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California Department of Education

September 3, 2020

Elaine M. Howle, State Auditor
California State Auditor
621 Capitol Mall, Suite 1200
Sacramento, CA 95814

Subject: Youth Suicide Prevention: Local Educational Agencies Lack the Resources and Policies Necessary to Effectively Address Rising Rates of Youth Suicide and Self-Harm, Report Number 2019-125, September 2020

Dear Ms. Howle:

The California Department of Education (Education) appreciates the opportunity to provide comments and address the recommendations outlined in the California State Auditor’s (CSA) Audit Report titled, Youth Suicide Prevention: Local Educational Agencies Lack the Resources and Policies Necessary to Effectively Address Rising Rates of Youth Suicide and Self-Harm, which offered helpful insight into how six of California’s Local Educational Agencies (LEAs) are addressing youth suicide prevention.

The State Superintendent of Public Instruction (SSPI), Tony Thurmond, is deeply committed to addressing students’ mental health wellness and needs, including leading the charge to provide mental health services to kids to help combat the pressures of bullying, the impact of trauma, and other barriers to success. The SSPI’s dedication to student and staff wellness is stronger than ever as we continue to face emotional challenges that stem from COVID-19 and ongoing struggles for racial justice. The SSPI’s call to action to assist students with mental health support is documented in Education’s News Release at http://www.cde.ca.gov/nr/ne/yr20/yr20rel43.asp, where several links to Education’s resources for educators, families, and students are provided.

To further assist LEAs and school communities in appropriately addressing the complex issues of student wellness and mental health needs, Education has developed and implemented programs, supports, and resources, which can be accessed at https://www.cde.ca.gov/ls/cg/mh/mhresources.asp and https://www.cde.ca.gov/ci/se/index.asp.

Education plans to implement the CSA’s recommendations as described below.

Recommendation 1

To promote the adoption of the best practices that it has identified, Education should remind LEAs of the elements in its model policy. To do so, it should annually send a notice to all LEAs that describes suicide prevention resources, such as the model policy, and encourages their use.

Education should also work with external organizations that maintain model policies, including the School Boards Association, to encourage the development of policies that are consistent with state law and best practices by no later than September 2021.

Education’s Comments

Concur. Currently, Education encourages the use of the model suicide prevention policy by making it available on its web page, Youth Suicide Prevention. To further this effort, Education will send a letter annually and use other communication channels to remind LEAs of their responsibility to adopt, implement, and review their policies, along with resources, best practices, activities, programs, and trainings related to suicide prevention.

In addition, Education will collaborate with the California School Boards Association and other organizations in an effort to align policies and request the inclusion of the same elements as Education’s model suicide prevention policy by September 2021.

Recommendation 2

To encourage LEAs to incorporate elements of suicide prevention training that provide teachers and staff with the knowledge necessary to assist students at risk of self-harm and suicide, Education should remind all LEAs of the statutorily required elements for suicide prevention training.

Education’s Comments

Concur. Education will include information in the annual reminder letter sent to all LEAs regarding the statutorily required elements for suicide prevention training as required by EC Section 215.

Recommendation 3

To support the provision of suicide prevention education to students while LEAs operate through distance learning, Education should complete and issue to LEAs the resources and guidance it is developing on how to conduct suicide prevention education remotely.

Education’s Comments

Concur. Education is in the process of developing guidance and resources for LEAs to use as part of their suicide prevention virtual programming; dissemination is anticipated to occur by October 2020. In addition, Education will collaborate with external partners to identify programs that can be delivered virtually to LEAs.

If you have any questions regarding the Education’s comments and/or corrective actions, please contact Kimberly Tarvin, Director, Audits and Investigations Division, by phone at 916-323-1547 or by email at ktarvin@cde.ca.gov.
Sincerely,

Stephanie Gregson, Ed.D.
Chief Deputy Superintendent of Public Instruction

SG:kl

California Department of Public Health

September 3, 2020

Elaine Howle
California State Auditor
1621 Capitol Mall, Suite 1200
Sacramento, CA 95814

Dear Ms. Howle:

The California Department of Public Health (CDPH) has reviewed the California State Auditor's draft audit report titled "Youth Suicide Prevention: Local Educational Agencies Lack the Resources and Policies Necessary to Effectively Address Rising Rates of Youth Suicide and Self-Harm." CDPH appreciates the opportunity to respond to the report and provide our assessment of the recommendation contained therein.

Below we reiterate the audit finding pertaining to CDPH and our response to the auditor's specific recommendation.

