ADMINISTRATIVE REGULATION REGULATION NUMBER PAGE NUMBER

700-10 1 OF 11

CHAPTER: Offender Health Services

COLORADO DEPARTMENT OF CORRECTIONS SUBJECT: Quality Management Program

RELATED STANDARDS: ACA Standards: 2-CO-4E-01, 5- EFFECTIVE DATE: November 1, 2021

ACI-6A-10, 5-ACI-6A-29, 5-
ACI-6A-36, 5-ACI-6D-02, 5- SUPERSESSION: 06/15/19
ACI-6A-03

OPR: OCS REVIEW MONTH: OCTOBER Dean Williams

Executive Director

I. POLICY

It is the policy of the Colorado Department of Corrections (DOC) to maintain a multi-disciplinary Quality Management
Program for Clinical Services that evaluates and improves offender care pursuant to Colorado Revised Statute (C.R.S.)
25-3-109.

II. PURPOSE

The purpose of this administrative regulation (AR) is to establish an overview of the structure, authority, and general
operating principles of the Quality Management Program. The mission of the Quality Management Program is to
develop and implement processes to facilitate, monitor, and improve quality throughout the Clinical Services health care
system. The Quality Management Program will identify system issues that may compromise offender health care
outcomes and is not intended to address personnel issues. [2-CO-4E-01]

III. DEFINITIONS

A. Continuous Quality Improvement: A structured process within the health care delivery system used to identify areas
for improvement; once identified a plan for improvement is developed and implemented to correct the area and a
follow-up review is conducted to evaluate the success of the plan implementation.

B. Health Authority: The health authority for the Colorado Department of Corrections is designated, in writing, by the
Executive Director.

C. Health Care Provider: A clinician trained to diagnose and treat patients, e.g., physicians, dentists, psychologists,
optometrists, nurse practitioners, and physician assistants.

D. Quality Occurrence: Event or happening outside expected health care standards or one that is contrary to
administrative regulations or clinical standards of practice.

E. Serious Mental Illness: The current diagnosis of any of the following DSM diagnoses accompanied by the P code
qualifier of M, denoting the presence of a major mental disorder: schizophrenia, schizoaffective disorder, delusional
disorder, schizophreniform disorder, brief psychotic disorder, substance-induced psychotic disorder (excluding
intoxication and withdrawal), unspecified schizophrenia spectrum and other psychotic disorder (previously
psychotic disorder not otherwise specified), major depressive disorders, and bipolar disorders. These offenders,
regardless of diagnosis, demonstrate a high level of mental health needs based upon acute severity and/or high
resource demands, which demonstrate significant impairment in their ability to function in the community.
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Offender Health Services Quality Management Program 700-10 11/01/21

IV. PROCEDURES

A. The Quality Management Program (QMP) provides a system of documented internal review developed and
implemented under the direction of the health authority and the chief of behavioral health services, if applicable.
The necessary elements will include:

1. Participating in multi-disciplinary quality improvement committees;

2. Collecting, trending, and analyzing data combined with planning, intervening, and reassessing;

3. Evaluating defined data which will result in more effective access, improved quality of care, and better
utilization of resources;

4. Monitoring of health services outcomes on a regular basis through:

a. Chart reviews by the responsible health care provider or designee, including investigation of complaints
and quality of health records;

b. Review of prescribing practices and administration of medication practices;

c. Review and monitoring of plans of action;

d. Review of facility continuous quality improvement (CQI) program results;

e. Monitoring performance parameters for certain common chronic diseases.

5. Review of all deaths in custody, suicides or suicide attempts, and other serious incidents (use of force,
assaults, restraints, emergency medications/involuntary medications) involving offenders identified with
serious mental illness, and illness outbreaks. [5-ACI-6A-10; 5-ACI-6A-29]

6. Request facilities complete a plan of action for identified areas of deficiency, as needed. Monitor and track the
progress of correction for the identified areas of deficiency.

7. Re-evaluating problems or concerns to determine if corrective measures have achieved and sustained desired
results;

8. Incorporating findings of internal review activities into educational and training activities;

9. Maintaining appropriate records (meeting minutes) of internal review activities;

10. Providing quarterly reports to the health services administrator and the facility administrative head or
designee of the findings of internal review activities;

11. Internal review activities comply with legal requirements on confidentiality of records; [5-ACI-6A-10]

B. Structure and function of the QMP

1. The QMP structure consists of the QMP Committee, the Suicide Prevention Committee, the Peer Review
Committee, the Infectious Disease Committee, and the Infection Control Nurse Committee.

