Q&A Attachment 13 - Medical and Mental Health Audits.pdf

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Medical and Mental Health Services
Solicitation number
1301
Issued by
Idaho

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This document is a Contract Performance Measure Audit Summary prepared by the Idaho Department of Correction (IDOC) detailing medical and mental health service delivery audits across multiple correctional facilities. The audit evaluates compliance with established performance standards across 23 medical/health metrics and 11 mental health metrics at ten IDOC locations: ICIO, IMSI, ISCC, ISCI, MVTC, NICI, PWCC, SAWC, SBWCC, and SICI. Audit periods range from July 2025 through May 2026, with each location assessed against specific performance thresholds. Medical audit categories include credentialing and training, medication transfers, sick call chart reviews, continuity of care, chronic disease management, oral care, tuberculosis screening, hepatitis C tracking, and pharmacy operations. Mental health audits measure performance on mental health screening, assessment and treatment planning, suicide risk assessment, high-security resident care, restrictive housing protocols, and psychiatric encounters.

Overall facility performance on medical audits ranges from 86 percent to 99 percent, with most locations exceeding or near the 95 percent threshold for critical care measures. Notable areas of concern include Oral Care compliance, which falls significantly below the 85 percent threshold at IMSI (31 percent), ISCC (31 percent), and SICI (51 percent), and Hepatitis C Tracking at SICI (27 percent). Mental health audit scores range from 86 percent to 98 percent overall, with most facilities performing above the 90 percent threshold. Specific mental health performance gaps appear in Assessment and Treatment Planning at NICI (71 percent) and Mental Health Screening at NICI (83 percent). The data classification indicates L3 Restricted sensitivity, reflecting the confidential nature of correctional health services information.

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Location

ICIO

Overall Score 98%

Threshold Audit Results 1 Credentialing / Training 95% 100% 2 Transfer DC Meds 90% 100% 3 RDU Screen 95% NA 4 Sick Call GP Chart Review 95% 98%

4a Sick Call General Population Offered 95% 100% 5 Sick Call Segregation Chart Review 95% 100%

5a Sick Call Segregation Offered 95% 100% 6 Sick Call RDU Chart Review 95% NA

6a Sick Call RDU Offered 95% NA 7 Continuity of Care 90% 98% 8 Periodic Health Assessment 85% NA 9 Chronic Disease 95% 97%

9a Treatment Plans 95% 99% 10 Oral Care 85% 100% 11 Annual TB 100% 100% 12 Segregation 85% 100% 13 Pregnant Resident 95% NA 14 LTC - Inpatient 95% NA 15 Acute Infirmary Care 95% NA 16 23HR Observation 95% NA 17 HEP C Tracking 95% 76% 18 Transfer Screen (RCV) 95% 100%

19 LTBI 100% 100%

20 MAR 95% 99%

21 Diagnostics 90% 100% 22 Pharmacy Operations 100% 100% 23 Annual Tool 90% NA

Idaho Department of Correction Contract Performance Measure Audit

Summary of Audit Information Au di t

N um be r

Audit Period

Sept 2025 - Feb 2026

# IDOC Data Sensitivity Classification - L3 Restricted

IMSI

Overall Score 87%

Threshold Audit Results 1 Credentialing / Training 95% 100% 2 Transfer DC Meds 90% 78% 3 RDU Screen 95% NA 4 Sick Call GP Chart Review 95% 92%

4a Sick Call General Population Offered 95% 100% 5 Sick Call Segregation Chart Review 95% 95%

5a Sick Call Segregation Offered 95% 100% 6 Sick Call RDU Chart Review 95% NA

6a Sick Call RDU Offered 95% NA 7 Continuity of Care 90% 83% 8 Periodic Health Assessment 85% NA 9 Chronic Disease 95% 92%

9a Treatment Plans 95% 96% 10 Oral Care 85% 31% 11 Annual TB 100% 94% 12 Segregation 85% 93% 13 Pregnant Resident 95% NA 14 LTC - Inpatient 95% NA 15 Acute Infirmary Care 95% NA 16 23HR Observation 95% NA 17 HEP C Tracking 95% 69% 18 Transfer Screen (RCV) 95% 91%

