Corrective Action Plan
Addressing Recommendations in
Technical Assistance Report on Suicide Prevention
within the Massachusetts Department of Correction
February 12, 2007

In April, 2006 Commissioner Dennehy initiated outreach to Lindsay Hayes to seek a
Review of the Massachusetts Department of Correction’s physical plant, policies and
practices concerning suicide prevention. In July, 2006 contract was entered into with
commencement of the review in September, 2006. Though his report was nearing
completion at year’s end, Dr. Hayes’ was asked and agreed to extend his review to
include the three tragic suicides that occurred in late December.
Commissioner Dennehy and DOC’s Executive Staff have carefully reviewed and
analyzed the 29 specific recommendations contained in the Technical Assistance Report
on Suicide Prevention within the Massachusetts Department of Correction completed by
Lindsay Hayes, dated January 31, 2007. These recommendations are broad,
comprehensive and practical. The DOC is committed to implementing all of these
recommendations and has completed an expedited planning process for their
implementation herein. The dramatic increase in the number of inmates with mental
illness and the severity of their disease is of great concern. Adequately and appropriately
addressing this need increases successful rehabilitative and reentry of inmates, enhances
public safety and prison safety. It is good medical practice and public policy; it is humane
and constitutionally required and sound correctional practice.
Each recommendation has been addressed with Product, Responsible staff, Timelines,
and Cost. Timelines have been designated with Immediate being that which will be
accomplished within ten days; Short Term within sixty days; Intermediate less than six
months and Long Term more than six months. Action has already begun on many of
these recommendations and the department is committed to full implementation of all.
The recommendations are addressed in the order in which Dr Hayes presented them in his
report. The detailed plan for full corrective action and implementation follows.

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I Staff Training
1) It is strongly recommended that the DOC increase the pre-service suicide
prevention training from 2 to 8 hours. At a minimum, the revised training
program should include much of information currently offered in the Suicide
Prevention: Risks, Roles and Responses for Massachusetts Correctional Staff
training curriculum, with additional emphasis placed on avoiding negative
attitudes to suicide prevention, updated statistics and case studies on inmate
suicides within the Massachusetts DOC, identifying suicidal inmates despite the
denial of risk, dealing with manipulative inmates, components of the
DOC/UMCH suicide prevention policies, and liability issues associated with
inmate suicide.
Product:

8 hour curriculum on Suicide Prevention

Responsible Party: Training Academy
Health Services
Timeline:

Immediate

Cost:

Neutral

Comments:

Though the current curriculum addresses the current
training as a 2 hour block, there are other components
of suicide prevention that are scattered over the 10
week Basic Recruit Training, comprising a total of eight
hours. However, the Director of the Training Academy
has been directed to concentrate this into one eight hour
block. This has been addressed immediately and it will
be ready for the next recruit class.
Health Services Division is collaborating with the
Training Academy to identify case studies to be
reviewed in the training program.

2) It is strongly recommended that all correctional, medical, and mental health staff
complete the 8-hour pre-service suicide prevention training program, either at the
Correction Training Academy or respective agency.
Product:

A. Training Plan
B. Completed Training

Responsible Party: Training Academy/Health Services Division
Timeline:

A Short term
B. Long-term

Cost:

Significant costs will accrue for overtime and
backfilling of both DOC and vendor’s medical staff to
accomplish this training, though actual cost is unknown
at this time.
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Comments:

Within 45 days, Director Dupre is to create a plan to
provide all direct care staff Suicide Prevention
Training. This plan should prioritize the training of
housing officers and direct line staff in maximum and
medium security facilities first.
Negotiations with collective bargaining units will be
required to alter the current training provisions.
Similarly, Health Services Division will engage the
medical vendor to address training attendance.
Given that there are currently over 5,000 employees, the
complete implementation of this training will
necessarily take place over a substantial period of time.

