Filed: Jun. 19, 2018
Latest Update: Jun. 19, 2018
Summary: PHASE 2A ORDER AND INJUNCTION ON MENTAL-HEALTH PYSCHOTHERAPY AND CONFIDENTIALITY REMEDY MYRON H. THOMPSON , District Judge . On June 8, 2018, the parties submitted stipulations regarding psychotherapy and confidentiality. They agreed that the stipulations should be reduced to an enforceable order and further agreed to some clarifications of the stipulations during an on-the-record hearing on June 13, 2018. They submitted amended stipulations incorporating some of those clarifications on Jun
Summary: PHASE 2A ORDER AND INJUNCTION ON MENTAL-HEALTH PYSCHOTHERAPY AND CONFIDENTIALITY REMEDY MYRON H. THOMPSON , District Judge . On June 8, 2018, the parties submitted stipulations regarding psychotherapy and confidentiality. They agreed that the stipulations should be reduced to an enforceable order and further agreed to some clarifications of the stipulations during an on-the-record hearing on June 13, 2018. They submitted amended stipulations incorporating some of those clarifications on June..
More
PHASE 2A ORDER AND INJUNCTION ON MENTAL-HEALTH PYSCHOTHERAPY AND CONFIDENTIALITY REMEDY
MYRON H. THOMPSON, District Judge.
On June 8, 2018, the parties submitted stipulations regarding psychotherapy and confidentiality. They agreed that the stipulations should be reduced to an enforceable order and further agreed to some clarifications of the stipulations during an on-the-record hearing on June 13, 2018. They submitted amended stipulations incorporating some of those clarifications on June 14, 2018. On June 18, 2018, during an on-the-record hearing, the parties further agreed that the stipulations prohibit placement of segregation inmates in the residential treatment units—that is, the RTU, SU, and SLU units—and require that placement of any inmate in those units be based on clinical judgment. Accordingly, it is the ORDER, JUDGMENT, and DECREE of the court as follows:
(1) The stipulations (doc. no. 1893) as clarified during on-the-record hearings on June 13 and June 18, 2018, amended on June 14, 2018, and as attached to this order, are approved.
(2) Pursuant to the stipulations, and by agreement of the parties made on-the-record on June 18, 2018, segregation inmates are prohibited from being placed in the residential treatment units—that is, the RTU, SU, and SLU units—and placement of any inmate in those units must be based on clinical judgment.
(3) Defendants Jefferson Dunn and Ruth Naglich are ENJOINED and RESTRAINED from failing to comply with the stipulations (doc. no. 1983) as clarified during on-the-record hearings on June 13 and June 18, 2018, amended on June 14, 2018, and as attached to this order.
ATTACHMENT
ADOC agrees to implement the matters set forth below within ninety (90) days of the Court's acceptance of and entry of an Order regarding these Stipulations (the "Implementation Date").
1. General Provisions
1.1. Treatment Modalities
1.1.1. Mental health treatment services shall be tailored to adequately meet the clinical needs of each inmate-patient considering the functional level, readiness for treatment, insight into mental illness, and motivation for treatment.
1.1.2. Residential mental health units (RTUs, SUs, SLUs) shall have available at least: psycho-educational groups, individual therapy, group psychotherapy, pharmacotherapy, and activity therapy.
1.1.3. Facilities with solely outpatient mental health care shall have available, at least psycho-educational groups, individual therapy, group psychotherapy, and pharmacotherapy.
1.1.4. Psychotherapy shall be evidence-based.
1.1.5. Group psychotherapy shall be offered on topics such as medication management, cognitive retraining, stress management, social skills, and anger management in sufficient quantity to accommodate the treatment services prescribed for the population of each facility.
1.1.6. If an intervention or program that is set forth in the treatment plan is not offered in the facility in which the inmate-patient is housed, either the inmate-patient will be moved to allow the inmate-patient to participate in that intervention, or the intervention will be offered in the facility where the inmate-patient is housed. However, no inmate-patient in need of residential care may be moved to a facility not offering residential care. If an ADOC facility offering residential care does not have a given program or intervention, then that program or intervention shall be provided at the facility with residential care capacity.
1.1.7. The relative timing of the appointments with the psychiatric provider and the counselor shall be determined by clinical judgment based on the needs of the inmate-patient.
1.1.8. Each inmate-patient will have access to the treatment modalities prescribed by his or her treatment team.
1.1.9. Placement in restrictive housing shall not be a basis for denying or delaying the inmate-patient's access to the interventions prescribed in his or her treatment plan or for deferring prescription of such interventions until after the inmate-patient is released from restrictive housing.
