TennCare Death Reporting Protocol & Reviews Effective Jan 1, 2025
The Division of TennCare's Operational Protocol outlines the systematic review process for deaths of individuals receiving specific services. Providers are required to report deaths promptly, initiate investigations, and submit necessary forms within set timeframes for comprehensive analysis and improvement of services.
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Division of TennCare Operational Protocol Death Reporting & Comprehensive Death Reviews Effective January 1, 2025
Purpose The Protocol sets forth the process for conducting the systematic review of the death of a person who was receiving one of the following services at the time of the death: 1915(c)Waiver services, Katie Beckett Part A (KB Part A) Employment and Community First CHOICES (ECF), and/or services through an Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID) program (collectively provider ) The systematic review of death will identify the cause of death, any circumstances and/or factors which contributed to the death, and identification of any preventive measures which would improve supports and services for people moving forward This systematic reporting and review of the death of people provides identification of any trends and patterns that indicate needed service and/or systemic changes as well as ongoing evaluation to ensure corrective actions are being implemented and that systemic changes are effective in reducing risk to members
Required Notifications Once a provider has been made aware of the death of a person supported, it is the responsibility of the provider to: Immediately report the death to law enforcement, if applicable Report the death to the Department of Disability and Aging (DDA) via the protocol outlined in the One Reportable Event Management System Operational Protocol Contact the DDA Investigation Hotline, if applicable As soon as possible, but within 4 hours if it is an unexplained or unexpected death that might be linked to Abuse, Neglect, or Exploitation Submission of a Reportable Event Form (REF) Within one (1) business day
Additional Notifications Within four (4) hours notify: Person s family/next of kin Legal Representative If notification is not completed within four (4) hours, the provider must document the extenuating circumstances preventing notification within this timeframe. Documentation must be made available to DDA and/or the MCO upon request The notification may be sent by text, phone, email, or in any other manner which ensures the family has been contacted and notified
Notice of Death (NOD) Form The provider must submit the NOD form to DDA and the MCO by the end of the next business day after becoming aware of the person s death Submit the Notice of Death form to the DDA Regional Director East Region Director, Terry.Jordan-Henley@tn.gov, o Administrative Assistant, Kristen.Norton@tn.gov West Region Director, CJ.McMorran@tn.gov o Administrative Assistant, Tracy.Rappel@tn.gov Middle Region Director, Levi.Harris@tn.gov o Administrative Assistant, Charlene.Haywood@tn.gov Submit the Notice of Death form to the Person s MCO BlueCare reportableevents@bcbst.com United Health Care uhctnrem@uhc.com Wellpoint TN-REM@wellpoint.com
Initial Agency Death Review (IADR) If the person was receiving RESIDENTAL SERVICES, the provider must complete the Initial Agency Death Review Initiate the internal review immediately, but no later than 24 hours after becoming aware of the person s death Identify questions or concerns to be addressed and must include the following: A review of records and documents relevant to the death of the person A review of the events surrounding the death Identification of any conditions or practices that may have contributed to the death which require immediate intervention or corrective action plan to ensure the health and safety of others o o o
Initial Agency Death Review (IADR) If the person was receiving RESIDENTIAL SERVICES, the provider is required to submit the IADR to DDA and the MCO within five (5) business days after becoming aware of the person s death. Submit the IADR to the DDA Regional Director East Region Director, Terry.Jordan-Henley@tn.gov o Administrative Assistant, Kristen.Norton@tn.gov West Region Director, CJ.McMorran@tn.gov o Administrative Assistant, Tracy.Rappel@tn.gov Middle Region Director, Levi.Harris@tn.gov o Administrative Assistant, Charlene.Haywood@tn.gov Submit the IADR to the Person s MCO BlueCare reportableevents@bcbst.com United Health Care uhctnrem@uhc.com Wellpoint TN-REM@wellpoint.com
Provision of Records Providers and the MCO shall provide records related to the death of the person to DDA and/or TennCare upon request DDA has the authority to request and review the records of providers of services to members and the MCOs related to the death of members
Preliminary Death Review (PDR) A Preliminary Death Review will be conducted by DDA for all deaths of people who were receiving services through the following programs: 1915 (c) Waiver Katie Beckett Part A Employment & Community First CHOICES (ECF) ICF/IID
Preliminary Death Review Committee (PDRC) The PDRC will determine if the criteria for a suspicious death have been met. If that determination is made, then the PDRC will request a DDA Comprehensive Death Review be conducted, and a Clinical Death Summary be issued As defined in One Reportable Event Management System Definitions, a death is considered suspicious if the death occurred under circumstances that are unexpected or unexplained. DDA will initiate the Preliminary Death Review within one week of receipt of the Notice of Death Form The PDRC may choose to reconvene, in its discretion, if pertinent information is received (such as an autopsy) prior to the DDA Comprehensive Death Review (CDR) taking place The Commissioner of DDA has authority to at any time request a DDA CDR be conducted