19 LTBI 100% NA

20 MAR 95% 81%

21 Diagnostics 90% 84% 22 Pharmacy Operations 100% 100% 23 Annual Tool 90% NA

Idaho Department of Correction Contract Performance Measure Audit

Summary of Audit Information Au di t

N um be r

8/1/26 - 1/31/26

ISCC

Overall Score 90%

Threshold Audit Results 1 Credentialing / Training 95% 100% 2 Transfer DC Meds 90% 90% 3 RDU Screen 95% NA 4 Sick Call GP Chart Review 95% 92%

4a Sick Call General Population Offered 95% 100% 5 Sick Call Segregation Chart Review 95% 84%

5a Sick Call Segregation Offered 95% 100% 6 Sick Call RDU Chart Review 95% NA

6a Sick Call RDU Offered 95% NA 7 Continuity of Care 90% 91% 8 Periodic Health Assessment 85% NA 9 Chronic Disease 95% 90%

9a Treatment Plans 95% 98% 10 Oral Care 85% 31% 11 Annual TB 100% 99% 12 Segregation 85% 99% 13 Pregnant Resident 95% NA 14 LTC - Inpatient 95% 100% 15 Acute Infirmary Care 95% 94% 16 23HR Observation 95% 96% 17 HEP C Tracking 95% 65% 18 Transfer Screen (RCV) 95% 99%

19 LTBI 100% 75%

20 MAR 95% 97%

21 Diagnostics 90% 94% 22 Pharmacy Operations 100% 100% 23 Annual Tool 90% NA

Idaho Department of Correction Contract Performance Measure Audit

Summary of Audit Information Au di t

N um be r

10/1/2025 - 3/31/2026

ISCI

Overall Score 95%

Threshold Audit Results 1 Credentialing / Training 95% 100% 2 Transfer DC Meds 90% 92% 3 RDU Screen 95% 88% 4 Sick Call GP Chart Review 95% 96%

4a Sick Call General Population Offered 95% 100% 5 Sick Call Segregation Chart Review 95% 97%

5a Sick Call Segregation Offered 95% 100% 6 Sick Call RDU Chart Review 95% 99%

6a Sick Call RDU Offered 95% 100% 7 Continuity of Care 90% 93% 8 Periodic Health Assessment 85% NA 9 Chronic Disease 95% 88%

9a Treatment Plans 95% 98% 10 Oral Care 85% 63% 11 Annual TB 100% 99% 12 Segregation 85% 100% 13 Pregnant Resident 95% NA 14 LTC - Inpatient 95% 98% 15 Acute Infirmary Care 95% 97% 16 23HR Observation 95% 98% 17 HEP C Tracking 95% 96% 18 Transfer Screen (RCV) 95% 97%

19 LTBI 100% 100%

20 MAR 95% 88%

21 Diagnostics 90% 88% 22 Pharmacy Operations 100% 98% 23 Annual Tool 90% NA

Idaho Department of Correction Contract Performance Measure Audit

Summary of Audit Information Au di t

N um be r

12/1/2025 - 5/31/2026

MVTC

Overall Score 88%

Threshold Audit Results 1 Credentialing / Training 95% 100% 2 Transfer DC Meds 90% 91% 3 RDU Screen 95% NA 4 Sick Call GP Chart Review 95% 54%

4a Sick Call General Population Offered 95% 100% 5 Sick Call Segregation Chart Review 95% NA

5a Sick Call Segregation Offered 95% NA 6 Sick Call RDU Chart Review 95% NA

6a Sick Call RDU Offered 95% NA 7 Continuity of Care 90% 84% 8 Periodic Health Assessment 85% NA 9 Chronic Disease 95% 84%

9a Treatment Plans 95% 92% 10 Oral Care 85% 96% 11 Annual TB 100% 98% 12 Segregation 85% NA 13 Pregnant Resident 95% NA 14 LTC - Inpatient 95% NA 15 Acute Infirmary Care 95% NA 16 23HR Observation 95% NA 17 HEP C Tracking 95% 76% 18 Transfer Screen (RCV) 95% 97%

19 LTBI 100% 63%

20 MAR 95% 95%

21 Diagnostics 90% 93% 22 Pharmacy Operations 100% 90% 23 Annual Tool 90% NA

Idaho Department of Correction Contract Performance Measure Audit

Summary of Audit Information Au di t

N um be r

7/1/25 - 12/31/25

NICI

Overall Score 95%

Threshold Audit Results 1 Credentialing / Training 95% 100% 2 Transfer DC Meds 90% 96% 3 RDU Screen 95% NA 4 Sick Call GP Chart Review 95% 99%

