DSHS unexpected fatalities

AN ACT Relating to unexpected fatalities of residents of 1
department of social and health services facilities; amending RCW 2
43.382.005; adding a new section to chapter 43.20A RCW; adding a new 3
section to chapter 43.382 RCW; and creating a new section.4
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF WASHINGTON:5
NEW SECTION. Sec. 1. A new section is added to chapter 43.20A 6
RCW to read as follows: 7
(1)(a) The department shall conduct an unexpected fatality review 8
upon the unexpected fatality of any resident of a department facility 9
or in any case identified for an unexpected fatality review by the 10
office of the developmental disabilities ombuds or the office of the 11
patient rights ombuds. 12
(b) The department shall convene an unexpected fatality review 13
team and determine the membership of the review team. The team shall 14
comprise of individuals with appropriate expertise including, but not 15
limited to, individuals whose professional expertise is pertinent to 16
the dynamics of the case. The unexpected fatality review team shall 17
include a representative from the health care authority, and either a 18
representative from the office of the patient rights ombuds in cases 19
of an unexpected fatality of a resident of a department facility that 20
is not a residential habilitation center or state-operated living 21
H-2601.2
HOUSE BILL 2415
State of Washington 69th Legislature 2026 Regular Session
By Representatives Farivar, Penner, Scott, Simmons, Pollet, Reed, and
Hill
Read first time 01/13/26. Referred to Committee on Early Learning &
Human Services.
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alternative, or the developmental disabilities ombuds or the ombuds' 1
designee in cases involving an unexpected fatality of a resident of a 2
residential habilitation center or state-operated living alternative. 3
The department shall ensure that the unexpected fatality review team 4
is made up of individuals who had no previous involvement in the 5
case. 6
(c) The primary purpose of the unexpected fatality review shall 7
be the development of recommendations to the department and 8
legislature regarding changes in practices or policies to prevent 9
fatalities and strengthen safety and health protections for residents 10
in department facilities. The unexpected fatality review must not 11
take precedence over investigations being conducted by adult 12
protective services, child protective services, residential care 13
services, or law enforcement. 14
(d) Upon conclusion of an unexpected fatality review required 15
pursuant to this section, the department shall, within 120 days 16
following the fatality, issue a report on the results of the review, 17
unless an extension has been granted by the governor. Prior to 18
issuing a report, the review team must perform an internal review for 19
accuracy and thoroughness of the report. The report must contain a 20
record of each review team member's vote, participation, or comment 21
in relation to the findings and recommendations. If the report 22
concerns a person who was the subject of one or more reports of abuse 23
or neglect within the last year, the report must also describe the 24
nature of any abuse or neglect reports. Completed reports must be 25
distributed to the appropriate committees of the legislature, and the 26
department shall create a public website where all unexpected 27
fatality review reports required under this section must be posted 28
and maintained. An unexpected fatality review report completed 29
pursuant to this section is subject to public disclosure and must be 30
posted on the public website, except that confidential information 31
must be redacted by the department consistent with the requirements 32
of applicable state and federal laws. 33
(e) Within 10 days of completion of an unexpected fatality review 34
under this section, the department shall develop an associated 35
corrective action plan to address any concerns and implement any 36
recommendations made by the review team in the unexpected fatality 37
review report. Corrective action plans shall be implemented within 38
120 days, unless an extension has been granted by the governor. 39
Corrective action plans are subject to public disclosure, and must be 40
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posted on the department's website in accordance with (d) of this 1
subsection, except that confidential information must be redacted by 2
the department consistent with the requirements of applicable state 3
and federal laws. 4
(f) The department shall develop and implement procedures to 5
carry out the requirements of this section. 6
(2) In any review of an unexpected fatality, the department and 7
the unexpected fatality review team shall have access to all records 8
and files regarding the person or otherwise relevant to the review 9
that have been produced or retained by the department including, but 10
not limited to, critical incident reviews, root cause analysis, and 11
mortality review committee reports. 12
(3)(a) An unexpected fatality review completed pursuant to this 13
section is subject to discovery in a civil or administrative 14
proceeding, but may not be admitted into evidence or otherwise used 15
in a civil or administrative proceeding except pursuant to this 16
