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AUTHORITY: Tennessee Code Annotated (TCA) 4-3-2708 and 33-3-103 through 115, and, Code of Federal Regulations (CFR) 42 § 483.420. PURPOSE: The purpose of this policy is to establish a process for conducting systematic reviews of deaths of persons with intellectual or developmental disabilities, served by the Home and Community Based (HCBS) waivers, to identify factors which may have contributed to the death; to recommend necessary preventive measures; and, to improve supports and services for all persons in the system. APPLICATION: This policy applies to staff of the Department of Intellectual and Developmental Disabilities (hereinafter Department or DIDD), providers of HCBS waiver services, and individuals responsible for reporting and/or reviewing deaths of persons receiving services and supports. DEFINITIONS:A.Clinical Death Review Summary shall mean a written report by a qualified registered nurse regarding the circumstances surrounding an individual’s death that includes information such as services received or omitted, significant events, healthcare and medication histories, cause of death and autopsy findings (if available), and other information relevant to the person’s death. DIDD Comprehensive Death Review Committee shall mean a committee whose role is to conduct a comprehensive analysis of the relevant facts and circumstances, including the healthcare provided, to identify practices or conditions which may have contributed to the death and to make recommendations to prevent similar occurrences. It is not intended to be an investigative, fault finding process.Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule establishes national standards to protect individuals’ medical records and other personal health information and applies to health plans, health care clearinghouses, and those health care providers that conduct certain health care transactions electronically.? The Rule requires appropriate safeguards to protect the privacy of personal health information, and sets limits and conditions on the uses and disclosures that may be made of such information without patient authorization. The Rule also gives patients rights over their health information, including rights to examine and obtain a copy of their health records, and to request corrections.Home and Community-Based Services Waiver or Waiver shall mean a waiver program approved for Tennessee by the Centers for Medicare and Medicaid Services to provide services to a specified number of Medicaid eligible individuals who have an intellectual disability and who meet criteria for Medicaid reimbursement of care in an Intermediate Care Facility for Individuals with Intellectual Disabilities.Independent Review by a Qualified Physician shall mean a medical review of a death covered under this policy through which a qualified physician unaffiliated with treatment of deceased individual will conduct a detailed medical review of the records to render evidenced based, objective determinations as to the cause of death and associated contributing factors. Initial Agency Death Review shall mean an internal review, conducted by the Provider Agency, of the person’s tenure with the agency and circumstances surrounding the death to identify any preventable or systemic conditions that may have contributed to the death of the person that require immediate intervention in order to protect other individuals.Mortality Nurse shall mean a licensed Registered Nurse trained in the death review process and completion of the Clinical Death Summaries.Preliminary Death Review shall mean a meeting of the Preliminary Death Review Committee to determine if a death meets the criteria for a DIDD Comprehensive Death Review.Preliminary Death Review Committee (PDRC) shall mean a designated group of persons in the DIDD Regional Office that includes the Regional Office Director of Nursing or designee, Regional Office Director or designee, the Regional Office Compliance Director or designee, and Regional Investigations Coordinator or designee.Unexpected or Unexplained Death shall mean any death that did not result from the normal progression of a known medical condition or disease, including but not limited to healthcare or emergency intervention that is inappropriate, untimely, or inconsistent with physicians’ orders, advance directives, or applicable policies or standards governing withholding of medical treatment. POLICY: The Department implements and maintains a systematic death reporting and review process that ensures timely reporting of deaths of persons supported; identification of the cause of death and the circumstances contributing to or associated with the death; identification of corrective action, trends and patterns in deaths that indicate needed service and/or systemic changes; ongoing evaluation to ensure corrective actions are implemented and systemic changes are effective in reducing risk to persons receiving services. PROCEDURES:Death Notification and Reporting TimelinesPrimary ProviderThe person’s primary provider is responsible for reporting the person’s death and implementing necessary follow-up actions in accordance with this policy. If the person supported had more than one provider of services and supports, the priority order for determining the agency responsible for reporting the death, from highest to lowest, is as follows:The provider of Residential Services. The provider of Day Services.The provider of Personal Assistance Services.The Independent Support Coordinator or equivalent.The DIDD Regional Office.NotificationA person’s death shall be reported in accordance with the following timelines:Notification of law enforcementRegardless of setting, the provider agency staff shall notify law enforcement or the medical examiner immediately if the person’s death occurred suddenly when the person was in