Section

Comment

Action

Level II Serious Incident

Requiring a licensed residential provider to report on an incident that occurs within the confines of another licensed program/setting will cause the data regarding serious incidents to be inaccurate due to duplicate reporting of the same incident.  It is also inefficient for staff in both settings. 

Remove the example at the top of page two related to this requirement and remove the language regarding residential providers being required to report all incidents as it goes beyond what the regulations require.

Unplanned Medical Hospitalization

The provider cannot control when a hospital might admit someone for observation vs. treatment and it would seem that if someone is admitted for observation only, the incident does not rise to the level of required reporting.

Please change language to reflect that the individual must be admitted for treatment in order to initiate the reporting requirement

Any Death

Deaths will likely be reported by multiple providers if a process for notification following an initial report is not implemented

Include in the guidance language that makes DBHDS responsible for identifying and notifying other service providers once an initial report is received.

Root Cause Analysis

The definition of and procedure for performing this analysis is incompatible with the regulatory requirement that the analysis be conducted within 30 days of the incident.  In addition, the guidance document seems to be making a suggestion about how to go about conducting an RCA at the same time it is attempting to require that particular members be part of the suggested team.

Remove the language regarding the “suggested” approach.