1.1.10. The minimum treatment requirements for care at the various levels of care are listed below. The amount of treatment required by each inmate-patient shall be determined by his or her treatment team, based on their clinical judgment.
1.2. Confidentiality
1.2.1. Individual counseling sessions, medication management encounters, and therapeutic groups shall take place out-of-cell in a setting that provides for confidentiality, unless that is not possible due to safety concerns, based upon clinical determinations. If confidentiality is not possible for an individual counseling session, medication management encounter, or therapeutic group, then that fact, the reason, and the actions taken to maximize confidentiality shall be documented in the progress note for that individual counseling session, medication management encounter, or therapeutic group. For purposes of this Stipulation, a "medication management encounter" means a discussion between a physician or CRNP and an inmate-patient about medication recommendations, informed consent, efficacy, adherence, side effects, or other related topics.
1.3. Documentation obligations
1.3.1. All contacts for purpose of providing mental health services shall be documented in the inmate-patient's mental health records.
1.3.2. A progress note filed in the inmate-patient's mental health record will document each significant clinical interaction. For purposes of this Stipulation, a "significant clinical interaction" means any communication and interaction between an inmate-patient and any member of the mental-health staff involving the exchange of information used in the treatment of that inmate-patient, excluding any casual exchanges, administrative communications, or other communications which do not relate to the inmate-patient's mental-health condition or on-going mental-health treatment.
1.3.3. Progress notes shall be created for all significant clinical encounters, consistent with Section 4 of the Treatment Team and Planning Stipulations.
1.3.4. A Form XXX (similar to the Individual Group Participation Progress Note attached hereto as Exhibit A) will be prepared for each inmate-patient participating in a group activity or therapy and will be maintained in each inmate-patient's medical record. Additionally, all group activities and therapy will be recorded in a log identifying the date, start and stop time, the leader or facilitator of the activity or therapy, the participants, the nature of the activity or therapy, and whether it is counted as a structured therapeutic activity or as an unstructured activity.
1.3.5. For persons housed in cells, if any of the out-of-cell counseling, group activities, or other treatment interventions cannot safely be accommodated out-of-cell, based on a clinical determination at the time of the counseling, activity, or intervention, such determination shall be documented in the documentation of the encounter (progress note or log), including the fact that the determination was made, the basis for such determination, and the person who made the determination. The psychiatric provider, counselor, or group facilitator can make this determination.
1.4. Telepsychiatry
1.4.1. A psychiatric provider treating an inmate-patient via telepsychiatry shall be provided, in advance of the telepsychiatry session, the inmate-patient's most recent mental health treatment plan, laboratory reports (if applicable), physician orders, problem list, and mental health progress notes from the past six (6) months.
1.5. Triage of mental health sick call requests
1.5.1. Mental health staff shall triage requests for mental health services submitted through the sick call process within 2 working days of receipt of the request by any medical or mental health staff, pursuant to the provisions in the Stipulation Regarding Mental Health Referral Process, Doc. 1786.
1.6. Oversight Period
1.6.1. The Parties have not agreed upon what monitoring, reporting or oversight should be required. The Parties will brief the Court separately regarding the appropriate monitoring, reporting and oversight procedures.
2. Treatment requirements: Outpatient
2.1. MH-A
2.1.1. Inmate-patients who are not on the mental health caseload shall be seen by mental health staff (either ADOC staff or vendor staff) in the event of a mental health crisis, after receipt of a mental health referral, or for follow up, as clinically indicated.
2.2. MH-B
2.2.1. Treatment Team
2.2.1.1. An initial treatment team meeting will occur within fourteen (14) days of an inmate-patient's assignment of the mental health code MH-B.
2.2.1.2. After the initial treatment plan is developed, the inmate-patient's treatment team will review the inmate-patient's treatment plan and meet consistent with Section 1.4.2 of the Treatment Team and Planning Stipulations, and more often if clinically indicated.
2.2.2. Psychiatric Provider Appointment Intervals
2.2.2.1. If the inmate-patient is prescribed psychiatric medications, then the inmate-patient will have an opportunity to see his or her psychiatric provider (psychiatrist or CRNP) at intervals not exceeding ninety (90) days and more often if clinically indicated.
2.2.2.2. For inmate-patients assigned to work release, after six (6) months and two (2) appointments with the psychiatric provider during the period at work release, the treatment team may evaluate the inmate-patient and, if clinically appropriate, reduce the frequency for seeing the psychiatric provider to intervals not exceeding one hundred twenty (120) days.