apparent good health, if the death occurred in a suspicious, unexpected, or unexplained manner or if the death is the result of a suspected crime. Providers of HCBS waiver services shall report deaths of persons supported in accordance with the DIDD Provider Manual Chapter 7 Protection from Harm. Timelines for reporting the person’s death and submission of the Reportable Incident Form (RIF) DIDD-0495 are as follows: As soon as possible and no later than one hour of awareness of the person’s death, notify law enforcement and the DIDD Investigations Hotline if it is suspected the death is the result of a crime. If no crime is suspected, as soon as possible and no later than four hours of awareness of the person’s death:Notify the DIDD Regional Office Administrator on Duty. ANDNotify the DIDD Investigation Hotline if the death is suspicious (alleged abuse or neglect involved), unexpected or unexplained.(3) As soon as possible, and no later than 24 hours of awareness of the person’s death, notify the person’s family, next of kin, and/or legal representative. By the end of one business day, following awareness of the person’s death.Submit a completed Notice of Death Form DIDD-0483 to the DIDD Regional Director. Submit a completed RIF to the DIDD Central Office, the person’s Independent Support Coordination Agency or DIDD Case Manager.Initial Agency Death Review Residential services providers shall immediately initiate (no later than 24 hours) an agency death review after becoming aware of the death of a person supported by the agency. The Initial Agency Death Review Form DIDD-0487 shall be completed and submitted electronically to the appropriate office of the DIDD Regional Director within five (5) business days of the agency becoming aware of the person’s death. The agency may consult with a qualified physician to conduct an independent death review as part of the Agency Death Review or at any time following the death of the person. An effective Agency Death Review will identify questions or concerns to be addressed in subsequent proceedings, including investigations. Providers should ensure that their agency death review process includes the following elements listed below. Review of relevant records and documents.Review of events surrounding the death, identification of known or likely contributing factors, and review of any other pertinent information. Identification of any conditions or practices that may have contributed to the person’s death that require immediate intervention in order to protect the health and safety of other persons receiving services. Examples of such conditions or practices include environmental hazards, a delay in emergency response or in seeking medical intervention, or abusive or neglectful conduct on the part of staff or others. Identification of any systemic and preventable conditions or practices that may have contributed to the death of the person that requires corrective action over time.Development of a corrective action plan to address issues identified during the review process.C.DIDD Regional Preliminary Death ReviewA Preliminary Death Review shall be conducted for all deaths of persons supported receiving home and community based services that are reported to the Department. Within one (1) week of receipt of the Notice of Death Form DIDD-0483, the Preliminary Death Review Committee (PDRC) shall conduct a review of the person’s death to determine the following: Have the criteria for an unexpected or unexplained death been met; andRequest a clinical death summary (CDS) and DIDD comprehensive death review be conducted, if applicable.3. If the criteria for an unexpected or unexplained death have not been met then the PDRC will not request a Clinical Death Summary (CDS) or DIDD Comprehensive Death Review. If the criteria for an unexpected or unexplained death have been met, then a member of the PDRC shall request a CDS and DIDD comprehensive death review. The activities of the PDRC will conclude once the request for a CDS has been made. The PDRC will reconvene if pertinent information is received (e.g., autopsy) prior to the occurrence of a DIDD comprehensive death review. The PDRT will follow the procedures discussed in VI.C.2 of this policy.The DIDD Commissioner may at any time request that a DIDD Comprehensive Death Review be conducted.D.Clinical Death SummariesA Clinical Death Summary (CDS) shall be completed within thirty (30) calendar days of receipt of the Notice of Death Form DIDD-0483. This time period may be extended for good cause with the written approval of the DIDD Central Office (CO) Director of Nursing or designee. The CDS will address the following components: Demographic InformationPerson Supported ProfileReview of SystemsRecent Clinical HistoryDiagnoses and MedicationsReview of the Terminal EventThe Regional Mortality Nurse shall distribute the CDS within one (1) business day of its completion to the following: The DIDD Central Office Nursing Director.The DIDD Regional Office Director.The DIDD Regional Compliance Director. The DIDD Director of Investigations.The Executive Director of the primary provider agency responsible for delivering services and supports to the person supported, if applicable. E.DIDD Comprehensive Death ReviewsThe purpose of a DIDD Death Review is to conduct a comprehensive analysis of the relevant facts and circumstances, including the healthcare provided, to identify practices or conditions which may have contributed to the death and to make recommendations to prevent similar occurrences. It is not intended to be a punitive or fault finding process.Death Reviews shall be conducted within forty-five (45) business days of the person’s death. However, this time period shall be automatically extended for thirty (30) business days when the autopsy report, CDS or investigation report (if applicable) is not completed. Any extensions beyond