016.05.11 Ark. Code R. 001

Current through Register Vol. 49, No. 10, October, 2024

Rule 016.05.11-001 - Policy 3018- Mortality Review of Deaths of Persons Receiving Alternative community Services Waiver Services

INTRODUCTION

The Alternative Community Services (ACS) Mortality Review is an integral part of the Continuous Quality Improvement process for the Division of Developmental Disabilities Services (DDS). The mortality review is a process that entails a review of the specific circumstances of the death of an individual by at least one of two committees as well as a review of cumulative data regarding information on all deaths occurring within specific periods.

The review is not investigative in nature. Rather, the purpose is to facilitate Continuous Quality Improvement by gathering information to identify systemic issues that may benefit from scrutiny and analysis in order to make system improvement and to provide opportunities for organizational learning.

I. Purpose

The purpose of the review is to identify issues and trends related to deaths of Alternative Community Services Waiver service recipients in order to improve Division and Provider practices by:

1. Identifying social, health and systems strengths and weaknesses as they impact circumstances leading to death,

2. Recommending changes in procedures, resources and service delivery systems that impact circumstances leading to death,

3. Influencing the development of policies and laws regarding provision of ACS Waiver services, and

4. Gathering data about deaths among individuals with developmental disabilities, such as cause of death and demographic information so that the DDS may aggregate data over time to identify and analyze trends.

II. Intent

The intent of the review is to facilitate a better understanding of factors contributing to deaths and to develop enhanced strategies for addressing preventable deaths, developing recommendations for appropriate care, and, ultimately, to prevent the occurrence of future preventable deaths.

III. Definitions

Division - The Division of Developmental Disabilities Services, Department of Human Services.

Expected Death - A death that is natural or a death that is medically determined, based on a death certificate and supporting documentation, to have resulted solely from a diagnosed degenerative condition or similar circumstance or a death that occurs as the result of an undiagnosed condition resulting from an explained condition, such as the aging process.

Full Review - A review of the death of an individual in which no identifying information regarding the decedent or the Provider is available for consideration by the Mortality Review

Committee.

Mortality Review Committee - A group, made up of individuals identified in Section VIII of this document, who conduct a Full Review of all deaths designated as unexplained or unexpected, as well as some deaths designated as expected.

Mortality Review Coordinator - The individual responsible for gathering specific information regarding deaths of persons receiving ACS Waiver services and for coordinating meetings of the Review Team and Mortality Review Committee.

Preliminary Review - A review of the death of an individual in which all identifying information regarding the decedent and the Provider is available for consideration by the Review Team. The purpose of the review is to determine the designation of the death as unexpected, unexplained or expected.

Provider - The entity licensed or certified by DDS providing services to the individual whose death is under review.

Record - The written or electronic file containing information pertaining to the individual, including relevant facts, dates, and actions taken related to the individual, and contacts made and the results of those contacts.

Review Team - A group, made up of specified individuals who conduct a Preliminary Review of the deaths of all persons receiving ACS Waiver services.

Reviewable Death - The death of a person who is receiving waiver services, whose waiver status is in abeyance, or whose waiver status had been closed with 60 days prior to their death.

Unexpected death - A death that occurs as the result of an accident, an undiagnosed condition, suicide, homicide or suspected maltreatment, abuse, or neglect.

Unexplained death - A death in which the cause of death noted on a person's death certificate is not supported by documentation found in the person's medical history and other documentation on file with the Provider, the DDS Waiver Section, or other source.

IV. Preliminary Review

During the Preliminary Review, the Review Team will analyze the information regarding a reviewable death that the Mortality Review Coordinator has provided to them in order to determine if they will designate the death expected, unexpected, or unexplained. The Team may also recommend that the Mortality Review Committee review a death designated as expected. All members must be present in order for the Team to convene to review any death.

The Mortality Review Committee must conduct reviews of all deaths considered by the Review Team to be unexpected or unexplained, as determined by their Preliminary Review.

