This regulation requires Local Mental Health Authorities (LMHAs) in Oregon to develop, document, and annually review Communication Protocols and Response Protocols for coordinating community response following a suspected youth suicide (individuals 24 years of age or younger). LMHAs must designate a reporter to notify the Oregon Health Authority within seven days of a suspected youth suicide and coordinate postvention activities with community partners, tribes, schools, and youth-serving entities. The Oregon Health Authority provides technical assistance to LMHAs in developing and implementing these protocols. This rule does not license or set operating standards for any specific behavioral health facility type — it governs LMHA administrative and coordination obligations.
View official sourceOregon Health Authority Health Systems Division: Behavioral Health Services - Chapter 309 Division 27 YOUTH SUICIDE COMMUNICATION AND POST-INTERVENTION PLAN 309-027-0010 Purpose and Scope (1) Oregon Administrative Rules (OAR) 309-027-0010 through 309-027-0060 implement Senate Bill (SB) 561 from Oregon’s 2015 Regular Session, and SB 485 and SB 918 from Oregon’s 2019 Regular Session. (2) These administrative rules: (a) Identify Local Mental Health Authorities (LMHAs) as the entities responsible for initiating and coordinating the community response to each case of suicide which meets the criteria established in SB 561 (2015): (b) Identify what information shall be communicated to tribes, youth-serving entities, and individuals after a suspected youth suicide death by the LMHAs; and (c) Describe the information public school districts, public universities listed in ORS 352.002, or private post-secondary institutions of education are required to report to LMHAs after a suspected youth suicide death. (3) The four purposes of these administrative rules are: (a) To establish minimum standards for the communication protocol and post-intervention protocol to address suspected youth suicide between LMHA’s, Oregon Health Authority, and youth-serving entities; (b) To reduce the risk of contagion among individuals 24 years of age or younger after a suspected youth suicide by establishing overall guidelines for communication and postvention response protocols for effective communication and response by local agencies, groups, or individuals; (c) To establish the process for LMHAs to report suspected youth suicides to the Oregon Health Authority within seven days of the death; and (d) To establish the process for public school districts, public universities listed in ORS 352.002 or private post-secondary institutions of education are required to report suspected youth suicides to the Oregon Health Authority through LMHAs within seven days of the death. (4) The Oregon Health Authority shall provide technical assistance to LMHAs in developing and implementing the protocols and reporting of suspected youth suicides. Statutory/Other Authority: ORS 413.042, 430.630 & 430.640 Statutes/Other Implemented: ORS 418.735 History: BHS 6-2021, amend filed 02/24/2021, effective 02/24/2021 MHS 24-2016, f. & cert. ef. 12-5-16 309-027-0020 Definitions (1) “Authority” means the Oregon Health Authority (OHA). (2) “Authority’s Plan” means the Authority’s Youth Suicide Communication and Postvention Plan developed to implement SB 561 codified as ORS 418.735. (3) “Communication Protocol” means the plan identifying information-sharing pathways to improve notifications and information-sharing regarding a suspected youth suicide between the LMHA and community partners, and the individuals within those entities to communicate or receive communications. (4) “Community partners” includes local individuals, entities, and organizations including medical examiners, public school districts, public universities, private post-secondary institutions of education, or any facility or organization that provides services or resources to runaway or homeless youth. (5) “Coordinator” means the Authority’s Youth Suicide Prevention Policy Coordinator or their designee. (6) “Decedent” means an individual 24 years of age or younger who is no longer living as reported by a medical examiner or designee. (7) “Designated Reporter” means the individual designated by the primary LMHA to report a suspected youth suicide to the Oregon Health Authority. (8) “LMHA” means a Local Mental Health Authority as defined in ORS 430.630. (9) “Medical examiner” has the same meaning given that term in ORS 146.003(10) or a physician appointed as provided by ORS 146.003 to 146.189 to investigate and certify the cause and manner of deaths requiring investigation, including the State Medical Examiner. (10) “Post-Intervention” or “Postvention” means the activities implemented after a suspected youth suicide, including support for the bereaved family, friends, professionals, peers and those with geographic, social or social media ties to the decedent. “Post-intervention and “postvention” are used interchangeably. In order to meet the needs of those bereaved