Risk Assessment and Safety Planning Policy

Policy: Risk Assessment and Safety Planning

Policy Number: 401 Policy Section: Clinical Care
Owner: Head of Clinical & Quality Approved By: Dr. Mark Willenbring
Effective Date: 2/22/2022 Date of Last Review:

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 a thorough, consistent, and high standard of practice with regards to clinical risk assessment and management in order for providers to effectively manage clinical risk thereby increasing the safety of patients, their family, providers, and members of the public. 


This policy applies to team members who provide treatment services to 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. 



Safety Plan: is a document designed for providers and patients to work together to develop person-centered coping and highly individualized strategies, problem solving and provide details of where to go and who to contact when in crisis. 



  1. Assessing for and managing risk is an essential and unavoidable aspect of clinical care. It is important that all 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 a good therapeutic relationship between Providers and their patients and the use of structured clinical judgment that is guided by the use of clinical risk assessment tools. 
  2. All providers must complete annual training on risk assessment and management best practices. 
  3. All patients must have a complete risk assessment completed at the time of the initial assessment regardless of their diagnosis, age, or primary reason for treatment. The risk assessment must screen for risk to self, others and self-harm and must document the presence or absence of such conditions. 
  4. A risk assessment tool built within the electronic health record is utilized and is based on the Columbia- Suicide Severity Rating Scale (C-SSRS). However, providers are able to add additional details to their documentation regarding clinical risk factors and assessment. 
  5. Risk assessments are completed by psychiatric providers at each visit with a patient. Additional team specific safety protocols for psychiatric providers must also be followed as indicated. 
  6. Risk assessments should be completed by therapists whenever new, relevant information becomes available or there is a change in the patient’s clinical presentation or circumstances including but not limited to:
    1. At the time of initial assessment for new services
    2. Significant life event that had the potential to increase the patient’s risk 
    3. Significant changes in treatment 
    4. Patient, family member, collaborating provider, or other entity’s expressed report or concern for the patient’s risk of harm to self or others
    5. Increased hostility towards others
    6. Additionally, providers may choose to complete a risk assessment at any point in time during care with a patient. 
  7. Risk assessment and management for children and adolescents should involve parents/guardians whenever possible. 
  8. The process of risk assessment and risk management may involve gathering information from other healthcare providers, prior medical records, the patient, and collaterals. 
  9. Safety Planning
    1. All patients with expressed suicidal or homicidal risk should have a completed safety plan that is up to date and unique to the patient.
    2. The use of an evidenced-based safety planning template is encouraged and recommended. The Stanley-Brown Suicide Saftey Planning template is available in the electronic health record.  This same template is available through mobile apps such as My3 or Suicide Safety Plan, which is appropriate to use in a telehealth environment. 
    3. Safety plans should be developed collaboratively with the patient.  
    4. Documentation that the safety plan was shared with the patient is required.  Safety plans may also be saved in the patient’s electronic health record.
    5. The treatment plan will be updated to include documentation of safety planning when active risk issues are identified.
  10. Behavioral Health and Psychiatric Emergencies 
    1. The Group and Rula, CCM do not provide emergency behavioral health or psychiatric services to patients. If a person contacts the Support or Scheduling Team during an emergency, the individual should be directed back to their provider, to call 911 or use other crisis resources.  
    2. If a patient is in crisis and looking for immediate support, patients are encouraged to contact 911 or the Suicide & Crisis Lifeline: 988. Additional hotline resources are available at SpeakingOfSuicide.com/resources  
    3. All patients will be provided with emergency crisis resources from their treating provider during the first appointment and as requested throughout treatment.  These resources may be used in the event of a behavioral health or psychiatric emergency. Providers should document the resources provided to the patient. 
  11. 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 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) or the public. This may include the patient’s emergency contact, others involved in the patient’s care, and/or 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 electronic health record.
  12. 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 Improvement team who will have responsibility for clinical quality chart audits and any other quality monitoring related to risk assessment and safety planning as required or needed.

Attachments: None.

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