The Review Team will consist of the following individuals:

1. DDS Assistant Director for Quality Assurance,

2. DDS Licensure and Certification Administrator,

3. DDS Children's Services Registered Nurse,

4. DDS Mortality Review Coordinator,

5. DDS Medical Director, (available for telephone consultation, as needed), and

6. Representative from the Provider or Providers of ACS Waiver services for the person whose death is under review (optional, at the discretion of the Provider and non-voting).

The Review Team will hold Preliminary Review meetings at least quarterly to review and analyze the information referenced above. The Mortality Review Coordinator will present a brief written and verbal description of the facts and circumstances surrounding the death. Members of the team will take into consideration all information presented to make a determination regarding how to categorize the death and whether the Mortality Review Committee should review it.

Members of the Review Team may request additional information and delay assigning a designation until after receipt and review of that information.

V. Review Disposition

The Review Team must reach a unanimous decision regarding the designation and the recommendation for review by the Mortality Review Committee. If the team cannot reach a unanimous decision, then the Mortality Review Committee must review the death.

The Team may request that the DDS Investigations Unit conduct an investigation of the circumstances of the death. In such case, the Team must refer the death to the Mortality Review Committee for review.

VI. Mortality Review Committee - Objectives and Tasks

The Mortality Review Committee provides a forum to ensure that relevant information is shared and available to determine why an individual has died and to understand better all the contributing factors leading to a death. The benefits of sharing information and clearly understanding Division and Provider responsibilities can make the process worthwhile even if new information does not surface at a review.

1. The Mortality Review Committee conducts reviews by discussing each death individually. The review should include a discussion of the following:

a. The circumstances surrounding the death,

b. Identification of the primary risk factors involved in the death,

c. The appropriateness and coordination of care as planned, delivered, and overseen by the ACS Waiver Provider, up to and at the time of the person's death,

d. Issues that arose near the time of the person's death which were under the control of an ACS Waiver Provider that may require further review for quality improvement,

e. Best practices in the delivery of services, and,

f. If, and the degree to which, the death was believed to be preventable.

2. The Mortality Review Committee will review information on all deaths that occurred over a specified period. The purpose of the review of the aggregated data will be to identify any patterns or trends. The Committee will review information regarding at least the following:

a. Age

b. Gender

c. Residence

d. Place of death

e. Cause of death as designated on the Death Certificate

VII. Review Disposition

Prior to moving to review of the next death, all Committee members should express confidence that they understood all information as presented or ask for further clarification. The Mortality Review Committee will provide disposition as follows:

1. Close review

2. Hold for additional review, due to the following:

a. The Committee requests that the Mortality Review Coordinator obtain additional information from a Provider or other source,

b. Final findings from the medical examiner are not available, if an autopsy was performed, and

c. Any other reason deemed acceptable by the Committee.

VIII. Mortality Review Committee Membership

The circumstances involved in most deaths are multidimensional. As a result, the responsibility for review should not rest in any one profession. The membership of the Committee must include representatives of agencies or stakeholder groups, who may, based on their individual professional experience and knowledge, address the complex dimensions of a death. The Mortality Review Committee membership must include the following individuals or representatives of the following departments, agencies or organizations:

1. DDPA Member, who is also a certified ACS Waiver Provider (2 positions),

2. The Arkansas Waiver Association (2 positions),

3. Waiver Service Recipient or Family Member of a Waiver Service recipient (2 positions),

4. DDS Director's Office designee,

5. DDS Licensure and Certification Administrator,

6. DDS Ombudsman,

7. DDS Medical Director,

8. DMS Quality Assurance,

9. DDS Registered Nurse,

10. DDS Waiver Services Administrative Staff,

11. Member-At-Large who is not a member of any organization represented by positions 1 or 2, and

12. Representative from the Arkansas protection and advocacy agency

The Committee may designate ad hoc members when they need additional information or expertise.