3) It is strongly recommended that DOC and UMCH officials ensure that all
personnel (i.e., correctional, medical, and mental health) receive a consistent and
uniform 2-hour block of suicide prevention training on a yearly basis.
Product:

A. Curriculum
B. Documentation of completed training

Responsible Party: Training Academy/ Health Services Division
Timeline:

A. Immediate
B. Long Term

Cost:

Significant costs will accrue for overtime and
backfilling of both DOC and vendor’s medical staff to
accomplish this training, though actual cost is unknown
at this time

Comments:

The 2 hour training curriculum will be completed
immediately. In-service training with the curriculum
takes place over the course of the year for all affected
employees. Full implementation of this component will
be planned and will take place over a period of more
than six months.

4) It is strongly recommended that both DOC and UMCH suicide prevention
policies be revised to include a richer description of the requirements for both preservice and annual in-service suicide prevention. Much of the inconsistency
found in both the length and content of the in-service training at the toured facilities
could be corrected with policy revisions that specified the required length and
description of the training programs.
Product:

Revised Policy

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Responsible Party: Health Services Division/Training Academy/
Policy Development and Compliance Unit
Timeline:

Immediate/Short Term

Cost:

Neutral

Comments:

Training policy is to be amended to reflect
recommendations 1, 2, 3, above and to require phased
in, not immediate, completion of training.

II Identification/Screening
5) Consistent with current Old Colony Correctional Center practices, it is strongly
recommended that DOC and UMCH explore the feasibility of formalizing into
agency policy a requirement that medical staff briefly assess all inmates returning
from court hearings.
Product:

A Directive to Vendor by Health Services Director
B Notice to Superintendents by Associate Commissioner
C Policy Revision
D. Implementation of increased assessments

Responsible Party: Health Services/Medical Vendor/Superintendents
Timeline:

A Immediate
B Immediate
C. Short Tern
D. Immediate to Intermediate

Cost:

Additional cost for mental health clinicians may be
required, though is unknown at this time.

Comments:

Policy change and memos will reflect that the policy will
continue where it is already in place; where staff levels
permit increased assessments, it will be implemented
immediately, for all other facilities full implementation
will take place with new medical contract on July 1,
2007.

6) In order to increase the availability of information regarding an inmate’s suicide
risk within the county correctional system, it is strongly recommended that the
sending agency (e.g., county jail, etc.) and/or transporting personnel be required
to complete and submit a brief discharge/transfer form to DOC booking/reception
staff documenting any immediate concerns about the newly arrived inmate. The
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form should be reviewed by the intake
nurse and subsequently placed in
the inmate’s health care file. UMCH currently utilizes an “IntraSystem Transfer
Form” to communicate the health care needs of inmates between DOC facilities.
This is an excellent form and could be adapted for use by county jail personnel as
a discharge and transfer form.
Product:

A. Proposed Memorandum of Understanding;
B. Proposed Legislation

Responsible Party: Health Services Division/Classification
Timeline:

A Immediate
B. Short Term

Cost:

Neutral

Comments:

Proposed Memorandum of Understanding will seek to
require that mental health and medical information on
the DOC form or Sheriff’s form, if they have one, will
accompany all inmates coming into the DOC. This
MOU will be sent to the Executive Director of the Mass
Sheriff’s Association.
Proposed legislation will be to be drafted to require this
sharing of needed information.

7) It is strongly recommended that the Q5 Inquiry section of CJIS be updated each
time an inmate is placed on mental health watch for suicide risk (regardless of
whether or not actual injury occurs), and that booking/admission staff and medical
personnel access both the “Medical/Mental Health Section” and “Mental Health
Watch” screen of IMS to determine if the newly arrived inmate was on a mental
health watch during a previous DOC confinement.
Product:

A Letter to the Criminal History Systems Board
B Revision of the 103 DOC 401 policy

Responsible Party: Legal/Health Services Division/Superintendents
Policy Development and Compliance Unit
Timeline:

A. Immediate
B. Short Term

Cost:

Neutral

Comments:

Entry of information into the “Q5” file (which is a file
of suicide attempts while in custody, available to all
criminal justice agencies) is directed by statute and
overseen by the Criminal History Systems Board. A
letter will be sent to the CHSB seeking clarification of
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of incidents that are to be entered into

the types
the Q5 file.
103 CMR 401 Booking and Admission policy will be
revised to require booking officer to query IMS for
medical/mental health information, when upon
admission, an inmate is determined to be previously in
DOC custody.