2. These committees monitor and improve the quality of health care provided to offenders in the DOC.

C. Quality occurrence reporting and review

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Offender Health Services Quality Management Program 700-10 11/01/21

1. AR Form 700-10A, Quality Occurrence Reporting Form, will be completed by DOC employees and contract
workers, as well as outside entities such as private prison employees who are witness to, knowledgeable about,
or affected by quality occurrences.

a. All suicides, suicide attempts, use of force, and assaults involving offenders with a psychological code (P
code) of P3M, P3O, or P4-5 which may be associated with a mental health watch, medications, the use of
restraints, residential treatment program placements and any other related trends require a quality report.
[5-ACI-6A-29] The QMP mental health coordinator will review the relevant incident reports related to the
incidents listed above and will enter the quality report.

b. Quality reporting forms completed by non-clinical DOC or private prison employees or contract workers
will be faxed to the Quality Department.

c. DOC and private prison Clinical Services employees or contract workers are required to use the electronic
quality occurrence reporting system.

d. If the electronic system is not functional, AR Form 700-10A will be completed and faxed to the Quality
Department.

2. Quality occurrence reporting is the responsibility of the employee discovering the quality issue.

3. The occurrence must be reported by the end of the shift at the time of discovery and must include information
necessary to promote a clear understanding of the occurrence. If a quality occurrence requires a facility incident
report, the report will be completed in accordance with AR 100-07, Incident Reporting and Incident
Management System. Incident reporting does not take the place of the quality occurrence report. Both must be
completed.

4. Quality occurrence reports will be reviewed daily by QMP coordinators who will assign an initial severity code
based on the circumstances of the incident. The initial severity code is subject to change after documentation
has been received and reviewed. Severity codes are defined as follows:

a. Level 0: No quality issue identified.

b. Level 1: Action or inaction resulting in no adverse effect and of itself does not rise to a level requiring
intervention; however, tracking and trending could reveal a more significant concern necessitating
advancement to a level 2 or 3 based on frequency or pattern of occurrence.

c. Level 2: Action or inaction which resulted in, or could have resulted in, a minor adverse outcome. This
type of issue may warrant notification for purposes of increasing awareness of the concern and in some
cases may require corrective measures be implemented at the facility level. The Quality Department will
track and trend these cases, if applicable.

d. Level 3: Action or inaction which resulted in, or could have resulted in, a sentinel event or a serious
adverse outcome.

1) A root cause analysis will be completed within one week of the event by the facility of occurrence on all
level 3 actions.

a) This analysis will be presented at the monthly QMP Committee meeting.

b) If additional information is required after the initial quality occurrence report has been submitted,
a case review worksheet may be sent to the facility for completion utilizing the electronic quality
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Offender Health Services Quality Management Program 700-10 11/01/21

management program.

c) The Quality Department will conduct follow-up on plans of action and provide feedback to the
QMP Committee, if applicable.

e. Level 4: Offender death. For purposes of reporting, there are two categories of Level 4 cases determined
by final review:

1) 4A: No quality issues identified. Natural expected or unexpected offender deaths.

2) 4B: A quality issue identified where an error occurred that may have contributed to or resulted in an
expected or unexpected offender death.

5. Quality occurrences assigned a severity level 1 may initially be utilized to track and trend reoccurring issues or
problems.

6. Quality occurrences assigned a severity level 2 will be researched by the affected facility CQI coordinator or
designee and an electronic case review worksheet may be requested unless determined otherwise by the QMP
coordinator in consultation with the QMP administrator. These cases will be discussed at the facility CQI
meetings.

7. Quality occurrences assigned a severity level 3 will be researched by the Quality Department. The facility CQI
committee will complete a root cause analysis and may be required to complete an electronic case review
worksheet. Findings will be reported to the office of Quality Management. The results of the root cause analysis
will be presented at the QMP committee meeting.

8. Quality occurrences assigned a severity level of 4 will be assigned to a health care provider for a case review
and presented to the QMP committee.

a. A letter will be sent via the electronic quality reporting system through a confidential encrypted email
requesting the case review.

b. An electronic case review worksheet will be completed by the reviewer. If the reviewer does not have
access to the electronic system, the case review worksheet can be faxed.

c. If the QMP medical coordinator and the assigned health care provider determine there were no quality
issues identified the cases will be placed on a consent agenda and closed as a 4A after the motion is
approved by the committee.

