Horizon Behavioral Health Responses to Proposed Licensing Regulations Comments
Re: 12VAC35-105-520. Risk management. - The provider shall designate a person responsible for the risk management function who has training and expertise in conducting investigations, root cause analysis, and data analysis. Revise with more specific language, such as: The provider shall designate a CQI team to conduct investigations, root cause analysis, and data analysis instead of “a person”. Using the word “person” narrows the scope unnecessarily vice the full breadth of a CQI team.
Re: 12vac 35 105-160 - Requiring all serious incidents in all tiers for all DBHDS licensed organization is going to cause a hardship in administrative duties. Root cause analysis should be for specific tiers only.
Re: 12VAC35-105-400 - Concern about having to get background check results and review before hire. No problem with checking OIG before hire, but the other process, particularly DSS, can take weeks. Candidates won’t wait weeks for a job offer. 400 checks completed prior to hiring of staff will prevent us from getting staff hired in a timely manner. Therefore, I would recommend changing the wording so we can hire them and make their continued employment be based on the findings of the background check.
Conflict with VA Code: Also, it is important to note that the proposed revision of 12VAC35-105-400 appears to conflict with Code of Va 19.2-389A 29 that specifies that a criminal background check may be completed for applicant who accepts employment in any direct care position. This revision appears to read that to process a criminal background check, the job offer of employment must have been made and accepted.
Comments on ICF / Housing
Re: Typos
Page 1 5. “an individual” change to: “the individual” in physical or mechanical restraint. 6. “his individualized services plan” change to: “the individualized service plan” 7. “an individual” change to: “the individual” also later in this same sentence instead of: is not consistent with “his individualized services plan” change to “the individualized service plan”
Page 2 4th paragraph: and their family member “in assessing accessing needed services” change to: “and their family members in order to determine the needed services and supports that are responsive…”
Page 3 1st paragraph: “identified independently” change to: “identified independent of one another”
Page 4 2nd paragraph: toward the end…fullest potential to the greatest extent possible change to “for individual optimal health and wellness, self-esteem, and overall functioning.”
Page 7 3rd paragraph from bottom make “disabilities” singular to correspond with the others of which are singular change to: developmental disability Last paragraph: after family basis, take out the and change to: group, or family basis, usually in a clinic…
Re: Community intermediate care facility/mental retardation (ICF/MR):
Removes the word “community” from the definition. We provide ICF/ID services in the community. Removing the word is appears to be a step towards treating the community based ICF/IDs as institutions.
Re: Instrumental activities of daily living:
Meal preparation” change to “food and meal preparation and consumption” second to some clients also need to be fed in order to not just PREPARE but to consume food for adequate nutrition and wellness.
ALSO: HEALTH AND HYGEINE was left out IE: bathing, toileting. Why change the name and what is the advantage of adding the word “instrumental” to the phrase?
Re: Medical evaluation:
The statement, “Within the scope of his license” should be changed to “within the scope of the practitioner’s stated license”.
Re: Neglect:
The definition does not include the peer to peer or other items we have been required to document in CHRIS
Re: Person-centered:
CHANGE ENTIRE DEFINITION TO READ: “means focusing on the needs and preferences of the individual, promoting self-determination, community involvement, and recovery in order to empower and support the directions of the individual’s life”.
Re: "Quality improvement plan":
The description lacks detail, who will complete it? How often? What will be required? the end of the last sentence defined add to the end “Quality improvement plan” and health status of the individual to promote or maintain optimal level of individual wellness and overall functioning.
Re: "Qualified Developmental Disability Professional (QDDP)" :
QIDP is still a CMS term and staff will have to maintain dual credentials
Re: Recovery:
In the sense that in reference to individuals with DD change to: “in the sense that while the supports may change, the individual will most likely need supports and services throughout their entire lifespan. The definition is wordy & not clear otherwise.
Re: Restraint:
Means change the term, “prevent change” to: “hands-on hold restricting the movement of the individual in order to prevent a behavior compromising safety to the individual and/or others.”
Re: "Root cause analysis" :
Description lacks detail, who will complete it? How often? What steps and elements will be required?
Re: Seclusion:
Actually means the involuntary placement of solitude of an individual secured by a locked door, or held shut by a staff member, for safety precaution to prevent danger or harm to self or others.