8) Consistent with previous mortality review recommendations, it is strongly
recommended that the DOC, in conjunction with UMCH, develop effective
alternative placement options for those inmates suffering from severe and
persistent mental illness, but whose behavioral difficulties and security needs
require more strict containment than can be afforded in general population. (In
beginning to address this problem, mental health personnel must be regularly
invited participants in the institution’s segregation review meetings.) This issue
should be among the highest priorities facing the DOC in its efforts to improve
suicide prevention practices within the agency.

Product:

A Development of specialized units
B Memo

Responsible Party: Executive Staff/Resource Management/Health Services

Timeline:

A Short Term
B Immediate

Cost:

Significant in scope but final cost to be determined

Comments:

A DOC is in the process of contracting for medical services
with the new contract to be effective July 1, 2007. In the
Request for Response that is pending for which bids will
be received on February 14, 2007, several specialized
units are requested: 60 bed Residential Treatment Unit
for maximum security and two in medium custody for
men; a twelve bed behavior management unit for men
and behavior management services for women in
addition to a Residential Treatment Unit for women.
The effective date of this new contract is July 1, 2007.
Currently the DOC maintains. DOC is currently
assessing the possibilities of opening an interim unit as
an alternative to segregation placement to address the
needs of inmates with serious mental illness, but who
require enhanced security.

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B
Memo
to Superintendents
will
require
attendance of mental health staff at all Segregation
Review meetings and at morning meetings/climate
meetings as held daily. Documentation of compliance
with each of these requirements will be sent to ADC,
Health Services Director, and Associate Commissioner,
Reentry & Reintegration.

III Communication
9) It is strongly recommended that DOC and UMCH embark upon a quality
assurance process to audit selective security files and health care charts on a
regular basis and take corrective action when appropriate. Initially, it is suggested
that the files of inmates on the Mental Health Risk List be selected for audit.

Product:

Unified audit protocol

Responsible Party: Health Services/Medical Vendor
Timeline:

Intermediate

Cost:

Neutral

Comment:

Health Services Director and staff working with new
medical/mental health vendor will develop a process
that will include the Deputy Superintendent and the
assigned Health Services Regional Administrator,
whereby records/communications will be identified on a
random basis to assure effective communication of all
information critical to medical/mental health care
needs.

10) It is strongly recommended that the process for developing and maintaining
inmates on the Mental Health Risk List be revised collaboratively by DOC and
UMCH. In order for the List to be effective, selected inmates must receive
increased attention from both mental health and correctional personnel. If the
sole criteria remains that inmates are maintained on the list when they are
determined to be “at risk to themselves or others because of mental illness,” then
those inmates should be observed more frequently by correctional staff (e.g., at
documented 30-minute intervals) and assessed more frequently by mental health
staff (e.g., at least three times per week). In addition, inmates on the List should
be stronger candidates to be excluded from designation to segregation. Simply
stated, if there is increased concern regarding an inmate, then DOC and UMCH
must demonstrate increased attention to that inmate.

7

Product:

8
Directive from Health Services Director addressing
the elimination of Mental Health Risk List and
announcing the new process at risk inmates.

Responsible Party: Health Services/Medical Vendor
Timeline:

Intermediate

Cost:

Neutral

Comments:

Health Services Director and new medical vendor will
develop an alternative process for dedicated increased
assessment and treatment for those inmates at risk or in
need of mental health services that implicate placement.
Further, they will develop a process for reviewing these
cases on a regular basis.

