First, we would like to extend our thanks to DBHDS for issuing and seeking input regarding this draft guidance document.  In addition, we are appreciative of the consistent message that the majority of Serious Incidents occur during the actual moments of service delivery or while an individual in on a provider’s property and of the accompanying reduction in duplicate reporting and reduced focus on events generally unrelated to our role in individuals’ lives. 

The guidance related to Level II events raises some additional questions.  Regarding the requirement for residential providers to report all incidents will result in duplicate reporting.  Is there a means to ensure providers attest to notification to residential providers and case managers within CHRIS, e.g. by having to put in the date of notification?  If not, when an event occurs during a day program provided by the same agency that provides residential services, please confirm that the agency need only report this event once, in connection to the residential license, but identifying the day program as the specific location.

Please find ways to ensure consistency among Licensing Specialists regarding the interpretation of “serious injury”, as in recent years there has been some expectation of reporting any event that was treated by someone with the identified credentials, regardless of actual harm or potential for harm.  Along these lines, the recognition that emergency rooms and urgent care facilities are used when PCPs are unavailable is much appreciated. 

The additional guidance related to “unplanned psychiatric admissions” is appreciated, as is the recognition of the role of Emergency Services providers.  A focus on TDOs is, indeed, the most similar terminology to that used by pre-screeners.  As ECOs only enable a person to be brought for evaluation and may result in voluntary hospitalization (or even no hospitalization), please consider removal of that aspect of the guidance document.

For instances where an individual is taken to the hospital in accordance with their medical protocol and is admitted following the evaluation, please confirm that the 24 hour reporting period starts when the provider is notified of the decision to admit the individual.

In general, the events selected as Level III incidents are logical topics to be viewed as sentinel events.  Most questions relate to the expectation of conducting a root cause analysis for all events of “Sexual Assault”.  First, how is that term being defined and who is to determine that sexual assault occurred? Second, if an event occurs during service provision, it would be considered an Allegation of Abuse or of Neglect and should be reviewed under the Human Rights process, certainly with attention to systemic root causes that enabled any abusive actions to occur.  Similarly, if Provider A learns that this allegedly occurred during service delivery by Provider B, then mandated reporting, ensuring the Office of Human Rights is aware, and ensuring safety of the alleged victim would be the keys to a response.  When an event such as this occurs outside of any provider’s direct service provision and outside of any provider’s premises, there are concerns about how this review could impact the victim’s experience with a provider.  Considered from the perspective of the victim, having any number of staff members potentially unfamiliar with their treatment reviewing a highly personal event could feel like an additional violation.  Few facts could be obtained and the individual him/herself should not be interviewed for this purpose.

Finally, please provide some additional clarification regarding expectations for reviewing of incidents beyond initial information gathering and root cause analyses.  Specifically, Section 160 addresses reviewing Level I incidents as part of the Quality Improvement Program, referencing 105-620.  However, 105-620 does not specify review of incidents, whereas 105-520, Risk Management, clearly specifies “a review of serious incidents”.  Perhaps this is comment better suited for clarification within the regulations themselves, but what is the appropriate venue to review these events?  Three tiers of review (addressing the incidents immediately, via the QIP, and via the Risk Management Plan) seems likely to create additional work with little gain and to result in potentially conflicting messages and internal plans for correction actions.  We look forward to attending DBHDS sponsored training on root cause analysis and hope multiple sessions will be offered per region.