2.2.3. Counselor Appointment Intervals
2.2.3.1. Each inmate-patient will have an opportunity to see his or her counselor (MHP or psychologist) at intervals not exceeding ninety (90) days and more often if clinically indicated.
2.2.3.2. For inmate-patients assigned to work release, after six (6) months and two (2) appointments with the counselor during the period at work release, the treatment team may evaluate the inmate-patient and, if clinically appropriate, reduce the frequency for seeing the counselor to intervals not exceeding one hundred twenty (120) days.
2.3. MH-C
2.3.1. Treatment Team
2.3.1.1. An initial treatment team meeting will occur within fourteen (14) days of an inmate-patient's assignment of the mental health code MH-C.
2.3.1.2. After the initial treatment plan is developed, the inmate-patient's treatment team will review the inmate-patient's treatment plan and meet consistent with Section 1.4.2 of the Treatment Team and Planning Stipulations, and more often if clinically indicated.
2.3.2. Psychiatric Provider Appointment Intervals
2.3.2.1. If the inmate-patient is prescribed psychiatric medications, then the inmate-patient will have an opportunity to see his or her psychiatric provider (psychiatrist or CRNP) at intervals not exceeding ninety (90) days and more often if clinically indicated.
2.3.3. Counselor Appointment Intervals
2.3.3.1. Each inmate-patient will have an opportunity to see his or her counselor (MHP or psychologist) at an interval of thirty (30) to sixty (60) days and more often if clinically indicated.
3.Treatment Requirements: Structured Living Unit
3.1. A Structured Living Unit (SLU) is a diversionary outpatient unit for persons with serious mental illness or who are otherwise found to be inappropriate for a restrictive housing placement in lieu of a restrictive housing placement. Inmate-patients in need of residential-level care shall not be housed in the SLU.
3.2. Initial assessment
3.2.1. Within twenty-four (24) hours of an inmate-patient's arrival in the SLU, a registered nurse ("nurse") shall assess each inmate-patient to ensure continuity of medication and determine whether the inmate-patient has any urgent or emergent medical or mental health needs.
3.2.2. A nurse shall complete an initial nursing assessment within seventy-two (72) hours of an inmate-patient's arrival in the SLU.
3.2.3. A psychiatrist or CRNP (in collaboration with a psychiatrist who will review the initial psychiatric assessment performed by the CRNP shall complete the initial psychiatric assessment of inmate-patient within three (3) working days of an inmate-patient's arrival in the SLU.
3.2.4. A counselor (a psychologist or licensed MHP) shall complete an initial assessment within seventy-two (72) hours of an inmate-patient's arrival in the SLU.
3.3. Treatment
3.3.1. Inmate-patients in the SLU shall have structured, therapeutic out-of-cell time as provided below. Any individual out-of-cell interactions with the treatment team, psychiatric provider (psychiatrist or CRNP), counselor (psychologist or licensed MHP), or group facilitator or therapeutic groups will count towards the applicable structured, therapeutic out-of-cell time.
3.3.2. Inmate-patients in the SLU shall have unstructured out-of-cell time as provided below. This out-of-cell time is in addition to the structured, therapeutic out-of-cell time.
3.3.3. The provision of unstructured out-of-cell time shall begin immediately upon arrival at the SLU, without waiting for the initial treatment team meeting.
3.3.4. The implementation schedule for providing structured therapeutic and unstructured out-of-cell time shall be as follows
3.3.4.1. No later than September 15, 2018: Two (2) hours of structured, therapeutic out-of-cell time and four (4) hours of unstructured out-of-cell time per week;
3.3.4.2. No later than March 15, 2019: four (4) hours of structured, therapeutic out-of-cell time and six (6) hours of unstructured out-of-cell time per week;
3.3.4.3. No later than September 15, 2019: Six (6) hours of structured, therapeutic out-of-cell time and eight (8) hours of unstructured out-of-cell time per week; and
3.3.4.4. No later than March 15, 2020: Ten (10) hours of structured, therapeutic out-of-cell time and ten (10) hours of unstructured out-of-cell time per week.
4.Treatment Requirements: Residential Care
4.1. Intensive Stabilization Unit
4.1.1. Initial assessments
4.1.1.1. An inmate-patient may be admitted to the SU from any ADOC facility or an inpatient hospital.
4.1.1.2. A mental health nurse shall complete the initial nursing assessment within four (4) hours of an inmate-patient's admission to the SU.
