(a) The facility shall implement a written suicide
prevention plan, developed in consultation with a mental health provider.
Consultation with the mental health provider shall be verified on
documentation containing:
(1) the date;
(2) the provider's name, title, and professional credentials/licensing
designation (e.g., LPC, LMSW, etc.); and
(3) the provider's signature or other means of verifying
the provider's identity (e.g., email from the provider's email account).
(b) The suicide prevention plan shall include:
(1) definitions of moderate and high risk for suicidal
behavior;
(2) 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;
(3) identification of the suicide screening instrument
to be used and the personnel responsible for conducting the screening;
(4) policies and procedures for suicide screening,
including:
(A) conducting a screening within two hours after a
resident's admission into the facility;
(B) conducting suicide screenings upon any indication
a resident previously screened may now be at moderate or high risk
for suicidal behavior or at other times during a resident's stay;
(C) assessing risk when a resident refuses or is unable
to cooperate with the screening process; and
(D) using information from the screening to determine
a resident's risk for suicidal behavior;
(5) policies and procedures for written and/or verbal
communication among facility staff; mental health providers; the resident's
juvenile probation officer; the resident; and the resident's parent,
legal guardian, or custodian, including:
(A) communication about staff concerns that a resident
previously screened may now be at moderate or high risk for suicidal
behavior;
(B) communication about a resident's past or current
classification as moderate or high risk for suicidal behavior;
(C) procedures for referring residents classified as
moderate or high risk for suicidal behavior to a mental health provider
as required by §343.346 of this title; and
(D) identification of which types of information must
be communicated, who is responsible to initiate the communication,
who is required to receive the information, and how the information
is communicated (e.g., direct contact, telephone, email, etc.);
(6) level of supervision for residents assigned to
moderate or high risk for suicidal behavior;
(7) policies and procedures for intervening in suicide
attempts, including:
(A) staff responsibilities for administering first
aid, contacting outside emergency medical services, and notifying
other staff for assistance;
(B) the process by which emergency medical services
personnel will gain access to the facility and how they be guided
to the resident;
(C) identification and location of life-saving and
emergency equipment (e.g., first aid kit, mask resuscitator, rescue
tools, ladder, etc.) that is available for staff to use; and
(D) identification of personnel responsible for maintaining,
issuing, and using the life-saving and emergency equipment;
(8) reporting of resident suicides and attempted suicides,
in accordance with any applicable state law, administrative rule,
or local policy or ordinance, including:
(A) reporting a resident's death to local law enforcement
and TJJD as required by §358.600 of this title;
(B) reporting the death of an incarcerated resident
to the Texas Attorney General's office as required by §358.640
of this title and Texas Code of Criminal Procedure Article 49.18(b);
and
(C) reporting a resident's attempted suicide to TJJD
as required by §358.300 of this title;
(9) policies and procedures for training all juvenile
supervision officers on the contents and implementation of the suicide
prevention plan, including:
(A) identification of the training topics and curriculum;
and
(B) a timeline for the initial training and any follow-up
training;
(10) housing of residents classified as moderate or
high risk for suicidal behavior, including removal of any dangerous
objects such as clothing and bedding items from the resident; and
(11) policies and procedures for conducting mortality
reviews for suicides, including:
(A) identification of the person or position that is
responsible for leading the mortality review and identification of
any other review team members;
(B) identification of how the findings and recommendations
will be recorded and relayed to the facility's governing board;
(C) a requirement that the mortality review shall be:
(i) designed to review the specific circumstances that
occurred before, during, and after the suicide to determine if there
is a need for modifications to policies, procedures, or the physical
plant; and
(ii) separate and distinct from any and all formal
investigations such as investigations conducted by the facility, law
enforcement, or TJJD.
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Source Note: The provisions of this §343.340 adopted to be effective January 1, 2010, 34 TexReg 7095; amended to be effective September 1, 2013, 38 TexReg 4387; amended to be effective January 1, 2015, 39 TexReg 9243 |