by a suicide, and to reduce the risk of suicide contagion “postvention” includes: (a) Immediate postvention response implemented in the immediate days and weeks after a suspected youth suicide; (b) Intermediate postvention response implemented in the several months after a suspected youth suicide; and (c) Long-term postvention response implemented up to a year after the suspected youth suicide. (11) “Primary LMHA” means the LMHA serving the county where the suspected youth suicide occurred. (12) “Response Protocol” means the plan identifying the roles, responsibilities and actions of the LMHA and community partners that are activated in response to a suspected youth suicide. (13) “Suicide Contagion” means the exposure to the suicide or suicidal behavior of one or more individuals that influences others to engage in suicidal behavior, including to attempt or complete suicide. (14) “Suspected Youth Suicide” means a death of an individual 24 years of age or younger reported by a medical examiner or designee that is believed to have been caused by self-directed injurious behavior with an intent to die as a result of the behavior. (15) “Traumatic Death” means a death that is sudden, unanticipated, violent, mutilating or destructive, random and/or preventable, involves multiple deaths, or one in which the mourner has a personal encounter with death. It may be caused by an accident, homicide, suicide or death in war. (16) “Youth-serving entity” refers to any public school district, public university listed in ORS 352.002, private post-secondary institution of education, any facility that provides services or resources to runaway or homeless youth, the juvenile department, Oregon Youth Authority, community developmental disabilities programs, local child welfare and self-sufficiency agencies, local substance use disorder programs, organizations serving transitional-aged youth or any other organization or individual identified by the local mental health authority as necessary to receive notice to preserve public health. Statutory/Other Authority: ORS 413.042, 430.630 & 430.640 Statutes/Other Implemented: ORS 418.735 History: BHS 6-2021, amend filed 02/24/2021, effective 02/24/2021 MHS 24-2016, f. & cert. ef. 12-5-16 309-027-0030 Communication Protocol (1) Each LMHA, in collaboration with tribes and community partners, shall identify local pathways for information-sharing and shall establish a Communication Protocol to communicate across and within the LMHA and community partners, including tribes, to inform and mobilize postvention response. This includes both a protocol from the LMHA to youth-serving entities and from any public school district, public university listed in ORS 352.002, and private post-secondary institution of education to the LMHA in the event of a suspected youth suicide death. (2) Communication Protocols from the LMHA to youth-serving entities shall, at the minimum: (a) Identify the tribes, community partners, and youth-serving entities involved in developing and implementing the protocol; (b) Identify the specific roles and responsibilities of the LMHA, community partners, and youth-serving entities for implementing the protocol; (c) Identify how a Communication Lead will be identified for responding to each suspected youth suicide. The Communication Lead may vary among incidents, depending on the nature of the death, location of the death, age of the decedent, or other factors. The Communication Lead may be an individual designated by a tribe, school district or university, the LMHA, another facility, or another community partner. The Communication Lead is responsible for centralizing information-sharing activities in the event of a suspected youth suicide; (d) Detail the communication-sharing process among community partners, including tribes; and (e) Identify the process for determining the specific information and data that will be communicated from the LMHA via the Communication Lead to all relevant youth-serving entities or individuals. This may vary based on the specific circumstances of the youth suicide death, but must include: (A) The name of the decedent; (B) The birthdate of the decedent; (C) The date of death of the decedent; (D) Any other information that the local mental health authority determines is necessary to preserve the public health and that is not otherwise protected from public disclosure by state or federal law. (3) The LMHA shall document the completed Communication Protocol in writing and submit to the Coordinator within 120 days of the effective date of these rules, and annually on or before December 15th. (4) At least annually on or before December 15th, each LMHA, in collaboration with community partners, shall review the Communication Protocol and evaluate the protocol’s effectiveness over the past year, and provide a rationale for all revisions to the Coordinator. The Communication Protocol shall be updated and provided to the Coordinator within two weeks of a change of LMHA staff named in the protocol. (5) The