disorder excluding substance use disorder 2. Schizotypal personality disorder 3. Borderline personality disorder 4. Mental retardation

D. Inmates who have or are suspected of having any of the several psychoactive substance use disorders shall be referred to the department's Substance Abuse Treatment Program. This shall be done via memorandum to the classification supervisor, a copy of which shall be filed in the health record under the Other Mental Health Related Correspondence subdivider.

E. Isolated or repeated acts of aggression or assaultiveness toward property, inmates, or staff by inmates who have no signs or symptoms of one of the disorders described above is not a condition suitable for ongoing outpatient care. TECHNICAL INSTRUCTION NO. 15.05.18 Page 5 of 16

V. GOALS OF OUTPATIENT MENTAL HEALTH SERVICES:

A. S-I/II Institutional Staff:

1. Provide continuity of care for S-1, S-2, and S-2P inmates received from other facilities, both reception centers and permanent institutions.

2. Prevent onset of acute mental disorder through timely responses to staff and self-referrals, monitoring and counseling at-risk inmates, and timely referral of inmates who need a higher level of care.

B. S-I/II/III Institutional Staff:

1. Provide continuity of care for S-1, S-2, S-2P, and S-3 inmates received from other facilities, both reception centers and permanent institutions.

2. Prevent onset of acute mental disorder through timely responses to staff and self-referrals, monitoring and counseling at-risk inmates, provision of ongoing outpatient psychological and psychiatric care as needed, and timely referral of inmates who need a higher level of care.

VI. SCREENING AND ORIENTATION OF NEWLY ARRIVING INMATES:

A. All inmates, regardless of assigned S grade, shall be oriented to mental health services within eight (8) calendar days of arrival to include verbal and written description of services available as well as how to access those services. The written description shall be available in English and Spanish. Such orientation shall be documented in one of three ways:

1. As an incidental note on DC4-642 Chronological Record of Outpatient Mental Health Care (a stamp will suffice);

2. Within a SOAP note if the orientation was given during a clinical encounter;

3. On DC4-773 Inmate Health Education.

B. The limits of confidentiality shall be explained and consent to evaluation or counseling shall be obtained by completing DC4-663 Consent to Mental Health Evaluation or Treatment before initiation of screening or treatment., unless this form was completed previously within the past 12 months (consent is valid for a maximum of 12 months). TECHNICAL INSTRUCTION NO. 15.05.18 Page 6 of 16

C. Medical staff shall ensure continuity of psychotropic medications for newly arriving S-2P and S-3 inmates. Continuity of medication can best be assured by medical nursing staff/mental health nurse reviewing the health record and forwarding a copy of the existing medication order to the pharmacist at the receiving institution on the day of arrival, and coordinating with the assigned physician or designee (e.g., on-call psychiatrist) to obtain a new order and prescription within 72 hours. Efforts must be made to obtain the new order on the day of arrival, if possible, so that there is no break in the continuity of receipt of medication by the patient.

D. A psychiatric update shall be completed for each newly arriving S-3 inmate by a psychiatrist within ten (10) calendar days of arrival. (Refer to IIIC for required content). A psychiatrist shall update DC4-643A Individualized Service Plan (ISP). Medication changes shall be addressed at this time . The mental status examination shall include an evaluation in at least the following areas:

1. Appearance/behavior 2. State of consciousness (alertness) 3. Orientation 4. Memory (immediate, recent, and remote) 5. Thinking 6. Perception 7. Speech 8. Mood 9. Affect 10. Suicidal/homicidal ideation 11. Vegetative functions 12. Side effects of psychotropics 13. Ability to consent to treatment

This comprehensive psychiatric review will be documented DC4-642 identifying the review as a psychiatric update and shall be placed in the health record below the blue divider (Mental Health Evaluation Reports).

A psychiatric update shall be completed on an annual basis for all S-2P and S-3 inmates.

A complete psychiatric evaluation, as defined in HSB/TI 15.05.19, shall be performed when a newly arriving S-3 inmate has not received the same within the department, or when psychotropic medication is initiated on an outpatient basis. Such an evaluation shall be documented on DC4-655 Psychiatric Evaluation. DC4-655 Psychiatric Evaluation shall be placed in the health record below the blue divider (Mental Health Evaluation Reports). TECHNICAL INSTRUCTION NO. 15.05.18 Page 7 of 16

A psychiatric follow-up (every 30, 60, or 90 days as applicable), shall be documented on DC4-642.

