Hospital Death Reporting Requirements
PDF Version of OQA 06-026
(PDF 30 KB)
Date: October 12,
2006 -- OQA 06-026
To: Hospitals Hosp 11
From: Cremear Mims, Section Chief
Health Services Section
Via: Otis Woods, Director
Office of Quality Assurance
Hospital Death Reporting
Requirements
On September 29, 2006, the Office of Quality Assurance received
direction from the federal Centers for Medicare and Medicaid Services
(CMS) via a letter
S&C-06-31, to communicate the following information to hospitals in Wisconsin.
(web address for letter: http://www.cms.hhs.gov/SurveyCertificationGenInfo/downloads/SCLetter06-31.pdf)
The federal Patients' Rights regulation at 42
CFR 482.13(f)(7) (exit DHS) requires that a hospital must report to CMS any
patient death that occurs while the patient is restrained or in seclusion
for behavior management, e.g., for violent behavior toward self or others.
It also requires reporting where it is reasonable to assume that a
patient's death is the result of restraint or seclusion used for behavior
management.
CMS noted in S&C -06-31 that there is no death reporting
requirement under the standard at 42
CFR 482.13(e), (exit DHS) "Restraint for acute medical and surgical
care." When the restraint/seclusion is used in an emergency to
address violent behavior presenting a risk to the patient or others, it
falls under the behavior management standard at (f), including the death
reporting requirement, rather than the acute medical/surgical standard at
(e).
Wisconsin hospitals must report directly to the Region 5 CMS regional
office any death that occurs while a patient is restrained or in seclusion
for management of behavior, or where it is reasonable to assume that a
patient's death is a result of restraint or seclusion used to manage
violent behavior. The death must be reported to the RO prior to the close
of business on the business day following the day of the patient's death.
The CMS contact for Wisconsin
hospitals is:
Justin C. Pak
Department of
Health and Human Services
Centers for
Medicare & Medicaid Services
Division of Survey
and Certification - Midwest Consortium
233 North Michigan
Avenue, Suite 600
Chicago, Illinois
60601
(312) 353-0519
(phone)
(312) 353-8053
(fax)
Within two working days of receipt of the report, the CMS regional
office will notify the State Office of Quality Assurance (OQA) authorizing
a survey to investigate the hospital's compliance with the Patient's
Rights Condition of Participation. Prior to OQA going onsite, the CMS
regional office will provide OQA with the Restraint/Seclusion Death Report
Worksheet containing all the data the regional office has collected to
date from the hospital. The CMS regional office will also notify the CMS
Central Office and the hospital's accrediting organization, if deemed, and
the appropriate State Protection and Advocacy Group (Disability Rights
Wisconsin), providing them with the hospital's name and address, the
patient's name, and the date of death.
The Office of Quality Assurance will complete an investigation of the
death within five working days of receiving the survey authorization from
the Region 5 CMS regional office. The investigation will include the
surveyor's completion of the federally required Restraint/Seclusion Death
Report Worksheet, which will be e-mailed or faxed to the CMS regional
office within two working days of completing the survey
Within two working days following receipt of the completed
Restraint/Seclusion Death Report Worksheet from OQA, the Region 5 CMS
regional office will send the worksheet via e-mail or fax to the CMS
Central Office. The CMS Central Office regularly reviews the status of all
outstanding restraint/seclusion death reports with each region.
The full text of S&C-06-31, including the mandated
Restraint/Seclusion Death Report Worksheet, will be referenced in the next
OQA Quarterly Information Update. Because OQA has recently been relocated
in the DHS organization, the Quarterly Information Update may be moved to
a new web address. The new address can be located, starting November 2006,
by going to http://www.dhs.wisconsin.gov/ and entering "OQA Quarterly
Information Update" in the DHS search engine.
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