1) If a quality issue was identified by either the QMP medical coordinator or the assigned health care
provider, the case will be presented at the QMP committee meeting.

d. QMP committee decisions/findings will be communicated to the applicable health services administrator
(HSA) in writing via the electronic quality occurrence reporting system.

e. Level 4 suicide occurrences will result in a case review completed by the QMP administrator or designee
within 14 days of the occurrence. The review report will be presented to the QMP Committee.

9. The QMP administrator will notify the assistant director of Clinical Services and the appropriate chief of service
of any sentinel events. All sentinel events will require a root cause analysis conducted with a
multidisciplinary team and a plan of action will be created. Sentinel events include, but are not limited, to the
following:
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Offender Health Services Quality Management Program 700-10 11/01/21

a. Any offender death, fall, paralysis, coma, or other major permanent loss of function associated with a
medication error or delay of care;

b. A completed offender suicide;

c. An invasive procedure on the wrong side of an offender’s body, on the wrong site on an offender’s body, or
on the wrong offender;

d. Use of force on offenders with a P3 code or higher that results in death or major permanent loss of
function;

e. Unsuccessful offender suicide attempts that result in major permanent loss of function.

10. All DOC employees and contract workers, including non-clinical personnel, are required to respond to a quality
committee request for information regarding a quality occurrence investigation or a quality initiative. The
response will be complete and detailed.

11. The QMP administrator will notify the assistant director of Clinical Services and the appropriate chief of service
of any quality issues posing imminent danger. The assistant director of Clinical Services and chiefs of service
will determine immediate action.

12. Occurrences which are considered reportable to the Health Facilities and Emergency Medical Services Division
(HFEMSD) of the Colorado Department of Public Health and Environment (CDPHE) will be reported to the
QMP administrator or designee by phone and via the electronic quality occurrence reporting system by
selecting letter “I. Other Issue” of the Quality Reporting Form. These occurrences include: all in-custody
unexpected offender deaths that do not occur in a hospital, brain injuries, spinal cord injuries, life-threatening
complications of anesthesia, life-threatening transfusion errors/reactions, severe burns, missing persons,
physical abuse, verbal abuse, sexual abuse, neglect, misappropriation of property, diverted drugs and
malfunction/misuse of equipment as defined in the HFEMSD Occurrence Reporting Manual found on the
CDPHE website.

To ensure continuity, the QMP coordinator handling the occurrence is responsible for reporting it to the
CDPHE by following this link: www.cohfportal-egov.com.

D. Structure and function of the QMP Committees

1. General Committee Provisions:

a. Committee members will be appointed by the QMP administrator and the assistant director of Clinical
Services.

b. With the exception of standing committee members, members will be appointed for a term of three years
and will serve until the end of that period unless the member’s successor is appointed sooner. One third of
the appointed membership will turn over every year.

c. Any committee member may resign by submitting a letter of resignation to the QMP administrator.

d. Missing more than two meetings per year may jeopardize appointed membership status on the committee.

e. If a member ceases to be a member in good standing because of, but not limited to, employment status,
corrective/disciplinary action, professional standards review, or absenteeism, that member will be removed
by the QMP administrator. The member will be notified in writing.
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f. The QMP administrator will appoint a committee chair for each of the quality committees.

g. Written reports of committee activities will be provided by the committee chairs to the QMP administrator
and assistant director of Clinical Services at least quarterly.

h. Decisions and recommendations are approved or denied by quorum.

i. Should more than one third of the membership be absent at any committee meeting, the meeting will be
adjourned and noted as such in meeting minutes.

j. All committees will meet at least quarterly.

k. Meeting minutes and appropriate plans of actions will be submitted to the chief of operations within 10
days of the meeting.

l. All committee members will be required to sign AR Form 700-10B, Quality Management Program
Confidentiality Statement, annually.