Finding 1: "Public Health Has Not Established a School Health Center Support Program Required by Law"

Recommendation to CDPH:
To support LEAs' efforts to provide mental health services, CDPH should establish the support program for school health centers as state law requires. If CDPH lacks the funding to do so, it should request additional funds as needed. The support program should assist LEAs in establishing school health centers and in identifying and applying for available funding as authorized by law, such as Medi-Cal reimbursement and MHSA funds.

Management Response:
CDPH will evaluate the resources necessary to establish and implement the Public School Health Center Support Program (PSHCSP) as written in the Health and Safety Code §124174-124174.6.

CDPH works continuously to reduce physical and mental health disparities among vulnerable and underserved communities to achieve health equity throughout California.

As a part of this work, CDPH will continue its collaboration and active partnership with the California School-based Health Alliance and their member school-based health centers to improve understanding of the needs of, and to share resources with, school based health centers.

We appreciate the opportunity to respond to the audit. If you have any questions, please contact Monica Vazquez, Chief, Office of Compliance, at (916) 306-2251.

Sincerely,

Sandra Shewry, MPH, MSW
Acting Director

Comment

CALIFORNIA STATE AUDITOR’S COMMENT ON THE RESPONSE FROM PUBLIC HEALTH

To provide clarity and perspective, we are commenting on the response to our audit report from Public Health. The number below correspond to the number we placed in the margin of Public Health’s response.

Although state law requires it to do so, Public Health does not commit to establishing the support program. After evaluating the resources necessary to do so, Public Health should establish the support program in accordance with the requirements in state law described here, or request the funds necessary to do so.

Department of Health Care Services

September 2, 2020

Elaine M. Howle
California State Auditor
621 Capitol Mall, Suite 1200
Sacramento, CA 95814

DRAFT REPORT RESPONSE

Dear Ms. Howle:

The California Department of Health Care Services (DHCS) is submitting the enclosed response to the California State Auditor's (CSA) draft report titled, "Youth Suicide Prevention: Local Educational Agencies Lack the Resources and Policies Necessary to Effectively Address Rising Rates of Youth Suicide and Self-Harm." CSA issued one recommendation for DHCS.

DHCS agrees with the recommendation and has prepared a corrective action plan to implement. After reviewing, DHCS has also noted four areas of the report containing incorrect or misleading information:

1. The draft report page 64 states "Health Care Services oversees the billing option program which allows [Local Educational Agencies (LEA)] to seek federal reimbursement for 50% of their costs to provide medically necessary health related services performed by qualified medical practitioners."

a. The bolded language must be added to the sentence as the term medically necessary is nowhere mentioned in the report but is a requirement of the program as is the requirement only certain specified practitioners may perform each medically necessary service. Requirements must be met in order to receive federal funding.

2. The draft report page 65 states "The health care services branch chief identified an additional advantage of centralizing these administrative responsibilities: it decreases the number of LEAs that must register with Health Care Services as Medi-Cal Providers."

a. The language is incorrect because all Medi-Cal providers must be registered providers. Under Welfare and Institutions Code section 14132.06 the LEAs "shall be considered the provider of services." As providers of services, LEAs who voluntarily agree to participate in the LEA Billing Option Program (BOP) must submit a Provider Participation Agreement, a Data Use Agreement, and an annual report to DHCS.

b. In addition, the correct title is "Medi-Cal Claims and Services Branch Chief' rather than "health care services branch chief."

3. The draft report page 66 states "Health Care Services does not actively send information about the program to nonparticipating LEAs."

a. The statement is incorrect. DHCS works closely with school associations to provide information regarding the LEA BOP to nonparticipating LEAs. In addition, the LEA BOP website is an information source concerning all aspects of the program to any LEA interested in participating in the voluntary program.

4. The draft report page 66 states "Further, according to the branch chief of health care services, it has not informed LEAs of the option to leverage county offices of education to handle the administrative tasks associated with the billing option program."

a. The statement is incorrect. DHCS regularly informs LEAs on the stated option; however, DHCS does not have any formal written guidance in the area.

b. In addition, the correct title is "Medi-Cal Claims and Services Branch Chief' rather than "health care services branch chief."

If you need additional information about the above comments, please contact Brian Fitzgerald, Chief, Local Governmental Financing Division, at (916) 345-8690 or via email at Brian.Fitzgerald@dhcs.ca.gov.

DHCS appreciates the work performed by CSA and the opportunity to respond to the draft report. If you have any other questions, please contact Internal Audits at (916) 445-0759.

Sincerely,

Will Lightbourne
Director

Comments

CALIFORNIA STATE AUDITOR’S COMMENTS ON THE RESPONSE FROM HEALTH CARE SERVICES

To provide clarity and perspective, we are commenting on the response to our audit report from Health Care Services. The numbers below correspond to the numbers we placed in the margin of Health Care Services’ response.