Re: Serious incident:
The system of level 1, 2, 3 is confusing, what documentation will be required, by whom , and how often? Assuming it will need to be recorded in the CHRIS system and it is a barely functioning software. Hospital admissions are not always a crisis- Scheduled surgeries for example will not meet the definition of a serious injury. Less than reputable providers will delay/deny medical care to avoid completing documentation. Level 2 does not include med errors, however we have a FAQ from years ago that suggests "several missed medications" might be neglect. It would be great to get clarification.
Re: Service:
Planned individualized interventions and supports delivered to individuals with mental illness, developmental disabilities, or substance abuse. Services include (i) outpatient, intensive in-home, opioid treatment, inpatient psychiatric hospitalization, community gero-psychiatric residential, assertive community treatment, and/or other clinical services, day support, day treatment, partial hospitalization, psychosocial rehabilitation, and habilitation services, case management, supportive residential, special school, halfway house, in-home services, crisis stabilization, and other residential services; and (ii) planned individualized interventions intended to reduce or ameliorate the effects of brain injury through care, treatment, or other supports provided in residential services for persons with brain injury.
Re: 12VAC35-105-120. Variances.
As providers we do not have a way to contact DBHDS during non business hours to report emergencies or seek guidance if there was a need for a variance. An example would be if there was a need for an emergency relocation. We can email and leave voice mail messages but there is no expectation of response on weekends or holidays
Re: 12VAC35-105-160:
The Depts. web based reporting system is not user friendly. It locks us out before we can finish the reports. It gives error messages that prevents information from being saved. The 24 hour requirement to enter the information is unreasonable. The support for the system is not open on weekends/ holidays and DBHDS staff are not there to read the reports if we manage to get the information entered. We must report the information from the hospitals when providers are often not informed of treatment from them. Consent to share information with hospitals can be revoked. Providers do not have any recourse if we disagree with the diagnosis. It can be weeks before we get written discharge information, and often the verbal discharge information is inaccurate.
Re: 12VAC35-105-400:
1) A disclosure statement signed by applicant stating whether or not the applicant has ever been convicted of or is the subject of pending charges for any offense.
Re:115-230 C 4.:
Why would we complete a Root Cause analysis of a scheduled hospitalization? What and who can complete the RCA and how will it be documented? Is it a part of the client record? What if it documents performance issues of staff?
Re: 12VAC35-105-170. Corrective action plan.:
Can providers have a date to expect a CAP after a visit? We have received CAP's several months after visits. It is difficult to remember details when they come that far after a visit, and delay the improved service delivery.
Re: 12VAC35-105-320. Fire inspections
Where are we to document it?
Re: 12VAC35-105-520. Risk management
How will state define expertise?
How do state define serious injuries?
Re: 12VAC35-105-590. Provider staffing plan. C #7
"Experience may be substituted for the education requirement" How much experience and who will decide? What type of experience? Will we have to submit our managers and Q's to the DHP?
Will the following requirement be billable or and be an unfunded mandate? A. provider shall employ or contract with persons with appropriate training, as necessary, to meet the specialized needs of and to ensure the safety of individuals being served receiving services in residential services with medical or nursing needs; speech, language, or hearing problems; or other needs where specialized training is necessary.
Re: 12VAC35-105-620. Monitoring and evaluating service quality.:
A quality improvement program, what are the credentials of the staff, how will it be documented, how often will DBHDS change the performance measures? Will we have to document it in the CHRIS system? Will there be training? Who will indicate improvements are indicated?
Re: 12VAC35-105-650. Assessment policy:
Since the SIS audits have minimized the supports needed for individuals should we use them for the provider assessments or document the care required?
Re: 12VAC35-105-660. Individualized services plan C
How should we handle absent AR, or an AR that does not wish to participate in the assessments or in the development of the ISP?
Do you expect a full meeting monthly if a client has not met their outcomes?
Re: 12VAC35-105-830. Seclusion, restraint, and time out:
Needs to include:
-A “time-frame” the MD order stands for seclusion and or restraint?
-Assessment and circulation checks if restrained (for safety)
-How often client will be assessed for safety and thus release from seclusion or restraint.