4.1.1.3. A psychiatrist or CRNP (in collaboration with the psychiatrist who will meet with the inmate-patient, review and approve or modify the initial psychiatric assessment performed by the CRNP) shall complete the initial psychiatric assessment as follows:
4.1.1.3.1. If an inmate-patient's SU admission occurs between 7 a.m. on Monday and 3 p.m. on Friday, then the psychiatric assessment will occur within twenty-four (24) hours of an inmate-patient's admission to the SU; or
4.1.1.3.2. If an inmate-patient's SU admission occurs after 3 p.m. on a Friday or on a weekend or holiday, then
4.1.1.3.2.1. a psychiatrist or CRNP (in collaboration with the psychiatrist will enter initial orders for the inmate-patient based upon a telephone consultation with a mental health nurse after the nursing assessment; and
4.1.1.3.2.2. the psychiatric assessment will occur on the next business day following the date of the inmate-patient's SU admission.
4.1.1.4. A counselor (licensed MHP or psychologist) shall complete a mental health assessment within twenty-four (24) hours of an inmate-patient's admission to the SU.
4.1.2. Treatment
4.1.2.1. An inmate-patient's treatment team shall meet and review the treatment plan consistent with Section 1.4.2 of the Treatment Team and Planning Stipulations, and more often if clinically indicated.
4.1.2.2. Until December 1, 2019, at least two (2) times per week, the inmate-patient shall have a confidential, out-of-cell clinical encounter with the psychiatrist or CRNP. At least one (1) of these two (2) weekly encounters will be with the psychiatrist.
4.1.2.3. Starting December 1, 2019, at least three (3) times per week, the inmate-patient shall have a confidential, out-of-cell clinical encounter with the psychiatrist or CRNP. At least one (1) of these three (3) weekly encounters will be with the psychiatrist.
4.1.2.4. The psychiatrist must be a member of the treatment team. If the CRNP conducts 50% or more of the encounters described in §§ 4.1.2.2 and 4.1.2.3., the CRNP must also be a member of the treatment team.
4.1.2.5. The inmate-patient shall have daily (7 days a week) interaction with a mental health nurse.
4.1.2.6. The inmate-patient shall have daily (7 days a week) confidential, out-of-cell counseling with the assigned psychologist or licensed MHP.
4.1.2.7. Inmate-patients in the SU shall have structured, therapeutic out-of-cell time as provided below, unless clinically contraindicated. Any individual out-of-cell interactions with the treatment team, psychiatric provider (psychiatrist or CRNP), counselor (psychologist or licensed MHP), or group facilitator or therapeutic groups will count towards the applicable structured, therapeutic out-of-cell time.
4.1.2.8. Inmate-patients in the SU shall have unstructured out-of-cell time as provided below, unless clinically contraindicated. This out-of-cell time is in addition to the structured, therapeutic out-of-cell time.
4.1.2.9. The implementation schedule for providing structured therapeutic and unstructured out-of-cell time shall be as follows
4.1.2.9.1. No later than September 15, 2018 Two (2) hours of structured, therapeutic out-of-cell time and two (2) hours of unstructured out-of-cell time per week;
4.1.2.9.2. No later than March 15, 2019: Five (5) hours of structured, therapeutic out-of-cell time and five (5) hours of unstructured out-of-cell time per week;
4.1.2.9.3. No later than September 15, 2019 Eight (8) hours of structured, therapeutic out-of-cell time and eight (8) hours of unstructured out-of-cell time per week; and
4.1.2.9.4. No later than March 15, 2020: Ten (10) hours of structured, therapeutic out-of-cell time and ten (10) hours of unstructured out-of-cell time per week.
4.1.3. Length of Stay
4.1.3.1. An inmate-patient's assignment to the SU shall be clinically determined.
4.1.3.2. Until full implementation described in §4.1.2.9.4. above, on an inmate-patient's fifteenth (15th) day in the SU, if the inmate-patient has not stabilized sufficiently to be transferred to the RTU or general population, then the treatment team shall consider hospitalization and may recommend hospitalization if clinically appropriate. Reconsideration of the appropriateness of hospital-level care shall occur at least every fifteen (15) days thereafter, with such reconsideration documented in the inmate-patient's medical record. Starting with the first reconsideration at thirty (30) days in the SU, reconsideration shall be conducted in a case conference including the treatment team and the mental health vendor's psychiatric director. Such case conference shall be repeated every fifteen (15) days thereafter until the inmate-patient is sufficiently stabilized to progress to RTU Level 1 or is transferred to a higher level of care. A copy of the documentation related to the case conference will be transmitted to the ADOC Director of Psychiatry for administrative oversight purposes.