IV Housing

11) It is strongly recommended that the DOC ensure that all cells designated to house
suicidal inmates are as reasonably “suicide-resistant” as possible. For example,
wall and ceiling ventilation grates should contain holes that are ideally 1/8 inches
wide, and no more than 3/16 inches wide or 16-mesh per square inch; clothing
hooks should be removed; gaps between window bars and glass should be closed;
and bed rails and bunk holes should be removed.
This writer’s complete
recommended guidelines for removing obvious cell protrusions can be found in
Appendix A.
Product:

A Report of review of suicide risk cells
B Documentation of Full Implementation

Responsible Party: Resource Management/Health Services
Superintendents & Directors of Engineering
Timeline:

A Short Term for Review
B Long Term for full implementation

Cost:

There will be costs for equipment and rehabilitation
that will be determined in report.

Comments:

A Review will identify preferred cells and the necessary
physical rehabilitation of those cells.
B. Full implementation will occur over time.

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12) It is strongly recommended that the
DOC work collaboratively with
UMCH to completely revamp the use of the Health Services Unit for suicide
precautions. The revised policy should include, but not be limited to, the
following procedures:
• The removal of an inmate’s clothing and issuance of safety
garment shall be commensurate with the level of suicide risk as
determined by mental health staff;
• All inmates on suicide precautions shall be allowed all routine
privileges (e.g., family visits, telephone calls, recreation, etc.)
unless the inmate has lost those privileges as a result of a
disciplinary sanction;
• All inmates on suicide precautions shall have unimpeded access to
their attorneys at any time;
• All inmates on suicide precautions shall have shower access
commensurate with their security level; and
• To every extent possible, mental health staff should avoid
conducting daily assessments through the food slot of the inmate’s
cell door. In addition, prior to discharging an inmate from suicide
precautions, the inmate must be provided with an out-of-cell
mental health assessment.
Product:

A Revised Policy by DOC and Vendor
B Training on policy revisions

Responsible Party: Health Services/Medical Vendor/Superintendents
Timeline:

A. Short Term
B. Short Term

Cost:

Neutral

Comments:

Vendor’s policy should reflect a process allowing for
gradations of privileges based upon individualized
assessments of inmates current mental health status by
evaluating clinician; visits and showers will be
permitted or prohibited on a case by case basis. No
interviews are to be completed thru food slots in cell
doors and removal of clothing will be directed only
upon clinical assessment.
Health Services Division and Vendor to develop a
training curriculum and plan relative to policy
revisions.
DOC Policy will reflect unimpeded access by attorneys
and elimination of interviews through food slots in the
cell doors. DOC will evaluate the existing disciplinary
sanctions for inmates on watch, and develop a process
for consideration of suspension of said sanctions.
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N.B. Placement in the Intensive Treatment Unit (ITU) at BSH
is not to be considered mental health watch for purposes of
policy interpretation.

13) It is strongly recommended that the clinical decision regarding placement of an
inmate on any level of suicide precautions should not be dictated by the
availability of bed space and staff; rather it should be based upon the specific
needs of the identified suicidal inmate. As such, the DOC should ensure that it
provides sufficient staff to the HSU and any other unit housing suicidal inmates to
ensure proper observation at constant or 15-minute intervals, as well as to allow
adequate out-of-cell time for the inmate. In addition, placement and length of
stay on suicide precautions should be based solely upon the clinical judgment of
mental health staff, and DOC officials and staff should refrain from interfering
with, and/or unduly influencing, that judgment.
Product:

A Policy revision
B Audit of daily suicide watches by facility
C Plan providing for staffing and post orders to reflect
15 minute watches and additional out of cell time.

Responsible Party: Health Services
Operations
Superintendents
Timeline:

A Immediate
B Immediate
C Short Term

Cost:

Unknown at this time, but overtime costs will be
tracked.

Comments:

Policy needs to require that suicide watch is a clinical
decision irrespective of bed availability and when
designated cells are not available, constant observation
is required.
In addition to policy revisions, facilities will report daily
those inmates on suicide watch, where the watch is
occurring,
and
any
overtime
use.
Plan for the establishment of 15 minute rounds and
additional out of cell time to be drafted assessing
additional staff needed, related costs and development
of appropriate post orders.