thirty (30) business days shall require approval of the DIDD Commissioner or designee. The DIDD Comprehensive Death Review includes a review of relevant records and documents associated with the person’s death, including (if available):Individual Support Plan. Notes related to service delivery, including psychosocial history. Incident reports related to the person in the 12 months prior to death.Death certificate.Autopsy and medical examiner or coroner reports.Emergency medical personnel reports and documentation.Medical records including physician, specialists, hospital, and emergency room records related to the person who is deceased in the 12 months before death. Records and documentation of medical professionals who treated the person who is deceased within the 12 months of his or her death. Notice of Death Form DIDD-0483.Reportable Incident Form DIDD-0495. Initial Agency Death Review Form DIDD-0487.DIDD Investigation Report (if applicable).Clinical Death Summary. F.DIDD Comprehensive Death Review CommitteeDeath Reviews shall be performed by the Comprehensive Death Review Committee (hereinafter CDRC or Committee). The composition of the Committee shall be as follow:The chair of the Committee shall be the Regional Office Compliance Director or designee.A qualified physician unaffiliated with treatment of deceased person and who was not associated with the provider agency, within a year of the person’s death. A DIDD physician shall, upon request of the chairperson, serve as the independent physician on the CDRC.c.The registered nurse who completed the CDS or designee.d.The Executive Director or designee of the primary provider agency serving the person through a HCBS waiver program.e.At least one program staff person selected by the provider agency who is familiar with the person’s health status and history and the course of events prior to death. f.The person’s Independent Support Coordinator, Case Manager or equivalent.2.The Death Review Committee may also include the following members by invitation of the Chair.The person’s primary care physician, nurse practitioner, or physician assistant who coordinated or provided the person’s health care. The primary provider agency Director of Nursing or the nurse who provided care to the person while receiving services through a HCBS waiver program.As needed, one or more health specialists (e.g., psychiatrist, neurologist, occupational therapist, physical therapist) as determined by the Central Office Director of Nursing in consultation with the DIDD Director of Health Services.The parent of a person with a disability unrelated to the deceased person. 3.Upon appointment, each committee member shall sign a Conflict of Interest and Confidentiality Statement. No member shall be allowed to participate in any committee business until such statement is signed.prehensive Death Review Committee Chair ResponsibilitiesThe Regional Office Compliance Director or designee shall be responsible for coordinating meeting logistics including selecting a time and location that takes into consideration the participants’ schedules, and notifying members and the DIDD Central Office Nursing Director in writing about the meeting. The Regional Office Compliance Director or designee shall determine who, in addition to standing Committee members, will be included on the Committee for the person’s comprehensive death review.Requests by additional persons (e.g., non-committee members) to attend the death review must be submitted in writing in advance of the meeting to the Death Review Committee chair and Central Office Director of Nursing. The Committee chair will be responsible for notification that the request has or has not been granted. Preparation of death review packets for Committee members. The contents of the death review packet shall include (if available):Individual Support Plan. Death certificate.Autopsy and medical examiner or coroner reports. Notice of Death Form DIDD-0483.Reportable Incident Form DIDD-0495. Initial Agency Death Review Form DIDD-0487.DIDD Investigation Report (if applicable).Clinical Death Summary. Additionally, Clinical Members of the Death Review Committee shall receive:Notes related to service delivery, including psychosocial history. Incident reports related to the person in the 12 months prior to death.Emergency medical personnel reports and documentation.Medical records including physician, specialists, hospital, and emergency room records related to the person who is deceased in the 12 months before death. Records and documentation of medical professionals who treated the person who is deceased within the 12 months of his or her death. 5.At least five (5) calendar days prior to the Death Review meeting, distribute the appropriate Death Review Packet to each Death Review Committee member. prehensive Death Review Committee Member ResponsibilitiesCommittee members shall review Death Review Packets prior to the meeting.In instances when an autopsy is conducted but the final report is not available at the time of the meeting, the registered nurse or designee who wrote the CDS shall be responsible for attempting to obtain a preliminary oral or written autopsy report for discussion at the Committee meeting.If warranted, at the conclusion of its review the Committee may recommend the primary provider implement quality improvements. Recommendations must adhere to the following criteria:Members must be present at the meeting to offer recommendation(s). The Committee must agree to offer the recommendation(s)The recommendation(s) must be realistic and achievable.The recommendation(s) must be measurable.There must be written rationale for the recommendation(s).4.The Death Review Committee may reconvene to consider additional information that is pertinent to the death (e.g., autopsy, death certificate or investigation report) that is submitted subsequent to the