Settlement Agreement Provision

V.C.5

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Reports

• Mortality Review Committee Annual Report SFY2023
• Mortality Review Committee Annual Report SFY2022
• Mortality Review Committee Annual Report SFY2021
• Mortality Review Committee Annual Report SFY2020

Compliance Indicators

Compliance Indicators V.C.5

1. The Commonwealth has a charter describing standard operating procedures for conducting mortality reviews that addresses:

a. The charge to the Mortality Review Committee (“MRC”)

b. The chair of the committee and an executive sponsor within DBHDS

c. The membership of the mortality review committee (by role)

d. The responsibilities of chair and members

e. The frequency of activities of the committee (e.g., meetings)

f. Review of unexplained and unexpected deaths reported through the

DBHDS incident reporting system, what a complete mortality review must entail, standards for closing a review, committee quorum, recusal from case reviews, and confidentiality protections for reviews.

g. The definitions of “unexplained” and “unexpected” deaths

h. The requirements for periodic review and analysis of mortality data to identify trends, patterns and problems at the individual service delivery and systemic-level factors related to deaths; the development and implementation of quality improvement initiatives to reduce mortality rates to the fullest extent practicable; and the reporting of quality improvement initiatives to the DBHDS Quality Improvement Committee.

2. The MRC membership includes at minimum (one member may satisfy up to 2 roles):

a. DBHDS Chief Clinical Officer (former title Medical Director)

b. DBHDS Senior Director of Clinical Quality Management (former equivalent position Assistant Commissioner for Quality Improvement)

c. A member with clinical experience to conduct mortality reviews who is otherwise independent of the State

d. A medical doctor

e. A nurse

f. DBHDS staff with quality improvement expertise

g. DBHDS staff with programmatic/operational expertise

3. MRC members will receive training that includes:

a. orientation to the MRC charter to educate the member on the scope, mission, vision, charge, and function of the MRC

b. review of the policies, processes, and procedures of the MRC;

c. education on the role/responsibility of the member(s); and

d. training on continuous quality improvement principles.

4. The MRC meets regularly (at least monthly) and at a frequency that enables the Committee to conduct required reviews of deaths. Meetings meet quorum requirements as set forth by the MRC charter, which at minimum require the presence of:

a. a medical clinician (medical doctor, nurse practitioner, or physician assistant);

b. a member with clinical experience to conduct mortality reviews;

c. a professional with quality improvement expertise; and

d. a professional with programmatic/operational expertise.

e. One member may satisfy up to two roles.

5. DBHDS utilizes an information management system to track the referral and review of individual deaths, as well as the recommendations of the MRC at the provider level and the quality improvement initiatives that have been approved by the MRC chair for implementation.

6. DBHDS requires all DBHDS-licensed providers to report deaths through the incident reporting system within 24 hours of discovery. The DBHDS Licensing Investigations Team reviews all deaths of individuals with a developmental disability reported to DBHDS through its incident reporting system.

a. Each case is assigned to an investigator on the Licensing Investigations Team who conducts an initial review of available information within 24 hours after the death is reported to DBHDS or the next business day.

b. Any deaths that appear to be related to abuse or neglect or that pose an imminent and substantial threat to the health, safety, or welfare of other individuals served by that provider have an investigation initiated by the DBHDS Licensing Investigations Team immediately, with actions taken, as appropriate, in accordance with licensing protocols.

c. The Licensing Investigations Team provides available records and information it obtains and the completed investigation report to the MRC within 45 business days of the date the death was reported on at least 86% of deaths required to be reviewed by the MRC.

7. For quality assurance purposes in identifying deaths subject to MRC review:

a. The incident reporting system is queried monthly to extract reports of all deaths of individuals, including unexplained or unexpected deaths of all individuals with an ID/DD diagnosis, receiving a licensed ID/DD service, and/or residing in a training center. Such reports will be included in the data tracking log for MRC review.

b. The MRC clinical reviewers review the information received for those individuals on the data tracking log and determine if a death is unexplained or unexpected and requires review by the MRC.

c. DBHDS provides the identifying information of individuals in the Waiver Management System (WaMS) who receive DBHDS-licensed services on a monthly basis to the Virginia Department of Health, which will identify the names for which a death certificate is on file. The results are provided to DBHDS and used by DBHDS to attempt to identify deaths that were not reported through the incident reporting system. The DBHDS Office of Licensing will investigate all unreported deaths identified by this process and take appropriate action in accordance with DBHDS licensing regulations and protocols.

8. 86% or greater of unexplained or unexpected ID/DD deaths as reported through the DBHDS incident reporting system have a complete review by the MRC within 90 days of the date of the death.

9. A complete mortality review includes:

a. the review, or documentation of the unavailability of, medical records, including physician case notes and nurse’s notes, and all incident reports, for the three months preceding the individual’s death; the most recent individualized program plan and physical examination records; the death certificate and autopsy report; and any evidence of maltreatment related to the death; and

b. interviewing, as warranted, any persons having information regarding the individual’s care.

10. The MRC prepares and delivers to the DBHDS Commissioner a report of deliberations, findings, and recommendations, if any, for 86% of deaths requiring review within 90 days of the death. If the MRC elects not to make any recommendations, it must affirmatively state that no recommendations were warranted.

11. The MRC 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.

a. The MRC prepares an annual report of aggregate mortality trends and patterns for all individuals reviewed by the MRC, as described in Indicator 7 for V.C.5, within six months of the end of the year (the annual interval may be selected by DBHDS as either fiscal or calendar). The annual report will, at minimum, include:

i. the total number of deaths and cause of death in DBHDS-licensed residential settings;

ii. crude mortality rate of individuals on a DD HCBS waiver and receiving a DBHDS licensed service;

iii. crude mortality rate of individuals by residential setting in aggregate known to DBHDS;

iv. crude mortality rate of individuals by age, gender, and race; and

v. analyses of patterns of mortality by age, gender, and race; residential settings and DBHDS facilities; service program; and cause of death.

b. A summary of the findings will be released publicly.

12. The MRC documents recommendations for systemic quality improvement initiatives coming from patterns of individual reviews (on an ongoing basis), or patterns that emerge from any aggregate examination of mortality data (either twice annually or annually as relevant to the review).

13. The MRC makes four recommendations for systemic quality improvement initiatives based on aggregate patterns or trends annually and reports these recommendations to the QIC and the DBHDS Commissioner.

14. DBHDS develops and implements quality improvement initiatives, either regionally or statewide, as recommended by the MRC and approved by the DBHDS Commissioner. On a quarterly basis, DBHDS staff assigned to implement quality improvement initiatives will report data related to the quality improvement initiatives to the MRC to enable it to track implementation.

15. DBHDS 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 consistent with indicator V.B.4.f.