LOS ANGELES COUNTY
DEPARTMENT OF MENTAL HEALTH
  Policy 303.05 Reporting Clinical Events Involving Clients
 
  PROCEDURES
 
 
  1. Event Reports 
     
    1. If a clinical event report (CER), as defined in this policy, occurs at a clinic/program site or during delivery of clinical service at any location, the physical well-being and safety of persons involved shall be the primary consideration. Referrals shall be made immediately to appropriate lifesaving and/or safety agencies (e.g., paramedics and/or law enforcement).
       
      1. If an event occurs that is not defined as a CER in this policy, do not enter the event. Clinical Risk Management (CLRM), Post-Release Services (PRS) Assembly Bill (AB) 109, or Health Access & Integration- Managed Care Operations (HAI-MCO) may be contacted for consultation at the telephone numbers listed in the web-based online reporting system.
         
      2. For additional questions, the three (3) DMH divisions may also be contacted via email at DMHSafetyIntelligence@dmh.lacounty.gov.
         
      B. Submitting Event Reports
 
    1. Staff shall immediately notify clinical events to their Clinical Program Director(s)/Manager(s) or designated representative(s) and                enter the event in the web-based online reporting system within two (2) business days.
  1. CER(s) may be entered by staff, Clinical Program Director(s)/Manager(s), or designated representative(s) with a C or E-number.
  2. CER(s) may be entered anonymously.
    2. Critical CER shall be entered as soon as practicable, but in no circumstance later than two hours after the event, in the web-based online reporting system once an event has                                 occurred.
  1. Clinical Program Director(s)/Manager(s) or designated representative(s) shall notify the appropriate DMH division: CLRM, PRS AB109, or HAI-MCO of the critical CER and when the CER is entered in the web-based online reporting system.
  2. CLRM, PRS AB109, HAI-MCO staff shall determine appropriate notification to the DMH Director or their designated representative(s).
  3. Upon receiving the notification of a critical CER from CLRM, PRS AB109, or HAI-MCO, the DMH Director or their designated representative(s) will determine appropriate notification to the Board of Supervisors (BOS).
            3. Manager Review for Event 
  1. Within ten (10) business days, Clinical Program Director(s)/Manager(s) or their designated representative(s) shall review, revise, and investigate CER(s) submitted in the web-based online reporting system. 
  2. Clinical Program Director(s)/Manager(s) or their designated representative(s) shall submit the findings of the managerial review investigation, including corrective action(s) planned/taken, and recommendations for county-wide system revisions to aid and mitigate reoccurrence(s) of risk towards the client.
  3. Clinical Program Director(s)/Manager(s) or their designated representative(s) shall notify CLRM, PRS AB109, or HAI-MCO if additional time is needed to complete the Event Report (within 2 days) and/or Manager Review for Event (within 10 days).
    C. CER Confidentiality
  1. CERs, or information regarding the existence of a CER, shall not be entered into a client record, printed, copied, distributed, emailed, or faxed to preserve the confidentiality of the report from discovery in the event of a legal matter.
     
  2. CERs are federally protected and, therefore, shall not be printed.
     
  3. CERs and related correspondence shall be treated as privileged, confidential communication between DMH, Los Angeles County’s third-party administrator, County Counsel, and contracted legal counsel in areas of risk management and medical malpractice in preparation for litigation. CERs shall not be made available to anyone other than CLRM, PRS AB109, or HAI-MCO staff, or County consultants.
     
  4. CERs entered in the web-based online reporting system is a component of the DMH Patient Safety Evaluation System (PSES), a safe space for reporting, deliberation, and analysis of system quality improvements, and for reporting into the associated Patient Safety Organization (PSO) as outlined in the Los Angeles County Board of Supervisors Policy 8.040.
     
  5. CER(s) do not preclude reporting required by other bureaus or regulations such as:
     
    1. DMH Health Information Management Quality Assurance (HIM-QA) Unit Director/staff for events related to clinical records;
       
    2. DMH Human Resources Bureau (HRB) Health & Safety Unit through Accident Investigative Reporting (AIR) for client/visitor injuries on County property or property damage;
       
    3. DMH HRB Health & Safety Unit staff through AIR for work-related employee illnesses or injuries;
       
    4. DMH Patients’ Rights Office (PRO) for events involving patients' rights issues;
       
    5. DMH Compliance Clinical Investigations Unit (CIU) for potential compliance violations/billing improprieties;
       
    6. DMH Pharmacy & Laboratory Services for event involving evaluation of medication safety for Directly Operated programs;
       
    7. DMH Contract Management & Monitoring Division (CMMD) for ensuring Legal Entities adhere to County Contract;
       
    8. DMH Designation Coordinator and HAI-MCO for events occurring at Lanterman-Petris-Short (LPS) designated facilities; or
       
    9. Appropriate licensing agency for facilities according to their respective reporting requirements.  
    D. Quality Improvement
  1. CLRM, PRS AB109, HAI-MCO, and/or Directly Operated or Contracted Providers' designated staff with managerial/consultant responsibilities for the reporting area(s) shall review CERs for risk mitigation and quality improvement purposes. This includes, but is not limited to, the following processes:
     
    1. CLRM, PRS AB109, and HAI-MCO staff shall conduct regular reviews on CERs, claims, lawsuits, and trends of reported clinical events with members of DMH Quarterly Clinical Risk Management Committee (QCRMC). Directly Operated programs may be requested by CLRM to participate in presenting a case review during a DMH QCRMC meeting. Presented case reviews may be utilize for education and training purposes to prevent and mitigate risk of potential claims and lawsuits. Reviews will also aid in improving the departments mental health services by analyzing and implementing necessary system changes recommended by Directly Operated and Contracted Providers.
       
    2. CERs and related materials submitted to and reviewed by CLRM, PRS AB109, and HAI-MCO staff, including those presented or discussed at QCRMC meetings, are privileged and strictly confidential under state law (WIC 5328(a), EVID 1157(a), and GOV 6254(c)) in preparation for litigation and under federal law if reported in the web-based online reporting system. (Patient Safety and Quality Improvement Act of 2005).