12VAC35-105-20. Definitions

• The information in the definition of “unplanned psychiatric or unplanned medical hospital admission” under the definition of a Level II incident  presents challenges and may be interpreted differently among providers and licensing specialists. In order to avoid citations, we support clarifying this definition.   For example, there are circumstances where an individual may be ECO’ed, but decide to voluntarily admit themselves to the hospital.

12VAC35-105-160. Reviews by the Department; requests for information; required reporting.

• We appreciate the change made to Section E to require a root cause analysis only for those serious incidents which occur on a provider’s premises or during provision of service.
• We continue to have concern that the required components of the root cause analysis described in Section E. One of the requirements is to include identified solutions to mitigate its reoccurrence when applicable. We suggest clarification that an individual has the right to indicate they do not want the identified solutions implemented.  It must be clear that individuals have the right to choice and dignity of risk. We suggest “identified solutions to mitigate its reoccurrence when applicable and at the choice of the individual.

12VAC35-105-320. Fire Inspections

• The requirement to have annual fire inspections for all residential service locations regardless of the number of beds is costly and burdensome. Local fire departments/Fire Marshals may not have the ability or resources to complete this mandate. Additionally, there are many interpretations of what a fire inspection must include and who has the authority to conduct them. We suggest revising this section to have the providers complete the fire inspection with a standardized fire inspection checklist.
•  Additionally, the requirement: “The provider shall evaluate each individual and, based on that evaluation, shall provide appropriate environmental supports and adequate staff to safely evacuate all individuals during an emergency” does not specify what is adequate and appropriate. We suggest adding further definition (i.e., what type of evaluation is needed, where is it maintained, what is meant by “appropriate environmental supports”) to avoid misinterpretation and citations.

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

• Section D. We respectfully request this section to be omitted or at least revised to clarify the minimum required documentation of risk, benefits and alternatives within the ISP for the following reasons:

1. Health Record systems may not provide a way to add this information in the ISP.  Implementation would require time and money for modifications.  Assessing for appropriateness for a service is part of the required assessment process.
2.   Services such as Case Management do not have alternative services to offer. Thus, providers cannot meet this requirement.
3.   What are expected alternatives that must be discussed? Are providers to consider only ones that are available for the person in the area they want to live? Only those the individual qualifies for? Only other licensed services? 
4.  What are the specific risks individuals must be informed about services?  What specifically is expected?

• We suggest adding timeframes for the Department’s response to items received (e.g., service modifications) to promote positive collaboration between the Department and licensed providers. We support having timeframes for when actions by providers need to be completed and also support timeframes for when an anticipated response by the Department to licensed providers.