Virginia Regulatory Town Hall
Agency
Department of Behavioral Health and Developmental Services
 
Board
State Board of Behavioral Health and Developmental Services
 
Guidance Document Change: This guidance is intended to clarify the reporting requirements to the Office of Human Rights (OHR) for peer-on-peer aggressions that occur in licensed or DBHDS-funded community provider settings. It is intended to supersede guidance dated June 15, 2017, entitled “Office of Human Rights Peer-to-Peer Reportable Incidents.” The impetus for clarification was a comprehensive review of neglect data entered by providers in the DBHDS Computerized Human Rights Information System (CHRIS), and collaborative conversations with key stakeholders.
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6/12/23  3:55 pm
Commenter: Nicole Lewis, Southside Behavioral Health

Internal Review of Peer-on-Peer Aggression
 

I am writing to provide feedback and seek clarification regarding the guidance document's instructions on the internal review of incidents involving peer-on-peer aggression. Specifically, I would like to address the timeframe for conducting the review, the reporting requirements in case of late reporting, and the distinction between the internal review and formal investigation processes.

  1. Timeframe for internal review: It would be helpful to specify the expected timeframe for conducting the internal review of incidents involving peer-on-peer aggression. Currently, the document does not mention a specific timeframe for completion. Considering the urgency of addressing such incidents, I recommend including a timeframe of no more than three business days from the date of discovery. This timeframe allows for a prompt evaluation of the incident to determine if CHRIS reporting is required and ensures timely resolution of any identified issues.

  2. Reporting requirements and date of discovery: In cases where the internal review determines that an incident needs to be reported and further investigated, it is essential to clarify whether the reporting timeframe is based on the date of discovery. If the reporting is expected upon discovery, it would be beneficial to include guidelines or consequences for late reporting to ensure compliance with reporting obligations. This clarification will provide a clearer understanding of the expectations and promote prompt and accurate reporting.

  3. Distinction between internal review and formal investigation: The document currently states that the internal review is separate from the formal investigation, but it refers to the internal review as a "formal" investigation. To align with the regulatory language, I recommend removing the term "formal" to eliminate any confusion. This revision will ensure consistency and clarity regarding the distinction between the internal review and the subsequent investigation process.

Furthermore, it would be beneficial to clarify that the internal review refers to the provider's standard processes to review incidents and determine any necessary actions to identify and address potential harm to an individual, as well as to reduce the likelihood of reoccurrence. By providing this clarification earlier in the document, it will enhance understanding and avoid any misinterpretation.

Lastly, I would like to address the section stating that the Office of Human Rights (OHR) may request provider information specific to the review of incidents involving peer-on-peer aggression. While it is essential to protect the rights of individuals receiving services, it would be helpful to provide more specific guidelines on the circumstances that may trigger such a request. This clarification will ensure transparency and facilitate cooperation between providers and the OHR.

Thank you for considering my feedback and suggestions. I believe that incorporating these clarifications and addressing the mentioned concerns will further enhance the effectiveness and clarity of the guidance document. Should you require any further information or assistance, please do not hesitate to reach out. I look forward to your response and continued collaboration.

CommentID: 217196