4.1.3.3. Upon full implementation of §4.1.2.9.4. above, on an inmate-patient's thirtieth (30th) day in the SU, if the inmate-patient has not stabilized sufficiently to be transferred to the RTU or general population, then the treatment team and the mental health vendor's psychiatric director shall consider hospitalization and may recommend hospitalization if clinically appropriate. Reconsideration of hospital-level care shall occur at least every fifteen (15) days thereafter, including the participation of the mental health vendor's psychiatric director, with such reconsideration documented in the inmate-patient's medical record. A copy of the documentation related to the case conference will be transmitted to the ADOC Director of Psychiatry for administrative oversight purposes.
4.1.3.4. ADOC's mental health vendor shall maintain a log identifying all inmate-patients who have resided in the SU
4.1.3.4.1. More than fifteen (15) days, prior to full implementation of §4.1.2.9.4. above; and
4.1.3.4.2. More than thirty (30) days, after full implementation of §4.1.2.9.4. above.
4.1.3.5. The log shall include the dates and participants of the psychiatric evaluations required in the preceding paragraphs.
4.1.3.6. The number of people remaining in the SU longer than fifteen (15) days prior to full implementation of §4.1.2.9.4 or longer than 30 days thereafter shall be reviewed and considered in the continuous quality improvement (CQI) process.
4.1.4. Discharge from Intensive Stabilization Unit
4.1.4.1. From the SU, an inmate-patient may be discharged to an RTU (any level), an inpatient psychiatric hospital, or to general population.
4.2. Residential Treatment Unit Level 1
4.2.1. Initial assessments
4.2.1.1. An inmate-patient may be admitted to the RTU Level 1 from any ADOC facility or from an inpatient hospital.
4.2.1.2. If an inmate-patient is admitted directly to the RTU Level 1 from any location other than the RTU or the SU, an initial assessment shall be completed as follows:
4.2.1.2.1. A nurse shall complete the initial nursing assessment within twenty-four (24) hours of an inmate-patient's arrival in the RTU Level 1.
4.2.1.2.2. A psychiatrist or CRNP (in collaboration with a psychiatrist who will meet with the inmate-patient, review and approve or modify the initial psychiatric assessment performed by the CRNP) shall complete the initial psychiatric assessment
4.2.1.2.2.1. If an inmate-patient's RTU Level 1 admission occurs between 7 a.m. on Monday and 3 p.m. on Friday, then the psychiatric assessment will occur within twenty-four (24) hours of an inmate-patient's admission to the RTU Level 1; or
4.2.1.2.2.2. If an inmate-patient's RTU Level 1 admission occurs after 3 p.m. on a Friday or on a weekend or holiday, then
4.2.1.2.2.2.1. a psychiatrist or CRNP (in collaboration with the psychiatrist will enter initial orders for the inmate-patient based upon a telephone consultation with a mental health nurse after the nursing assessment; and
4.2.1.2.2.2.2. the psychiatric assessment will occur on the next business day following the date of the inmate-patient's RTU Level 1 admission.
4.2.1.2.3. A counselor (a psychologist or licensed MHP) shall complete an initial assessment within twenty-four (24) hours of an inmate-patient's arrival in the RTU Level 1.
4.2.1.3. Until December 1, 2019, if an inmate-patient is admitted to the RTU Level 1 from another level of the RTU or from the SU and any member of the inmate-patient's treatment team changes, the new member(s) of the treatment team must review the inmate-patient's mental health record prior to the first treatment team meeting in the RTU Level 1.
4.2.1.4. Starting December 1, 2019, if an inmate-patient is admitted to the RTU Level 1 from another level of the RTU or from the SU and any member of the inmate-patient's treatment team changes, the new member(s) of the treatment team must review the inmate-patient's mental health record and meet with the inmate-patient prior to the first treatment team meeting in the RTU Level 1.
4.2.2. Treatment
4.2.2.1. The treatment team shall meet and review the treatment plan consistent with Section 1.4.2 of the Treatment Team and Planning Stipulations, and more often if clinically indicated.
4.2.2.2. Until December 1, 2019, the inmate-patient shall have at least two (2) confidential, out-of-cell clinical encounters each week with a psychiatrist or CRNP. At least every other week, at least one (1) encounter shall be with the psychiatrist.
