Subd. 12b.

Department of Human Services systemic critical incident review team.

(a)
The commissioner may establish a Department of Human Services systemic critical incident
review team to review critical incidents reported as required under section 626.557 for
which the Department of Human Services is responsible under section 626.5572, subdivision
13; chapter 245D; deleted text begin ordeleted text end Minnesota Rules, chapter 9544new text begin ; or child fatalities and near fatalities
that occur in licensed facilities and are not due to natural causesnew text end . When reviewing a critical
incident, the systemic critical incident review team shall identify systemic influences to the
incident rather than determine the culpability of any actors involved in the incident. The
systemic critical incident review may assess the entire critical incident process from the
point of an entity reporting the critical incident through the ongoing case management
process. Department staff shall lead and conduct the reviews and may utilize county staff
as reviewers. The systemic critical incident review process may include but is not limited
to:

(1) data collection about the incident and actors involved. Data may include the relevant
critical services; the service provider's policies and procedures applicable to the incident;
the community support plan as defined in section 245D.02, subdivision 4b, for the person
receiving services; or an interview of an actor involved in the critical incident or the review
of the critical incident. Actors may include:

(i) staff of the provider agency;

(ii) lead agency staff administering home and community-based services delivered by
the provider;

(iii) Department of Human Services staff with oversight of home and community-based
services;

(iv) Department of Health staff with oversight of home and community-based services;

(v) members of the community including advocates, legal representatives, health care
providers, pharmacy staff, or others with knowledge of the incident or the actors in the
incident; and

(vi) staff from the Office of the Ombudsman for Mental Health and Developmental
Disabilities and the Office of Ombudsman for Long-Term Care;

(2) systemic mapping of the critical incident. The team conducting the systemic mapping
of the incident may include any actors identified in clause (1), designated representatives
of other provider agencies, regional teams, and representatives of the local regional quality
council identified in section 256B.097; and

(3) analysis of the case for systemic influences.

Data collected by the critical incident review team shall be aggregated and provided to
regional teams, participating regional quality councils, and the commissioner. The regional
teams and quality councils shall analyze the data and make recommendations to the
commissioner regarding systemic changes that would decrease the number and severity of
critical incidents in the future or improve the quality of the home and community-based
service system.

(b) Cases selected for the systemic critical incident review process shall be selected by
a selection committee among the following critical incident categories:

(1) cases of caregiver neglect identified in section 626.5572, subdivision 17;

(2) cases involving financial exploitation identified in section 626.5572, subdivision 9;

(3) incidents identified in section 245D.02, subdivision 11;

(4) behavior interventions identified in Minnesota Rules, part 9544.0110;

(5) service terminations reported to the department in accordance with section 245D.10,
subdivision 3a; and

(6) other incidents determined by the commissioner.

(c) The systemic critical incident review under this section shall not replace the process
for screening or investigating cases of alleged maltreatment of an adult under section 626.557.
The department may select cases for systemic critical incident review, under the jurisdiction
of the commissioner, reported for suspected maltreatment and closed following initial or
final disposition.

(d) The proceedings and records of the review team are confidential data on individuals
or protected nonpublic data as defined in section 13.02, subdivisions 3 and 13. Data that
document a person's opinions formed as a result of the review are not subject to discovery
or introduction into evidence in a civil or criminal action against a professional, the state,
or a county agency arising out of the matters that the team is reviewing. Information,
documents, and records otherwise available from other sources are not immune from
discovery or use in a civil or criminal action solely because the information, documents,
and records were assessed or presented during proceedings of the review team. A person
who presented information before the systemic critical incident review team or who is a
member of the team shall not be prevented from testifying about matters within the person's
knowledge. In a civil or criminal proceeding, a person shall not be questioned about opinions
formed by the person as a result of the review.

(e) By October 1 of each year, the commissioner shall prepare an annual public report
containing the following information:

(1) the number of cases reviewed under each critical incident category identified in
paragraph (b) and a geographical description of where cases under each category originated;

(2) an aggregate summary of the systemic themes from the critical incidents examined
by the critical incident review team during the previous year;

(3) a synopsis of the conclusions, incident analyses, or exploratory activities taken in
regard to the critical incidents examined by the critical incident review team; and

(4) recommendations made to the commissioner regarding systemic changes that could
decrease the number and severity of critical incidents in the future or improve the quality
of the home and community-based service system.