2. QMP Committee

a. The QMP committee will be composed of multi-disciplinary employees.

b. Committee membership will consist of the following standing members:

1) QMP administrator (chair);

2) QMP coordinators for medical and behavioral health services;
3) Private prison medical monitor;
4) Private prison mental health monitor;
5) Chief medical officer;
6) Chief of clinical operations;
7) Chief of behavioral health services;
8) Chief of psychiatry;
9) Third party administrator designee(s);
10) Headquarters epidemiologist;
11) Support Services regional HSA.

c. Appointed members will include,

1) HSA;
2) Physician or a health care provider;
3) Mental health clinician;
4) Ad hoc committee members will be assigned as needed.

d. The committee will meet monthly and will review level 3 quality occurrence cases to include the root cause
analysis and all offender deaths.

e. The support services manager will assure all records pertaining to offender deaths are obtained and
delivered to the committee chair within 60 days of the offender’s death.

f. Communication of committee decisions will be forwarded to the responsible HSA within 10 working days
of the committee meeting.

g. A plan of action to address committee decisions will be forwarded to the QMP administrator within ten
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Offender Health Services Quality Management Program 700-10 11/01/21

working days of notification with monthly updates thereafter until completion.

h. The QMP committee will oversee facility-based CQI/Infection Control Committee processes and outcomes
of CQI activities to ensure they are being conducted in the manner specified and within the specified
timeframes.

3. Facility CQI/Infection Control Committees

a. Facility CQI/Infection Control Committees will be composed of multi-disciplinary employees.

b. Committee membership will consist of the following standing members:

1) Facility CQI manager (chair);
2) Facility CQI coordinator (co-chair);
3) Facility infection control nurse (ICN) (co-chair);
4) Medical provider;
5) Mental health clinician;
6) Facility ACA coordinator;
7) Administrative head and/or associate warden;
8) At least one representative from custody/control, food service, programs, and case management.

c. Committee members are appointed by the facility CQI manager and the facility administrative head.
Selection is based on the authority of members in their respective areas to implement decisions made by the
committee. Designees will not be utilized.

d. Meeting attendance is mandatory. Two thirds multidiscipline member attendance is required for decision
making purposes at every meeting. Should more than one third of the membership be absent or the chair
(or co-chair) and the administrative head (or associate warden) at any committee meeting, the meeting will
be adjourned and held at a later date.

e. Proceedings of the committee meetings are confidential and committee members will sign AR Form 700-
10C, Quality Management Program Confidentiality Statements, annually. The completed forms will be
maintained electronically.

f. Meetings focus on CQI and infection control activities designed to improve facility operations related to
patient care. Meeting minutes will contain information discussed to include, at a minimum, communicable
disease statistical reports, management plan review, corrective action plan evaluation and follow up, and
round table discussions. Facility quarterly reports may also be discussed at this meeting.

g. Facility CQI/Infection Control Committee meeting minutes will be forwarded to the office of Quality
Management and the regional health services administrator within 10 days of the meeting.

4. Suicide Prevention Committee

a. The Suicide Prevention Committee will meet at least quarterly to discuss suicide prevention strategies.

b. The committee will review all completed suicides within DOC facilities and private prisons.

1) AR Form 700-10D, Psychological Autopsy Report, will be completed by the mental health program
administrator and will be included in the review process. [5-ACI-6A-36]

2) The results of each review, to include AR Form 700-10D, will be presented to the QMP Committee by
the mental health QMP coordinator.
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Offender Health Services Quality Management Program 700-10 11/01/21

c. Committee membership will consist of the following standing members:

1) Mental health program administrator (chair);

2) Mental health QMP coordinator (co-chair);
3) Mental health supervisor;
4) Chief of behavioral health services;
5) Chief of psychiatry;
6) HSA;
7) Private Prison mental health monitor.

d. Committee members are appointed by the QMP administrator.

e. Meeting minutes will be completed within 30 days of the facility suicide review. The minutes will be
provided to the QMP administrator to be reviewed at the quarterly QMP meeting.

5. Peer Review Committee

a. The Peer Review Committee will review the practice and/or practice patterns of clinical services DOC
employees providing medical, dental, and behavioral health care services.

b. The peer review process is educational/remedial and provides a mechanism for on-going assessment and
improvement of offender care.

c. Committee membership will consist of the following standing members:

1) The QMP coordinator responsible for the peer review;

2) Health care provider (1);
3) Mid-level health care provider (1);
4) Psychologist (1);
5) Psychiatrist (1);
6) HSA (1);
7) Dentist (1).

d. The QMP coordinator will be responsible to select one employee from each discipline to attend the peer
review committee meeting.

e. A documented peer review for all full time health care professionals which includes physicians, mid-level
providers, dentists, psychiatrists (includes contract psychiatrists), and psychologists is completed every two
years. [5-ACI-6D-03] Agency health care professionals receive a documented peer review every six
months.

