Risk Assessment and Safety Planning Policy

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 promotes thorough and consistent best practices regarding clinical risk management, including clinical risk assessment, patient safety planning, following licensure expectations, and supporting the safety of the patient, others, and the public.

Applicability:

This policy applies to individuals who provide treatment services to Rula patients.

Policy

1. All providers are expected to assess for clinical risk and manage any signs of risk when indicated. Assessing for and managing risk is an essential and unavoidable aspect of clinical care. It is not only important but also required by State licensure and law that all mental health providers are familiar with the principles of good practice which promote effective risk assessment and management. Risk assessment and management is an integral part of routine clinical care and therefore relies upon sound and structured clinical judgment, which is guided by the use of clinical risk assessment tools.
   
   
2. All patients must receive an initial session that includes a risk assessment, regardless of their diagnosis, age, or primary reason for treatment. The risk assessment must screen for risk to self and others, and must be documented within the patient record to inform whether there is the presence or absence of clinical risk. 

3. The risk assessment tool utilized must align with best practices, such as the Columbia- Suicide Severity Rating Scale (C-SSRS) for suicidality. However, providers are able to add additional details to their documentation regarding clinical risk factors and assessment. Providers are required to use the proper assessment tool that best fits the patient’s clinical risk challenges.
   
   
4. Risk assessments should be conducted at each patient visit or whenever new and/or relevant information becomes available, or there is a change in the patient’s clinical presentation or circumstances including but not limited to:
   1. Significant life event that had the potential to increase the patient’s risk 
   2. Significant changes in treatment 
   3. Significant changes in presentation or symptoms
   4. Patient, family member, collaborating provider, or other entity expressed report or concern for the patient’s risk of harm to self or others
   5. Increased hostility or danger expressly towards others or the public
   6. Psychiatric Specific Consideration: Document the potential risks, benefits and side effects of a medication regimen which have been discussed with the patient including the need for labs when indicated.
   7. Additionally, providers may choose to complete a risk assessment at any point in time during care with a patient.
      
      
5. Following best practices and licensure regulations, clinical risk assessment and risk management for minors (children and adolescents) should involve parents or guardians whenever required or possible.
   
   
6. The process of risk assessment and risk management may involve gathering information from other healthcare providers, prior medical records, the patient, and collaterals.
   
   
7. Safety Planning
   1. All patients deemed to present with clinical risk challenges must have a completed safety plan that is up to date and unique to the patient. Note: Rula does not endorse the use of a  “No-Harm Contract” in place of a safety plan. The use of evidenced-based safety planning templates is required. The Stanley-Brown Suicide Saftey Planning template is available for use and is located in the Provider Portal, the patient’s chart, and provider notes. 
   2. Safety plans should be developed collaboratively with the patient and shared with the patient.  
   3. Documentation that the safety plan was shared with the patient is required. Safety plans and all risk management approaches must be saved within the patient’s record.
   4. The treatment plan must be updated to include documentation of the safety plan.
      
      
8. Behavioral Health and Psychiatric Emergencies 
   1. Rula is not a designated 24 hour emergency behavioral health service for patients. If a patient  contacts the Rula Support team or any other department while experiencing what appears to be an emergency or mental health crisis, they will be transferred to a 24 hour designated crisis center or directed to their nearest emergency room. If a patient contacting Rula is in crisis and requires immediate support for life threatening events, patients will be encouraged to contact 911 and/or transferred to a 24 hour designated crisis center or call line. 
   2. Providers are required to provide all patients with after hours crisis center information and emergency crisis resources, as indicated throughout treatment.  Providers  must  document within the patient record the crisis resources provided to the patient. 
   3. Providers must document within the patient record all actions taken to ensure a patient's safety and wellbeing.
   4. Following a clinical crisis or risk event, providers are required to submit an Adverse Event Incident Report to Rula using this form
9. Confidentiality
   1. The Health Insurance Portability and Accountability Act (HIPAA) helps mental health professionals by allowing them to make decisions about when to share mental health information, in order to treat patients and prevent them from harming themselves or others. Psychiatrists, psychologists, psychiatric nurses, clinical social workers, mental health counselors, and other professionals who provide treatment to patients with a mental health condition may share protected health information, including mental health information, in order to treat patients and prevent them from harming themselves or others. 
   2. A mental health professional may contact the emergency contact person or, if not available, anyone who is reasonably able to lessen the risk of harm when they believe that a patient presents a serious and imminent threat to the health or safety of a person (including the patient), others, or the public. As indicated, this may include the patient’s emergency contact, others involved in the patient’s care, and/or local law enforcement.
   3. Providers are expected to contact 911 if an imminent threat is suspected.  A welfare check may be requested. 
   4. Providers must document any breaks in confidentiality due to a risk of harm using a Blank Note in the patient’s record.
   5. Following a confidentiality breach, providers are required to submit an Adverse Event Incident Report to Rula using this form
10. Monitoring compliance and effectiveness: The provisions outlined within this policy apply to all providers. Providers and services are subject to evaluation and monitoring by Rula’s Quality and/or Patient Safety Clinical Risk teams who will have responsibility for clinical quality and/or clinical risk chart audits and any other quality monitoring related to risk management, assessment or safety planning as required or needed.

Attachments: None.