Coordinator shall: (a) Review the communication protocols submitted by the LMHAs; (b) Review any revisions to the communication protocols as submitted annually; and (c) Provide feedback to the LMHA, including information on best practices, and offer technical assistance for preparation and implementation of the protocols. (6) Communication Protocols from any public school district, public university listed in ORS 352.002, or private post-secondary institution of education to LMHAs shall, at the minimum: (a) Identify the staff member responsible for notifying the LMHA of a suspected suicide death; (b) Include the following information in the notification: (A) The date of the death, or approximate date if not known; (B) That the suspected manner of death is suicide; and (C) A name, phone number, and email address for the school representative. (c) No requirement of this section requires disclosure of information that is protected by state or federal public disclosure law. Statutory/Other Authority: ORS 413.042, 430.630 & 430.640 Statutes/Other Implemented: ORS 418.735 History: BHS 6-2021, amend filed 02/24/2021, effective 02/24/2021 MHS 24-2016, f. & cert. ef. 12-5-16 309-027-0040 Response Protocol (1) Each LMHA, in collaboration with community partners, shall develop a Response Protocol identifying tribes, community partners, programs, individuals and others within the community that may be notified of a suspected youth suicide or mobilized to provide post-intervention response to a suspected youth suicide. (2) At minimum, the Response Protocol shall: (a) Identify the community partners and youth-serving entities, which shall be involved in developing and implementing the Response Protocol; (b) Identify the roles, responsibilities, services, and available resources of each community partner involved in implementing the Response Protocol including the immediate, intermediate and long-term postvention response; (c) Identify the process for notification to local systems that had contact with the decedent individual in the event of a suspected youth suicide. This may include: (A) Sample scripts for communication of death notification to local youth-serving entities; (B) A description of the process to determine what information should be included in each notification. (d) Identify how a Postvention Response Lead shall be identified for responding to each suspected youth suicide. The Postvention Response Lead may vary, depending on the circumstances and may be an individual designated by a tribe, school district or university, the LMHA, or another community partner. The Postvention Response Lead is responsible for coordinating postvention response and the notification process to local systems that had contact with the decedent in the event of a suspected youth suicide. The Postvention Response Lead for the Response Protocol also may be the Communication Lead; (e) Establish and disseminate the postvention notification and response process among community partners and youth-serving entities or individuals connected to the decedent, including outreach to families, families of choice, and tribes, if applicable; and (f) Identify the evaluation process used by community partners to debrief and assess the effectiveness of each suspected youth suicide response and the mechanism to adjust processes, as indicated, in the future. The evaluation process shall include an assessment of the effectiveness of meeting the needs of grieving families and families of choice; friends or others with relationships with the decedent; and the wider network of community members impacted by the suspected youth suicide; (g) Identify how the Primary LMHA will notify other LMHAs linked to the decedent through residency, employment, school attendance, or significant family or social ties. (3) The LMHA shall document the completed Response Protocol in writing and submit to the Coordinator. (4) At least annually on or before December 15th, each LMHA in collaboration with community partners shall review the Response Protocol to debrief and evaluate the protocol’s effectiveness in the past year, and provide a rationale for all revisions to the Coordinator. (5) For the purposes of Response Protocols, the Coordinator shall: (a) Review the response protocols submitted by the LMHAs; (b) Review any revisions to the response protocols submitted annually; and (c) Provide feedback to the LMHA and offer technical assistance on best practices for development and implementation of the protocols. Statutory/Other Authority: ORS 413.042, 430.630 & 430.640 Statutes/Other Implemented: ORS 418.735 History: BHS 6-2021, amend filed 02/24/2021, effective 02/24/2021 MHS 24-2016, f. & cert. ef. 12-5-16 309-027-0050 Technical Assistance As part of the Authority’s plan for communication and response coordination among LMHAs and community partners, the Authority shall provide technical assistance for developing and updating protocols, including Coordinator assistance through: (1) Providing comments regarding best