4a Sick Call General Population Offered 95% 100% 5 Sick Call Segregation Chart Review 95% NA

5a Sick Call Segregation Offered 95% NA 6 Sick Call RDU Chart Review 95% NA

6a Sick Call RDU Offered 95% NA 7 Continuity of Care 90% 97% 8 Periodic Health Assessment 85% NA 9 Chronic Disease 95% 96%

9a Treatment Plans 95% 100% 10 Oral Care 85% 72% 11 Annual TB 100% 100% 12 Segregation 85% NA 13 Pregnant Resident 95% NA 14 LTC - Inpatient 95% NA 15 Acute Infirmary Care 95% NA 16 23HR Observation 95% NA 17 HEP C Tracking 95% 94% 18 Transfer Screen (RCV) 95% 100%

19 LTBI 100% 100%

20 MAR 95% 96%

21 Diagnostics 90% 80% 22 Pharmacy Operations 100% 100% 23 Annual Tool 90% NA

Idaho Department of Correction Contract Performance Measure Audit

Summary of Audit Information Au di t

N um be r

September 2025 - February 2026

PWCC

Overall Score 98%

Threshold Audit Results 1 Credentialing / Training 95% 100% 2 Transfer DC Meds 90% 100% 3 RDU Screen 95% 100% 4 Sick Call GP Chart Review 95% 100%

4a Sick Call General Population Offered 95% 100% 5 Sick Call Segregation Chart Review 95% 100%

5a Sick Call Segregation Offered 95% 100% 6 Sick Call RDU Chart Review 95% NA

6a Sick Call RDU Offered 95% NA 7 Continuity of Care 90% 90% 8 Periodic Health Assessment 85% NA 9 Chronic Disease 95% 96%

9a Treatment Plans 95% 100% 10 Oral Care 85% 98% 11 Annual TB 100% 99% 12 Segregation 85% 95% 13 Pregnant Resident 95% 96% 14 LTC - Inpatient 95% 100% 15 Acute Infirmary Care 95% 100% 16 23HR Observation 95% 100% 17 HEP C Tracking 95% 100% 18 Transfer Screen (RCV) 95% 99%

19 LTBI 100% 89%

20 MAR 95% 93%

21 Diagnostics 90% 99% 22 Pharmacy Operations 100% 100% 23 Annual Tool 90% NA

Idaho Department of Correction Contract Performance Measure Audit

Summary of Audit Information Au di t

N um be r

11/1/2025 - 4/30/2026

SAWC

Overall Score 99%

Threshold Audit Results 1 Credentialing / Training 95% 100% 2 Transfer DC Meds 90% 100% 3 RDU Screen 95% NA 4 Sick Call GP Chart Review 95% 98%

4a Sick Call General Population Offered 95% 100% 5 Sick Call Segregation Chart Review 95% NA

5a Sick Call Segregation Offered 95% NA 6 Sick Call RDU Chart Review 95% NA

6a Sick Call RDU Offered 95% NA 7 Continuity of Care 90% 96% 8 Periodic Health Assessment 85% NA 9 Chronic Disease 95% 99%

9a Treatment Plans 95% 100% 10 Oral Care 85% 100% 11 Annual TB 100% 98% 12 Segregation 85% NA 13 Pregnant Resident 95% NA 14 LTC - Inpatient 95% NA 15 Acute Infirmary Care 95% NA 16 23HR Observation 95% NA 17 HEP C Tracking 95% 100% 18 Transfer Screen (RCV) 95% 96%

19 LTBI 100% 100%

20 MAR 95% 100%

21 Diagnostics 90% 98% 22 Pharmacy Operations 100% 100% 23 Annual Tool 90% NA

Idaho Department of Correction Contract Performance Measure Audit

Summary of Audit Information Au di t

N um be r

11/1/25 - 4/30/26

SBWCC

Overall Score 94%

Threshold Audit Results 1 Credentialing / Training 95% 100% 2 Transfer DC Meds 90% 98% 3 RDU Screen 95% 100% 4 Sick Call GP Chart Review 95% 97%

4a Sick Call General Population Offered 95% 100% 5 Sick Call Segregation Chart Review 95% 100%

