Current through Reg. 50, No. 13; March 28, 2025
(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.