During the publication process for the audit report, page numbers shifted. Therefore, the page numbers cited by Health Care Services in its response do not correspond to the page numbers in the final published audit report.

At Health Care Services’ suggestion, we have revised the sentence here. To clarify that elective health services are not covered through this program; we have replaced the phrase certain health related services—which is the term Health Care Services uses in its published materials for this program—with medically necessary health related services, and added the term qualified medical practitioners.

Health Care Services has misconstrued the nature of its branch chief’s statement. As we describe here, LEAs can partner with their respective county offices of education to centralize responsibilities and reduce the administrative burden of obtaining reimbursement for the services the LEA provides. For example, Ukiah Unified partners with the Mendocino County Office of Education. The Mendocino County Office of Education is listed in Health Care Services’ list of Medi-Cal providers participating in the billing option program, but Ukiah Unified is not and does not need to be. As Health Care Services LEA Onboarding Handbook describes, multiple LEAs can pool their resources and bill Medi-Cal under one provider identifier number. Thus, the number of LEAs registered with Health Care Services is lower than it would be if those entities were registered as individual Medi-Cal providers.

To simplify the report text for readers, we abbreviated the title of “Medi-Cal Claims and Services Branch Chief” to “branch chief.”

Health Care Services’ statement does not align with the information it provided during the course of the audit. We repeatedly requested information and documentation from Health Care Services regarding its billing option program outreach. Because it was unable to provide evidence that it had provided information to nonparticipating LEAs, we spoke with the branch chief who informed us that Health Care Services delegates such outreach to Education, as we describe here. Further, we do not dispute that the billing option program website may be a useful resource; however, our statement in the report addresses sending information to nonparticipating LEAs. Without informing the LEAs of the program’s existence, it is unclear how they would learn of the website that Health Care Services describes.

Health Care Services’ statement does not align with the information it provided during the course of the audit. We requested information and documentation from Health Care Services regarding its efforts to inform LEAs of the option to leverage county offices of education to handle the administrative tasks associated with the billing option program. Because it was unable to provide evidence that it had provided this information to nonparticipating LEAs, we spoke with the branch chief who confirmed that Health Care Services did not inform LEAs about the option to partner with county offices of education to handle the administrative tasks associated with the program, as we describe here.

Gateway Public Schools

September 3, 2020

Elaine M. Howle, CPA
California State Auditor

Dear Ms. Howle:

On behalf of Gateway Public Schools, I want to thank you for the opportunity to respond to the draft report titled “Local Educational Agencies lack the Resources and Policies Necessary to Effectively Address Rising Rates of Youth Suicide and Self-Harm”, which details the results of audit that you conducted with our organization.

The goal of our response is to address the items that you identified as being insufficient at our organization related to suicide prevention. Some of these items represent welcome opportunities for continued improvement on this important topic. We believe other areas of identified deficiencies do not fully reflect the policies and activities that we do pursue each year to support our students. Below are the items from the tables in the report that we are responding to.

Table 1 - The LEA Suicide Prevention Policies We Reviewed Lacked Crucial Elements

Requirement or Best Practice	Gateway Charter - Response
Addresses needs of at-risk groups, such as LGBTQ youth and youth in foster care	Gateway provides a broad support system for at-risk youth and is committed to ensuring that all future suicide prevention trainings emphasize high risk groups, including LGBTQ youth and youth in foster care.
Constructed in consultation with community stakeholders	Gateway’s suicide prevention policy was initially developed in collaboration between administrators and school site counselors across schools. Moving forward, Gateway will ensure that additional stakeholders, particularly students, families, and other community members, are involved in updating the policy.

Table 2 - In Academic Year 2019-20 None of the LEA’s Trainings We Reviewed Included ALL of the Elements Identified in State Law and Education’s Best Practices

State law requires trainings to:	Gateway Charter - Response
Identify community-based mental health services and when and how to refer them	Gateway mental health counselors have provided referrals to many outside agencies and have partnered closely with several community-based organizations in providing support for our students. And teachers know to work through our counselors for these referrals. Moving forward, we will also ensure that all faculty will be trained in when and how to refer students to community-based mental health services. However, the referral process has been happening successfully.
Education recommends trainings to:	Gateway Charter - Response
Discuss high risk groups	Gateway is committed to ensuring that all future trainings emphasize high risk groups, including LGBTQ youth and youth in foster care.
Discuss all three elements of suicide identifiction - risk factors, warning factors, and protective factors	Future suicide prevention training will include all three elements of suicide identification, including a review of risk factors, warning factors, and protective factors.
Discuss trends identified in data on self-harm incidents and suicides within the LEA’s region	Gateway will continue to use data trends to guide suicide prevention policies and trainings. We will ensure that data from our local region continues to be included in this practice.