5a Sick Call Segregation Offered 95% 100% 6 Sick Call RDU Chart Review 95% N/A

6a Sick Call RDU Offered 95% N/A 7 Continuity of Care 90% 93% 8 Periodic Health Assessment 85% NA 9 Chronic Disease 95% 95%

9a Treatment Plans 95% 95% 10 Oral Care 85% 85% 11 Annual TB 100% 99% 12 Segregation 85% N/A 13 Pregnant Resident 95% 95% 14 LTC - Inpatient 95% 67% 15 Acute Infirmary Care 95% 100% 16 23HR Observation 95% 79% 17 HEP C Tracking 95% 100% 18 Transfer Screen (RCV) 95% 94%

19 LTBI 100% 87%

20 MAR 95% 95%

21 Diagnostics 90% 81% 22 Pharmacy Operations 100% 100% 23 Annual Tool 90% N/A

Idaho Department of Correction Contract Performance Measure Audit

Summary of Audit Information Au di t

N um be r

7/1/25 - 12/31/25

SICI

Overall Score 86%

Threshold Audit Results 1 Credentialing / Training 95% 100% 2 Transfer DC Meds 90% 77% 3 RDU Screen 95% NA 4 Sick Call GP Chart Review 95% 95%

4a Sick Call General Population Offered 95% 100% 5 Sick Call Segregation Chart Review 95% 95%

5a Sick Call Segregation Offered 95% 100% 6 Sick Call RDU Chart Review 95% NA

6a Sick Call RDU Offered 95% NA 7 Continuity of Care 90% 91% 8 Periodic Health Assessment 85% NA 9 Chronic Disease 95% 95%

9a Treatment Plans 95% 100% 10 Oral Care 85% 51% 11 Annual TB 100% 97% 12 Segregation 85% 88% 13 Pregnant Resident 95% NA 14 LTC - Inpatient 95% NA 15 Acute Infirmary Care 95% NA 16 23HR Observation 95% NA 17 HEP C Tracking 95% 27% 18 Transfer Screen (RCV) 95% 88%

19 LTBI 100% 82%

20 MAR 95% 86%

21 Diagnostics 90% 93% 22 Pharmacy Operations 100% 80% 23 Annual Tool 90% NA

Idaho Department of Correction Contract Performance Measure Audit

Summary of Audit Information Au di t

N um be r

8/1/25 - 1/31/26

86% Audit

Number Description Threshold Audit Results

01 MH Screens 95% NA 02 Assessment / Tx Planning 90% NA 03 Contacts & Groups 90% NA 04 Suicide Risk 98% NA 05 HSR's 90% 78% 06 Restrictive Housing 90% NA 07 DOR Recommendations 85% NA 08 MHU's 95% NA 09 Psychiatric Encounters 90% 94% 10 MH Emergency Meds 95% NA 11 PC Board Reports 90% NA

ID Department of Corrections Contract Performance Measure Audit

Overall Score

MH Audit Tool Summary Audit PeriodLocation

ICIO Sept 2025-Feb 2026

98%

Number Description Threshold Audit Results

01 MH Screens 95% 100% 02 Assessment / Tx Planning 90% 99% 03 Contacts & Groups 90% 100% 04 Suicide Risk 98% 99% 05 HSR's 90% 87% 06 Restrictive Housing 90% NA 07 DOR Recommendations 85% 100% 08 MHU's 95% 100% 09 Psychiatric Encounters 90% 100% 10 MH Emergency Meds 95% 100% 11 PC Board Reports 90% 100%

ID Department of Corrections Contract Performance Measure Audit

Overall Score

MH Audit Tool Summary Audit PeriodLocation

IMSI August 2025-January 2026

96%

Number Description Threshold Audit Results

01 MH Screens 95% 100% 02 Assessment / Tx Planning 90% 99% 03 Contacts & Groups 90% 98% 04 Suicide Risk 98% 100% 05 HSR's 90% 80% 06 Restrictive Housing 90% 97% 07 DOR Recommendations 85% 100% 08 MHU's 95% 100% 09 Psychiatric Encounters 90% 95% 10 MH Emergency Meds 95% NA 11 PC Board Reports 90% 88%

