1193 Mortality Review

Scope of Service

Upon notice and receipt of all clinical documentation from the Division of Mental Health, the provider will complete Mortality Reviews on Williams Class Members who have died after transition from the Nursing Facility (NF)/Institutions for Mental Disease/Specialized Mental Health Rehabilitation Facility (IMDs/SMHRF) to independent community living arrangements. The Williams Consent Decree expects consenting residents of current NF/IMDs/SMHRF, who have been assessed and determined to be candidates for transition to community based living arrangements, to do so under the guidance of the Implementation Plan. The most ideal setting is defined as Permanent Supportive Housing - self-contained, leased-held rental apartments. However, Class Members have also been approved for transition to Supervised or Supported Residential settings. Since implementation, 51 Class Members have died after transitioning from an IMD/SMHRF to independent living arrangements. The majority of these deaths have been the result of natural causes, as determined by first responders or medical examiners (accompanied autopsy).

DMH's contracted Williams provider agencies have routinely completed Reportable (Critical) Incident staffing and Root Cause Analyses (RCA) reviews on all deaths. An independent assessment of Reportable Incidents that resulted in a death, by clinicians with expertise in Mortality Review analyses, is necessary to assure credence with the overall findings. The entity DMH will contract with to conduct the Mortality Reviews is in alignment with the Colbert Consent Decree, and will use the same protocol when deaths occur with Williams Class Members.


Provider will provide the following:

  1. Review documentation of the death, as collected from DMH, on the Reportable Incident form.
  2. Collect information from the Williams Provider agencies, i.e., Root Cause Analysis (RCA)
  3. Review documentation provided via the autopsy report or Medical Examiner's Report or other medical reports
  4. Convene exploratory discussions with the assigned community mental health center's staff to explore strategies in addressing risk factors (psychiatric, medical, substance abuse, behavioral, environmental, etc.), mitigation planning, monitoring approaches and service activities/approaches
  5. Conduct interviews with family members, guardians or significant others, as appropriate, about past behaviors and functional level, capabilities and performances before death.
  6. Prepare a final comprehensive Root Cause Analysis document on each death
  7. Convene a staffing with DMH and the assigned provider agency to review findings and recommendation for each RCA
  8. Submit an annual Root Cause Analysis Summary Report and submit to the DMH Contact by the end of the fiscal year.

Reporting Requirements:

  1. Financial Report in accordance with Exhibit C.
  2. Performance Report in accordance with Exhibit E.


Payment will be issued in response to Provider submitted quarterly invoices on the appropriate DMH invoice template at the established rate(s) (if applicable). Invoices shall be submitted to the DMH program contact no later than November 1, February 1, May 1, and August 1, and will be reconciled on the basis of reported allowable expenses per the Grant Funds Recovery Act [30 ILCS 705/7 and 8]. (The Grant Funds Recovery Act is not applicable to Fixed-Rate Grants.) All invoices shall be HIPPA compliant and encrypted utilizing DHS approved encryption software.

The Provider shall report quarterly allowable grant expenses on the appropriate DMH reporting template to the DMH program contact no later than November 1, February 1, May 1, and August 1, and reported expenses should be consistent with the submitted annual grant budget. If any budget variances are noted, the DMH program contact may request that the provider submit a revised grant budget before subsequent monthly payments will be made. DMH program contacts and reporting templates can be found in the Provider section of the DHS website.

Performance Measures

The Provider shall report quarterly performance on the appropriate DMH reporting template to the DMH program contact no later than November 1, February 1, May 1, and August 1. DMH program contacts and reporting templates can be found in the Provider section of the DHS website.

The following are included in the reporting template:

  1. Number of referrals, for a death RCA received, will be reviewed
  2. Number of unduplicated efforts initiated to Williams provider agencies to collect information on the decedent
  3. Number of autopsy reports or Medical Examiner (ME) Reports received and reviewed
  4. Number of RCA discussions held with community mental health centers' staff will commence within two weeks of contact.
  5. Number of contacts initiated with family or collaterals
  6. Number of RCAs completed
  7. Number of joint staffings convened with DMH and provider agency
  8. Submission of the Annual Mortality Review Analysis Summary

Performance Standards

  1. 100% of deaths received will be processed for a Mortality Review RCA.
  2. 100% of efforts will be initiated to Williams providers to collect RCA information
  3. 100% of autopsy reports or ME records received will be reviewed for the RCA
  4. 100% of discussions will be held with community mental health centers within two weeks of referrals.
  5. 100% contacts will be initiated with family or collaterals
  6. 100% RCAs will be completed
  7. 100% of joint staffings will be convened with the providers and DMH
  8. 100% submission of the annual Mortality Review Analysis Summary