4.2.2.3. Starting December 1, 2019, the inmate-patient shall have at least three (3) confidential, out-of-cell clinical encounters each week with a psychiatrist or CRNP. At least every other week, at least one (1) encounter shall be with the psychiatrist.
4.2.2.4. The psychiatrist must be a member of the treatment team. If the CRNP conducts 50% or more of the encounters described in §§ 4.2.2.2 and 4.2.2.3., the CRNP must also be a member of the treatment team.
4.2.2.5. The inmate-patient shall have at least two (2) interactions per week with a mental health nurse.
4.2.2.6. Until December 1, 2019, the inmate-patient shall have at least two (2) confidential, out-of-cell counseling sessions each week with the assigned psychologist or licensed MHP.
4.2.2.7. Starting December 1, 2019, the inmate-patient shall have at least three (3) confidential, out-of-cell counseling sessions each week with the assigned psychologist or licensed MHP.
4.2.2.8. Inmate-patients in the RTU Level 1 shall have structured, therapeutic out-of-cell time as provided below, unless clinically contraindicated. Any individual out-of-cell interactions with the treatment team, psychiatric provider (psychiatrist or CRNP), counselor (psychologist or licensed MHP), or group facilitator or therapeutic groups will count towards the applicable structured, therapeutic out-of-cell time.
4.2.2.9. Inmate-patients in the RTU Level 1 shall have unstructured out-of-cell time as provided below, unless clinically contraindicated. This out-of-cell time is in addition to the structured, therapeutic out-of-cell time.
4.2.2.10. The implementation schedule for providing structured therapeutic and unstructured out-of-cell time shall be as follows
4.2.2.10.1. No later than September 15, 2018 Two (2) hours of structured, therapeutic out-of-cell time and two (2) hours of unstructured out-of-cell time per week;
4.2.2.10.2. No later than March 15, 2019 Five (5) hours of structured, therapeutic out-of-cell time and five (5) hours of unstructured out-of-cell time per week;
4.2.2.10.3. No later than September 15, 2019 Eight (8) hours of structured, therapeutic out-of-cell time and eight (8) hours of unstructured out-of-cell time per week; and
4.2.2.10.4. No later than March 15, 2020: Ten (10) hours of structured, therapeutic out-of-cell time and ten (10) hours of unstructured out-of-cell time per week.
4.2.3. Length of Stay
4.2.3.1. An inmate-patient's length of stay shall be clinically determined.
4.2.3.2. If an inmate-patient stays on RTU Level 1 for thirty (30) days, the treatment team and the mental health vendor's psychiatric director shall have a case conference to determine the reasons for the inmate-patient's failure to stabilize sufficiently to progress to RTU Level 2. Such case conference shall be repeated every thirty (30) days thereafter until the inmate-patient is sufficiently stabilized to progress to RTU Level 2 or is transferred to a higher level of care.
4.2.3.3. The number of people remaining in RTU Level 1 longer than thirty (30) days shall be reviewed and considered in the CQI process.
4.2.4. Discharge from RTU Level 1
4.2.4.1. From the RTU Level 1, an inmate-patient may be discharged to a SU, a RTU (any level), an inpatient psychiatric hospital, or to general population.
4.3. Residential Treatment Unit Level 2
4.3.1. Initial assessments
4.3.1.1. An inmate-patient may be admitted to the RTU Level 2 from any ADOC facility or from an inpatient psychiatric hospital.
4.3.1.2. If an inmate-patient is admitted directly to the RTU Level 2 from any location other than the RTU or the SU, an initial assessment shall be completed as follows:
4.3.1.2.1. Within twenty-four (24) hours of in inmate-patient's arrival in the RTU, a nurse shall assess each inmate-patient to ensure continuity of medication and determine whether the inmate-patient has any urgent or emergent medical or mental health needs.
4.3.1.2.2. A nurse shall complete the initial nursing assessment within forty-eight (48) hours of an inmate-patient's arrival in the RTU Level 2.