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14) Given the increase in suicides in the
Health Services Units (HSU), it
is strongly recommended that correctional staff conduct documented observation
at 15-minute intervals within these units.
Product:

A Report of assessment of staffing required to
implement increased observation
B Directive and post orders requiring 15 minutes
observations in HSU

Responsible Party: Superintendents/E-Staff
Timeline:

A. Short Term
B. Short Term

Cost:

Unknown at this time; may need additional officers

Comments:

Assessment of the need for additional staff by each
facility to accommodate these additional watches will be
done and cost identified.
At implementation, directive will issue with relevant
post orders to all superintendents.

15) It is strongly recommended that no inmate (regardless of their mental status)
should receive a punitive sanction (i.e., disciplinary report) based solely upon
self-injurious behavior.
Product:

A Memo prohibiting practice
B Revision of Disciplinary CMR

Responsible Party: Deputy Commissioner
Superintendents
Director, Disciplinary Unit
Timeline:

A. Immediate
B. Short Term

Cost:

Neutral

Comments: Policy directive can be immediate. The disciplinary regulations
are not DOC policy, but under the Code of Massachusetts Regulations and
revision of the them will require adherence to the process established by the
Secretary of State, which includes public hearing.
16) Given the increase in the number of “open” mental health cases within the DOC
during the past several years, it is strongly recommended that additional suicideresistant cells be identified for the housing of suicide inmates. These cells need
not be necessarily located in the HSUs.
Product:

A. Plan identifying additional suicide resistant cells
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B. Request for funding for outfitting additional cells
Responsible Party: E-Staff
Health Services Division/Resource Management
Timeline:

A. Immediate
B. Short Term for new cells

Cost:

Unknown at this time, to be addressed in report.

Comments:

This review will be done in conjunction with the review
that is referenced in Recommendation # 11.

17) It is strongly recommended that the DOC work collaboratively with UMCH to
create a transitional housing unit and/or step-down process following an inmate’s
discharge from mental health watch in the HSU. On a trial basis, it might be
beneficial to identify beds in the DOC’s Residential Treatment Units (RTU) to
begin this initiative.
Product

A. Identification of beds in existing RTUs
B. Establishment of RTU at NCCI-Gardner increasing
treatment beds
C. Identification of additional RTU beds

Responsible Party: Health Services/Vendor
Superintendents
Timeline:

A. Immediate
B. Short term
C. Intermediate

Cost:

Unknown at this time

Comments:

A Health Services Director to meet with and proceed
with step down thru RTU where possible.
B Health Services Director will collaborate with
Associate
Commissioner
Duval
and
NCCI
Superintendent regarding feasibility of establishing
NCCI-Gardner RTU.
C. New RTU beds will be established after July 1, 2007,
with the new medical contract.

V Levels of Supervision
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18) It is strongly recommended that both
the DOC and UMCH suicide
prevention policies be revised to include a better description of the type of
behavior and/or circumstances that necessitates a specific level of observation. A
proposed revision is offered as follows:
Product:

A. Direction to Medical Vendor to develop protocol
B. DOC policy revision

Responsible Party: Health Services/Vendor
Timeline:

A. Immediate
B. Short Term

Cost:

None for policy
Unknown for additional staff

Comments:

DOC will address the levels of supervision with the
language suggested in this report in 103 DOC 650.
Additionally, DOC will share with the current
medical/mental health vendor the need to make similar
revisions to their clinical protocols.

19) It is strongly recommended that reference to 30-minute observation for suicidal
inmates be deleted from DOC Policy 650.07. While this level of observation
would be appropriate for an inmate discharged from suicide precautions and
transferred to a transitional housing unit, it is not appropriate for an inmate in
suicidal crisis in the HSU.
Product:

A. DOC Mental Health Policy Revision
B. Change to Inmate Management System
C. Communication of revised policy to DOC and vendor
staff

Responsible Party: Health Services
Timeline:

A. Immediate
B. Short Term
C. Immediate

Cost:

Additional security staff will probably be required to
implement these more frequent rounds, though not yet
determined.