E. Each newly arriving S-2P inmate shall be interviewed by the physician who will be responsible for the medication management of the patient within ten (10) calendar days of arrival in order to assess mental status, and update DC4-643A Individualized Service Plan. The evaluation (see VID above) shall include evaluation of the areas specified in VID1-10 above and with additional information concerning changes in family mental health history, significant physical health changes, all new medications, review of all case management summaries, all psychiatric updates, and any diagnostic tests conducted.

F. A case manager shall be assigned (by the psychology supervisor) to each S-2P and S-3 inmate within 72 hours of receiving an inmate who is receiving mental health services. This assignment shall be documented as an incidental note on DC4-642 Chronological Record of Outpatient Mental Health Care and any subsequent change of case manager shall be documented similarly. The case manager shall complete DC4-643C Bio-Psychosocial Assessment (BPSA) on within 14 calendar days of case assignment, if one was not completed previously within the past 12 months. The BPSA shall be completed yearly as long as the inmate is receiving ongoing mental health services.

G. Each newly arriving S-2 and S-2P inmate shall be interviewed by a psychological specialist, psychologist, or in their absence, by a registered nurse specialist, within 14 days of arrival, in order to assess mental status, assess the status of all active MH problems, and update DC4-643A Individualized Service Plan. The interview must be documented using DC4-642B Psychological Screening.

H. All S-1 inmates who did not receive intake mental health screening (at a reception center) or a subsequent interview at a permanent institution shall be interviewed by a psychological specialist, psychologist, or in their absence, by a registered nurse specialist within 14 days of arrival to assess mental status and confirm the S grade. The interview shall be documented on DC4-642. Screening of all other newly arriving S-1 inmates shall minimally consist of review of the health record to determine whether further evaluation and/or treatment shall be initiated. This record screen shall be documented as an incidental note on DC4-642 and shall include a brief summary of findings.

VII. ONGOING SERVICE DELIVERY:

A. All S-2P and S-3 inmates who are taking psychotropic medication must receive psychiatric follow-up at least every 30 days, which shall be documented on DC4-642A using the format specified in DC4-642A Psychiatric Follow-Up. Patients who have been stable on medications for at least six (6) months may be seen once every two (2) months for medication review and renewal. Patients who TECHNICAL INSTRUCTION NO. 15.05.18 Page 8 of 16

have previously been in such a two-month review cycle in another institution could be placed in a two-month cycle after having been stable on medications for at least 90 days at the receiving institution. In addition, each S-2P and S-3 inmate shall receive case management as defined in VIID below.

B. When the grade of S-2, S-2P, or S-3 is assigned, a psychology case manager shall be designated within 72 hours. Those S-2, S-2P, and S-3 inmates who are judged to need verbal therapy shall be given the opportunity to participate in group and/or individual counseling as well. Therapy progress notes shall be documented on DC4-642E Individual and Group Therapy Progress Note.

C. Some inmates will exercise the right to refuse medication that the physician considers necessary. When this occurs, the inmate must be maintained as S-2P or S-3 (for at least 90 days) and be provided periodic psychiatric follow-up and case management until it is determined that medication is no longer needed. Psychiatric follow-up for such cases shall occur at least every 90 days. Case management via psychology staff shall occur at least every 30 days, with the case manager referring the inmate to the treating physician as the need arises.

D. Case management for S-3 inmates shall consist of at least the following:

1. Review of DC4-701A Medication and Treatment Record at least once every 30 days to evaluate and document relative compliance.

2. Monthly review of all other treatments specified in the ISP to determine compliance and progress.

3. Review of the monthly classification progress report (OBIS DC-14 screen) to assess institutional adjustment to housing, school, and job assignment and to track the tentative release date. Also in the event of unsatisfactory adjustment or unstable mental condition, the case manager shall obtain such information through direct staff contacts.

4. Monthly contacts with other staff having regular contact with the inmate (e.g., dorm officer, work supervisor, institutional instructor) to evaluate institutional adjustment. This collateral information shall be documented in an incidental note on DC4-642.

5. Brief encounter at least once per month to assess relevant mental status and institutional adjustment.

6. Documentation of case management shall be done on a monthly basis on DC4-642D Outpatient Case Management Summary using the format specified. TECHNICAL INSTRUCTION NO. 15.05.18 Page 9 of 16

E. If the inmate refuses case management, the refusal shall be documented on DC4-711A. Such refusal, however, will not obviate the need for the case manager to continue to monitor functioning through call-outs, review of monthly classification reports, and collateral contacts.

F. All S-2P inmates shall receive case management as defined in VIID above every 30 days. Group and/or individual counseling shall also be provided if needed.

