We wish to offer our support to the change made regarding root cause analysis.  The changes made to this section of the regulations provide specificity regarding the expectations of providers in conducting root cause analysis and provides a sufficient level of guidance for root cause policy development.  The addition of identifying solutions to mitigate future risk of harm and the added requirement of a more detailed analysis when certain thresholds are met will aid providers in identifying additional manners in which to ensure the health and safety of the individuals served. 

We seek clarification and guidance regarding section (F) of the regulation which states “provider shall make available and, when requested, submit reports and information that the department requires to establish compliance.”  With the intent to provide foremost for the safety and security of the individuals we serve, we ask that guidance be established regarding the structure and timeliness of the requests for information made by the Department.  When an incident occurs, the priority of the provider should be the safety and security of the individual impacted.  When the provider receive immediate requests for information following submittal of an incident report, it takes away from the provider’s ability to conduct a complete and timely root cause analysis.  In turn, the likelihood of incomplete knowledge being shared with the Department is increased as is the need for frequent updates to the Department as root cause analysis uncovers more relevant information.  Furthermore, the immediate need for information takes away from the immediate needs of the individual which at that time should be the provider’s primary focus.  Due to these issues, we ask that requests be held and compiled until the completion of root cause analysis by the provider to ensure the information being provided to the Department is as complete and informative as possible and that the needs of the individual are addressed in the immediate. 

Realizing that certain requests from the Department may be out of urgent concern for the safety and security of an individual, we further suggest that the CHRIS platform be utilized foremost for such request and that the incident remain open in the CHRIS system until all needed information has been obtained and/or provided by the Department.  By keeping the incident open in the CHRIS system, it signals to the provider that further inquiries are likely to be made by the Department.  Likewise, closing of the case would signal to the provider that the Department has all information that is needed regarding the incident. We believe doing so will provide for ease of communication among the Department and Provider and foster a collaborative relationship for the betterment of the individuals we serve.