4.3.1.2.3. A psychiatrist or CRNP (in collaboration with a psychiatrist) shall complete the initial psychiatric assessment as follows
4.3.1.2.3.1. Until December 1, 2019, if an inmate-patient's RTU Level 2 admission occurs between 7 a.m. on Monday and 3 p.m. on Friday, then the psychiatric assessment will occur within forty-eight (48) hours of an inmate-patient's admission to the RTU Level 2;
4.3.1.2.3.2. Starting December 1, 2019, if an inmate-patient's RTU Level 2 admission occurs between 7 a.m. on Monday and 3 p.m. on Friday, then the psychiatric assessment will occur within twenty-four (24) hours of an inmate-patient's admission to the RTU Level 2; or 4.3.1.2.3.3. If an inmate-patient's RTU Level 2 admission occurs after 3 p.m. on a Friday or on a weekend or holiday, then
4.3.1.2.3.3.1. a psychiatrist or CRNP (in collaboration with the psychiatrist will enter initial orders for the inmate-patient based upon a telephone consultation with a mental health nurse after the nursing assessment; and
4.3.1.2.3.3.2. the psychiatric assessment will occur on the next business day following the date of the inmate-patient's RTU Level 2 admission.
4.3.1.2.4. Until December 1, 2019, a counselor (a psychologist or licensed MHP) shall complete an initial assessment within forty-eight (48) hours of an inmate-patient's arrival in the RTU Level 2.
4.3.1.2.5. Starting December 1, 2019, a counselor (a psychologist or licensed MHP) shall complete an initial assessment within twenty-four (24) hours of an inmate-patient's arrival in the RTU Level 2.
4.3.1.3. Until December 1, 2019, if an inmate-patient is admitted to the RTU Level 2 from another level of the RTU or from the SU and any member of the inmate-patient's treatment team changes, the new member(s) of the treatment team must review the inmate-patient's mental health record prior to the first treatment team meeting in the RTU Level 2.
4.3.1.4. Starting December 1, 2019, if an inmate-patient is admitted to the RTU Level 2 from another level of the RTU or from the SU and any member of the inmate-patient's treatment team changes, the new member(s) of the treatment team must review the inmate-patient's mental health record and meet with the inmate-patient prior to the first treatment team meeting in the RTU Level 2.
4.3.2. Treatment
4.3.2.1. The treatment team shall meet and review the treatment plan consistent with Section 1.4.2 of the Treatment Team and Planning Stipulations, and more often if clinically indicated.
4.3.2.2. The inmate-patient shall have at least weekly confidential, out-of-cell clinical encounters with the psychiatrist or CRNP.
4.3.2.3. The inmate-patient shall have at least weekly confidential, out-of-cell counseling with the assigned psychologist or licensed MHP.
4.3.2.4. A daily interaction with a mental-health nurse documented in the inmate-patient's mental-health record. The daily interaction with a mental-health nurse will take place outside the inmate-patient's cell in a location that provides for confidentiality.
4.3.2.5. Inmate-patients in the RTU Level 2 shall have structured, therapeutic out-of-cell time as provided below, unless clinically contraindicated. Any individual out-of-cell interactions with the treatment team, psychiatric provider (psychiatrist or CRNP), counselor (psychologist or licensed MHP), or group facilitator or therapeutic groups will count towards the applicable structured, therapeutic out-of-cell time.
4.3.2.6. Inmate-patients in the RTU Level 2 shall have unstructured out-of-cell time as provided below, unless clinically contraindicated. This out-of-cell time is in addition to the structured, therapeutic out-of-cell time.
4.3.2.7. The implementation schedule for providing structured therapeutic and unstructured out-of-cell time shall be as follows
4.3.2.7.1. No later than September 15, 2018 Two (2) hours of structured, therapeutic out-of-cell time and four (4) hours of unstructured out-of-cell time per week;
4.3.2.7.2. No later than March 15, 2019: four (4) hours of structured, therapeutic out-of-cell time and six (6) hours of unstructured out-of-cell time per week;
4.3.2.7.3. No later than September 15, 2019 Six (6) hours of structured, therapeutic out-of-cell time and eight (8) hours of unstructured out-of-cell time per week; and
4.3.2.7.4. No later than March 15, 2020: Ten (10) hours of structured, therapeutic out-of-cell time and ten (10) hours of unstructured out-of-cell time per week.
4.3.3. Length of Stay
4.3.3.1. An inmate-patient's length of stay shall be clinically determined.
4.3.4. Discharge from RTU Level 2
4.3.4.1. From the RTU Level 2, an inmate-patient may be discharged to SU, a RTU (any level), an inpatient psychiatric hospital, or to general population.
4.4. Residential Treatment Unit Level 3
4.4.1. Initial assessments
4.4.1.1. An inmate-patient may be admitted to the RTU Level 3 from an RTU Level 1 or 2, or from an SU.
4.4.1.2. Until December 1, 2019, if any member of the inmate-patient's treatment team changes, in the transfer from the SU or other level of the RTU, the new member(s) of the treatment team must review the inmate-patient's mental health record prior to the first treatment team meeting in the RTU Level 3.