G. All S-2 inmates shall receive case management as defined in VIID above, except that it may be provided every 60 days, as the inmate's condition permits. Group and/or individual counseling shall also be provided if needed.

H. Periodic staffings, involving the case manager, the psychiatric nurse, the psychologist, and the psychiatrist shall be held for each S-3 inmate. These staffings shall coincide with required service plan reviews, but shall also occur more frequently if indicated. The case manager shall document each staffing on DC4-643B Individualized Service Plan Review. Case staffings for S-2Ps shall include the case manager, the psychologist, and the treating physician. Case staffings for S-2s shall include the case manager and the psychologist. Protocol for development of ISPs for S-2Ps and time frames for ISP reviews for S-2Ps shall follow the guidelines outlined in HSB/TI 15.05.11 for S-3s.

I. Each permanent institution shall provide a series of group therapies that are designed to meet the needs of inmates who are eligible for ongoing outpatient services; that is, meet the criteria stated in section IVA of this technical instruction. For example, any number of the following or other groups may be running at any given time, commensurate with the needs of the inmate population:

1. Medication Compliance 2. Problem Solving 3. Stress/Anger Management 4. Social Skills Training 5. Life After Prison: Making The Transition 6. Sexual Disorder Group (as defined in HSB/TI 15.05.03) 7. HIV-Support Group (for HIV-infected inmates having cognitive and/or adjustment problems associated with the HIV status)

J. All inmates who are returned to general population from a mental health infirmary admission, a TCU, or a CSU shall (at a minimum) receive case management for at least 60 days following discharge to the general inmate population.

K. When discontinuing psychotropic medication, the treating physician shall determine whether the inmate is in need of follow-up and refer cases needing such care to psychology staff who shall provide case management for at least two months. Such cases shall be assigned a health grade of S-2, dropped from the TECHNICAL INSTRUCTION NO. 15.05.18 Page 10 of 16

psychiatric caseload, and placed on a mental health hold for 60 days. After 60 days, the S-2 grade may either be continued or may be changed to S-1 (by the supervising psychologist), and case management discontinued as clinical judgment dictates.

VIII. SERVICE DELIVERY LOGS:

A. Each institution shall maintain the following logs within the mental health office:

1. DC4-740 Daily Operations Log for each clinician.

2. Inmate Requests/Staff Referral Log—shall include inmate name/number, date received, referral source, and date answered.

3. Treatment Waiting List for Permanently Assigned Sex Offenders Log— shall include inmate name/DC#, date screened, tentative release date (TRD), date enrolled in treatment, date treatment terminated, and date treatment summary completed.

4. Requests for Formal Psychological and Psychiatric Evaluations Log— shall include inmate name/DC#, date of request, responsible staff, and completion date.

5. Outpatient ISPs Log—shall include inmate name/number, S grade, date opened, date closed, dates ISP reviewed, and date treatment summary completed.

6. Admissions to IMRs for Mental Reasons Log—shall include inmate name/DC#, presenting problem (e.g., disorientation; self-injurious behavior), date of admission, date of discharge, destination upon discharge, and "S" grade at the time of discharge.

7. Referrals to CSUs and TCUs Log—shall include inmate name/DC#, presenting problem, date/time referred, date/time transported, and destination.

8. Screening of Newly Arriving S-2, S-2P, and S-3 Inmates Log—shall include inmate name/DC#, S grade, date of arrival, and date screened (by psychology for S-2s; by treating physician for S-2Ps; by psychiatrist for S-3s).

9. Five-Day, 30-Day and 90-Day Confinement Evaluations Log—shall include inmate name/DC#, "S" grade, due date, and completion date. TECHNICAL INSTRUCTION NO. 15.05.18 Page 11 of 16

10. Use of Psychiatric Restraints Log (as defined in HSB/TI 15.05.10)—shall include inmate name/DC#, S grade, precipitating behavior, type of restraints, date/time placed in restraints, date/time released from restraints.

11. Psychotropic Medication Refusers Log—shall include inmate name/DC#, diagnosis, date of refusal, medication refused, and date refusal status terminated (inmate consents to treatment, no longer needs the recommended treatment, or is involuntarily admitted to a higher level of care).

12. Patients on Two-Month Medication Review Cycle Log—shall include inmate name/DC#, S grade, date of initial prescription, date when two- month cycle was begun, and date when the two-month cycle was discontinued.

13. Newly Arriving Inmates Who did not Receive Intake Screening (at a reception center) or Subsequent Screening (at least mental status examination and relevant history) at a Permanent Institution Log—shall include inmate name/DC#, date received at reception center, date received at current institution, and date screened at current institution.