Comments:

DOC will revise its policy deleting 30 minute
observation, make appropriate change to its IT system,
Inmate Management System (IMS), and work with
medical/mental health vendor on communication plan.

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20) The DOC should ensure that all
facilities are utilizing the
“Correction Officer Observation Check Sheet” (DOC 650, Attachment B-4) that
does not contain pre-printed 15-minute time intervals. In addition, a “Mental
Health Watch Form” (DOC 650, Attachment C), completed by the assigned
mental health clinician, should be attached to the door of each cell housing a
suicidal inmate. The report provides a daily listing of the inmate’s level of
observation, and personal items and privileges that are allowed/prohibited. It is
also strongly recommended that the DOC develop and enforce a policy that
prohibits it officers from allowing inmates on suicide precautions to cover their
heads with blankets or other bedding.
Product:

A Revision of Mental Health Services Policy 103 DOC
650 and relevant forms.
B Memo directing enforcement of requirement that
inmates on watch not cover their heads.

Responsible Party: Health Services/Vendor
Superintendents
Timeline:

A. Short Term
B. Immediate

Cost:

Neutral

Comments:

Policy and attached forms will be revised; “door sheets”
will be required to be posted and signed by clinician.
This will be audited by Health Services Division
Regional Administrators.
Memo will direct enforcement of prohibition of inmates
placing blankets over their heads.

21) It is strongly recommended that correctional officers conduct documented 30minute rounds of all special housing units, including residential treatment units.
As previously recommended, documented 15-minute rounds should be conducted
in the Health Services Units. In addition, to ensure compliance with these
directives, it is strongly recommended that DOC officials conduct more frequent
audits (via review of closed circuit telephone monitors) of these units, as well as
the segregation units.
Product:

A Post Orders
B Audit Process

Responsible Party: Superintendents
Timeline:

A Short Term
B Short Term

Cost:

Unknown at this time

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Comments:

15
Assessment of cost and plan for the increase in
rounds to 30 minutes on special housing and residential
treatment units will be made and implemented as any
necessary additional funds are identified.

22) It is strongly recommended that UMCH revise its suicide prevention policy to
ensure that an inmate is not discharged from suicide precautions until their case
was reviewed during the daily clinical team meeting. In addition an inmate
placed on constant observation should always be downgraded to close (i.e., 15minute) observation for a reasonable period of time prior to being discharged
from suicide precautions. Further, progress notes regarding inmates on suicide
precautions should always reflect a thorough suicide risk assessment and
justification for a particular level of observation. UMCH should embark upon a
quality assurance process to audit selective health care charts on a regular basis
and take corrective action when appropriate.
Product:

(a) Memo to Vendor
(b) Vendor’s documentation of full compliance

Responsible Party: Health Services/Vendor
Timeline:

A. Immediate
B. Short Term/Intermediate

Cost:

To be determined

Comments: DOC will refer to vendor the following recommendations for
full compliance:
a) limit release from mental health watch only
through daily clinical team meeting,
b) require a step down to 15 minute watch
following constant observation
c) ensure that progress notes adequately reflect
suicide risk assessment and support for the level
of observation ordered.
d) Develop QA process for mental health charts
ensuring compliance with above referenced
inadequacies.

23) In order to safeguard the continuity of care for suicidal inmates, all inmates
discharged from suicide precautions should remain on mental health caseloads
and receive regularly scheduled follow-up assessments by mental health staff until
their release from DOC custody
Product:

A. Memo to Vendor
B. Documentation of Full Compliance by Vendor
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Responsible Party: Health

16
Services/Vendor

Timeline:

A. Immediate
B. Short Term/Intermediate

Cost:

To be determined

Comments:

These recommendations will be referred to the
medical/mental health vendor for full compliance.

