Home and Community Services Fatality Reviews

H10- 004– Procedure

January 11, 2010

TO: / Home and Community Services (HCS) Division Regional Administrators
Area Agency on Aging (AAA) Directors
FROM: / Bill Moss, Director, Home and Community Services Division
SUBJECT: /

Home and Community Services Fatality Reviews

Purpose: / To notify HCS and AAA staff of the implementation of the new ADSA/HCS Fatality Review
Background: / RCW 74.34.300 allows the department to conduct vulnerable adult fatality reviews as follows:

The department may conduct a vulnerable adult fatality review in the event of a death of a vulnerable adult when the department has reason to believe that the death of the vulnerable adult may be related to the abuse, abandonment, exploitation, or neglect of the vulnerable adult, or may be related to the vulnerable adult's self-neglect, and the vulnerable adult was:

Receiving home and community-based services in his or her own home, described under chapters 74.39 and 74.39A RCW, within sixty days preceding his or her death; or
Living in his or her own home and was the subject of a report under this chapter received by the department within twelve months preceding his or her death.

What’s new, changed, or
Clarified / The department is implementing a process to conduct vulnerable adult fatality reviews to identify opportunities for system improvements by systematically:

Examining the relationship between the death and abuse, abandonment, neglect, self-neglect, or exploitation (the department does not have expertise to, and will not, determine the cause of death).
Evaluating the effectiveness of laws, policies and procedures to minimize the risk of a similar occurrence to other clients.
Examining the coordination among community systems, such as law enforcement, medical personnel, and other social services agencies.
Improving risk assessment and prevention of similar occurrences through data analysis and remedial measures.

The Fatality Review policy and procedurewill be addedto Chapter 6 (APS) of the Long-Term Care Manual during an upcoming chapter revision.The fatality review and recommendations are documented in the ADSA Fatality Review 2009 form located in SharePoint.
The fatality review process does not address personnel issues.
ACTION: / Immediately implement the new fatality review policy.
Those AAAs outside the DSHS firewall (Snohomish, King, Pierce, Yakama, Colville and Kitsap) must communicate via encrypted email. Please use the attached instructions for all communications during the fatality review process.
Related
REFERENCES: / RCW 74.34.300
ATTACHMENT(S): / Fatality Review Policy:

How to Respond to a Fatality Review for Staff Outside the DSHS Firewall:

CONTACT(S): / Carol Sloan, APS Program Manager
(360) 725-2345

Vicky Gawlik, APS Program Manager
(360) 725-2615