April 20, 2022 - Agenda & Minutes


First section of meeting is open to the public. Actual review of mortality review cases is closed to the public.


9:00 a.m. - 12:00 pm




  •  Welcome
  •  Approval of Meeting Minutes: January 19, 2022
  •  Hello and Goodbyes
  •  Announcements
  •  DHS OIG FY21 Annual Report

Meeting Notes


  • Dennis Beedle, MD, Interim Chairperson
  • Stephen Dinwiddie, MD, Northwestern University
  • Anne Fitz, RN, Department of Human Services, Division of Developmental Disabilities
  • Sarah Anderson, MD, Northwestern University Fellow
  • Fred Jones-Rosa, MD, Northwestern University Fellow
  • Stacey Aschemann, Equip For Equality
  • Randy Malan, RPh, Retired OCAPS
  • Chris Helfrich, RN, DD Homes Network
  • Amy Tarr, DHS/OIG Legislation
  • Sue Hughes, DHS/DMH Administrative Support

Welcome & Introductions

A quorum was met, and the open portion of the meeting was called to order by Chairperson, Dennis Beedle, MD at 9:00 a.m.

Dr. Beedle welcomed the group and thanked everyone for attending the meeting.

Review of Previous Draft Meeting Report

The current voting members approved the meeting report from January 19, 2022 as written.

Hello and Goodbyes

Dr. Beedle thanked Dr. Jones-Rosa and Dr. Anderson for the time they spent with this group during their fellowship with Northwestern Memorial Hospital as this will be the last Mortality Review Meeting, they will be attending.

Dr. Mackey has resigned from the group due to personal reasons. Dr. Beedle will be looking for a replacement member and requested if anyone has a recommendation for a possible replacement, please let him know.

Was hoping to have an additional administrative support person, but the person accepted a position with DoIT and therefore will not be available.

The new Fellows, Shane Burke and Justin Spring will be starting July 1 with Northwestern Memorial Hospital and will be introduced at July Mortality Review Board meeting.

DHS OIG FY21 Annual Report

Dr. Beedle asked the members what they felt what recommendations should be included in the annual report the Secretary to make things safer for people receiving DHS services and reduce preventable deaths. Stacy Aschemann suggested using the same training for temporary staff as for full time staff. Dr. Beedle stated the issue with training is currently being looked at with terms of Rule 116 revisions that Chris Helfrich is assisting with along with surveying again for nursing policies. There was further group discussion regarding Rule 116 and training in agencies and nursing policies. This will be included in the annual report. Will also look at the need for training for change in condition.

Randy Malan stated there is a need to note trends in medication, seeing which kinds of medications seem to be the most problematic regarding observation, evaluating seizures and allergic reactions.

Chris Helfrich stated the Developmental Disability Nursing Association has recently updated its practice standards and the publication is available through the website and will e-mail the group with this information. Chris has requested a copy and believes the content will be helpful in terms of the nursing policies and some of the recommendations that needs to be presented to the Secretary's annual report. Chris agrees with the comments that have been mentioned thus far and wants to underscore the importance that the Division is maintaining current and pertinent training materials for the DSPs, so those qualified personnel are presenting the basic health and safety training for the staff and the curriculum they are using is current and pertinent to what we are looking at for pattern and trends.

Randy Malan suggests the board consider talking about medication use and potential inappropriate prescribing in individuals with intellectual disability and especially as they age. This is when we start seeing more polytherapy that can lead to more potential drug interactions with adverse effects on existing conditions. Dr. Beedle would like to request and recommend access to the database for prescriptions in the state for OIG and the Mortality Review Board.

Dr. Beedle stated the team has inherited a challenging situation that the Board has put some time and effort in terms of developing a structure for doing Level I and Level 2 reviews. The back log is being worked on. Dr. Beedle has reviewed all 2022 Quarter 2 reports from OIG and most of Quarter 1. The hope is for next year the board will be able to have a report reflective of the data received this year. Currently, we are working through some older cases as well.

Case Reviews

Twelve level 2 cases reviewed.

The open meeting adjourned at 9:48 a.m. and the closed meeting began at 9:55 a.m.

Next meeting is scheduled for Wednesday, July 20, 2022, via Webex