Tiered Incident Reporting System:

• Does not help to streamline reporting and it is anticipated this will result in an increase in reporting requirements and demands. Providers currently report in most, if not all of these areas and frequently receive feedback from DBHDS regarding over reporting.
• Increases likelihood of Providers becoming responsible for reporting on issues the organization would otherwise not be responsible for reporting.
• Takes away the parameter of an individual requiring unscheduled medical attention as a perquisite for reporting.
• Reporting sexual assault: The regulation is unclear as to whether Providers would investigate (or even have the authority to) if the event did not occur during/on a program site, in a peer-to-peer instance or involving a Provider’s staff.

12VAC35-105-160 C:

• Quarterly reviews of all Level I serious incidents is superfluous. The initial review to determine its reporting value and level assignment is sufficient. Maintenance of these incidents for on-demand review by DBHDS is sufficient, given their low-level, sub-acute status.
• The requirement that a “root cause analysis” be completed of each serious incident is an unrealistic mandate. The proposed regulation provides no indication as to what Level of incident this applies, so it is assumed all would need to be done. Completing an analysis and subsequent report within 30-days of the incident, in addition to the currently required investigation and reporting requirements is not feasible. It is requested that the section be amended to remove this requirement from Level I serious incidents.
• It would be imperative that DBHDS provide ongoing support and training to providers on how to effectively complete the root cause analysis process to ensure fidelity of the system. However, DBHDS has often struggled with how to effectively offer training to Providers, in a timely and ongoing fashion, on best practices related to current mandates. It is unclear how additional support and technical assistance would be made available by DBHDS to Providers on this new mandate.

12VAC35-105-400:

• Requiring Providers to reserve hiring personnel until the receipt of background checks results is unreasonable and will significantly impact the ability for licensed Providers to attract and acquire qualified staff for critical positions.

12VAC35-105-520 C:

• This level of mandate would require a risk assessment tool, developed by DBHDS, to ensure accurate application and assessment across Providers. The requirement that the “process shall incorporate uniform risk triggers and thresholds as defined by the department” requires provision of an instrument by which to apply these measures.