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Risk Management and Mitigation

Beginning in Fiscal Year (FY) 2001-02, the Legislature appropriated funds to the Department of Developmental Services (DDS) and regional centers to develop a comprehensive risk management system to enhance the health, safety and well-being of individuals served by regional centers, and to implement preventive strategies and interventions to mitigate such risks.

DDS' risk management system addresses the challenges of California's diversity while respecting the basic roles and responsibilities of the State's service system structures. The overall risk management system involves numerous entities; however, the three key entities involved in risk management and mitigation activities within the developmental disabilities services system are DDS, the 21 regional centers and, the risk management independent contractor. For more information about the DDS risk management system, click here.

Risk Management Monitoring Reports

As one element of risk management and quality assurance, DDS and California's network of regional centers monitor the occurrence of adverse events, captured through Special Incident Reports (SIR), to identify trends and develop strategies to prevent and mitigate risks. As required by Title 17, Section 54327 of the California Code of Regulations, vendors and long-term health care facilities report occurrences of suspected abuse, suspected neglect, injury requiring medical attention, unplanned hospitalization, and missing persons, if they occur when an individual is receiving services funded by a regional center (under vendored care). In addition, any occurrence of an individual's mortality or an individual being the victim of crime must be reported, whether or not it occurred while they were under vendored care. Reports include the annual Report to the Legislature, the semi-annual Mortality Special Incidents Report, and the semi-annual Non-Mortality Special Incidents Report.

Report to the Legislature

This report is required by Section 55 of Assembly Bill 430, Chapter 171, Statutes of 2001, to provide an annual report regarding special incidents involving individuals with developmental disabilities served by regional centers.

• Fiscal Year 2014/2015 (PDF)
• Fiscal Year 2013/2014 (PDF)
• Fiscal Year 2012/2013 (PDF)
• Fiscal Year 2011/2012 (PDF)
• Fiscal Year 2010/2011 (PDF)
• Fiscal Year 2009/2010 (PDF)
• Fiscal Year 2008/2009 (PDF)
• Fiscal Year 2007/2008 (PDF)
• Fiscal Year 2006/2007 (PDF)
• Fiscal Year 2005/2006 (PDF)

Semi-Annual Risk Management Special Incident Reports

Mortality Special Incidents

This semi-annual report summarizes mortality special incident rates for individuals with developmental disabilities served by regional centers.

• January — June, 2016
• July — December, 2015
• January — June, 2015
• July — December, 2014
• January — June, 2014
• July — December, 2013
• January — June, 2013
• July — December, 2012
• January — June, 2012
• July — December, 2011
• January — June, 2011
• July — December, 2010
• January — June, 2010

Non-Mortality Special Incidents

This semi-annual report summarizes non-mortality special incident rates for individuals with developmental disabilities served by regional centers.

• January — June, 2016
• July — December, 2015
• January — June, 2015
• July — December, 2014
• January — June, 2014
• July — December, 2013
• January — June, 2013
• July — December, 2012
• January — June, 2012
• July — December, 2011
• January — June, 2011
• July — December, 2010
• January — June, 2010

Semi-Annual Mover Reports

These semi-annual reports summarize indicators regarding individuals with developmental disabilities who transitioned from developmental centers to the community.

• Developmental Center Mover Report - December 2014

For questions about these reports, please contact the Quality Management Section of DDS: (916) 654-3767.

System Improvement Initiatives

DDS continually strives to establish systematic and continuous actions that lead to measurable improvements in risk management and mitigation practices.

Preventive Health Campaign

Flu and pneumonia are common causes of serious illness and even death, and these diseases are largely preventable. The best way to prevent flu and pneumonia is to get vaccinated.

The California Department of Developmental Services is launching a campaign to get everyone with a developmental disability vaccinated for flu, and everyone vaccinated for pneumonia if they are 65 years old or older, as well as those from 19 to 64 years old who have a chronic health condition.

DDS has created materials for this campaign. These materials include informational brochures on the flu vaccine and the pneumonia vaccine, and a poster, in English, Chinese, Spanish, Tagalog, and Vietnamese. Campaign materials, related videos, and articles are also available on the DDS SafetyNet website at http://ddssafety.net/health/preventive-health/fighting-flu-and-pneumonia.

English

• Flu brochure
• Pneumonia brochure
• Poster

Chinese

• Flu brochure
• Pneumonia brochure
• Poster

Spanish

• Flu brochure
• Pneumonia brochure
• Poster

Tagalog

• Flu brochure
• Pneumonia brochure
• Poster

Vietnamese

• Flu brochure
• Pneumonia brochure
• Poster

RESOURCES

Tools developed to help regional centers, service providers, and families improve health and safety among the individuals they support.

Fall Prevention

The fall prevention materials provide some easy and practical things that can be done to prevent falls.

• Clinical Professionals — Medical Risk Factors and Prevention of Falls and Fractures
• Preventing Falls and Fractures — Information for Supporters and Providers
• Risk Assessment Inventory: Falls
• Preventing Falls

Chronic Conditions & Checklists

The Chronic Condition Checklists are tools to help regional center staff, service providers and families monitor common chronic conditions in order to assure appropriate care and prevent potential special incidents (SIRs) from occurring.

• Checklist: Aspiration/Aspiration Pneumonia
• Checklist: Impaction & Severe Constipation
• Checklist: Insulin Dependent Diabetes
• Checklist: Epilepsy
• Checklist: Gastrostomy Tube (G-tube) Feeding
• Checklist: Osteoporosis
• Checklist: Staphylococcus "Staph" Infection
• Checklist: Weight Management

Medication Errors

The Medication Error Report Diagnostic Tool and Medication Administration Checklist can be used by regional centers and service providers to lower the rate of medication error special incidents (SIRs) by improving the processes for managing and administering medications.

• Checklist: Medication Administration
• Medication Error Report Diagnostic Tool

Risk Management Training Manual

The manual is a tool for regional centers to use in their staff development and quality assurance efforts. Regional centers can utilize the training modules for their own staff or as training opportunities for their vendors.