LOS ANGELES COUNTY
DEPARTMENT OF MENTAL HEALTH
  Policy 303.05 Reporting Clinical Events Involving Clients
 
Policy Category:  Clinical
Distribution Level:  Directly Operated and Contractors
Responsible Party:  Clinical Risk Management
 
Approval completed on Jul 15, 2026
 
 
 
I.  PURPOSE
 
To establish uniform protocols for promptly reporting clinical events involving clients in Los Angeles County Department of Mental Health (DMH/Department) directly operated programs and contracted mental health agencies to Clinical Risk Management (CLRM), Post-Release Services (PRS) Assembly Bill (AB) 109, and Health Access & Integration – Managed Care Operations (HAI-MCO) through a web-based online reporting system.

Clinical Event Reports (CERs) shall be used by the Department for evaluating and recommending improvements to the quality of mental health services rendered in DMH directly operated programs and contracted mental health agencies.

Contracted agencies shall develop an internal policy and associated procedures that are consistent with their organizational practices and meet the requirements set forth in this policy.
 
II.  DEFINITIONS
 
Client: An individual receiving mental health services within the past 180 days (6 months).

Critical Clinical Event Report: An adverse event report involving a client that has generated or may generate governmental and/or immediate community-wide attention and may require DMH to notify the Board of Supervisors (BOS).

Clinical Event Report: An adverse event report involving a client receiving mental health services that fall within the fourteen (14) reportable clinical event categories:
  • The (14) clinical event categories reportable to CLRM, PRS AB109, HAI-MCO include:
    1. Death – Unknown Cause;
    2. Death – Suspected or Known Cause Other than Suicide;
    3. Death – Suspected or Known Suicide;
    4. Suspected or Known Suicide Attempt Requiring Emergency Medical Treatment (EMT);
    5. Client Self-Injury Requiring EMT (Not Suicide Attempt);
    6. Client Injured Another Person Who Required EMT;
    7. Suspected or Alleged Homicide by Client;
    8. Medication Error/Medication-related Event;
    9. Suspected or Alleged Inappropriate Interpersonal Relationships with Client by Staff;
    10. Threat of Legal Action;
    11. Client Assault by another Client Requiring EMT;
    12. Adverse Drug Reaction Requiring EMT;
    13. Alleged Assault by Staff Member to Client; and
    14. Inaccurate, Absent, or Unchecked Laboratory Data Resulting in a Client Requiring EMT.
       
  • Categories reportable to PRS AB109 include all of the above (14) clinical events.
     
  • Categories reportable to HAI-MCO by its providers include all of the above (14) clinical events plus the additional (3) clinical events below:

  •     15. Fire-Setting;
        16. Absence Without Leave (AWOL) or attempt to AWOL; and
        17. Emergency Transfer for Medical or Psychiatric Reasons to an Acute Care Hospital
III.  POLICY
 
All directly operated programs and contracted mental health agencies shall report clinical event categories identified in the Clinical Event Report definition through the web-based online reporting system.

Clinical Program Manager(s)/Director(s) or designated representative(s) shall review & thoroughly investigate CERs for improvements following the protocol described in Procedures Section B.3.
 
IV.  PROCEDURES
 
V.  AUTHORITIES
 
VI.  ATTACHMENTS
 
Web-based online reporting system (for Directly Operated) 
DMH SSL VPN (for Contractor Operated) to access the web-based online reporting system