Table 4 - Only four LEA’s Provided Suicide Prevention Training to Both Teachers and Other Staff During School Year 2019-2020.

Requirement or Best Practice	Gateway Charter - Response
Provided suicide prevention training to other staff	Gateway will ensure that all staff, including coaches, security guards, and secretaries, are required to attend suicide prevention training moving forward.

Thank you again for the opportunity to respond to your draft report. We remain available for additional questions and we are confident that this audit process will only strengthen our organization’s ongoing efforts in suicide prevention.

Sincerely

Sharon Olken
Executive Director
Gateway Public Schools

Comments

CALIFORNIA STATE AUDITOR’S COMMENTS ON THE RESPONSE FROM GATEWAY CHARTER

To provide clarity and perspective, we are commenting on the response to our audit report from Gateway Charter. The numbers below correspond to the numbers we placed in the margin of Gateway Charter’s response.

We stand by our audit conclusions. Our review of Gateway Charter’s suicide prevention policies and training found that they failed to fully address legislative requirements and did not include all of the best practices that Education recommends, which we discuss beginning here.

Gateway Charter does not have a method to ensure that teachers are aware of the process it describes. Although some of its staff may be aware of the community-based mental health services available and how to refer students to them, this element was not included in the suicide prevention training Gateway Charter conducted, as indicated in Table 2. Further, Gateway Charter did not provide the training to all teachers and staff during academic year 2019–20. Thus, as we discuss here, some Gateway Charter personnel may not be aware of the relevant resources or properly equipped to identify and respond to a student in crisis.

Gateway Charter’s statement is misleading. As Table 2 indicates, we found that Gateway Charter’s suicide prevention training did not discuss trends identified in data on self-harm incidents and suicides within its region. Therefore Gateway Charter should alter its training to include this information.

Heartland Charter Schools

September 3, 2020

Via electronic mail and USPS

California State Auditor

Elaine M. Howle, CPA

621 Capital Mall, Suite 1200

Sacramento, CA 95814

Dear Ms. Howle:

I write in response to the California State Auditor's draft report entitled Youth Suicide Prevention received by Heartland Charter School on August 28, 2020. First, I would like to thank you and your staff for conducting this audit and for the insight provided to Heartland as a result of your review of our school’s suicide prevention plan. We desire to serve and protect our students’ emotional well-being and do all we can to prevent this heartbreaking problem of youth suicide within California.

Heartland recognizes the areas of improvement needed in its school suicide prevention as identified in the report. While the audit covered our first year of operation when we were under a charter management organization that served us in this area, we are now independent and have certainly grown in this. We do plan to take the following necessary steps to further align our practices with the administrative requirements of the California Education
Code and will be prepared to implement any future changes in state law.

In response to the recommendations in the report, Heartland will make the following changes:

· Incorporate our local partners including our public health department and California Medical Assistance Program (Medi-Cal) to support our efforts and serve students utilizing all that is available to them.

· We will organize a postvention response team

· Heartland has since created a suicide prevention tool kit and improved training for our staff which identifies trends within our region.

· Currently the report states we were understaffed in school nurses, counselors, and social workers. Last year these positions were employed by the charter management organization while serving our school. This year, as an independent school, we employ these positions directly. We also utilize outsourcing with contracted NPAs when needed to ensure we are meeting the needs of students. And it is with great joy that we have learned that Heartland qualifies for MHSA to employ more mental healthcare professionals.

Heartland is committed to improve the safety of our students and meet the suicide prevention safeguards required by state law.

Sincerely,

Courtney McCorkle

Executive Director

Heartland Charter School

Kern High School District

To: Elaine Howle, California State Auditor
From: Dr. Brenda Lewis, Associate Superintendent of Instruction
RE: California State Suicide Prevention Audit
Date: September 4, 2020

The Kern High School District is in receipt of the August 28, 2020 draft findings report prepared by the California State Auditor’s Office related to its audit of the suicide prevention efforts of local educational agencies in California. Having reviewed the draft report, the District offers the following response:

The Kern High School District is a dedicated grade 9 – 12 high school District located in Kern County, California. The District educates over 40,000 students each day at its 18 comprehensive high school campuses, 5 continuation schools, and numerous satellite programs. The District has a deep and ongoing commitment to the health and well-being of its students and allocates significant resources annually toward aiding students in all aspects of academic achievement, social and emotional development, addressing mental health and substance abuse issues, and overall emotional support, while creating a safe and open learning environment where students feel empowered to succeed, positively contribute to school climate, and express themselves as they grow. The District employs 123 Counselors, 46 full-time and 17 part-time School Community Specialists, 24 School Social Workers, 26 School Psychologists, 21 Licensed Behavior Specialists, 23 Interventionists, 20 School Mental Health Clinicians, 8 Substance Abuse Specialists, and 2 Outreach Specialists for a total of 310 individuals dedicated to addressing all aspects of student mental and emotional health and academics. The District’s budget for these support professionals is approximately $35 million which constitutes approximately 7.7% of the overall budget. The District is very proud of its work to support all students, including our students suffering with mental health concerns.

