| (a) The 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 §405.272(b) of this subchapter
(relating to Community Centers: Clinical Death Review Determinations);
or
(3) immediately after the receipt of the information
from the clinical death review committee as described in §405.274(c)
of this subchapter (relating to 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 HHSC
and not related to or associated with the deceased (e.g., a member
of the public responsibility committee, a member of the 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 HHSC; 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 Family and Protective
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 to which the individual was transferred before 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 HHSC:
(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 HHSC within
28 calendar days following the submission of the elements contained
in subsection (f)(1) - (7) of this section.
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