The comments to follow are being submitted by Community Residences, Inc.

Guidance for Serious Incident Reporting

As stated in other public comments, the Office of Licensing is attempting, by guidance, to expand regulatory requirements and dictate the method or approach that providers will use to satisfy the regulation(s) including:

• Reporting serious incident that occurred when the individual was NOT receiving services from the provider

• Defining the “best way” to conduct a root cause analysis and the use of the word “requirement” in the guidance language

• Mandating a root cause analysis for Level I incidents

It would be helpful to consistently use the term “serious incident”. Currently, CHRIS uses the term “serious injury” which causes confusion to users.

Will CHRIS be enhanced to include a Level II and Level III indicator? Will CHRIS be enhanced to provide a field or fields to capture the results of provider’s RCA?

To clarify reporting responsibility, it would be helpful to consistently define reportable serious incidents as incidents occurring during “the provision of their (provider’s) service or on the premises of the provider” in all guidance text. Requiring a provider to report serious incidents which occurred outside of their direct provision of services is unreasonable. ALL licensed providers are required to report Level II and Level III serious incidents, including day support, in-home supports, etc.

The definition of Level I serious incident is very broad - Level I “serious incidents" do not result in significant harm to individuals, but may include events that result in minor injuries that do not require medical attention, or events that have the potential to cause serious injury, even when no injury occurs. A plethora of events have the potential to cause serious injury. A succinct definition, with examples, would be helpful to clarify your intent.

The following guidance is contradictory and open to interpretation concerning the severity of the medical concern. If the intent is to say that Level I serious incidents are NOT required to be reported, the guidance should clearly state that. The first statement appears to mean that any incident where an individual is unexpectedly taken to the ER or Urgent Care must be reported. However, the second statement appears to be an exception to this rule.  The second statement appears to mean that if the individual was taken to the ER in accordance to a protocol and not admitted then no reporting is required. Please clarify.

3. An emergency room or urgent care facility visit when not used in lieu of a primary care physician visit;

The guidance below for Level II serious incidents is confusing and contradictory. Additionally, the guidance indicates that providers ae required to report “serious incident” even if they occurred during the provision of service by another provider or when an individual is visiting family.

• Providers are required to report Level II serious incidents that occurred, originated, or happened during the provision of service or on the premises of the provider.

• Residential Providers are responsible for individuals 24 hours, therefore required to report all incidents once notified.

Level II serious incident includes “allegation of financial exploitation”. All allegations – abuse, neglect, or exploitation - are required to be reported to the Office of Human Rights in CHRIS as “abuse” cases.  All allegations must be investigated as defined in the Human Rights regulations. Reporting allegations of exploitation as “serious injury” cases in CHRIS is redundant.

Level III serious incidents include “serious injury of an individual that results in or likely will result in permanent physical or psychological impairment”. Determining the likelihood of future impairment is highly subjective. To meet the 24-hour reporting requirement providers will need to make a decision regarding future impairment in the moment and most likely will not have facts or diagnosis to support their reporting decision.

Mandatory reporting of allegations of sexual assault without the consent of an adult individual receiving services would be considered a violation of their human rights and confidentiality. Additionally, reporting allegations of sexual assault, without consent, is contradiction of person-centered and trauma-informed practices. I do not believe this is the intent of the guidance. Adults have the right to choose reporting a criminal report to law enforcement agencies. However, citing mandated reporting law, licensed providers have a legal and moral responsibility to report all known allegations of abuse, sexual or otherwise, for “minors or incapacitated adults”. We suggest revising the language used to better define the intent of this guidance and the population(s) included. All allegations of sexual abuse by an employee of a licensed provider must be reported to CPS/APS and the Office of Human Rights in CHRIS as “abuse” cases. Reporting allegations of sexual assault as “serious injury” cases in CHRIS is redundant.

Guidance for a Quality Improvement Program:

As stated in other public comments, the Office of Licensing is attempting, by guidance, to expand regulatory requirements and dictate the method or approach that providers will use to satisfy the regulation(s) including:

• Referencing quality improvement policies and procedures when this language was specifically removed from the regulations

• Defining specific components/requirements for a provider’s annual review of their quality improvement program

• Requiring that the quality improvement plan be signed and dated by the person designated as responsible