Current through Reg. 49, No. 38; September 20, 2024
(a) The community
center CEO shall convene an administrative death review committee:
(1) immediately after the determination of
the need for an administrative death review, if a clinical death review was not
conducted;
(2) when a preliminary
administrative death review is to take place as determined in §
405.272(b)
of this subchapter (relating to Community Centers: Clinical Death Review
Determinations); or
(3) immediately
after the receipt of the information from the clinical death review committee
as described in §
405.274(c)
of this subchapter (relating to Community Centers: Clinical Death
Review).
(b) The
membership of the administrative death review committee shall consist of:
(1) three senior administrative and medical
personnel (e.g., CEO, medical director, director of nursing, director of
quality assurance, etc.) one of whom shall be designated as the chair by the
CEO;
(2) a representative of the
public, external to HHSC and not related to or associated with the deceased
(e.g., a member of the public responsibility committee, a member of the
community hospital's ethics committee, a family member, an advocate, a
consumer, etc.). If such representative of the public is not available, then
the effort to obtain external membership must be documented in the information
sent to HHSC; and
(3) other
individuals appropriate to the death being reviewed (e.g., the investigating
officer).
(c) The purpose
of the administrative death review committee is to:
(1) review the information and
recommendations provided by the clinical death review committee and/or from the
preliminary investigation;
(2)
review operational policies and procedures and continuity of care issues which
may have affected the care of the individual and formulate written
recommendations for changes in policies and procedures, if appropriate;
and
(3) act upon the
recommendations described in paragraphs (1) and (2) of this
subsection.
(d) If
information presented during the administrative review indicates the need for a
clinical death review or a re-review, then the administrative death review
committee has the authority to request such review.
(e) Suspected abuse or neglect must be
reported in accordance with the rules of the Texas Department of Family and
Protective Services.
(f) Within 14
calendar days of the determination of the need for an administrative death
review (or 45 days in cases in which an autopsy is performed, or for deaths
occurring at medical facilities to which the individual was transferred before
death) or within 14 calendar days after the receipt of the information from the
clinical death review committee, the administrative death review committee
shall submit the following elements to HHSC:
(1) a copy of the death/discharge summary, if
available;
(2) a copy of the death
certificate, bearing a valid diagnosis, if available;
(3) a copy of the preliminary or full autopsy
report, if available;
(4) the
probable final diagnosis, including contributory causes, and reasons for
variance from the death certificate, if any;
(5) a copy of the clinical death review
committee's recommendations, if such review was conducted;
(6) a copy of the administrative death review
committee's recommendations; and
(7) if applicable, documentation of the
effort to obtain external membership for the clinical death review committee
and/or the administrative death review committee, if no such medical
professional and/or representative of the public was available.
(g) A summary of the resulting
actions taken in response to the recommendations of the administrative and
clinical death review committees shall be forwarded by the CEO or designee to
HHSC within 28 calendar days following the submission of the elements contained
in subsection (f)(1) - (7) of this section.
