12VAC35-105-160

2. The provider shall develop and implement a root cause analysis policy for determining when a more detailed root cause analysis, including convening a team, collecting and analyzing data, mapping processes, and charting causal factors, should be conducted. At a minimum, the policy shall require for the provider to conduct a more detailed root cause analysis when:

a. A threshold number, as specified in the provider's policy based on the provider's size, number of locations, service type, number of individuals served, and the unique needs of the individuals served by the provider, of similar Level II serious incidents occur to the same individual or at the same location within a six-month period;

Will there be guidance from DBHDS on determining a “threshold number” to ensure consistency among providers and DBHDS representatives?  Without appropriate guidance this “threshold number” is arbitrary.

12VAC35-105-170. Corrective action plan.

1. Continue implementing the corrective action plan and put into place additional measures to prevent the recurrence of the cited violation and address identified systemic deficiencies; or

“Prevent the recurrence” is an impossible standard to meet and should be removed from regulations.  It indicates the presumption that all risk factors are under a provider’s control and removes any possible consequence due to external factors such as individual choice, acts of nature, deficits in available services, etc.  Providers should have a method to analyze effectiveness of a CAP, should be accountable for ensuring measures outlined in a CAP are enforced, but the end goal to “prevent the recurrence” is impossible.

12VAC35-105-660. Individualized services plan (ISP).

D.1.      a. The ] proposed services to be delivered [ ,;

b. Any ] alternative services that might be advantageous for the individual [ ,; ] and

c. Any ] accompanying risks or benefits [ of the proposed and alternative services ].

2. If no alternative services are available to the individual, it shall be clearly documented within the ISP, or within documentation attached to the ISP, that alternative services were not available as well as any steps taken to identify if alternative services were available.

Additional clarification is necessary.  Who is responsible for the identification of and communication to the individual regarding alternative services?  The SC?  The provider?  This action is beyond the provider’s purview to be aware of services beyond their license in a manner sufficient to accurately describe availability, benefits, and risks.