It is important to note that while the KHSD developed its Suicide Prevention Guidelines, numerous specialists were engaged as the KHSD Suicide Prevention Guidelines Committee completed research as it prepared the final guideline document. As noted above, the District employs considerable staff in areas of student mental health and utilized its in-house professionals. The KHSD took this process seriously and involved mental health experts, school psychologists, social workers, counselors, intervention counselors, district directors, the Chief of the Kern High School District Police Department, as well as school site administrators on the Committee.

The District’s original staff training developed by the KHSD Suicide Prevention Committee, “Suicide Prevention – Kern High School District,” met all legal standards for suicide prevention training as was noted by the auditors and included the relevant current trend data and local community resources. Staff training was transitioned to an online outside vendor, however, and that training did not include the data and local resources but did comply with all other required training components. The KHSD has supplemented the online training to ensure that all staff are provided the trends data and community resources and are appropriately trained in compliance with the law.

Lastly, District policies have been updated to clarify that the District’s response to an attempted suicide is the same whether the attempt takes place at school, or outside of school.

The District agrees with the three findings and recommendations and has already corrected the issues identified, if possible, as noted above.

The District appreciates the work performed by the CSA and the opportunity to respond to the findings.

Regards,

Dr. Brenda Lewis
Associate Superintendent of Instruction
Kern High School District

Comments

CALIFORNIA STATE AUDITOR’S COMMENTS ON THE RESPONSE FROM KERN HIGH SCHOOL DISTRICT

To provide clarity and perspective, we are commenting on the response to our audit report from Kern High School District. The numbers below correspond to the numbers we placed in the margin of Kern High School District’s response.

Although Kern High School District employs a large number of mental health professionals, it failed to employ the recommended number in every category, as Table 6 shows. For example, it employed only 21 percent of the school nurses and 53 percent of the school psychologists required to meet the recommended ratios, as discussed here.

Kern High School District’s statement does not address the individuals that it failed to include when creating its suicide prevention policy. As we describe here, Kern High School District was unable to demonstrate that it obtained feedback from external stakeholders when constructing its suicide prevention policy. State law and Education’s model policy identify the groups that LEAs must or should involve when developing suicide prevention policies.

Kern High School District has misrepresented our conclusions. Contrary to Kern High School District’s statement, we did not determine that its original staff training met all legal standards for suicide prevention training. We assessed the adequacy of suicide prevention training conducted during the 2019–20 academic year. As we show in Table 2 , the training Kern High School District used during that year failed to fully address legislative requirements and include best practices that Education recommends, potentially depriving teachers and staff of all the knowledge or confidence necessary to respond appropriately when students are at risk of suicide.

We look forward to reviewing Kern High School District’s responses describing its progress in implementing these recommendations at 60 days, 6 months, and 1 year after the publication of this report.

San Francisco Unified School District

September 3, 2020

Elaine M. Howle, CPA, California State Auditor
621 Capitol Mall, Suite 1200
Sacramento, CA 95814

Dear Ms. Howle,

Thank you for the opportunity to review the draft report entitled “Youth Suicide Prevention: Local Educational Agencies Lack the Resources and Policies Necessary to Effectively Address Rising Rates of Youth Suicide and Self Harm.” Our relevant student health staff have reviewed the draft report and have provided the following feedback and clarifications, organized by page number in the draft report:

(P. 5,6) The SFUSD Wellness Initiative model is not the same as a "school-based health center." Rather, it is a model of service devised by the district to reach students in schools with necessary services and acting as a mechanism to refer to community based or primary care services when needed. School based health centers provide primary care as well as other sexual health medical services not available in Wellness centers. However, SFUSD does have one DPH school based health center co-located in a Wellness center, and two DPH sexual health clinics co-located within Wellness centers.

(P. 11) "Committed suicide" should be changed to "died by suicide" per American Foundation for Suicide Prevention - Reporting on Suicide Guidelines

(P. 17 Figure 5) It does not appear that this chart considers suicide or self harm by transgender or gender non conforming students, is that correct? The chart does not acknowledge whether this was considered.

(P. 19) Recommend changing "commits suicide" to "died by suicide" for reason stated above.

