1. (a) Purpose. The purpose of this rule is to provide for a protective custody program for the temporary placement of youth who are determined to be at risk of serious harm to themselves.
2. (b) Applicability. This rule only applies to high restriction facilities operated by TYC.
3. (c) Definitions. Definitions pertaining to this rule are under §91.87 of this title.

4. (d) General Provisions.

   1. (1) The protective custody program is administered in the security unit. All standard security unit service delivery and programming requirements as set forth in §97.40 of this title, unless otherwise noted herein, will be observed while the youth is in the security unit.
   2. (2) Placement of youth in protective custody will be used only as a last resort when a mental health professional (MHP) determines that the youth cannot be safely managed in his/her assigned living unit and no appropriate less restrictive placements are immediately available. Protective custody will be used only as a temporary placement until the youth can be safely returned to his/her assigned living unit or another appropriate housing or facility assignment can be arranged.
   3. (3) Youth in protective custody will be monitored, assessed, and treated in accordance with procedures set forth in §91.88 of this title for youth on suicide alert, unless otherwise noted herein.

5. (e) Referral for Placement in Protective Custody.

   1. (1) Only an MHP may authorize the referral of a youth to the security unit for possible placement in protective custody. The referral may be made only:

      1. (A) after a trained designated staff member completes a suicide risk screening, as described in §91.88 of this title;
      2. (B) after the MHP has consulted with the staff member concerning the results of the screening; and
      3. (C) if the MHP determines that the youth is in imminent risk of serious self-injury and cannot be safely managed in his/her assigned living unit.
   2. (2) The youth may be held in the security unit on referral for up to four hours, pending the completion of a face-to-face suicide risk assessment by an MHP.
   3. (3) Once referred to the security unit, the youth will be placed on one-to-one observation until assessed by the MHP. Doors will not be locked while the youth is awaiting the suicide risk assessment, unless the youth presents an imminent danger to staff due to aggressive behavior. In such cases, doors may be locked in accordance with subsection (g)(2) of this section.
   4. (4) The youth's suicide observation folder will be transferred to the security staff who will continue documenting the youth's status at the required interval.

6. (f) Admission Criteria. Only an MHP, in consultation with the facility's designated mental health professional (DMHP), may admit a youth to protective custody due to suicide risk. A youth may be placed in protective custody only if the MHP has conducted a face-to-face suicide risk assessment as described in §91.88 of this title, and the MHP has determined that:

   1. (1) based on the youth's actions, statements, or mental status, the youth is a serious and immediate physical danger to himself/herself; and
   2. (2) confinement in the security unit is necessary to protect the youth from self-harm, and there is no less restrictive setting that provides the necessary level of security and staff supervision.

7. (g) Program Requirements.

   1. (1) Youth will be placed in suicide resistant rooms. Except for youth assigned to one-to-one observation, individual room doors will remain locked.
   2. (2) For youth assigned to one-to-one observation, individual room doors will remain unlocked, except when a youth presents an imminent danger to staff due to aggressive behavior. In such cases, the youth's room door may be locked provided that the MHP determines (in consultation with the DMHP) that locking the door is necessary to manage the youth's aggressive behavior and still allows adequate supervision to ensure the youth's safety.
   3. (3) In accordance with requirements established under §91.88 of this title, the MHP will develop an individualized treatment plan that identifies crisis stabilization issues to be addressed and includes a plan of action to address the issues.
   4. (4) The MHP will conduct a face-to-face assessment of the youth at least once every 24 hours while the youth is admitted to the protective custody program. As part of the assessment, the MHP will determine if the youth continues to be a serious and immediate physical danger to himself/herself and if continued confinement is necessary to prevent self-harm.
   5. (5) At least once every 48 hours following the youth's admission into protective custody, the DMHP will review the documentation relating to protective custody, including the youth's treatment plan and any other documentation relating to the youth's stay in protective custody.
   6. (6) A youth may not remain in the protective custody program for more than five calendar days without written approval from the division director over treatment programming or designee. Such approval must be obtained for every 24-hour period thereafter.

8. (h) Review of Admission and Extensions. The director of security or designee will review each admission and 24-hour extension decision within one workday to determine if policy and procedure were followed. If it is determined that a youth is being held in violation of policy, the director of security or designee will:

   1. (1) immediately notify the facility administrator or duty officer;
   2. (2) unless otherwise instructed by the facility administrator or duty officer, return the youth to the general population; and
   3. (3) ensure the youth remains on one-to-one observation until an MHP conducts a face-to-face suicide risk assessment.

9. (i) Release Criteria. The youth will be released from protective custody when:

   1. (1) an MHP, in consultation with the DMHP, determines the youth may return to the general population with appropriate supervision and monitoring;
   2. (2) an MHP, in consultation with the DMHP, determines that the youth meets criteria for transfer to a facility providing specialized mental health treatment, the Corsicana Stabilization Unit, or a psychiatric hospital;
   3. (3) the division director over treatment programming or designee disapproves an extension request; or
   4. (4) a review of the admission or extension in protective custody reveals that the youth is being held in violation of policy.
10. (j) Appeals. The youth may appeal his/her placement in protective custody to the facility administrator or designee. The facility administrator or designee will consult with the DMHP when reviewing the appeal.

Source Note:The provisions of this §380.9745 adopted to be effective December 1, 2009, 34 TexReg 8544; transferred effective June 4, 2012, as published in the Texas Register June 22, 2012, 37 TexReg 4639.