Settlement Agreement Provision
The Commonwealth shall conduct monthly mortality reviews for unexplained or unexpected deaths reported through its incident reporting system. The Commissioner shall establish the monthly mortality review team, to include the DBHDS Medical Director, the Assistant Commissioner for Quality Improvement, and others as determined by the Department who possess appropriate experience, knowledge, and skills. The team shall have at least one member with the clinical experience to conduct mortality reviews who is otherwise independent of the State. Within ninety days of a death, the mortality review team shall: (a) review, or document the unavailability of: (i) medical records, including physician case notes and nurse’s notes, and all incident reports, for the three months preceding the individual’s death; (ii) the most recent individualized program plan and physical examination records; (iii) the death certificate and autopsy report; and (iv) any evidence of maltreatment related to the death; (b) interview, as warranted, any persons having information regarding the individual’s care; and (c) prepare and deliver to the DBHDS Commissioner a report of deliberations, findings, and recommendations, if any. The team also shall collect and analyze mortality data to identify trends, patterns, and problems at the individual service-delivery and systemic levels and develop and implement quality improvement initiatives to reduce mortality rates to the fullest extent practicable.
About Mortality Reviews
The DBHDS Mortality Review Committee (MRC) is established consistent with the requirements of the provision. The MRC Charter outlines the duties and responsibilities of the Committee, its membership and its standard operating procedures. DBHDS Licensing Regulations require all providers to report deaths through the incident reporting system within 24 hours of discovery. The DBHDS Special Investigations Unit (SIU) reviews all deaths of individuals with an IDD diagnosis reported to DBHDS through its incident reporting system and provides the investigation information to the MRC within 45 business days of the date the death was reported. The Clinical Nurse Reviewers then compose a succinct clinical case summary from reviews of all documents submitted by OL. From mortality case reviews, the committee makes determinations and monitors recommendations and/or actions within 90 days from the date of an IDD death, working in collaboration with the Offices of Licensing and Integrated Health. The MRC monitors, collects and analyzes mortality data to identify trends, patterns, and concerns at the individual service-delivery and systemic levels on an ongoing basis. The Committee then develops quality improvement initiatives in order to reduce mortality rates to the fullest extent practicable.
Mortality reviews are conducted in accordance with Virginia Code § 37.2-314.1. Portions of meetings in which individual death cases are reviewed by the MRC are closed pursuant to Virginia Code § 2.2-3711(A) (21). In addition, the information, records, discussion, and opinions disclosed during meetings at which the MRC reviews a specific death are confidential. Pursuant to Virginia Code § 37.2-314.1, members of the MRC and any person presenting information or records on specific deaths sign an agreement to maintain this confidentiality.
In order to promote the health, safety, and well-being of IDD individuals, the MRC makes recommendations for systemic quality improvement initiatives based on aggregate trends, patterns and concerns, and reports these quarterly to the DBHDS Commissioner and Quality Improvement Committee. DBHDS Office of Clinical Quality Management disseminates to stakeholders the Quality Management Annual Report, which contains information related to quality improvement initiatives, including any alerts or identified resources that promote quality improvement.
Authorizing Authority
Processes, Protocols and Standards
- DBHDS MRO Process Document (February 2023)