SECTION 380.9189. Suicide Alert for Medium-Restriction Facilities

(a) Purpose. This rule establishes procedures for identification, assessment, treatment, and protection of youth in medium-restriction facilities who may be at risk for suicide.

(b) Applicability.

(1) This rule applies to all youth currently placed in medium-restriction facilities operated by the Texas Juvenile Justice Department (TJJD).

(2) Responsibilities assigned to mental health professionals in this rule apply only to mental health professionals employed by TJJD.

(3) For facilities that do not have a mental health professional employed by TJJD and during periods when a TJJD-employed mental health professional is not on call or on duty:

(A) TJJD uses community resources such as local mental health authorities and psychiatric hospitals for all required clinical services;

(B) TJJD staff will attempt to obtain guidance from the mental health professional regarding any enhanced precautions or supervision requirements (consistent with §380.9187 of this chapter when possible) and frequency of follow-up assessments. TJJD staff follow the guidance and instructions provided by the community mental health professional regarding precautions and supervision for youth even when such differ from this rule; and

(C) TJJD staff are authorized to seek additional instruction, guidance, or assessments from mental health professionals within TJJD or in the community at any time if there are concerns about the appropriateness of precautions or required supervision level.

(c) Definitions. Definitions pertaining to this rule are under §380.9187 of this chapter.

(d) General Provisions.

(1) Treatment for youth determined to be at risk for suicide is provided within the least restrictive environment necessary to ensure safety.

(2) Youth determined to be at risk for suicide participate in regular programming to the extent possible.

(3) A rescue kit for use in medical emergencies is placed in at least one designated location within the facility that is not accessible to youth.

(4) As soon as possible, but not to exceed two hours, after a suicide attempt, the youth's parent or guardian is notified (with the youth's consent if the youth is age 18 or older).

(e) Intake Screening.

(1) Upon a youth's admission to a medium-restriction facility, a trained designated staff member conducts a health screening, which includes a review of the youth's file and questions relating to suicidal ideation and behavior. The results of the health screening are documented.

(2) If a youth is identified during the screening as potentially at risk for suicide:

(A) the staff member who conducted the screening immediately notifies the facility administrator or designee;

(B) the facility administrator or designee contacts a mental health professional to conduct a suicide risk assessment; and

(C) the youth is placed on the one-to-one suicide observation level until assessed by a mental health professional.

(3) If a TJJD-employed mental health professional is contacted to conduct the suicide risk assessment, the assessment must be completed as soon as possible, not to exceed 72 hours.

(f) Responding to Suicidal Ideation, Self-Harming Behavior, or Suicidal Behavior.

(1) A staff member who has reason to believe that a youth has verbalized suicidal ideation or demonstrated suicidal or self-harming behavior must:

(A) immediately use the rescue kit if appropriate and seek medical attention if there is a medical emergency;

(B) verbally engage the youth;

(C) immediately notify the facility administrator or designee and document the notification;

(D) provide one-to-one observation;

(E) begin a suicide observation log to document status checks of the youth; and

(F) refer the youth for a suicide screening.

(2) As soon as possible but no later than one hour after notification, a trained designated staff member initiates a suicide risk screening or a mental health professional initiates an assessment. If a screening is conducted:

(A) the staff member who conducted the screening immediately communicates the results of the screening to the facility administrator or designee; and

(B) the facility administrator or designee ensures the youth is assessed by a mental health professional.

(3) This screening or assessment is not required when deemed inappropriate due to a medical emergency.

(4) If a TJJD-employed mental health professional is contacted to conduct the suicide risk assessment, the mental health professional assigns an observation level based on the results of the suicide screening.

(5) Youth who are waiting for a suicide risk assessment are not allowed community access (e.g., community service, employment, academic attendance) unless TJJD staff supervise the youth on one-to-one observation.

(6) If the youth is transported to the emergency room, upon return to the medium-restriction facility, the youth is placed on one-to-one observation until assessed by a mental health professional.