Preliminary Death Review Committee (PDRC) PDRC is made up of: The DDA Regional Director of Nursing or designee The DDA Regional Director or designee The DDA Regional Compliance Director or designee The DDA Regional Investigations Coordinator or designee Providers, advocates, family members, and invested community members may provide additional information to the PDRC prior to the Preliminary Death Review by submitting that information to the DDA Regional Director of the Region where the member resided at the time of death
Clinical Death Summary (CDS) A written report by a qualified licensed Registered Nurse regarding the circumstances surrounding the person s death Completed if the PDRC determines the criteria for an unexpected or unexplained death have been met Unexpected or Unexplained Death shall mean any death that did not result from the normal progression of a known medical condition or disease Completed by the DDA Regional Mortality Nurse or designee within thirty (30) calendar days of DDA s receipt of the NOD Form (can be extended with written approval by the DDA Director of Nursing or designee)
Clinical Death Summary (CDS) The CDS shall include: DDA Regional Mortality Nurse distributes CDS to: MCO DDA Nursing Director DDA Regional Director DDA Regional Compliance Director DDA Director of Investigations Executive Director for the provider(s) responsible for delivering services and supports to the person at the time of death Demographic information Person s profile A review of systems Recent clinical history Diagnoses Medications taken by the person A review of the terminal event Healthcare history Autopsy finding (if available) Any other relevant information
Comprehensive Death Review (CDR) A review conducted by the Comprehensive Death Review Committee (CDRC) to: Provide a comprehensive analysis of the relevant facts and circumstances, including the healthcare provided Identify practices or conditions which may have contributed to the death Make recommendations to prevent similar occurrences The provider is required to submit all relevant records and documents associated with the person s death as requested by DDA and/or the CDRC Conducted within forty-five (45) business days of DDA s receipt of the NOD. This shall automatically be extended thirty (30) business days when the autopsy and/or DDA investigation report (if applicable) is not completed. Any additional extensions must be approved by the DDA Commissioner or designee
Comprehensive Death Review Committee (CDRC) CDRC is responsible for conducting the CDR in accordance with the DDA Comprehensive Death Review Committee IOG CDRC shall include: The Chair of the Committee assigned by the DDA Regional Compliance Director or designee. A qualified licensed physician appointed by the Regional Director of Compliance or designee who was unaffiliated with the treatment of the person and unassociated with their provider within at least a year of the person s death. The physician may be an employee of an MCO or DDA Regional Mortality Nurse or designee who completed the CDS Executive Director and/or designee(s) of the provider of waiver services or ICF/IID program who supported the person at the time of their death At least one staff person (selected by the Executive Director) of the provider of waiver services or ICF/IID program who is familiar with the person s health status and history and the course of events prior to death
Comprehensive Death Review Committee (CDRC) Additional participants as needed and upon invitation from the CDRC Chair: The Primary Care Physician (PCP), Nurse Practitioner (NP) or Physicians Assistant (PA) who coordinated or provided the person s healthcare Director of Nursing or Nurse employed by the person s provider of waiver services or ICF/IID program Person s Independent Support Coordinator, or Case Manager, or equivalent position Healthcare specialists i.e.; psychiatrist, neurologist, etc. as deemed warranted by the DDA Director of Nursing An employee of the person s MCO (selected by the MCO) The DDA Director of Nursing or designee
CDRC Recommendations CDRC may recommend the provider implement quality improvements. CDRC will consult the DDA Director of Nursing regarding whether any aspect of the death should be referred to any licensing or regulatory agency or to law enforcement officials The Executive Director or designee of the provider of waiver services or ICF/IID program will provide a written response to the CDRC recommendations within thirty (30) calendar days of receipt of the recommendations. Must include: Quality Improvement Plan Time frames for implementation The response shall be submitted to the DDA Regional Director of Compliance, or designee.
CDRC Minutes Minutes shall be maintained in accordance with HIPAA and other state/federal confidential privacy statues, rules & regulations. CDRC Minutes are distributed to: DDA Commissioner or designee DDA Nursing Director or designee DDA Director of Clinical Services DDA Regional Director Provider or ICF/IID Executive Director MCO representative TennCare representative
Annual Data Review At least annually, the DDA Director of Nursing or designee shall review and analyze the data received through the Death Review Protocol to determine possible patterns or risk factors to people supported.
