| (a) Plan.
(1) The facility shall have a written suicide prevention
plan developed in consultation with a mental health provider. The
mental health provider's consultation services shall be documented
and retained. Acceptable documentation includes, but is not limited
to, the mental health provider's written name, signature, title, and
professional credentials or licensing designation (e.g., LPC, LMSW,
etc.).
(2) The plan shall address at least the following components:
(A) definitions of moderate risk and high risk for
suicidal behavior;
(B) a listing of the facility-specific criteria associated
with each of the two risk classifications and the identification of
staff with the authority and responsibility for assigning or determining
a resident's risk classification;
(C) a screening methodology which shall include, at
a minimum:
(i) policies and procedures relating to suicide screening
at intake/admission and at other times during the resident's stay
at the facility;
(ii) identification of the specific suicide screening
instrument, specific elements of the screening process, and identification
of the person(s) responsible for the screening process;
(iii) specific provisions regarding the assessment
of risk when a resident refuses or is unable to cooperate with the
screening process; and
(iv) policies and procedures relating to how completed
screening information and results are used in determining a resident's
risk for suicidal behavior;
(D) communication protocols which shall include, at
a minimum:
(i) policies and procedures specific to the internal
and external communications directly related to residents who have
been or are currently classified as moderate risk or high risk for
suicidal behavior. For purposes of this standard, communications are
defined as any written or verbal communications specific to the circumstances
relating to the resident's status as a moderate risk or high risk
for suicidal behavior; and
(ii) policies and procedures for notifying the sending
agency or a mental health provider as required in §355.534 of
this title for youth classified as high risk for suicidal behavior.
The policies and procedures shall identify what information must be
communicated, who is responsible for initiating the communication,
who is required to receive the information, and how the information
must be communicated (e.g., direct contact, telephone, email, etc.);
(E) level of supervision for residents assigned to
moderate risk or high risk for suicidal behavior;
(F) policies and procedures for intervening in an active
suicide attempt, which shall identify, at a minimum:
(i) staff responsibilities specific to the administration
of first aid (e.g., cardiopulmonary resuscitation, etc.) and emergency
notification of other facility staff for assistance and contact of
outside emergency medical services;
(ii) the process by which emergency medical services
personnel are to gain access to the facility and how they are to be
guided or escorted to the resident; and
(iii) any life-saving and emergency equipment (e.g.,
first aid kit, Ambu-bag, rescue tools, ladder, etc.) that will be
made available for staff to use in their intervention efforts, the
location of such equipment, and staff responsible for maintaining,
issuing, and using the equipment;
(G) reporting of resident suicides and attempted suicides:
(i) to TJJD as a serious incident within the time frames
established in Chapter 358 of this title; and
(ii) in accordance with any other applicable state
law, administrative rule, or local policy or ordinance;
(H) policies and procedures for staff training on the
contents and implementation of the suicide prevention plan. The policies
and procedures shall address, at a minimum, the training topics, curriculum
to be used, and timeline for initial training and any follow-up training;
(I) housing of residents assigned to moderate risk
or high risk for suicidal behavior, including removal of any dangerous
objects, which may include clothing and bedding items, from the resident's
presence; and
(J) formal mortality reviews following a resident's
suicide to examine the specific circumstances that occurred prior
to, during, and after the suicide to determine if there is a need
for modified policies, procedures, and physical plant configurations.
The mortality review plan shall, at a minimum:
(i) require a review process that is separate and distinct
from any and all formal investigations (e.g., investigations conducted
by the facility, law enforcement, TJJD, etc.);
(ii) identify the person or position who is responsible
for leading the mortality review and any other applicable review team
members (identified by name, position, or agency);
(iii) identify how the findings and recommendations
of the mortality review are to be recorded; and
(iv) identify how the findings and any subsequent recommendations
are to be relayed to the facility's governing board.
(b) Implementation. The facility shall implement the
suicide prevention plan. All residents shall be screened and assessed
for suicide risk upon admission and as necessary thereafter.
|
