Definitions: “Level II serious incidents include… “an emergency room visit”:  this is too broad and will result in hundreds of unnecessary reporting.  Please consider being more specific on this requirement.

12VAC35-105-160 Incident Reporting - The requirement to report level II and III serious incidents and human rights in CHRIS on weekends and holidays is unnecessary and an unfunded burden.  We recommend the requirement to enter such reports be changed from within 24 hours to the next business day.

12 VAC 35-105-170. Corrective Action Plan - 170.C and 170.H. - While it is reasonable for a provider to develop a corrective action plan which includes a detailed description of the actions to be taken that will minimize the possibility that the violation will occur again and correct any systemic deficiencies (albeit not all cited violations are the result of systemic deficiencies), the standard is raised to an unattainable level in Section 170.H to “prevent recurrence”.  - The “Indicators” agreed to between DBHDS and DOJ, and approved by the Court on January 14, 2020, state “prevent or mitigate future risks of harm” (page 36) and “prevent or substantially mitigate risks of harm (page 33). The proposed regulations including the absolute “prevent recurrence” are above and beyond the standard agreed to between DOJ, DBHDS and Judge Gibney. We recommend the deletion of Section 170H. This additional burden must not be placed upon providers.

12VAC35-105-320: Fire Inspections -  The regulation was amended to read, “The provider shall document at the time of its original application and annually thereafter that buildings and equipment in residential service locations serving more than eight individuals are maintained in accordance with the Virginia Statewide Fire Prevention Code (13VAC5-51). “ We are seeking clarification regarding the type and manner of documentation that will meet the Department’s standards in this section.  Statewide Fire Prevention Code does not currently require inspection for the locations noted in this section. We are finding it difficult in areas where there is not a local fire inspector to obtain this inspection and documentation and having to contact the state fire inspector who is also reluct to complete.

12VAC35-105-530. Emergency preparedness and response plan, A. 9, “Fire and evacuation drills shall be conducted at least monthly”—this is a reasonable expectation a residential service, but an overwhelming expectation for facilities like outpatient clinics.  The previous requirement was annually and would twice a year not be sufficient?  

12 VAC 35-105-520 - Risk Management

The expectation of hiring one Risk Manager can be a burden for small agencies as well as overwhelming for one person at bigger agencies, the Risk Management function can be carried out by multiple staff that have expertise in different subject matter, not just one. We recommend that providers be given the option of having a risk management team included that would have a collective knowledge base of root cause analysis, investigations, risk management, etc.

Also states that the “designated person” for risk management will complete “department approved training”. We have concerns about the qualifying statement of “department approved training”. Will DBHDS be the designated provider of this training? Will there be a list of approved trainings? It would improve consistency across the state if DBHDS provided the training and the language read “complete training provided or approved by DBHDS”.

Does the annual safety inspections apply to sponsored residential homes that are neither owned, rented nor leased by the provider agency? 

12VAC35-105-650. Assessment policy. - “Restrictive protocols or special supervision requirements” are not explicitly defined in the WAMS 3.1 version of the PCISP released by DBHDS.