Action | Compliance with Virginia’s Settlement Agreement with US DOJ |
Stage | Emergency/NOIRA |
Comment Period | Ended on 9/5/2018 |
Hampton – Newport News Community Services Board
Response to Proposed Changes to DBHDS – Emergency Regulations
"Serious incident" means any event or circumstance that causes or could cause harm to the health, safety, or well-being of an individual. The term "serious incident" includes death and serious injury. "Level I serious incident" means a serious incident that occurs or originates during the provision of a service or on the premises of the provider and does not meet the definition of a Level II or Level III serious incident. "Level I serious incidents" do not result in significant harm to individuals, but may include events that result in minor injuries that do not require medical attention or events that have the potential to cause serious injury, even when no injury occurs. "Level II serious incident" means a serious incident that occurs or originates during the provision of a service or on the premises of the provider that results in a significant harm or threat to the health and safety of an individual that does not meet the definition of a Level III serious incident. "Level II serious incident" includes a significant harm or threat to the health or safety of others caused by an individual. "Level II serious incidents" include: 1. A serious injury; 2. An individual who is missing; 3. An emergency room or urgent care facility visit when not used in lieu of a primary care physician visit; 4. An unplanned psychiatric or unplanned medical hospital admission; 5. Choking incidents that require direct physical intervention by another person; 6. Ingestion of any hazardous material; or 7. A diagnosis of: a. A decubitus ulcer or an increase in severity of level of previously diagnosed decubitus ulcer; b. A bowel obstruction; or c. Aspiration pneumonia. "Level III serious incident" means a serious incident whether or not the incident occurs while in the provision of a service or on the provider's premises and results in: 1. Any death of an individual; 2. A sexual assault of an individual; 3. A serious injury of an individual that results in or likely will result in permanent physical or psychological impairment; or 4. A suicide attempt by an individual admitted for services that results in a hospital admission.
E. A root cause analysis shall be conducted by the provider within 30 days of discovery of Level II and Level III serious Regulations Volume 34, Issue 25 Virginia Register of Regulations August 6, 2018 2510 incidents. The root cause analysis shall include at least the following information: (i) a detailed description of what happened; (ii) an analysis of why it happened, including identification of all identifiable underlying causes of the incident that were under the control of the provider; and (iii) identified solutions to mitigate its reoccurrence.
C. The provider shall conduct systemic risk assessment reviews at least annually to
identify and respond to practices, situations, and policies that could result in the risk of harm to individuals receiving services. The risk assessment review shall address (i) the environment of care; (ii) clinical assessment or reassessment processes; (iii) staff competence and adequacy of staffing; (iv) use of high risk procedures, including seclusion and restraint; and (v) a review of serious incidents. This process shall incorporate uniform risk triggers and thresholds as defined by the department.
D. 3. For goals and objectives that were not accomplished by the identified target date, the provider and any appropriate treatment team members shall meet to review the reasons for lack of progress and provide the individual an opportunity to make an informed choice of how to proceed.