Page 11-12 "Serious Incident" definition: The tiered system is a bit confusing. Tier 1 has no definition, so it is not clear what types of incidents would fall under that category. The tiers are not all-inclusive which makes it open to interpretation and open to corrective action if done improperly.

Page 12 (same category) Level III serious incident number 4. Should there be a clairifcation of a "medical" hosptialization?

Page 18D: Level III serious incidents to include consequences or risk of harm to be included in the reports. Not all consequences of an incident are known at the time of reporting and if a licensing specialist closes a CHRIS report, how is it to be documented?

page 18  Root Cause Analysis: To what extent are these required? Investigations are done, but not each incident requires the same level of inquiry. Will DBHDS require us to provide the root cause analysis for all incidents? How organizied/formal is this process?

page 28 D.3. what is the definition of "the team" shall meet to review.