regional Preliminary Death Review Committee meeting.5.The Death Review Committee, in consultation with the DIDD Central Office Nursing Director, shall determine from a review of the minutes whether any aspect of the death should be referred to any licensing or regulatory agency or to law enforcement officials, if referrals have not already been made.I.Records and Proceedings of Comprehensive Death Review Committee MeetingsRecords and deliberations of Comprehensive Death Review Committee meetings are confidential.The proceedings of the Death Review Committee, including discussions among the members and any documents reviewed, shall be treated as confidential.A Comprehensive Death Review Meeting Attendance Form containing a statement of confidentiality must be signed by all participants at the beginning of each meeting.Meeting minutes shall be maintained for each CDRC meeting.Draft minutes shall be prepared by the Chair and made available to all Committee members for comment within eight (8) business days after the mittee members shall have four (4) business days to review the draft minutes and submit corrections and comments to the Chair.Following the comment period, the Chair of the Committee shall finalize the minutes within three (3) business days.These timeframes may be extended by the DIDD Commissioner or designee for good cause.The minutes shall include:Date of the meeting.List of names and titles of committee members in attendance.Name of the deceased.Age of the deceased at the time of death.Place of residence of the deceased at the time of death.Date, time, and place of death.Cause of death (if known).Brief summary of the circumstances surrounding the death.Full summary of issues discussed by the committee.The Committee’s specific findings with regard to the care and treatment provided to the individual.Identification of any factors which may have contributed to the death in question.Any recommendations for improvement agreed to by the committee. The minutes must clearly indicate the basis for all such recommendations. 3.Distribution and maintenance of Death Review Committee minutes.Copies of the final minutes shall be distributed to the following:DIDD Commissioner or designee. DIDD Central Office Nursing Director.DIDD Director of Health Services.DIDD Regional Office Director.The Executive Director of the primary provider agency.The Division of TennCare.Individuals authorized to receive the minutes shall maintain their copies in a secure location in accordance with state and federal confidential privacy statutes, rules and regulations.DIDD Office of Health Services shall be responsible for maintaining a complete file of all relevant documents (including those reviewed by or made available to the Comprehensive Death Review Committee) in a secure location for at least ten years, in accordance with Tennessee Code Annotated 33-3-101. The DIDD Commissioner, in consultation with the DIDD Central Office Nursing Director, shall determine whether the death review findings should be disseminated more widely.J.Follow-up of Death Review Committee recommendationsThe Executive Director or designee of the provider agency, as applicable, shall provide a written response to any CDRC recommendations within thirty (30) calendar days of receipt of the recommendations. The response shall include a quality improvement plan with time frames for implementing each recommendation or an explanation of proposed alternative actions that will be taken to address the problem(s) identified. The response shall be submitted to the DIDD Regional Compliance Director who shall submit the response to the DIDD Regional Director for review.The DIDD Regional Office Director or designee shall be responsible for tracking and monitoring the provider’s implementation of the CDRC recommendations. Monitoring may include on-site review of records and the provider’s practices.The DIDD Regional Compliance Director or designee shall submit implementation status reports to the DIDD Central Office Nursing Director or designee on a quarterly basis.K.Additional quality improvement activitiesAt least annually, the Central Office Director of Nursing or designee shall review and analyze death data to determine possible patterns or risk factors in areas such as: The demographic, medical, mental health and service provision profile of the deceased persons.The immediate and root causes of death.The issues, problems, and deficient practices or procedures identified in death reviews.The implementation of recommendations issued as a result of the death reviews.2. Quality Reviews The Central Office Nursing Director will facilitate a semiannual quality review of Death Reviews.An External Mortality Review Committee (EMRC) will evaluate a statistical sample, which will be fifty percent but not less than 12 records reviewed by the Regional Mortality Review Committee (RMRC) since the previous EMRC review. The sample will include individuals who received services in both the community and in State run ICF/IIDs. The sample will be evenly distributed among the regions.The EMRC will evaluate the RMRC case reports and identify system wide issues for improvements that are achievable and measurable.The EMRC will produce and submit a formal report of its findings and recommendations to the Deputy Commissioner of Health Services. The Deputy Commissioner of Health Services or designee may propose recommendations for improving consistency and quality of death reviews based on results of the Quality Review.VII.CQL STANDARDS: 4cVIII.REVISION HISTORY: May 24, 2018IX.TENNCARE APPROVAL: X.ATTACHMENTS:Initial Agency Death Review Form DIDD-0487Comprehensive Death Review Attendance Form DIDD-####Notice of Death Form DIDD-0483Reportable Incident Form DIDD-0495Conflict of Interest and Confidentiality Statement DIDD-#### ................
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