section. 17
(b) A department employee responsible for conducting an 18
unexpected fatality review, or a member of an unexpected fatality 19
review team, may not be examined in a civil or administrative 20
proceeding regarding: (i) The work of the unexpected fatality review 21
team; (ii) the incident under review; (iii) his or her statements, 22
deliberations, thoughts, analyses, or impressions relating to the 23
work of the unexpected fatality review team or the incident under 24
review; or (iv) the statements, deliberations, thoughts, analyses, or 25
impressions of any other member of the unexpected fatality review 26
team, or any person who provided information to the unexpected 27
fatality review team relating to the work of the unexpected fatality 28
review team or the incident under review. 29
(c) Documents prepared by or for an unexpected fatality review 30
team are inadmissible and may not be used in a civil or 31
administrative proceeding, except that any document that exists 32
before its use or consideration in an unexpected fatality review, or 33
that is created independently of such review, does not become 34
inadmissible merely because it is reviewed or used by an unexpected 35
fatality review team. A person is not unavailable as a witness merely 36
because the person has been interviewed by, or has provided a 37
statement for, an unexpected fatality review, but if the person is 38
called as a witness, the person may not be examined regarding the 39
person's interactions with the unexpected fatality review including, 40
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without limitation, whether the person was interviewed during such 1
review, the questions that were asked during such review, and the 2
answers that the person provided during such review. This section may 3
not be construed as restricting the person from testifying fully in 4
any proceeding regarding his or her knowledge of the incident under 5
review. 6
(d) The restrictions set forth in this section do not apply in a 7
licensing or disciplinary proceeding arising from an agency's effort 8
to revoke or suspend the license of any licensed professional based 9
in whole or in part upon allegations of wrongdoing in connection with 10
an unexpected fatality reviewed by an unexpected fatality review 11
team. 12
(4) For the purposes of this section: 13
(a) "Department facilities" include facilities operated by the 14
department that provide care on a residential or inpatient basis, 15
including: 16
(i) Residential habilitation center facilities under chapter 17
71A.20 RCW; 18
(ii) State-operated living alternatives as defined in RCW 19
71A.10.020; 20
(iii) Transitional care facilities as defined in RCW 43.43.837;21
(iv) State hospitals under chapter 72.23 RCW; 22
(v) The child study and treatment center as identified in RCW 23
71.34.380; 24
(vi) The special commitment center and secure community 25
transition facilities under chapter 71.09 RCW; and26
(vii) Other facilities that provide inpatient services to 27
individuals who are placed in the care of the department under 28
chapter 71.05, 71.34, or 10.77 RCW. 29
(b) "Residents of a department facility" do not include residents 30
of facilities licensed or certified by the department of health 31
including, but not limited to, 23-hour crisis relief centers and 32
evaluation and treatment facilities. 33
(c) "Unexpected fatality" means a death of any resident of a 34
department facility, regardless of where the death actually occurred, 35
that: 36
(i) Was not the result of a diagnosed or documented terminal 37
illness or other debilitating or deteriorating illness or condition 38
where the death was anticipated; or 39
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(ii) Occurred within one year of a report of abuse or neglect of 1
the resident. 2
(d) "Unexpected fatality review" means a review of any unexpected 3
fatality. A review must include an analysis of the root cause or 4
causes of the unexpected fatality, and an associated corrective 5
action plan for the department to address identified root causes and 6
recommendations made by the unexpected fatality review team under 7
this section. 8
NEW SECTION. Sec. 2. (1) The department of social and health 9
services shall identify all fatalities of residents of department 10
facilities that occurred on or after July 1, 2015, and before the 11
effective date of this section, that would qualify as unexpected 12
fatalities. To the extent possible, the department of social and 13
health services must additionally identify the root cause or causes 14
of each included fatality along with a description of any corrective 15
action or other measures taken to address the cause of the fatality. 16
The department of social and health services shall, in compliance 17
with RCW 43.01.036, compile the information identified in this 18
section into a report and submit the report to the governor and the 19
legislature by November 1, 2027. Confidential information must be 20
redacted from the report consistent with the requirements of 21
applicable state and federal laws.22
(2) For purposes of this section, "department facilities" and 23
"unexpected fatalities" have the same meaning as in section 1 of this 24
act. 25
NEW SECTION. Sec. 3. A new section is added to chapter 43.382 26