(P. 20/21) In interviews with auditors, SFUSD shared that staff regularly collaborate with community based organizations for both consultation and services, including the Comprehensive Crisis Services (a program of DPH), Edgewood’s CSU, SF Suicide Prevention and Richmond Area Multi Services Agency. It is inaccurate to broadly conclude that “LEAs consistent failure to include community groups suggests that they may not fully recognize the benefits of doing so.” This conclusion ignores the meaningful collaborations between SFUSD and community stakeholders based solely on the absence of a sign-in sheet related to policy development. Recognizing the benefits of community stakeholder support goes beyond collecting feedback on a written policy; the more impactful and meaningful support comes from working collaboratively to support students and their families when an incident occurs, and in developing the operational protocols that implement the broad goals of a policy.

Additionally, this broad statement that LEAs fail to recognize the value of community input also ignores the fact that SFUSD employs internal experts that bring expertise from community organizations. For example, SFUSD employs a school social worker (SSW) who is a former board member of the American Foundation for Suicide Prevention and a member of the American Association of Suicidology; another SSW who is an expert in the field of Filipino mental health; and a SSW who is known nationally for work with LGBTQ students. These employees were ongoing consultants and presenters of the training for the district.

(P. 22 Table 2) Please provide clarity in the report about what element is missing from the SFUSD training program. The current report’s content may be misleading in that it implies that SFUSD’s training failed to include information about suicide risk factors or warning signs. Table 2 lists the 3 recommended elements (risk factors, warning factors, protective factors) and indicates with a red X that SFUSD failed to “discuss all three elements.” The report states that “all of the LEAs we reviewed lacked one or more of the elements.” But the report is vague about precisely what element or elements are missing from SFUSD’s training.

However, in the narrative there is a singular focus on risk factors and warning signs. The report explains that “These deficiencies may leave teachers and staff unprepared to identify and assist students at risk of self harm and suicide.” The report also states that “Youth who are contemplating suicide frequently exhibit signs of their distress, and teacher and staff trained to identify these warning signs are in key positions to obtain help and prevent suicide attempts.” [Emphasis added]. These conclusions may be misleading as they suggest that what is missing from the LEA training is information about risk factors and warning signs; and highlight the dangers of teachers failing to recognize risk factors and warning signs.

The SFUSD training does cover these topics; therefore we request that the report describe the specific factor that was missing (protective factors). SFUSD will add a slide to its training to list possible protective factors. However, the term “protective factors” can be misleading as having these factors does not “protect” students from suicide attempts or deaths. Several suicides have occurred involving students who did have such “protective factors.”

(P. 25/26) The report broadly concludes that “two LEAs did not conduct this [suicide prevention] training within the first three months of the beginning of the school year.” SFUSD has 13 middle schools, 15 high schools and 6 county schools. The audit reviewed one county school with an enrollment of 73 students to support the broad conclusion that the LEA does not provide timely training. For charter schools or smaller LEAs the selection of one school may provide statistical significance; but it is misleading to suggest an “apples to apples” comparison of training practices at one charter to those at an entire LEA based on the review of one school. Therefore, we request that the report be more transparent that its conclusions regarding training are based on the review of one of the LEA’s 34 middle, high and county schools. Currently there is only one small-print note below Figure 4 that acknowledges the review was based on review of one school.

(P. 27) The report states that SFUSD is missing an action plan for out of school suicide attempts. This distinction is confusing as the SFUSD protocols for responding to student suicide attempts do apply to “out of school” attempts; and in fact there has never been an “in school” suicide attempt. However, the district will clarify the applicability of its protocols to “out of school” suicide attempts in its Administrative Regulation. The Regulation will also include a single point of contact regarding suicide prevention and response.

(P. 37) The last paragraph should read San Francisco Unified High School Wellness Initiative, which includes 18 wellness centers.

(P. 53 Table A, 5(a)) This Table lists the Audit Goals and Methods Used to Address Them. Goal 5(a) is “Identify the extent to which each LEA and charter school tracks student suicides and attempted suicides.” In the “Method” column the report states that none of the LEAs tracked aggregate suicide or self harm data. SFUSD does track suicide ideation, attempts, and self harm via the CDC Youth Risk Behavior Survey. The district tracks completed suicides in individual student records because staff need to know if a student has died by any reason, especially suicide; but this information is not maintained in a searchable database.

Thank you for your consideration of our comments and clarifications.

Sincerely,

Angela Miller, Sr. Deputy General Counsel
San Francisco Unified School District

Comments

CALIFORNIA STATE AUDITOR’S COMMENTS ON THE RESPONSE FROM SAN FRANCISCO UNIFIED

To provide clarity and perspective, we are commenting on the response to our audit report from San Francisco Unified. The numbers below correspond to the numbers we placed in the margin of San Francisco Unified’s response.