IX. DOCUMENTATION:

A. All progress notes concerning outpatient mental health care, including incidental and SOAP notes, shall be made in the mental health section of the health record on DC4-642. This also includes written medication orders which shall normally be included under the P part of the physician's SOAP note. Each SOAP note that is written on DC4-642 must have a corresponding entry of Seen In Mental Health on DC4-701, which is generally the only documentation that mental health staff should record on DC4-701.

B. Except for group therapy contacts, each clinical encounter must be documented in SOAP format in the mental health section of the health record on DC4-642 as soon as possible, but not later than the date of the encounter. Group therapy contacts shall be documented with a SOAP note upon group enrollment and termination. The monthly therapy note on DC4-642E Individual and Group Therapy Progress Note shall include the number of scheduled sessions attended and the inmate's relative participation/progress as well as the ISP problem number. Documentation of relevant information from sources other than a clinical encounter shall be in the form of an incidental note on DC4-642. TECHNICAL INSTRUCTION NO. 15.05.18 Page 12 of 16

C. The following guidelines apply to the writing of SOAP notes:

1. Subjective data: The reason for the clinical encounter, for example, Inmate was seen at his request or Inmate seen by referral of medical staff for HIV counseling. Subjective data may also include what the inmate says that leads to identifying a problem, assessment of progress, or establishing a need for treatment or other action.

2. Objective data: What the clinician observes (hears and/or sees) that leads to identifying a problem and its severity, ruling out a problem, assessment of progress, or establishing a need for treatment or other action. This includes but is not limited to inmate behavior, symptoms, relevant history, verbal and written reports from other staff, i.e., what others observe. Any clinical encounter that is intended to monitor or evaluate an inmate's mental status, must result in observations being made under O in, at least, the following areas:

a. Appearance b. Behavior c. Orientation d. Mood/affect e. Perception f. Thinking (including suicidal/homicidal ideation) g. Vegetative functions (e.g., number of meals eaten per day; number of hours of sleep per night; bowel function)

3. Included in this section is information pertaining to lab tests and reports, an assessment of response to treatment (e.g., improvement of target symptoms), and documentation of any side effects of medications (whether these were noted by the clinician or were reported by the patient) as well as any education provided by the mental health practitioner.

4. Assessment: A judgment of subjective and objective data by the clinician, which includes a specific diagnosis, if indicated, comparison of current status with previous status relative to problems and goals (if reporting progress on the ISP) verification of a specific problem, or ruling out a problem.

5. Plan: What the clinician did to resolve the problem, if it was resolved during the session, and/or what the clinician will do to help resolve the problems/needs, issues pending for the next therapy session(s), a listing of medications prescribed linked to their respective target symptoms, lab tests requested, and referrals made to other providers shall also be included. TECHNICAL INSTRUCTION NO. 15.05.18 Page 13 of 16

D. Refusals of mental health evaluation/treatment shall be documented on DC4-711A which shall be filed under the Mental Health Authorizations and Consents subdivider. When an inmate refuses to sign DC4-711A, one additional staff member shall sign the form as a witness to the inmate's refusal.

E. Staff shall routinely attempt to obtain records of evaluation and treatment performed outside the department. Such attempts shall be briefly documented as an incidental note on DC4-642. A copy of each request that is sent to an outside provider must be filed under the Other Mental Health Related Correspondence subdivider. The case manager has the primary responsibility for requesting past mental health records.

F. An incidental note must be written on DC4-642 to document the date that each inmate request was received and answered. A stamp will suffice for this purpose. The pink copy of the inmate request shall be filed under the Other Mental Health Related Correspondence subdivider.

G. When ongoing outpatient care (e.g., case management, psychotherapy, chemotherapy) is discontinued altogether because it is no longer clinically indicated, DC4-661 Summary of Outpatient Mental Health Care must be prepared within seven (7) days. DC4-661 shall also be prepared when a major aspect of patient care is terminated as that care was unrelated to the outpatient care that continues. For example, when treatment is terminated for sexual disorder while continuing for bipolar disorder, DC4-661 shall be completed.

X. POSTRELEASE AFTERCARE PLANNING:

A. Inmates who require Outpatient Care After Release:

1. Each case manager (CM) shall monitor the EOS dates of all inmates on his/her caseload who are currently receiving mental health services. The CM shall begin the process of developing a continuity of care plan for each S-2P and S-3 inmate not later than 180 days prior to EOS. A continuity of care plan shall also be developed for an S-2 inmate, if indicated.