4.4.1.3. Starting December 1, 2019, if an inmate-patient is admitted to the RTU Level 3 from another level of the RTU or from the SU and any member of the inmate-patient's treatment team changes, the new member(s) of the treatment team must review the inmate-patient's mental health record and meet with the inmate-patient prior to the first treatment team meeting in the RTU Level 3.
4.4.2. Treatment
4.4.2.1. After the initial treatment team meeting, the treatment team will meet and an inmate-patient's treatment plan will be reviewed consistent with Section 1.4.2 of the Treatment Team and Planning Stipulations, and more often if clinically indicated.
4.4.2.2. The inmate-patient shall have confidential clinical encounters with the psychiatrist or CRNP at intervals not to exceed fourteen (14) days for the first six (6) weeks on RTU Level 3. After six (6) weeks, if clinically appropriate, the psychiatrist or CRNP can reduce to the frequency of encounters to intervals not to exceed thirty (30) days. To the extent inmate-patients in RTU Level 3 are housed in cells, these clinical encounters will not take place at the inmate-patient's cell.
4.4.2.3. The inmate-patient shall have confidential counseling session with the assigned psychologist or licensed MHP at intervals not to exceed fourteen (14) days for the first six (6) weeks on RTU Level 3. After six (6) weeks, if clinically appropriate, the counselor can reduce to the frequency of encounters to intervals not to exceed thirty (30) days. To the extent inmate-patients in RTU Level 3 are housed in cells, these counseling sessions will not take place at the inmate-patient's cell.
4.4.2.4. An inmate-patient will have a daily interaction with a counselor (licensed MHP or psychologist). The daily interaction with a counselor will take place in a location that provides for confidentiality. To the extent inmate-patients in RTU Level 3 are housed in cells, these interactions will not take place at the inmate-patient's cell.
4.4.2.5. For inmate-patients who are determined to need to stay in the RTU indefinitely, after six (6) months on the RTU Level 3, the following minimum treatment requirements can be reduced as follows, consistent with clinical judgment
4.4.2.5.1. An inmate-patient will be seen by a psychiatrist or CRNP for a psychiatric evaluation at intervals not exceeding ninety (90) days.
4.4.2.5.2. An inmate-patient will have an interaction with a counselor (licensed MHP or psychologist) at intervals not to exceed thirty (30) days.
4.4.2.6. Inmate-patients in the RTU Level 3 shall have structured, therapeutic out-of-cell time as provided below. Any individual out-of-cell interactions with the treatment team, psychiatric provider (psychiatrist or CRNP), counselor (psychologist or licensed MHP), or group facilitator or therapeutic groups will count towards the applicable structured, therapeutic out-of-cell time.
4.4.2.7. Inmate-patients housed in a dormitory-style RTU Level 3 will have the same amount of time outside their dormitory as inmates of the same security level who are not mentally ill. Inmate-patients housed in a cell-style RTU Level 3 will have unstructured out-of-cell time as provided below. This out-of-cell time is in addition to the structured, therapeutic out-of-cell time.
4.4.2.8. The implementation schedule for providing structured therapeutic and unstructured out-of-cell time shall be as follows
4.4.2.8.1. No later than September 15, 2018 Two (2) hours of structured, therapeutic out-of-cell time and four (4) hours of unstructured out-of-cell time per week; 4.4.2.8.2. No later than March 15, 2019: four (4) hours of structured, therapeutic out-of-cell time and six (6) hours of unstructured out-of-cell time per week;
4.4.2.8.3. No later than September 15, 2019 Six (6) hours of structured, therapeutic out-of-cell time and eight (8) hours of unstructured out-of-cell time per week; and
4.4.2.8.4. No later than March 15, 2020: Ten (10) hours of structured, therapeutic out-of-cell time and ten (10) hours of unstructured out-of-cell time per week or the same amount of unstructured out-of-cell time as other prisoners of the same security level, whichever is greater.
4.4.3. Length of Stay
4.4.3.1. An inmate-patient's length of stay shall be clinically determined.
4.4.4. Discharge from RTU Level 3
4.4.4.1. From the RTU Level 3, an inmate-patient may be discharged to a SU, RTU (any level), an inpatient psychiatric hospital, or to general population.
5. No Amendment to Stipulations or Remedial Orders. Nothing in this Stipulation supersedes or limits the requirements of other stipulations or Remedial Orders in this matter.