During the publication process for the audit report, page numbers shifted. Therefore, the page numbers cited by San Francisco Unified in its response do not correspond to the page numbers in the final published audit report.

San Francisco Unified has misinterpreted the terminology we used to define school health centers for the purpose of this report. As we describe here, the services that a school health center provides depend on the health professionals they employ, and may include a variety of physical and mental health services, such as mental health care, immunizations, substance abuse counseling, oral health care, and nutrition education. As a result, for the purposes of our report we defined school health centers broadly. Because San Francisco Unified’s wellness centers deliver on-campus mental health care we describe them as school health centers.

During the editing process we revised some terminology to consistently match language commonly used when discussing youth suicide prevention. Specifically, we removed the term committed suicide from text here and here.

As we state in the footnote to Figure 5, the available data did not specify gender for fewer than 10 incidents of self-harm. We did not include those incidents in Figure 5.

As we describe here, San Francisco Unified was unable to demonstrate that it obtained feedback from external stakeholders when constructing its suicide prevention policy. Notwithstanding its ongoing collaboration with community organizations and their involvement in its suicide prevention training, state law and Education’s model policy identify the groups that LEAs must or should involve when developing their suicide prevention policies.

Our analysis of suicide prevention trainings does not describe which specific elements of suicide identification LEAs did not include. During the audit, we informed San Francisco Unified’s staff which element their training was missing on several occasions. Because Education’s model policy and best practices created by suicide prevention organizations do not prioritize one factor over another, we considered all three to be crucial elements of an effective suicide prevention training.

As we describe here, and in the footnote to Table 4, we selected one school from each LEA for review. Further, we describe the specific San Francisco Unified school that we reviewed in Table 4. Although a larger selection of schools may have provided additional context, our review illustrates that LEAs throughout the State can improve their provision of suicide prevention training.

We revised the text to more clearly indicate that the term wellness program is used to describe San Francisco Unified’s Wellness Initiative.

San Francisco Unified’s description of how it maintains information does not conflict with our determination. As we state in the Appendix, San Francisco Unified does not track aggregate suicide or self-harm data. We did not attempt to review information in individual files due to the time it would take to compile such information, and we agree with San Francisco Unified that it does not aggregate such data into a searchable database.

Ukiah Unified School District

September 3, 2020

Ms. Elaine M. Howle
California State Auditor
c/o Aaron Fellner, Team Leader

Re: Local Educational Agencies Lack the Resources and Policies Necessary
To Effectively Address Rising Rates of Youth Suicide and Self-Harm

Dear Ms. Howle:

On behalf of the Ukiah Unified School District’s (“District”), I submit the attached response to the above-referenced Draft Report.

Sincerely yours,

Nancy L. Klein, Senior Associate General Counsel
School & College Legal Services of California

Enc.

On June 13, 2017, in response to the enactment of Education Code section 215, effective January 1, 2017, the District adopted Board Policy and Administrative Regulation 5141.5.

Although not required by Section 215, as originally enacted or as subsequently amended in 2019 and 2020¹“The policy shall address any training to be provided to teachers of pupils in grades 7 to 12, inclusive, on suicide awareness and prevention.” (Ed. Code sec. 215(a)(3)(A)) (Effective January 1, 2017 – December 31, 2019) “The policy shall address any training on suicide awareness and prevention to be provided to teachers of pupils in all of the grades served by the local educational agency. (Ed. Code sec. 215(a)(4)(A)) (Effective January 1, 2020), the District has provided annual suicide prevention training for staff. The training included identification of school-based mental health services and how to refer students for such services.

Until fall, 2020, the District used QPR training, which the California Department of Education (“CDE”) cites as a training resource at page 6 of its Model Youth Suicide Prevention Policy.

The specific QPR training materials used by the District, which were submitted in the course of the audit, list National Resource numbers and crisis lines. A full list of local crisis response resources is included in the District’s suicide intervention protocol, which is distributed to all district counselors, including the school social-emotional counselors whose specific duties include provision of school-based mental health services. The counseling staff maintains notes throughout a student’s enrollment in the District to ensure through the years that staff, as appropriate, are kept informed of a student’s prior history of social-emotional needs.

In the District’s QPR training materials, high risk groups are specifically addressed, as are Risk Factors (e.g., mental illness, substance abuse, trauma victims, depression, alcohol, psychosis and bipolar disorder, trauma and bullying) and warning factors, (e.g., introduction to warning signs, signs of suicide, direct verbal clues, indirect verbal clues, behavioral cues, situational cues, and acute suicide warning signs).

