The draft rules require both hospitals and behavioral health inpatient facilities to establish and implement additional policies and procedures to address suicide prevention for patients who are admitted after a suicide attempt or who exhibit suicidal ideation.

Draft Rules Applicable to Hospitals

If a patient is admitted after a suicide attempt or exhibits suicidal ideation, the draft rules require hospitals to meet certain additional requirements as part of the inpatient assessment and as part of the patient’s discharge or transfer. The additional requirements require hospitals to ensure that:

1. The patient receives a suicide assessment; and
2. The patient or the patient’s representative receives
   • the results of the suicide assessment;
   • contact information for age-appropriate suicide crisis services;
   • specific information about or a referral to another health care institution, medical practitioner, licensed psychologist, or licensed behavioral health professional for follow-up treatment related to suicide, including scheduling an appointment for the patient when practicable and
   • instructions on how to access information on the Department of Insurance and Financial Institution’s website regarding mental health parity requirements and how consumers can file an appeal or complaint for an alleged violation of these requirements.

Draft Rules Applicable to Behavioral Health Inpatient Facilities

Behavioral health inpatient facilities are required to meet similar additional requirements for a patient who is admitted after a suicide attempt or who exhibits suicidal ideation. Specifically, the draft rules require these facilities to: 

1. include a suicide assessment as part of the behavioral health assessment;
2. include as part of the patient’s treatment plan the results of the suicide assessment and information specific to help prevent a recurrence;
3. as part of discharge planning, ensure that the patient receives a suicide assessment and that the patient or the patient’s representative receives the results of the suicide assessment as well as contact information for age-appropriate suicide crisis services and instructions to access information on the Department of Insurance and Financial Institution’s website regarding mental health parity requirements and how consumers can file an appeal or complaint for an alleged violation of these requirements;
4. at the time of discharge, provide specific information about or a referral to another health care institution, medical practitioner, licensed psychologist or licensed behavioral health professional for follow-up treatment related to suicide, including scheduling an appointment for the patient when practicable; and
5. as part of the discharge summary, include
   • specific information about ongoing or follow-up treatment related to suicide;
   • whether a referral was made for the patient to another health care provider for follow-up or ongoing treatment related to suicide and information about the referral;
   • whether an appointment was scheduled for the patient with another health care provider for follow-up or ongoing treatment related to suicide and, if so, the date and time of the appointment.

Additionally, for a patient receiving court-ordered evaluation who attempts suicide or exhibits suicidal ideation, the behavioral health inpatient facility must ensure that the new requirements as stated above relating to patient assessments, treatment plans, discharge planning, discharge summaries, and requirements applicable to the time of discharge are met.