RCW to read as follows: 27
(1) The ombuds or the ombuds' designee shall serve as a member of 28
the unexpected fatality review team as required under section 1 of 29
this act. 30
(2) The department of social and health services shall:31
(a) Permit the ombuds or the ombuds' designee physical access to 32
department of social and health services facilities for the purposes 33
of carrying out its duties under section 1 of this act; and34
(b) Upon the ombuds' request, grant the ombuds or the ombuds' 35
designee the right to access, inspect, and copy all relevant 36
information, records, or documents in the possession or control of 37
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the department of social and health services that the ombuds 1
considers necessary in a review. 2
Sec. 4. RCW 43.382.005 and 2016 c 172 s 5 are each amended to 3
read as follows: 4
(1) There is created an office of the developmental disabilities 5
ombuds. The department of commerce shall contract with a private, 6
independent nonprofit organization to provide developmental 7
disability ombuds services. The department of commerce shall 8
designate, by a competitive bidding process, the nonprofit 9
organization that will contract to operate the ombuds. The selection 10
process must include consultation of stakeholders in the development 11
of the request for proposals and evaluation of bids. The selected 12
organization must have experience and the capacity to effectively 13
communicate regarding developmental disabilities issues with 14
policymakers, stakeholders, and the general public and must be 15
prepared and able to provide all program and staff support necessary, 16
directly or through subcontracts, to carry out all duties of the 17
office. 18
(2) The contracting organization and its subcontractors, if any, 19
are not state agencies or departments, but instead are private, 20
independent entities operating under contract with the state.21
(3) The governor or state may not revoke the designation of the 22
organization contracted to provide the services of the ombuds except 23
upon a showing of neglect of duty, misconduct, or inability to 24
perform duties. 25
(4) The department of commerce shall ensure that the ombuds staff 26
has access to sufficient training or experience with issues relating 27
to persons with developmental disabilities and the program and staff 28
support necessary to enable the ombuds to effectively protect the 29
interests of persons with developmental disabilities. The office of 30
the developmental disabilities ombuds shall have the powers and 31
duties to do the following: 32
(a) Provide information as appropriate on the rights and 33
responsibilities of persons receiving developmental ((disability 34
[disabilities])) disabilities administration services or other state 35
services, and on the procedures for providing these services;36
(b) Investigate, upon its own initiative or upon receipt of a 37
complaint, an administrative act related to a person with 38
developmental disabilities alleged to be contrary to law, rule, or 39
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policy, imposed without an adequate statement of reason, or based on 1
irrelevant, immaterial, or erroneous grounds; however, the ombuds may 2
decline to investigate any complaint; 3
(c) Monitor the procedures as established, implemented, and 4
practiced by the department to carry out its responsibilities in the 5
delivery of services to a person with developmental disabilities, 6
with a view toward appropriate preservation of families and ensuring 7
health and safety; 8
(d) Review periodically the facilities and procedures of state 9
institutions which serve persons with developmental disabilities and 10
state-licensed facilities or residences; 11
(e) Recommend changes in the procedures for addressing the needs 12
of persons with developmental disabilities; 13
(f) Participate in unexpected fatality reviews as required in 14
section 1 of this act;15
(g) Submit annually, by November 1st, to the governor and 16
appropriate committees of the legislature a report analyzing the work 17
of the office, including recommendations; 18
(((g))) (h) Establish procedures to protect the confidentiality 19
of records and sensitive information to ensure that the identity of 20
any complainant or person with developmental disabilities will not be 21
disclosed without the written consent of the complainant or person, 22
or upon court order; 23
(((h))) (i) Maintain independence and authority within the bounds 24
of the duties prescribed by this chapter, insofar as this 25
independence and authority is exercised in good faith and within the 26
scope of contract; and 27
(((i))) (j) Carry out such other activities as determined by the 28
department of commerce within the scope of this chapter.29
(5) The developmental disabilities ombuds must consult with 30
stakeholders to develop a plan for future expansion of the ombuds 31
into a model of individual ombuds services akin to the operations of 32
the long-term care ombuds. The developmental disabilities ombuds 33
shall report its progress and recommendations related to this 34
subsection to the governor and appropriate committees of the 35
legislature by November 1, 2019. 36
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