(a) The facility or 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 §405.271(d) or §405.272(b) off this title (relating to Facility Campus-Based Programs: Clinical Death Review Determination; Facility Community-Based Services and Community Centers: Clinical Death Review Determinations); or (3) immediately after the receipt of the information from the clinical death review committee as described in §405.273(c) or §405.274(c) of this title (relating to Facility Campus-Based Programs and Facility Community-Based Services: Clinical Death Reviews; 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 TXMHMR and not related to or associated with the deceased (e.g., a member of the public responsibility committee, a member of the facility or 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 the TXMHMR medical director; 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 Protective and Regulatory 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 off campus or for deaths occurring at medical facilities to which the person was transferred prior to 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 the TXMHMR medical director (who shall forward a copy to the appropriate deputy commissioner): (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 the TXMHMR medical director (who shall forward a copy to the appropriate deputy commissioner) within 28 calendar days following the submission of the elements contained in subsection (f)(1)-(7) of this section.
Source Note: The provisions of this §405.275 adopted to be effective June 1, 1993, 18 TexReg 2133