24) It is strongly recommended that administrative or security watches should not be
utilized in cases in which staff is concerned enough about an inmate’s behavior
that increased observation is necessary. These inmates, regardless of their
diagnoses, should be placed on mental health watch. And as previously stated,
these mental health watches need not necessarily be conducted in the HSUs.
Product:

A Memo to Vendor
B Documentation of Full Compliance by vendor

Responsible Party: Health Services
Superintendents
Timeline:

A. Immediate
B. Short Term/Intermediate

Cost:

Unknown at this time

Comments:

DOC will refer these comments and recommendations
to the vendor and work with the vendor to implement
this cultural change in clinical practice.

VI Intervention
25) Both DOC and UMCH policies should be slightly revised to better ensure a
proper response of both correctional and medical personnel to a suicide attempt.
At a minimum, policies should reiterate that CPR should be initiated immediately
(on a flat, hard surface) and the victim should not be carried away from the
cellblock area during the emergency. This writer’s complete recommended
guidelines for intervention following a suicide attempt can be found in Appendix
A.
Product:

Documentation of Enforcement/Training on existing policies

Responsible Party: Health Services
Training Academy
Timeline:

Immediate
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be determined

Cost:

To

Comments:

DOC will provide enforcement and retraining of staff
where necessary and continue to reinforce good suicide
prevention and emergency practices.

26) It is strongly recommended that the DOC ensure that all housing units contain an
emergency response bag that includes a first aid kit; pocket mask, face shield, or
Ambu-bag; latex gloves; and emergency rescue tool. All staff who come into
regular contact with inmates should know the location of this emergency response
bag and be trained in its use.
Product:

A. Memo to Superintendents directing compliance

Responsible Party: Deputy Commissioner/Superintendents
Timeline:

Immediate

Cost:

To be determined

Comments:

A memo will be directed to all Superintendents
mandating compliance with the placement of a rescue
tool on each unit to be locked/stored where feasible per
tool control policy and the maintenance of an
emergency response bag.

27) It is strongly recommended that the health services administrator at each facility
ensure that all equipment utilized in the response to medical emergencies (e.g.,
Code 99 bags, code cart, oxygen tank, AED, etc.) is inspected and in proper
working order on a daily basis.
Product:

Monitoring Plan

Responsible Party: Health Services/Vendor
Timeline:

Immediate

Cost:

Neutral

Comments:

Current policy requires that this equipment be checked
on every shift with documentation on each unit.
Documentation sheet will be kept for 30 days.

28) It is strongly recommended that the DOC review and revise its “mock drill”
training at each facility to ensure that correctional and medical staff review
specific instructions regarding the proper role in responding to suicide attempts
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29) and providing first aid/CPR.
The
mock drill training should occur
on an annual basis for all correctional and medical personnel.
Product:

A. Review of Mock drill training
B. Review 103 DOC 622 for needed visions

Responsible Party: Training Academy
Health Services
Timeline:

A. Immediate
B. Immediate

Cost:

Unknown at this time

Comments:

Policy should require regular mock suicide drill to be
done at each site and reported to Health Services
Director. Mock drills are also required at recruit
training.

VII Reporting
No recommendations made

VIII Follow-up/Mortality Review
30) It is strongly recommended that in order to ensure that all mortality review
recommendations are processed in a timely manner, a “corrective action plan”
(CAP) should be developed in response to each recommendation. Each CAP
should include, but not be limited to, the following: 1) the recommendation, 2)
whether it has been accepted or rejected by the DOC Commissioner and UMCH
program medical director (or their designees), 3) the corrective action, 4) target
date for completion, 5) completion date, and 6) the mechanism for periodically
monitoring continued compliance.
In addition, it is suggested that the
recommendations contained within this report be subject to the corrective action
format described above.

Product:

Corrective Action Plan for each Mortality Review

Responsible Party: Health Services Director
Timeline:

Immediate

Cost:

None

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Comments:

19
Health Services Division will immediately formalize
its existing follow up on what was recognized as an
excellent practice in its Mortality Reviews by taking
those findings and recommendations and formulating a
Corrective Action Plan for each Mortality Review. This
will be implemented with the next completed Mortality
Review.

VMM 2.20.07

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