IX. Mortality Review Committee Organization

The Committee will elect a chairperson and vice chairperson, who are not DHS staff, who serve in that role for a period of at least 1 year.

1. Persons in positions 1, 2 and 3 as described above, will serve three-year terms. Initial members will draw lots to determine initial term length so that term expiration is staggered.

2. By unanimous approval of those attending the meeting, the Committee membership may dismiss a member for repeated failure to attend Committee meetings.

3. The Committee will meet as determined by the Committee, but no less than quarterly if there are deaths that have been determined to require review.

X. Role of the Mortality Review Committee Members

The role of Mortality Review Committee members should be flexible in order to meet the needs of the particular issue under review. The Committee should recognize and utilize the individual abilities of each member in order to enhance the Committee's effectiveness. Each member should:

1. Contribute information from his or her expertise and experience,

2. Provide definitions of professional terminology,

3. Understand and apply Division procedures and policies,

4. Understand and explain the legal responsibilities, such as mandated reporting, or limitations of his or her profession,

5. Be aware and acknowledge that the Mortality Review Committee is not an investigative body,

6. Review all death review reports and participate in the decision to approve submission of the report, and

7. Review aggregated data regarding deaths in order to identify patterns or trends.

All Mortality Review Committee members must have a clear understanding of their own and other professional and individual roles and responsibilities in their community's response to the death of a service recipient. In addition, Committee members should be aware of and respect the expertise and resources offered by each profession and individual who is a part of the Committee.

XI. ACS Waiver Provider Responsibilities

The ACS Waiver Provider Executive Director of the program providing service to the person whose death is under review or designee will:

1. Submit initial required materials and any other additional materials as requested by the DDS Mortality Review Coordinator, and

2. Send knowledgeable staff, at their discretion, to the Preliminary Review meeting.

XII. Mortality Review Coordinator Responsibilities

The Mortality Review Coordinator will attend all Preliminary Review and Mortality Review Committee meetings and will facilitate by providing necessary information and following up on any requests made by Review Team or Mortality Review Committee members. He will retrieve all written information from each Review Team or Mortality Review Committee member at the close of each meeting. He will either destroy all documents or retain the documents in a secure manner until the next meeting, depending on the disposition of the review.

The DDS Mortality Review Coordinator or designee will gather information concerning the facts and circumstances surrounding all reported deaths, utilizing a standard process. The Coordinator will obtain the information according to the following time frames:

1. The Mortality Review Coordinator will request information from the Provider no sooner than 14 calendar days after receipt of the notice of a death.

2. The Mortality Review Coordinator will request that the Provider respond to the request by providing the information within 20 calendar days from the date the Provider received the request from DDS.

The Mortality Review Coordinator will compile the following information for analysis by members of the Review Team:

1. The Face Sheet from the Provider record,

2. A printout from the Incident Reporting Information System (IRIS) or, if unavailable, then a copy of the Incident Report of a death submitted by the Provider,

3. A summary prepared by the Provider for the exclusive use of the Mortality Review Committee, describing the events leading up to the death of the individual to include, at the discretion of the Provider, a suggested classification of the death, using one of the three categories included in the Mortality Review policy,

4. The most recent Individualized Program Plan, including any Behavior plan,

5. Daily case notes from Direct Care staff for the previous month,

6. Case manager notes for the last 6 months,

7. A list of current medications, if not on the Face Sheet,

8. Current diagnosis, if not on the Face Sheet,

9. The most recent (within one month) and pertinent records contained in the Provider file from physicians, nursing staff and hospitals. (If the Review Team determines that records from these entities are essential in determining antecedent causes of death, the DDS Mortality Review Coordinator will attempt to obtain these records directly from the appropriate entity),

10. Verification of any Guardianship or Power of Attorney,

11. The most recent physical examination (within one year), if available,

12. Behavior and Incident Reports for three months prior to the death,

13. Death certificate (obtained by the DDS Mortality Review Coordinator) and

14. A written summary of the events surrounding the death.

When the Mortality Review Coordinator has compiled the necessary information listed above, he will place the death on the schedule for review at the next quarterly Preliminary Review meeting. The Coordinator will:

1. Prepare a packet of information comprised of the documents listed in Section XII for distribution at the time of the meeting,

2. Notify Review Team members of the date, time and location of the meeting, and

3. Notify the Provider or Providers of services to the decedent that they may, at their discretion, attend the Preliminary Review.

