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Virginia Regulatory Town Hall
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Department of Behavioral Health and Developmental Services
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State Board of Behavioral Health and Developmental Services
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Rules and Regulations For Licensing Providers by the Department of Behavioral Health and Developmental Services [12 VAC 35 ‑ 105]
Action Compliance with Virginia’s Settlement Agreement with US DOJ
Stage Final
Comment Period Ends 7/22/2020
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7/22/20  2:41 pm
Commenter: Kim Black

Guidance on Serious Incidents
 

Serious Incident Reporting Requirements

 

Please note that these methods of reporting an incident in place of submitting an incident report into the CHRIS system will be deemed as non-compliant and the provider will be cited:

  • Reporting a serious incident to the provider’s licensing specialist via e-mail or phone call;
  • Reporting a serious incident to the provider’s human rights advocate via e-mail or phone call;
  • Reporting the incident to any other representative of DBHDS by any means other than the serious incident reporting function in CHRIS; and
  • Reporting an allegation of abuse or neglect that also meets the criteria for a Level II or Level III serious incident only on the DBHDS Office of Human Rights (OHR) side of CHRIS instead of reporting the incident on both the OHR and the DBHDS Office of Licensing sides of CHRIS.

An update should be made to the CHRIS system so that OHR is automatically notified when a serious incident involving an allegation of abuse or neglect is entered. Eliminating the duplication of data entry for providers and streamlining this process should be prioritized.

 

CHRIS System Errors and Network Outages

There may be unusual circumstances when a provider is unable to report an incident through the CHRIS system because of a CHRIS system error or a network outage. The ONLY valid reasons for not reporting a serious incident into CHRIS include: 1) The CHRIS system was not functioning at the time the incident was discovered; or 2) The provider was unable to access the CHRIS system for reasons that were not in the provider’s control. If a provider is unable to report a serious incident through the CHRIS system for one of these valid reasons, then the provider must notify the Office of Licensing’s Incident Management Unit (IMU) via e-mail incident_management@dbhds.virginia.gov) of the provider’s inability to report the incident through the CHRIS system within 24 hours of the discovery of the incident.

Clearly, the requirements as outlined for reporting in the event of a systems outage or failure are shortsighted as both methods of reporting (into the CHRIS system or via email) require that the provider has both electricity and internet available – a condition frequently not available in the midst of a significant weather event.  Given the frequency of the outages of either CHRIS or DELTA (such as the one that began on Monday, June 15th with “problems with the DELTA certification and continues at least through Monday, June 22nd); it is critical that either there be other alternative reporting OR that DBHDS assign at least some credibility to a provider’s inability to follow the rules as written.

The inflexible requirement to submit all entries in CHRIS within 24 hours of the incident provides an unrealistic expectation now that all ER visits must be reported even if a PCP office is closed or a protocol is in place. 

 

This option to directly email IMU should be listed on the department’s website so that it can be easily identifiable.

 

Updates to Serious Incident Reports

In some instances, a provider may need to update a serious incident report in CHRIS after its initial submission.

• A provider may be awaiting a medical report or other records related to an emergency room visit; or

• IMU staff may request that the provider update an incident report in CHRIS when the IMU identifies information that should have been included in the report, but was not included.

When the provider must update an incident report in CHRIS after the initial submission, the provider must do so within 48 hours from the initial submission of the incident report, or from the time that the provider is informed by the IMU of the need to update the report, whichever is later. Failure to update a serious incident report in CHRIS within 48 hours from the initial submission of the report, or from the time that the provider is informed by the IMU of the need to update the report, will be cited as a regulatory violation of 12VAC35-105-160.F. or 12VAC35-46-230.A., as applicable.

The “update within 48 hours” timeframe is unmanageable and will be a clear detriment to any intent to have the CHRIS system be a comprehensive data system.  The examples of when information is not (or should not) be known in the first 24 to 72 hours are endless:

  • Lab work is not returned so that a final diagnosis cannot be made/communicated
  • Follow-up PCP appointment cannot occur within the time frame so PCP instructions are not available
  • Information on a suicide cannot be reasonable obtained from a grieving family
  • Conclusive results of the success of a surgery cannot be given
  • A “missing” individual has not been located, etc.
  • The individual and/or family members may not be returning requests from the provider to acquire updated information due to the nature of the incident.

 

 

 

Progressive Actions for Repeat Citations

 

 

This penalizing system should not be based simply on the total number of citations. Instead, the volume of reports the provider is making should be considered. If the department strives for 86% compliance, the same standard should apply to providers.

 

Also, when a provider reports a serious incident but reports outside of the 24 hour required time frame, this should not count against the provider in the same measurement as a complete failure to report that is later found by a licensing specialists.  The expectation of perfection is unattainable and lends to a culture of non-reporting.

CommentID: 84111