1) The reviewing health care professional must work at a facility other than the reviewee's assigned
facility.

2) Health care professionals are also subject to peer review if consistent services are provided for a period
of six months regardless of full-time or part-time status.

3) Part-time health care professionals are subject to peer reviews and are required to follow these same
guidelines.

f. Peer reviews will be conducted in good faith by DOC health care professionals within the same service
group, at a classification level equal to, or in some cases, higher than that of the reviewee. Supervisors will
not conduct peer reviews on subordinate employees.
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Offender Health Services Quality Management Program 700-10 11/01/21

g. The Peer Review Committee will review and provide feedback to peer reviewees regarding the results of
each review. Opportunities for performance improvement such as training opportunities and/or mentorship
may be recommended.

h. An immediate review may be conducted at any time by decision of the appropriate chief of service if
problems in practice arise. Final disposition of the review rests with the chief of service.

i. In accordance with C.R.S. 25-3-109, all information related to the peer review process will be kept
confidential.

j. A summary statistical report will be provided quarterly by the QMP administrator to the chief of clinical
operations and the assistant director of Clinical Services.

6. Infectious Disease Committee

a. The Infectious Disease Committee will develop procedure to identify and assess infectious disease and
related health concerns. They will implement practices and procedures which reduce disease incident,
prevalence, and attenuation of health risks.

b. Committee membership will consist of the following standing members:

1) HQ Epidemiologist (Chair);
2) Regional HSA;
3) Pharmacy manager (co-chair);
4) Chief medical officer;
5) QMP coordinator for medical;
6) QMP coordinator for drug and alcohol services;
7) HSA

c. The Infectious Disease Committee will meet monthly.

7. ICN Committee

a. The ICN Committee will be chaired by the HQ Epidemiologist.

b. Meetings will be held bi-monthly with all facility ICNs.

c. The committee will be responsible to track and trend all infectious disease issues and track infectious
disease treatments.

d. The HQ Epidemiologist will provide training related to disease prevention and treatment.

e. A summary statistical report will be provided quarterly by the QMP administrator to the chief of clinical
operations and the assistant director of Clinical Services.

E. Quality Management Program confidentiality

1. Any information and/or documents utilized as part of the quality management review process is privileged and
confidential. [5-ACI-6D-02] Any information derived from participation in the QMP is protected from
subpoena, discovery, testimony, and further dissemination, except as provided in C.R.S. 25-3-109 (4).
Committee members, witnesses, and complainants will be subject to the immunities and privileges set forth in
statute if they:
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Offender Health Services Quality Management Program 700-10 11/01/21

a. Acted in good faith within the scope of their respective capacity;

b. Made a reasonable effort to obtain facts of the matter to which they acted;

c. Acted in reasonable belief that the action taken was warranted by facts; and

d. In no event will this immunity apply to any negligent or intentional act or omission in the provision of care.

2. Committee members, as well as non-committee DOC employees and contract workers who perform specific
QMP duties, therein will sign a confidentiality statement annually provided by the QMP administrator or
facility CQI managers having understood participation in the QMP is in good faith and without prejudice or
bias, and failure to comply with confidentiality concerning clinical and/or quality management issues is a
misdemeanor offense which may result in fines, incarceration, or both.

3. Under no circumstance will a committee member or other DOC employee or contract worker in good standing
be subject to reprisal, retaliation, or performance documentation for participating in any quality management
proceedings while acting in good faith and within the respective scope of their capacity.

F. The QMP administrator or designee will also serve as the division liaison to the CDPHE for reportable occurrences
and joint projects related to quality and/or infectious diseases. The medical QMP coordinator and HQ
Epidemiologist will participate in reporting for their discipline specific areas.

V. RESPONSIBILITY

A. The director of clinical services and the quality management program administrator are responsible to review this
AR annually and update as necessary.

VI. AUTHORITY

A. Chapters II and IX of the Colorado Department of Health licensure requirements for community clinic facilities.
B. Ramos vs. Lamm CA#77-K-1093 (1979).
C. C.R.S. 12-35-101, et seq. Dental Practice Law of Colorado.
D. C.R.S. 12-36-101, et seq. Colorado Medical Practice Act.
E. C.R.S. 12-36.5-104. Establishment of professional review committees – function – rules.
F. C.R.S. 12-38-101, et seq. Nurse Practice Act.
G. C.R.S. 12-43-101, et seq. Mental Health
H. C.R.S. 25-3-109. Quality management functions - confidentiality and immunity.