2. The CM shall contact the forensic client manager (see HSB/TI 15.05.05/appendix) in the patient's home district to determine the proper referral community mental health center or clinic. Home district refers to the Department of Children and Families (DCF) district that encompasses the patient's identified county of residence, or if s/he was a transient, the county in which the crime was committed. TECHNICAL INSTRUCTION NO. 15.05.18 Page 14 of 16

3. The DCF forensic client manager will designate the community mental health center (CMHC) or clinic to be called by the CM for an initial client appointment.

4. The CM shall obtain the appropriate release of information from the patient and contact the designated CMHC or clinic to make a referral and to obtain an initial appointment for the patient.

5. When contacting the CMHC or clinic, the CM shall be prepared to provide such patient information as identifying information, current diagnosis, current treatment, and compliance with treatment. The CMHC or clinic shall also be advised that a treatment summary shall be forwarded before EOS. After the telephone consultation, the CM shall send a letter to the CMHC staff person who received the verbal referral to advise the patient's current diagnosis, the treatment s/he is receiving, the anticipated treatment needs in the community, the estimated date the patient will be released, and the patient's anticipated residential address. The letter shall also state that a treatment summary will be forwarded before EOS.

6. The CM shall inform the patient verbally and in writing of his/her appointment time and, if indicated, shall consult with the inmate's treating psychiatrist to ensure that an ample supply of psychotropic medication will be given to the inmate at the time of release.

7. The CM shall complete DC4-661 Summary of Outpatient Mental Health Care not later than 45 days prior to EOS and shall send a copy to the CMHC or clinic contact person not later than 30 days prior to EOS.

8. The CM shall document all contacts with the DCF forensic client managers and CMHC or clinic staff via incidental notes on DC4-642 Chronological Record of Outpatient Mental Health Care. In addition, a copy of all written correspondence shall be filed under the Other Mental Health Related Correspondence subdivider.

9. Classification staff shall notify mental health staff (180 days prior to EOS or tentative release date) of the name and DC# of each inmate who will be released to probation and parole (P&P) supervision. Classification staff will also advise as to which P&P circuit office the inmate will be reporting.

10. If any inmate is classified as S-2, S-2P, or S-3 or one who has a diagnosis of sexual disorder, mental health staff shall forward (via regular mail) a copy of the DC4-661 Summary of Outpatient Mental Health Care to the designated P&P circuit office at least 30 days prior to release. This action TECHNICAL INSTRUCTION NO. 15.05.18 Page 15 of 16

shall be recorded as an incidental note in the health record. If the DC4- 661 has not been completed, mental health staff shall complete the same and forward it to the P&P circuit office at least 30 days prior to release. If the DC4-661 has been completed but lacks relevant current information, an addendum shall be prepared titled Addendum to Summary of Outpatient Mental Health Care of (date) and forwarded with DC4-661.

B. Inmates With Mental Retardation:

When inmates with clinically diagnosed mental retardation are nearing EOS, the following procedures shall be followed:

1. Not less than 180 days prior to the inmate's presumptive release date, the CM shall send the following to the DCF District Program Office for Developmental Services (DPODS) in the district where the inmate will be residing upon release:

a. Name of inmate and community where s/he will be residing. A map of Florida (showing the district boundaries) is available in an appendix to HSB/TI 15.05.05.

b. Tentative release date.

c. Intelligence quotient of the inmate, the name of the test used to obtain the score (test used must be either the Wechsler Adult Intelligence Scale-Revised or the Stanford-Binet), and the date of the test.

2. When the inmate receives the information from DPODS regarding how to apply for services, the CM shall ensure that the inmate understands the information and shall assist him/her in applying for services so that a habilitation plan may be developed before s/he is released.

3. If the inmate has not received information from DPODS within 30 days of the referral, the case manager shall call the DPODS contact person and follow up the telephone conversation with a letter. This process shall be repeated at least every 30 days until DPODS has forwarded the information to the inmate.

4. All actions taken to effect continuity of care for mentally retarded inmates shall be documented as follows: TECHNICAL INSTRUCTION NO. 15.05.18 Page 16 of 16

a. An incidental note shall be written in the mental health section of the health record on DC4-642 for each action that does not involve an inmate encounter. For example, telephone contacts and letters to the DPODS shall be documented in incidental notes.

b. A copy of all outgoing correspondence shall be filed under the Other Mental Health Related Correspondence subdivider.

c. A SOAP note relating to each inmate encounter shall be written on DC4-642.

XI. IMPLEMENTATION DATE:

Each institution will implement this technical instruction no later than 30 days after signature.

Director of Health Services Date

This Technical Instruction Supersedes: HSB 15.05.04 dated 4/15/91 HSB 15.05.18 dated 4/15/91