practices to LMHAs on the content of communication and response protocols; (2) Providing technical assistance regarding best practices in preparing the protocols; (3) Providing technical assistance on best practices in implementing the protocols; and (4) Providing technical assistance on best practices in responding to suspected youth suicides. This may include telephone assistance on a case by case basis, general information in the form of publications, web content, presentations or webinars. Statutory/Other Authority: ORS 413.042, 430.630, 430.634 & 430.640 Statutes/Other Implemented: ORS 418.735 History: MHS 24-2016, f. & cert. ef. 12-5-16 309-027-0060 Reporting To Coordinator (1) Each LMHA shall designate a Designated Reporter assigned to timely report suspected youth suicides and postvention activities to the Coordinator. Each LMHA shall provide the name and all contact information (including email address and phone number) for the Designated Reporter. The LMHA shall also designate a backup Designated Reporter to assume those responsibilities in the event of the Designated Reporter’s absence. The LMHA shall maintain updated contact information of the Designated Reporter and backup with the Coordinator. (2) Within seven days of a suspected or confirmed youth suicide the primary LMHA shall report to the Coordinator as follows or to the extent allowed by law. (3) The LMHA in the county where the death occurred shall report the death to the Coordinator. The Primary LMHA and each impacted LMHA shall report their respective postvention activities. At a minimum, the reports to OHA shall include: (a) Date of report; (b) The author’s name, affiliated LMHA, email address and phone number; (c) The date of the suspected youth suicide and the city and county in which the suspected youth suicide occurred; (d) Age of the decedent; (e) If a student, the name of the school, public or private university or college, or private post-secondary institution of education attended by the decedent. (f) A narrative discussing the postvention activities completed or to be completed by the Primary LMHA, other impacted LMHAs, if available, and community partners. The narrative must include activities completed or planned for: (A) The immediate postvention response; (B) The intermediate postvention response; and (C) The long-term postvention response, including how the interventions may change due to the end of a school year, at graduation, and at the anniversary of the death; (g) If the LMHA has not determined intermediate or long-term postvention response activities at the time of the seven- day report, the LMHA shall provide the narrative described in subsection (f) to the Coordinator within 45 days of the date of the initial report. (h) A request or decline of technical assistance from OHA. (i) If assistance is requested, the LMHA shall make the request by phone or secure email and include as much of the following as is possible: (A) The decedent’s age; race and/or ethnicity; gender; gender identity; and sexual orientation; (B) Identify the agency with custody of the decedent, if applicable; (C) Identify organizations or individuals that provided services or resources to the decedent if the decedent was a runaway or homeless youth at the time of death; (D) Location of the suspected youth suicide (such as a public place or private residence); (E) Any evidence of bullying (cyber or in person); (F) The manner in which, if at all, social media were involved; (G) Whether, within the previous year, the decedent’s family experienced another suicide; (H) A description of all other traumatic deaths within the community, if known within the previous year; (I) Whether the decedent was receiving mental or behavioral health services at or close to the time of death; (J) Whether substance use or abuse was a factor in the death, if known; and, (K) Any other information that the LMHAs deems necessary for the Coordinator to have in order to provide assistance. (4) LMHAs shall notify the Coordinator if a death reported as a suspected youth suicide is later determined by the medical examiner or designee to not be a suicide. (5) OHA shall provide LMHAs with a form for reporting the required information via e-mail to the Coordinator. (6) Annually by December 15th, each LMHA shall report to the Coordinator an assessment of the effectiveness of the: communication and response protocols; post-intervention services provided, and procedures for reporting deaths to OHA. The LMHA may also include an estimate of the costs to the LMHA in implementing these rules that year. (7) As part of the Authority’s Plan to improve communication and response to suspected youth suicides, the Coordinator shall use the information compiled from the LMHA annual reports to aid its efforts to serve as a resource to the LMHAs. Statutory/Other Authority: ORS 413.042, 430.630, 430.634 & 430.640 Statutes/Other Implemented: ORS 418.735 History: BHS 6-2021, amend filed 02/24/2021, effective 02/24/2021 MHS 24-2016, f. & cert. ef. 12-5-16