VII. HISTORY

June 15, 2019

August 25, 2014
April 1, 2013
January 1, 2012
November 1, 2011
November 1, 2010
October 1, 2009
September 1, 2008
October 15, 2007
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Offender Health Services Quality Management Program 700-10 11/01/21

November 1, 2006
February 15, 2006
October 15, 2005

ATTACHMENTS:

A. AR Form 700-10A, Quality Occurrence Reporting Form

B. AR Form 700-10B, Quality Management Program Confidentiality Statement
C. AR Form 700-10C, Quality Management Program Flowchart
D. AR Form 700-10D, Psychological Autopsy Report
E. AR Form 100-01A, Administrative Regulation Implementation/Adjustments
 AR Form 700-10A (11/01/21)
Clinical Services
Quality Occurrence Reporting Form

Date of Report: _______________________________

Facility of Occurrence: _________________________ Date of Occurrence: ______________________

Name of Reporter: ____________________________ Title of Reporter: ________________________

Offender Name: _____________________________ DOC Number: __________________________

Description of incidents and actions taken:

___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________

Name of the health care provider notified (if applicable): _______________________________________

Date the health care provider was notified: ___________

Action taken by the health care provider:

___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________

Date form was faxed to the Quality Department: __________________

Office of Quality Management fax #719-226-4565

Attachment A
Page 1 of 1
 AR Form 700-10B (11/01/21)
Quality Management Program Confidentiality Statement

The Colorado Department of Corrections, Clinical Services Quality Management Program (QMP) was established pursuant to
Colorado Revised Statute (C.R.S.) 25-3-109 to evaluate and improve patient care. I understand that any information related to the
QMP and/or documents utilized as part of the quality management process is privileged and confidential. I also understand that
any information derived from my participation in the QMP is protected from subpoena, discovery, testimony, and further
dissemination except as provided in C.R.S. § 25-3-109 (4).

I will maintain the confidence of all quality management information related to specific QMP assigned duties, including but not
limited to the tracking and trending of facility specific quality occurrences and infectious disease reports, facility quality case
reviews, quality audits, and/or peer reviews.

I understand that failure to comply with confidentiality concerning clinical and/or quality management issues is a misdemeanor
offense which may result in fines, jail time, or both.

Name (Print) Title

Name (Signature) Date

Facility

Attachment B
Page 1 of 1
 AR Form 700-10C (11/01/21)
Quality Management Program Flowchart

Report entered

Report reviewed –
severity code (level)
assigned

Level 0 Levels 1 or 2 Levels 3 or 4

Level 1 investigated or Case review and/or Fishbone

Case tracked/trended - Level 2 assigned by QMP coordinator or
Closed investigated by facility CQI administrator
staff and presented at the
facility CQI meeting for
QMP committee for review and
disposition
decisions

Trended issues will be

reported directly to the QMP
committee To appropriate party for
implementation and follow up

Plan of action
implementation and follow
up at facility level
Case closed or tracked

Case closed or tracked

depending on facility
decision

Attachment C
Page 1 of 1
 AR Form 700-10D (11/01/21)

Clinical Services
Psychological Autopsy Report
I. BIOGRAPHICAL INFORMATION

Offender name: ______________________________________________ DOC #: _________________________________

DOB: ______________________ Age: __________________________ Facility: _________________________________

Identified Gender: ____________________________________________

Precipitating Event: Died by suspected suicide

Type of Incident: ____________________________________________ Incident Date: ____________________________

List of documents examined:

________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________

Prepared and submitted by: _________________________________________________________________________________

II. BACKGROUND INFORMATION

Offense: ____________________________________________ Current/Index Offense: ______________________________

Past Convictions:
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________

Sentence: ____________________________________________ Time Served: ______________________________________

Release Plan:
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________

Education: ______________________________________________________________________________________________

Marital/Family Status: _____________________________________________________________________________________

Religious Preference/Involvement: ___________________________________________________________________________

Occupational History:
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________

Military History: _________________________________________________________________________________________

Attachment D
Page 1 of 4
III. PHYSICAL HEALTH AND PSYCHOLOGICAL/BEHAVIORAL HEALTH HISTORY

Physical Status-Functioning

Known medical conditions:

________________________________________________________________________________________________________
________________________________________________________________________________________________________

Known physical trauma history:

________________________________________________________________________________________________________
________________________________________________________________________________________________________

