Texas Administrative Code › Title 37 - PUBLIC SAFETY AND CORRECTIONS › Part 11 - TEXAS JUVENILE JUSTICE DEPARTMENT › Chapter 355 - NON-SECURE CORRECTIONAL FACILITIES › Subchapter E - RESIDENT HEALTH AND SAFETY › Section 355.530 - Suicide Prevention Plan

Current through Reg. 49, No. 28; July 12, 2024
(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.