ID Department of Corrections Contract Performance Measure Audit

Overall Score

MH Audit Tool Summary Audit PeriodLocation

ISCC October 2025-March 2026

Number Description Threshold Audit Results

01 MH Screens 95% NA 02 Assessment / Tx Planning 90% NA 03 Contacts & Groups 90% NA 04 Suicide Risk 98% NA 05 HSR's 90% 94% 06 Restrictive Housing 90% NA 07 DOR Recommendations 85% NA 08 MHU's 95% NA 09 Psychiatric Encounters 90% 99% 10 MH Emergency Meds 95% NA 11 PC Board Reports 90% NA

ID Department of Corrections Contract Performance Measure Audit

Overall Score

MH Audit Tool Summary Audit PeriodLocation

ISCI Dec 2025-May 2026

Number Description Threshold Audit Results

01 MH Screens 95% 100% 02 Assessment / Tx Planning 90% 91% 03 Contacts & Groups 90% 94% 04 Suicide Risk 98% 100% 05 HSR's 90% 85% 06 Restrictive Housing 90% NA 07 DOR Recommendations 85% 100% 08 MHU's 95% NA 09 Psychiatric Encounters 90% 100% 10 MH Emergency Meds 95% NA 11 PC Board Reports 90% NA

ID Department of Corrections Contract Performance Measure Audit

Overall Score

MH Audit Tool Summary Audit PeriodLocation

MVTC July-December 2025

Number Description Threshold Audit Results

01 MH Screens 95% NA 02 Assessment / Tx Planning 90% NA 03 Contacts & Groups 90% NA 04 Suicide Risk 98% NA 05 HSR's 90% 94% 06 Restrictive Housing 90% NA 07 DOR Recommendations 85% NA 08 MHU's 95% NA 09 Psychiatric Encounters 90% 99% 10 MH Emergency Meds 95% NA 11 PC Board Reports 90% NA

ID Department of Corrections Contract Performance Measure Audit

Overall Score

MH Audit Tool Summary Audit PeriodLocation

NICI Sept 2025-Feb 2026

90%

Number Description Threshold Audit Results

01 MH Screens 95% 83% 02 Assessment / Tx Planning 90% 71% 03 Contacts & Groups 90% 88% 04 Suicide Risk 98% 100% 05 HSR's 90% 91% 06 Restrictive Housing 90% NA 07 DOR Recommendations 85% 100% 08 MHU's 95% 94% 09 Psychiatric Encounters 90% 100% 10 MH Emergency Meds 95% NA 11 PC Board Reports 90% 80%

ID Department of Corrections Contract Performance Measure Audit

Overall Score

MH Audit Tool Summary Audit PeriodLocation

PWCC November 2025-April 2026

Number Description Threshold Audit Results

01 MH Screens 95% NA 02 Assessment / Tx Planning 90% NA 03 Contacts & Groups 90% NA 04 Suicide Risk 98% NA 05 HSR's 90% 92% 06 Restrictive Housing 90% NA 07 DOR Recommendations 85% NA 08 MHU's 95% NA 09 Psychiatric Encounters 90% 100% 10 MH Emergency Meds 95% NA 11 PC Board Reports 90% NA

ID Department of Corrections Contract Performance Measure Audit

Overall Score

MH Audit Tool Summary Audit PeriodLocation

SAWC November 2025-April 2026

89%

Number Description Threshold Audit Results

01 MH Screens 95% NA 02 Assessment / Tx Planning 90% NA 03 Contacts & Groups 90% NA 04 Suicide Risk 98% NA 05 HSR's 90% 95% 06 Restrictive Housing 90% NA 07 DOR Recommendations 85% NA 08 MHU's 95% NA 09 Psychiatric Encounters 90% 83% 10 MH Emergency Meds 95% NA 11 PC Board Reports 90% NA

ID Department of Corrections Contract Performance Measure Audit

Overall Score

MH Audit Tool Summary Audit PeriodLocation

SBWCC July 2025-December 2025

91%

Number Description Threshold Audit Results

01 MH Screens 95% NA 02 Assessment / Tx Planning 90% NA 03 Contacts & Groups 90% NA 04 Suicide Risk 98% NA 05 HSR's 90% 93% 06 Restrictive Housing 90% NA 07 DOR Recommendations 85% NA 08 MHU's 95% NA 09 Psychiatric Encounters 90% 88% 10 MH Emergency Meds 95% NA 11 PC Board Reports 90% NA

ID Department of Corrections Contract Performance Measure Audit

Overall Score

MH Audit Tool Summary Audit PeriodLocation

SICI August 2025-January 2026

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