Medication prescribed at time of death: _______________________________________________________________________

Psychological/Behavioral Health Status-Functioning

Diagnostic history:
________________________________________________________________________________________________________
________________________________________________________________________________________________________

Mental health history:

________________________________________________________________________________________________________
________________________________________________________________________________________________________

P-Code: ____________________ BPRS/RCS (if applicable): __________________________________________

Suicidal history:
________________________________________________________________________________________________________
________________________________________________________________________________________________________

Psychotropic medication history:

________________________________________________________________________________________________________
________________________________________________________________________________________________________

Substance use/abuse history:

________________________________________________________________________________________________________
________________________________________________________________________________________________________

Known trauma history:

________________________________________________________________________________________________________
________________________________________________________________________________________________________

Social Status-Functioning

Assaultive behavior history:

________________________________________________________________________________________________________
________________________________________________________________________________________________________

Institutional infractions:
________________________________________________________________________________________________________
________________________________________________________________________________________________________

IV. ANTECEDENT CIRCUMSTANCES

Identifiable stressors:
________________________________________________________________________________________________________
________________________________________________________________________________________________________

Attachment D
Page 2 of 4
Predictors of suicidal actions:
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________

The risk factors evidenced for suicide include:

________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________

Socioeconomic factors for offenders

Psychiatric disorders:
________________________________________________________________________________________________________
________________________________________________________________________________________________________

Depression: _____________________ Hopelessness: _____________________ Anxiety: ___________________________

Family history of mental illness: _____________________________________________________________________________

Family history of suicide: __________________________________________________________________________________

Voicing suicidal ideations to others: __________________________________________________________________________

Lack of social support system: ______________________________________________________________________________

Personality traits:
________________________________________________________________________________________________________
________________________________________________________________________________________________________

History of impulsive behavior: ______________________________________________________________________________

Borderline personality characteristics:

________________________________________________________________________________________________________
________________________________________________________________________________________________________

Antisocial personality characteristics:

________________________________________________________________________________________________________
________________________________________________________________________________________________________

Sudden change in psychological functioning:

________________________________________________________________________________________________________
________________________________________________________________________________________________________

Psychosocial stressors:
________________________________________________________________________________________________________
________________________________________________________________________________________________________

Institutional problems:
________________________________________________________________________________________________________
________________________________________________________________________________________________________

Security threat group/anti-social associations:

________________________________________________________________________________________________________
________________________________________________________________________________________________________

Attachment D
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Undesired unit placement: __________________________________________________________________________________

Legal processes: __________________________________________________________________________________________

Type of crime/shame, guilt, stigma:

________________________________________________________________________________________________________
________________________________________________________________________________________________________

Chronic medical conditions:

________________________________________________________________________________________________________
________________________________________________________________________________________________________

Recent losses:
________________________________________________________________________________________________________
________________________________________________________________________________________________________

Institutional factors:
________________________________________________________________________________________________________
________________________________________________________________________________________________________

Stages and setting of confinement:

________________________________________________________________________________________________________
________________________________________________________________________________________________________

Prison condition and experience:

________________________________________________________________________________________________________
________________________________________________________________________________________________________

Conflict:
________________________________________________________________________________________________________
________________________________________________________________________________________________________

Suicide note: ____________________________________________________________________________________________

V. FULL DESCRIPTION OF SUICIDE ACT AND SCENE

Date/time of incident: _____________________________________________________________________________________

Location: _______________________________________________________________________________________________

Method: ________________________________________________________________________________________________

Timeline of events:
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________

VI. LIST OF STAFF INTERVIEWED AND SUMMARY OF FACTS IDENTIFIED

The following is a summary of information gathered during the suicide review process:
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________

Attachment D
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 ADMINISTRATIVE REGULATION
IMPLEMENTATION/ADJUSTMENTS
AR Form 100-01A (10/01/10)

CHAPTER SUBJECT AR # EFFECTIVE

Offender Health Services Quality Management Program 700-10 11/01/21

(FACILITY/WORK UNIT NAME)______________________________________________________________________

WILL ACCEPT AND IMPLEMENT THE PROVISIONS OF THE ABOVE ADMINISTRATIVE REGULATION:

[ ] AS WRITTEN [ ] NOT APPLICABLE [ ] WITH THE FOLLOWING PROCEDURES

TO ACCOMPLISH THE INTENT OF THE AR

(SIGNED) (DATE) _________________________

Administrative Head
Attachment E
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