12VAC35-105-160D 2

Replace the 24 hour reporting requirement with a more realistic requirement of two business days (and remove the 48 hour requirement for updates all together) since no one from DBHDS works before 8am or after 5pm on any given Monday through Friday (nor on weekends and holidays).   

This shouldn’t be such a strenuous and adversarial push by the department considering the metric has been met over 90% of the time.  Certainly there are other more important initiatives for these state resources. 

Resulting guidance (that somehow went into effect on June 15^th despite not being open to public comment until June 22^nd) threatens the license of honest providers who will continue to choose to report late as opposed to not reporting at all, even though dishonest providers will choose not to report and only be cited if they get caught in an audit. 

That is unreasonable and encourages damage to a measure Virginia has actually shown success.  It is also impossible to implement fairly as the guidance does not take into account the sizes or scopes of the various service organizations throughout the Commonwealth.

12VAC35-105-160E 2

The expectation that a provider is going to pull together a team to address Level II and Level III incidents is not feasible for all providers.  Further, expecting a provider to develop a policy outlining the conditions when such a team would be convened is impossible when the criteria is defined by “thresholds” that have consistently been left undefined by DBHDS.  This should remain an internal decision by providers.

The requirement to complete a Root Cause Analysis is sufficient.  Further regulation to promote some “enhanced” Root Cause Analysis devalues the work done to complete the “standard” Root Cause Analysis, especially when the department is now implementing vague training requirements for Risk Management positions that would seemingly apply to all members of this “enhanced” Root Cause Analysis team.  Remove this requirement from regulations as it is unnecessary to meet the conditions of the DOJ Settlement Agreement.

12VAC35-105-170

Agree with the dozens of other commenters who have pointed out that “prevent the recurrence” is an impossible standard to meet and should be removed from regulations.  Risk Management is about mitigation not elimination.

12VAC35-105-530A 9

Monthly fire evacuation drills are too often and put lives in danger.  Gaining cooperation of all people during an emergency drill is key to success.  Overdoing drills is the fastest way to ensure they are not taken seriously.  Suggest replacing monthly requirement with no greater frequency than quarterly.  

12VAC35-105-530L 5

Remove "flashlights" from this requirement.  If the lights go out in an emergency, the flashlight is first thing someone is going to grab... otherwise how are they going to see the floor plan in the first place?  Floor plans must be simple and uncluttered to be effective tools in an emergency.