If the Review Team makes a recommendation for review by the Mortality Review Committee, the Mortality Review Coordinator will:

1. Place the review on the Mortality Review Committee schedule,

2. Prepare a packet of information, comprised of pertinent information gathered for the Preliminary Review as well as any other information obtained subsequent to that review,

3. Ensure that the packet of information contains no information that might identify the Provider or the decedent, and

4. Make the packet of information available to each member of the Mortality Review Committee at least 10 calendar days in advance of the meeting date.

If the Review Team makes a recommendation not to refer for review by the Mortality Review Committee, the Mortality Review Coordinator will notify the Provider in writing that the review has been competed

The Mortality Review Coordinator will, on a quarterly basis:

1. Prepare and submit to the DDS Licensure and Certification Administrator a list of all deaths determined not to meet the requirements for review, and

2. Ensure that the list contains a summary of the facts that supported the recommendation not to review, and

3. Prepare a quarterly report that summarizes data detailed in Section VI, 2 regarding each death that occurred during that quarter.

XIII. DDS Responsibilities

DDS will ensure that:

1. The DDS Quality Assurance Section will provide staff for Review Team and Mortality Review Committee support activities, such as making copies of materials, scheduling meetings and preparing reports.

2. The DDS Licensure and Certification Administrator will submit a list of all deaths not reviewed by the Mortality Review Committee to the DDS Director for final approval of the recommendation not to review, and

3. If the Director overturns a decision, the Mortality Review Coordinator will place the death on the agenda for review at the next scheduled Mortality Review Committee meeting.

4. The Annual Report produced by the Committee is distributed as appropriate and posted on the DHS website.

XIV. Mortality Review Reporting

The Committee shall prepare an annual report that describes and summarizes any findings or issues and contains any recommendations suggested by the Committee. It shall address as appropriate, the issues described in Section I of this document. It shall contain an annual summary of the quarterly data gathered during the year.

The report should address any trend identified by the Committee as well as the identification of any prevention activities proposed because of any review. The report should contain recommendations regarding specific actions, such as:

1. Revision of Provider or Division policy or forms,

2. Development of new Provider or Division policy to address systemic issues discovered in the review process,

3. Training, either on a statewide or individual Provider basis,

4. Facilitation of best practice, including new risk-prevention practices, through dissemination of recommendations for development of or modification to Provider policies, or

5. Issuance of a statewide safety alert.

The Mortality Review Coordinator will distribute a copy of the Mortality Review Committee's Annual Report to the DHS Director's office and to the Director of the Department of Developmental Disabilities Services.

Recipients of the report should consider all recommendations made by the Mortality Review Committee and take appropriate action as deemed necessary. In the determination of what may be deemed necessary action, DHS representatives will be mindful that the purpose of the Review

Committee is to gather information to identify systemic issues that may benefit from scrutiny and analysis in order to make system improvements. In the event that any sanction of a Provider is necessary, the DDS Licensure and Certification Unit will determine and issue the sanction, in accordance with applicable policies and procedures.

The Mortality Review Committee will review any Department of Human Services or DDS policy change or other action taken by the Department or Division in response to the Committee's recommendations. If requested, the Committee will review ACS Waiver Community Provider policy changes or other actions taken by the Provider in response to Mortality Review Committee recommendations.

016.05.11 Ark. Code R. 001

1/3/2012