Reporting Procedures for Statutorily
Reportable Deaths: DHS Responsibilities
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Reportable Death Review Purpose
Some of the most vulnerable citizens of the State of Wisconsin are served by a variety
of institutional, residential and community-based treatment programs overseen by the
Department of Health Services.
(exit DHS), Sections 48.60 (5), 50.035 (5),
50.04 (2t), 51.03 (2), and 51.64
establish the reporting requirements, enumerate the types of deaths to be reported and
authorize a Department investigation.
When there is reasonable cause to believe that
the death of a client of one of these programs may have been related to:
- the use of a
physical restraint or seclusion
- a prescribed psychotropic medication
- a suspected suicide
the Department has a responsibility to investigate the death. The
Division of Quality Assurance does the field investigation.
The Reportable Death Review Committee then reviews the
circumstances surrounding the death and may recommend program and service improvements to
reduce or eliminate the possibility of future deaths resulting from similar circumstances.
To fulfill this responsibility the Department does the following:
Investigates the death of a client of a Department licensed or certified program or
facility when there is reasonable cause to believe that the death was:
Determines if minimum standards were followed in the use of seclusion and/or restraints,
psychotropic medications, and the prevention of a suicide.
Takes appropriate action based on the findings of the death investigation which may
include, but not be limited to:
the provision of technical assistance to the
development of needed training
publication of special alerts
certification or licensing action.
Composition and Function of the Reportable Death
Review Committee (RDRC)
The RDRC is composed of administrative staff and at least one program specialist
from each of the following agencies in the Division of Disability & Elder
Division of Quality Assurance (DQA), which regulates programs and facilities.
Bureau of Mental Health and Substance Abuse Services.
Bureau of Developmental Disabilities Services.
The RDRC also has representation from the Division of Care and Treatment Facilities and
the Division of Child and Family Services Bureau of Regulation and Licensing. The
RDRC meets quarterly.
A Clinical Review Subcommittee (of the RDRC), composed of the program
specialists from the RDRC and a representative from the Division of Care and Treatment
- reviews the death reports and the DQA investigation of the death
its findings and recommendations to the RDRC
The Clinical Review Subcommittee meets at
least once prior to each quarterly meeting of the full RDRC.
In addition to reviewing the circumstances of reported deaths, the RDRC is charged with
identifying potential trends and developing needed non-regulatory actions resulting from
the committees review of reportable deaths.
These non-regulatory actions may include:
- the provision of technical assistance to the particular program or facility which reported
- development of informational or technical assistance bulletins or other
actions from the Department about a specific concern or issue that came to light as a
result of the committees review.
The goal of these actions is to develop strategies
to prevent deaths from similar circumstances from occurring in the future.
The Reportable Death Review Committees responsibility is a quality assurance
function and is covered by the peer review provisions under Wisconsin Statutes:
146.37, "Health care services review; civil immunity"
- ss. 146.38, "Health
care services review; confidentiality of information"
Relationship of the RDRC to the Division of
Disability & Elder Services and the Division of Child and Family Services
The RDRC does not regulate or cite programs or facilities for violations of
licensing or certification requirements. That is the responsibility of:
- Division of Quality Assurance (DQA) for programs and facilities
- the Division of Child and Family Services Bureau of Regulation
and Licensing (BRL) for Residential Care Centers for Children and Youth.
action occurs, it results from DQAs or BRLs investigation of a reportable
death prior to the RDRCs review of the circumstances of the death.
These Reporting and Investigation Procedures are included with the issuance of all
initial certification and license certificates by the DQA and BRL to programs and
facilities required to report these deaths to the Department.
Investigation by the Department
Wisconsin statutes require that the Department
investigate a death no later than 14 days after the date the death is reported to the
The Division of Quality Assurance conducts
reportable death field investigations for programs and facilities serving adults.
Division of Children and Family Service, Bureau of Regulation and Licensing conducts these
investigations for Residential Care Centers for Children and Youth.
All reportable death
investigations are on-site investigations.
The Department has the authority and
responsibility to conduct a thorough investigation using whatever customary means and
techniques are, at the Licensing/Certification Specialists discretion, appropriate
and warranted to conduct a thorough investigation including, but not limited to all of the
- individual interviews with staff, clients and other persons
- a review of
treatment, medication and somatic treatment records
- a review of policies and procedures
of the program/facility
- inspection of any buildings and their contents.
Licensing/Certification Specialists have access under ss. 51.30 (4) (b), Stats. to all
treatment and medication records without the informed written consent of the client (or
guardian when applicable), and may request:
- a copy of any documentation from the
clients treatment and medication records
- the programs/facilitys
policies and procedures.
The Division of Disability & Elder Services (DDES) publishes an annual report of selected
- the reportable death reports received each year
- any enforcement actions
taken by the DDES, Division of Quality Assurance and the Division of Child and Family
Services, Bureau of Regulation and Licensing resulting from their investigation of
- actions initiated by the Reportable Death Review Committee resulting
from its review of reported deaths.
This annual report is sent to all licensed or
certified programs required to report deaths to the Department, county agencies, tribal
chairpersons, and advocacy and consumer organizations. Copies of any of the annual reports
may be obtained without charge from the RDRC Coordinator:
Reportable Death Review Coordinator
Division of Quality Assurance
P. O. Box 2969
Madison, WI 53701-2969
Phone: (608) 261-0657
FAX: (608) 261-0655
Last Updated: March 23, 2011