OASAS Reportable Death Guidance for Providers

Published October 2024

Death Reporting Requirements

Pursuant to Part 836.8 (c) a death must be reported:

  • In the event of a client’s death in an inpatient or residential program under any circumstances, or
  • Within 30 days of such client’s discharge from a bedded service, or 
  • Death on program premises or in the context of program activity for any service, including outpatient services.

Immediate notification must be made to the Justice Center’s Vulnerable Persons Central Register (VPCR) Mortality Review Line (subject to the provisions of 42 CFR Part 2) at (855)373-2124 and fill out the Justice Center Report of Death form within five business days of the discovery of the death. If the death occurred on site, provider is responsible to call local law enforcement and any other services as necessary.

 

Next Steps after Reporting
  1. Ensure the health and safety of staff and clients. 
  2. Preserve and maintain evidence until you hear from the Justice Center (JC) or OASAS regarding the classification.
  3. Provider agency is required to notify the legal guardian or personal representative after learning of a death or learning of an allegation that was reported to the Justice Center IF a valid consent is on file in accordance with 42 CFR Part 2.
  4. The NYS Justice Center will classify the report and send to OASAS. OASAS Regional Office will reach out to the provider agency with the incident classification.
  5. Upon notification of a reportable death not classified as significant, abuse, or neglect follow these steps:
    1. If the death occurred on site, OASAS will request documentation pertaining to the incident for review and may conduct an on-site visit to the program.  
    2. Agency will complete their own investigation on the events that occurred. This will be reviewed through the agency’s incident management program and incident review committee in accordance with Part 836.5.
      1. If at any time during your investigation, you discover information which you have reasonable cause to suspect indicates potential Abuse or Neglect (as defined by Part 836), please stop investigating and immediately report the additional information to the Justice Center and OASAS Regional Office.

 

Documentation Required Based on Cause of Death

In the case of a natural death of an individual, with no known health issues, or obvious accidental cause (i.e., car accident) collect the following information in preparation of OASAS’ request: 

  • Relevant treatment history and a brief summary of the individual 
  • If you requested an autopsy, please indicate this in the incident report including other relevant details such as date the exam was requested and reference #, if available. 
  • If it is known that no autopsy will be conducted at the time of the original report submission, please document that in the report so it is clear that no additional information will be made available.

 

Expected (Natural Causes)

If known, please provide information about any medical treatment related to the cause of death, including the individual’s compliance with medical treatment and support.

Unexpected

Describe the immediate circumstances and nature of the event, such as if the cause of death is related to accidental, homicide, medical event (this is not an exhaustive list), and what policies and procedures were followed just prior, during and subsequent to the discovery.

Substance-Related 

When the cause of death is suspected to be or confirmed as the cause of death, the following information should be collected:

  • Substance use disorder (SUD) diagnoses (include all).
  • If the patient was offered and/or prescribed medication for addiction treatment, 
    • Include doses and amounts discharged with, if applicable.
  • If MAT was not offered or prescribed, what was the reason and was the reason documented in the patient record?  
    • Provide details regarding the content of the conversation with the patient regarding MAT and what counseling was done.
  • Was the patient trained on the use of and given naloxone, regardless of specific SUD diagnosis?  If not, reason why.
  • Known Cause of Death.
Death by Suicide

When suicide is noted as the confirmed or suspected cause of death, the following questions should be answered: 

  • On what date was the patient admitted to the program?
  • On what date was the patient initially screened with the Columbia-Suicide Severity Risk Screen (C-SSRS)?
  • What was the rating on the initial C-SSRS – low, moderate, or high risk for suicide? (if low risk, go to question 5)
  • If the patient was rated as moderate or high risk, on what date was a Stanley-Brown Suicide Safety Plan completed?
  • List the dates when the patient was rescreened with the C-SSRS since the initial screen.
  • If the patient was rated as moderate or high risk for suicide when re-screened, list all dates a Stanley-Brown Suicide Safety Plan was created or an existing Plan was updated.