June 19, 2003 

Audit of Unusual Incident Reporting Procedures at the District of Columbia Department of Mental Health

The District of Columbia Office of the Inspector General (OIG) has completed an audit of Unusual Incident Reporting Procedures at the District of Columbia Department of Mental Health (DMH) as requested by the Executive Office of the Mayor and DMH. This report is the third in a series of reports that address various functions associated with the delivery of mental health services by DMH. The audit was performed to determine: (1) the adequacy of policies and procedures for documenting, reporting, investigating, and resolving unusual incidents of unexpected deaths, abuse, or neglect of patients in the care of DMH; and (2) the effectiveness of procedures used to secure and account for forensic patients residing at Saint Elizabeth's Hospital. Improvements in these areas will strengthen the management and oversight of patient care at St. Elizabeth's Hospital and at community residential facilities (CRFs).