Section 355.530 - Suicide Prevention Plan(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.37 Tex. Admin. Code § 355.530
The provisions of this §355.530 adopted to be effective November 15, 2013, 38 TexReg 7973