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PURPOSE

This Department Order establishes a process to develop and convene a Quality Assurance Committee that will review all incidents involving the serious injury or death of an inmate (See DEFINITIONS in Department Order 1105, Inmate Mortality/Morbidity Review), and other incidents deemed appropriate by the Director. The Quality Assurance Committee shall identify preventable incidents and ensure that processes are established to learn from and improve the Department's routine and emergency responses to certain situations.

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PROCEDURES

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122.01 QUALITY ASSURANCE COMMITTEE RESPONSIBILITIES

1.1 The following Divisions shall forward information related to inmate death or serious injury to the Division Director for Program Services or designee within 30 calendar days.

1.1.1 Offender Operations shall provide information relating to:
1.1.1.1 Inmate grievances.
1.1.1.2 Incident Reports and Significant Incident Reports.
1.1.1.3 Riots, and inmate strikes or demonstrations.
1.1.1.4 Escapes or attempted escapes.
1.1.1.5 The use or discharge of weapons, other than during weapons qualification training.
1.1.1.6 Use of chemical agents or tasers.
1.1.1.7 Hostage situations.
1.1.1.8 Offenders released but still under the legal authority of the Department.
1.1.2 Program Services shall provide information relating to:
1.1.2.1 Inmate Mental Health and Health Care Services.
1.1.2.2 Allegations of misdiagnosis or delayed treatment.
1.1.2.3 Inmate hunger strikes.
1.1.2.4 Mortality Committee reviews.
1.1.2.5 Suicide Committee reviews.
1.1.2.6 Attempted Suicide reviews.
1.1.2.7 Peer Committee Reviews.
1.1.2.8 Inmate Medical Grievances.
1.1.2.9 Allegations of sexual assaults.
1.1.3 Support Services shall provide information relating to:
1.1.3.1 Human Services.
1.1.3.2 Inspector General, which shall provide information relating to:
1.1.3.2.1 Staff and inmate safety.
1.1.3.2.2 Structure or physical plant problems.
1.1.3.2.3 Power outages.
1.1.3.2.4 Criminal investigations.
1.1.3.2.5 Administrative investigations.
1.1.3.2.6 Audit reports.
1.2 The Division Director for Program Services or designee shall forward the information to the Quality Assurance Committee members listed in section 122.02 of this Department Order. The Committee members shall review the information prior to the scheduled meeting and shall be prepared to discuss each issue.

1.3 The Quality Assurance Committee shall convene quarterly or sooner, if necessary, to review all information and forward a report to the Director outlining a summary of issues. The summary for each issue may include:

1.3.1 The reasons that the incident occurred, whether it was preventable, and whether staff error, misconduct or negligence was involved.
1.3.2 What discipline, if any, was taken or recommended.
1.3.3 Recommendations for further review, investigation or action to be taken, if necessary.
1.3.4 Recommendations for changes to policy and procedures.
1.3.5 Any additional recommendations for the Director's approval.

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122.02 QUALITY ASSURANCE COMMITTEE MEMBERS
1.1 The Quality Assurance Committee shall be chaired by the Division Director for Program Services and consist of the following members:

1.1.1 The Division Director for Offender Operations.
1.1.2 The Health Services Administrator.
1.1.3 The Counseling and Treatment Services Administrator.
1.1.4 The Inspector General.
1.1.5 The Human Services Administrator.
1.1.6 The Constituent Services Administrator.
1.1.7 The General Counsel.
1.1.8 Other subject matter experts as necessary.

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122.03 DEATH OR SERIOUS INJURY REVIEW

1.1 Within 48 hours of notification of the death of an inmate or an inmate with serious or life threatening injuries, the Inspector General shall open an Administrative Investigation. The assigned investigator shall collect the appropriate and applicable information, which may include:

1.1.1 Information Reports, as outlined in Department Order 105, Information Reporting.
1.1.2 Significant Incident Reports.
1.1.3 Use of Force/Incident Management reports, if applicable.
1.1.4 Inmate Disciplinary Reports, if applicable.
1.1.5 Reports generated as outlined in Department Order 1105, Mortality Review.
1.2 The Inspector General shall develop a QAC checklist to ensure that all pertinent medical information is provided to the Quality Assurance Committee. Any medical information regarding the death of an inmate or an inmate with serious or life threatening injuries, shall be forwarded to the Quality Assurance Committee Chairman.


Dora B. Schriro
Director

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ATTACHMENTS

Attachment A - Quality Assurance Chart

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AUTHORITY

A.R.S. 36-2404, Quality Assurance Review Committees