(7) In facilities with a TJJD-employed mental health professional who is either on call or on duty, the mental health professional conducts a suicide risk assessment within an appropriate time frame, as established in agency procedures. Procedures will assign time frames based on the youth's assigned observation level and screening result.

(g) Actions Taken Upon Completion of Suicide Risk Assessment.

(1) Documentation Requirements. Upon completion of a suicide risk assessment conducted by a TJJD-employed mental health professional, the mental health professional documents the results of the assessment, including any changes in the youth's observation level.

(2) Notification of Assessment Results.

(A) Upon completion of a suicide risk assessment, the facility administrator or designee ensures appropriate facility staff are notified of the results.

(B) If the youth is placed on suicide alert:

(i) the facility administrator or designee immediately notifies facility staff of the youth's enhanced supervision requirements and any additional instructions; and

(ii) the youth's parent or guardian is notified as soon as possible after the youth is placed on suicide alert (with the youth's consent if the youth is age 18 or older).

(C) If the youth is not placed on suicide alert, the facility administrator or designee notifies the referring staff and the youth's case manager that the youth was assessed and not placed on suicide alert.

(3) Assignment of Staff to Monitor Youth. If the youth is placed on suicide alert, the facility administrator or designee assigns a specific staff member to monitor the youth and document status checks.

(h) Supervision of Youth on Suicide Alert.

(1) The facility administrator or designee coordinates a search of the youth's room and removes any potentially dangerous items.

(2) A suicide observation monitoring sheet must be in the possession of the monitoring staff member at all times while the youth is on suicide alert.

(A) At no time may the youth possess the suicide observation sheet.

(B) Each time the youth is transferred to the supervision of another staff member, the receiving staff member must take possession of the observation sheet and document the transfer of supervision.

(3) The monitoring staff member must:

(A) maintain direct visual observation of the youth if required;

(B) document the youth's status at the required interval; and

(C) follow any precautions set by the mental health professional.

(4) The monitoring staff member must not leave a youth assigned to one-to-one observation unattended or let the youth out of the staff member's sight.

(5) During waking hours, the monitoring staff must not leave a youth assigned to constant observation unattended or let the youth out of the staff member's sight.

(6) Any time a youth on one-to-one or constant observation is in the bathroom or shower, the monitoring staff must remain within six feet of the youth, and:

(A) observe at least a portion of the youth's body (i.e., head, feet, or other observable parts, excluding genitalia, breasts, and buttocks); and/or

(B) maintain verbal contact.

(7) Youth on suicide alert are not allowed access to off-site activities or appointments unless it is approved on a case-by-case basis. In such cases, the youth must be supervised on one-to-one observation.

(i) Treatment and Reassessment of Youth on Suicide Alert.

(1) Subparagraphs (A)-(D) of this paragraph apply to TJJD-employed mental health professionals.

(A) A mental health professional prepares a written treatment plan for each youth on suicide alert, updating or revising the plan as necessary. The treatment plan includes:

(i) identification of the crisis stabilization issues to be addressed in ongoing assessment sessions;

(ii) a plan of action to address these issues; and

(iii) the degree of community restriction necessary to provide for the youth's safety.

(B) The mental health professional consults with facility staff to recommend modifications to the youth's individual case plan based on issues identified in the treatment plan.

(C) While the youth is on suicide alert, the mental health professional assesses the youth as needed, but at least once every two calendar days.

(D) For each assessment, the mental health professional:

(i) reviews relevant suicide alert documentation and information;

(ii) determines whether any changes should be made to the youth's observation level or other precautions; and

(iii) documents any changes in the observation level, community restrictions, or other safety precautions.

(2) Each time a change is made to the youth's observation level or other safety precautions, the facility administrator or designee ensures the changes are documented and facility staff are notified.

(3) If the youth is receiving routine psychiatric services, the facility administrator or designee ensures the psychiatric provider is notified of the youth's placement on suicide alert and of any relevant information concerning the youth's treatment and supervision while on suicide alert.

(j) Youth Who Cannot Be Safely Managed in Current Placement.