The District is in the process of reviewing CDE’s model policy. After consulting with “community stakeholders” through the District’s Health Advisory Committee and Counselors’ Network, district administration plans to take a revised policy to the Governing Board for a first reading in November, 2020, and for a final reading and approval by March, 2021.

The District provided suicide prevention training this fall for all staff. The District has never limited training to teachers. (See f.n. 1 - Ed. Code sec. 215) At the recommendation of the California State Auditor’s team, the District discontinued use of QPR training. The District is reviewing its current online training to ensure that, by June, 2021, it aligns with the recommendations in the Draft Report.

The District posts continuously to hire school nurses to no avail. Despite district efforts, no applicant has accepted the District’s offer of employment since July 1, 2018. The District believes the inability to hire school nurses is due largely to the considerably higher compensation available in the private sector. The District would welcome the state allocation of funding for the employment of school nurses and other professional staff.

To meet students’ needs, the District has a district-wide Crisis Response Team that responds to suicides and other social-emotional crises that occur in and out of school. In addition to school counselors and school psychologists, the District employs at all sites health technicians who work directly with students. The District also employs at least one bilingual Family and Community Liaison at each site and two district-wide Family Community Liaisons for a total of 13 district wide.

In response to the District’s request for information regarding MHSA funds, the California State Auditor’s Office shared the Mendocino County MHSA three-year plan. Staff will be reviewing the plan and contacting Mendocino County Health and Human Services Agency to determine if there is an “application process” for the District to access MHSA funds for school counselors, school nurses, school social workers, and school psychologists.

Comments

CALIFORNIA STATE AUDITOR’S COMMENTS ON THE RESPONSE FROM UKIAH UNIFIED

To provide clarity and perspective, we are commenting on the response to our audit report from Ukiah Unified. The numbers below correspond to the numbers we placed in the margin of Ukiah Unified’s response.

Ukiah Unified’s statement does not align with the documentation that it provided to us. As we discuss here and show in Table 2, the training materials that Ukiah Unified provided did not include information about school or community-based mental health services and procedures for referring students to them, which is required by state law.

Ukiah Unified is describing information that it could not document. Although the suicide intervention protocol that Ukiah Unified describes does list crisis response resources, that protocol is not referenced in any of its suicide prevention training materials. Thus, as we discuss here, Ukiah Unified teachers and staff may not know what resources are available when responding to a student in crisis.

Ukiah Unified has overstated the extent to which its training addresses high-risk groups. Ukiah Unified provided us with additional documentation concerning this subject after it reviewed the draft of this report. However, that documentation only lists a number of high-risk groups and does not include any further discussion of those groups, such as specific characteristics. Without this information teachers and staff may not be aware of the warning signs, risk factors, and resources specific to those groups which, as we discuss here, may impede their ability to reduce suicide risk in the populations that most need help.

Ukiah Unified’s assertion does not address all three elements of suicide identification. Ukiah Unified provided additional documentation after it reviewed the draft of this report and the documentation it provided to us describes risk factors and warning factors, but it does not address protective factors. Our analysis of suicide prevention trainings does not describe which specific elements of suicide identification LEAs did not include. Because Education’s model policy and best practices created by suicide prevention organizations do not prioritize one factor over another, we considered all three to be crucial elements of an effective suicide prevention training.

Ukiah Unified’s statement is misleading. Although it may not have prohibited other staff from attending the training, during the audit Ukiah Unified’s director of alternative education confirmed that only teachers received the training, and that Ukiah Unified intended to add additional staff in future years.

Ukiah Unified has misstated the nature of our recommendations. The staff that performed this audit did not recommend that Ukiah Unified discontinue its use of the QPR training. During the course of the audit we did discuss with Ukiah Unified the elements we describe in Table 2 that the training did not address.

Ukiah Unified’s narrow focus on hiring additional school nurses does not account for other methods for obtaining their services. We encourage Ukiah Unified to review the report text starting here describing how school health centers increase youth access to mental health care, how school health centers allow schools to leverage access to additional funds—such as federal Medicaid funds—and how other entities such as community health centers or local health departments may employ the necessary medical support staff.

Ukiah Unified is already provided funds that can be used for this purpose. Described here, according to a program consultant at Education, state funds for LEAs are not restricted for specific purposes.

Ukiah Unified’s discussion of its crisis response team does not alleviate the shortcomings we identified in its suicide prevention policy. As we state here, some suicide prevention policy elements may be included in other documents and processes. However, we did not identify any references to the crisis response team in Ukiah Unified’s suicide prevention policy. Thus, we are concerned that Ukiah Unified has not clearly established the course of action to be taken to ensure timely response after a death by suicide.