12VAC35-105-160/E: A root cause analysis of each serious incidient shall be conducted by the provider within 30 days of each discovery. . ."

Comment: Does not distinguish between completing a root cause analysis across Level I, Level II, and Level III.  To complete a root cause analysis for "all" levels of serious incidents may be overly burdomsome a process for staff.  For example, a Level II incident includes "hospital admission" and "emergency room  or urgent care visits when not used in lieu of a primary care physician visit."  For the latter, often individuals may be seen in urgent care after hours when the primary care physician is not readily available.  Further, there are many individuals who, due to significant and reoccuring medical issues, may experience frequent/multiple hospitalizations.  To complete a root cause analysis "any and every time" an individual is hospitalized or seen in urgent care, especially in instances wherein the root cause is clearly established (e.g., seeking urgent care because PCP is not readily available/office closed or frequent hospital admissions due to chronic health conditions) may proved to be burdomsome and not what is intedned by completion of this important and valuable process.  While it seems clearly indicated for Level III and most Level II serious incidents, it is recommended that the regulations add clarity to when a root cause analysis shall be completed except to say for "each" serious incident.