(1) If the facility administrator or mental health professional determines that a youth cannot be safely managed within the structure of the current placement due to behavior that indicates imminent risk of suicide or serious self-injury, the facility administrator or designee:

(A) ensures one-to-one observation for the youth until an emergency psychiatric placement is obtained;

(B) obtains emergency psychiatric placement at a TJJD crisis stabilization unit or in a private psychiatric hospital. For youth not on parole status, the facility administrator or designee may also seek temporary admission to protective custody in a high-restriction TJJD facility pending emergency psychiatric placement if no such placements are immediately available; and

(C) maintains communication with staff at the emergency placement to obtain current mental status information and to assess the length and suitability of the current placement.

(2) For youth maintained on constant and/or one-to-one observation longer than seven days in a medium-restriction facility, the facility administrator or designee must pursue an alternative placement with longer-term stabilization, clinical resources, and increased supervision.

(k) Reduction of Observation Level and Removal from Suicide Alert.

(1) The observation level for a youth on suicide alert may be lowered or discontinued only after an assessment by a mental health professional.

(A) A youth's suicide observation level may be lowered by no more than one level every 24 hours.

(B) Only youth on the lowest available observation level may be removed from suicide alert.

(2) The facility administrator or designee notifies facility staff when a youth's observation level is reduced and when a youth is removed from suicide alert.

(3) The youth's parent or guardian is notified when the youth is removed from suicide alert (with the youth's consent if the youth is age 18 or older).

(4) For youth being treated by a TJJD-employed mental health professional, the mental health professional identifies in the treatment plan any needed follow-up mental health services when the youth is removed from suicide alert.

(l) Release or Discharge of Youth on Suicide Alert. Prior to releasing or discharging a youth on suicide alert to a community placement (i.e., another non-secure placement or home placement), the facility administrator or designee ensures a mental health professional has arranged for appropriate continuity of care when possible.

(m) Training.

(1) All staff who have regular, direct contact with youth receive initial training in suicide prevention and response during new-hire training. Training addresses topics including, but not limited to:

(A) identifying the warning signs and symptoms of suicidal and/or self-harming behavior;

(B) high-risk periods for suicidal and/or self-harming behavior;

(C) juvenile suicide research, to include the demographic and cultural parameters of suicidal behavior, incidence, and precipitating factors;

(D) responding to suicidal youth and youth experiencing mental health symptoms;

(E) communication between correctional and health care personnel;

(F) referral procedures;

(G) housing, observation, and suicide alert procedures; and

(H) follow-up monitoring of youth who engage in suicidal behavior, self-harming behavior, and/or suicidal ideation.

(2) All staff who have regular, direct contact with youth receive annual suicide prevention training.

(3) Staff designated to conduct suicide screenings receive annual training from a mental health professional regarding suicide alert policy, suicide indicators, and suicide screening.

(4) All training described by this subsection shall be accompanied by a test or demonstration to establish competency in the subject matter.

(n) Post-Incident Debriefing and Analysis.

(1) After a completed suicide or a life-threatening suicide attempt, the facility administrator or designee coordinates a debriefing with appropriate facility staff as soon as possible after the situation has been stabilized, in accordance with agency procedures.

(2) After a completed suicide, the executive director or designee may dispatch a critical incident support team to provide counseling for youth and staff, coordination of facility activities, and assistance with follow-up care.

(3) After a completed suicide, the medical director conducts a morbidity and mortality review in coordination with appropriate clinical staff. The medical director may conduct a morbidity and mortality review after a life-threatening suicide attempt.

(4) After a completed suicide or a life-threatening suicide attempt, a critical incident review is convened to determine if the incident reveals system-wide deficiencies and to recommend improvements to agency policies, operational procedures, the physical plant, and/or training requirements.

(5) In the event of a completed suicide, all actions, notifications, and reports required under §385.9951 of this chapter must be completed.

Source Note: The provisions of this §380.9189 adopted to be effective December 1, 2009, 34 TexReg 8543; transferred effective June 4, 2012, as published in the Texas Register June 22, 2012, 37 TexReg 4639; amended to be effective April 15, 2015, 40 TexReg 1976; amended to be effective August 1, 2023, 48 TexReg 2380