Duty to Warn Policy

Policy: Duty to Warn

Policy Number: 302 Policy Section: Quality
Owner: Cynthia Grant Approved By: Paul Vogelman, COO
Effective Date: 6/10/2022 Date of Last Review: 3/23/2023


SUD Specialty Group -- CA; Mental Health Specialty Group, P.A.; Mental Health Specialty Group NJ, PC; and Mental Health Specialty Group KS, P.A. (collectively, the "Group") contracts with Path CCM, Inc. d/b/a Rula Health ("Rula") for management and administrative support services. This policy applies to the Group and Rula.


Policy Statement

This policy provides direction to team members regarding mandated duty to warn requirements.  



This policy applies to all team members who have contact with patients. For purposes of this policy, the Group’s and Rula’s team members include individuals who would be considered part of the workforce such as employees, independent contractors, business team members, and other persons whose work performance is under the direct purview of Rula or the Group’s business practices.


Duty to Warn: For the purposes of this policy, duty to warn is defined as a legal concept that requires or allows mental health professionals and other licensed professionals to breach confidentiality in order to warn an identifiable third party of a potential serious threat of harm to their health. Duty to Warn statutes vary by state and some states may not have a duty to warn law or regulation. 


Threatened violence: an explicit and imminent threat to kill or seriously injure a clearly identified person or to commit a specific violent act or to destroy property which could lead to serious personal injury or death and the patient has an apparent intent and ability to carry out the threat. 


Minimum Necessary is the least amount of information, when using or disclosing confidential patient information, that is needed to accomplish the intended purpose of the use, disclosure, or request


  1. Risk Assessment 
    1. Patients are assessed continually throughout treatment for the risk of danger to others.
    2. When a threat and/or risk of harming others is present, the risk shall be clinically monitored, assessed, and documented at each service until it has been determined that the risk has sufficiently dissipated or has escalated to necessitating the initiation of duty to warn processes. 
  2. Non-clinical team members
    1. In the event that a non-clinical team member becomes aware of threatened violence by a patient, they will immediately
      1. Notify the patient’s provider (i.e., therapist and/or psychiatric nurse practitioner)
      2. Notify the Head of Clinical Care or designee if unavailable. When necessary, the Head of Clinical Care or designee will follow the duty to warn process described below.  
      3. Details such as date and time of the threatened violence and the statements made by the patient. 
    2. The provider is responsible for following the duty to warn process below.  If the provider does not respond to notification by the non-clinical team member within 15 minutes, the Head of Clinical Care or designee will follow the process below. 
  3. Duty to Warn Process
    1. A risk assessment will be completed with the patient either over the phone or via telehealth as soon as possible. The person completing the assessment will determine if duty to warn processes need to be implemented further. 
    2. Consultation with the Compliance Officer prior to initiating duty to warn processes is encouraged to ensure that HIPAA regulations are followed. State laws may be accessed to provide guidance regarding duty to warn.  
    3. If a patient who is under 18 years of age threatens violence (as defined above) and the parent is not present in session, the person completing this process shall make a reasonable effort to communicate the threat to the patient’s custodial parent/guardian. If the custodial guardian is unable to be reached within a reasonable time, the non-custodial guardian may be contacted. 
    4. If a determination is made to notify others, the response shall include notification to the law enforcement agency in the county/city where the client resides or notification to the state police in the state that the patient resides. The HIPAA minimum necessary rule will be followed during any notifications related to duty to warn. 
    5. The person completing the risk assessment will consider their duty to use reasonable care to protect third parties when there is potential harm to others identified. Reasonable care efforts may include notification to police, warning the intended victim, hospitalization of the patient, or informing reasonably identified people within a zone of danger. 
  4. Documentation of Duty to Warn
    1. The patient’s clinical record will include documentation of the risk assessment and any duty to warn notifications that were completed. 
    2. Duty to Warn documentation should occur within the appropriate progress note or as a blank note within the patient’s record. 
    3. Evidence of any follow-up communication will also be included in the patient’s record.

Attachments: None

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