WHEREAS, it is a fundamental responsibility of government to protect its most vulnerable citizens; and

WHEREAS, in June 2006 the Governor organized the Mental Health Task Force ("the Task Force") and charged it with the responsibility of overseeing a cross-agency effort to work together to make certain that no instance of abuse or neglect in public or private facilities is overlooked; and

WHEREAS, the Task Force's membership includes the Directors of the Departments of Mental Health, Social Services, Health and Senior Services, Public Safety along with families and representatives of contract service providers; and

WHEREAS, the Governor directed the Task Force to produce a short-term plan for conducting joint investigations while developing a long-term cooperative effort to make certain that every instance of potential abuse or neglect in public and private facilities is investigated and addressed appropriately; and

WHEREAS, on June 16, 2006, the Task Force developed and released five short-term action items for immediate implementation to identify and address gaps in the investigations process at the Department of Mental Health ("the Department"); and

WHEREAS, in addition to the short term plan, the Task Force, by soliciting public input and holding public hearings throughout the state to listen to consumers' families, providers, staff, and others with an interest in the safety of the mental health system, produced and provided to the Governor long-term recommendations to improve the state's mental health system; and

WHEREAS, all recommendations put forth by the Task Force deserve thorough review by the Department and some can and should be implemented immediately.

NOW THEREFORE, I, Matt Blunt, Governor of Missouri, by virtue and authority vested in me by the Constitution and laws of the State of Missouri, do hereby issue the following orders:

The Department shall continue to notify the Missouri State Highway Patrol and local law enforcement of any deaths or assaults in a facility that is operated, licensed, or certified by the Department. Additionally, the Department shall report all deaths in a facility that is operated, licensed, or certified by the Department to the local coroner or medical examiner.

The Department shall implement an information management system that can rapidly and effectively track critical data on abuse, neglect, and other safety information. This data will be used as a component of the Department's continuous quality improvement plan and the Department's annual report to the Governor and Lieutenant Governor.

The Department and community providers shall develop standard individualized training for consumers and families on identifying and reporting abuse and neglect.

The Department shall work with the Department of Health and Senior Services to establish formal ties to its adult abuse hotline, and with the Department of Social Services for formal ties to its child abuse hotline, so that the reporters of abuse and neglect of consumers of the Department fully utilize those hotlines as another means of reporting abuse and neglect.

The Department shall develop a process for triage of incidents for joint investigation of all deaths or near deaths that are suspect for abuse or neglect, as well as incidents of physical assault and sexual misconduct. In order to conduct "triage," strict procedural guidelines must be developed to allow for proper prioritizing of cases. This process should include notification of and cooperation with local law enforcement.

The Department shall prepare an annual report to the Governor, the Lieutenant Governor, and the Mental Health Commission on its progress in implementing the above-mentioned recommendations. The annual report shall include data that indicates the level of safety in the mental health system, along with plans for additional action where needed. The first report shall be submitted by June 30, 2007.

IN WITNESS WHEREOF, I have hereunto set my hand and caused to be affixed the Great Seal of the State of Missouri, in the City of Jefferson, on this 19th day of December, 2006.

[Matt Blunt's signature]

Matt Blunt


[Robin Carnahan's signature]

Robin Carnahan
Secretary of State

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