Commenter:
Henrico Area Mental Health & Developmental Services - Yvonne Russell
Guidance for Serious Incident Reporting
Additional direction is needed regarding the use of the guidance document by the department. Can a provider be cited because they have not implemented their root cause analysis as outlined in the guidance document yet includes the elements listed in the regulations 12 VAC35-105-160.E.?
Level II states reporting occurs for incident that occurs or originates during the provision of service or on the premises of the provider. In the guidance document it exceeds this requirement for residential services and states residential providers are responsible 24 hours a day for an individual. The provider may not be with the person 24 hours a day as they attend a day program, employed , with family and can only be held accountable for the time the person is with them. This exceeds the regulations and should be changed.
Level II serious injuries include an individual who is missing. The focus should be narrowed to residential and day programs as it becomes difficult to assess in other services that have less contact.
Level II emergency room visits - How would we know if the ER was being used in lieu of a primary care visit? Does this include urgent care visits in lieu of seeing the PCP, even when the PCP offices are closed?
Level II unplanned psychiatric or unplanned medical hospital admissions - If a client comes to the CSB to see a nurse and it is recommended to go to the ER is that reportable? Is that planned or unplanned? How do we handle voluntary hospitalizations, are they considered unplanned? Are they reportable? Considerations should be made to remove psychiatric hospitalizations as a reportable requirement.
Diagnosis of decubitus ulcer, bowel obstruction or aspiration pneumonia is stated in the guidance documents as typically reported by residential services. Should be clearer to state that it only applies to residential services.
Level III reporting - Level III. For level three reporting does the individual have the right to know what is being reporting to the state regarding what is shared with the provider?
Level III. 2. Sexual assault of an individual - In an outpatient service this has serious impacts on the therapeutic relationship and the individual may feel additionally victimized by the reporting, and a root cause analysis completed. This should be moved to level II.
