Virginia Regulatory Town Hall View Comments

Department of Behavioral Health and Developmental Services

State Board of Behavioral Health and Developmental Services

Guidance Document Change: The purpose of this memorandum is to remind DBHDS licensed providers of the requirements and expectations for reporting serious incidents to the DBHDS Office of Licensing, pursuant to 12VAC35-46-1070.C. and 12VAC35-105-160.D.2., including the timeframe for reporting incidents; the process for reporting incidents; the allowable timeframe for adding to, amending, or correcting information reported to the Office of Licensing through the Computerized Human Rights Information System (CHRIS); and to inform providers of the processes that the Office of Licensing will follow for issuing citations, repeat citations and sanctions for violations of serious incident reporting requirements. In addition to ensuring all providers understand the regulatory requirements associated with reporting incidents, the processes outlined in this memo are central to the department’s efforts to address compliance indicators related to serious incident reporting as mandated by the US Department of Justice’s (DOJ) Settlement Agreement with Virginia.

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7/22/20 6:07 pm

Commenter: Dana Dewing, Harrisonburg-Rockingham CSB

Incident Reporting Requirements

First, this guidance should NOT have gone into effect 6/15/20, as the review of the document is NOT complete.

Issues:

The DOJ Settlement Agreement states that at least 86% reportable SIRs need to be reported within timelines set by DBHDS policy. Hasn't this already been achieved with a statewide compliance rate of 91%? If so, why are the actions outlined in this guidance so severe?

There is one regulation that could be changed easily to assist with decreasing the late reporting of SIRs. It would be a simple fix that could be accomplished by changing the 24-hour reporting period to reporting by the next business day. This would decrease late reporting substantially.

The timeframe for reporting updates should also be amended. If it is expected that all updates to SIRs be made within 48 hours, one would need to expect many inaccurate or incomplete entries. Not all information can be obtained from doctors, hospitals, lab results, staff interviews, etc. within a 48 hour period.

Issuing a flat four-citation progressive protocol versus a percentage of citations per client number is biased against larger providers, and this guidance should be changed to reflect that.

Clarifications:

There needs to be clarification if the citations will be added against the individual program licenses or the overarching license of a multiple-licensed organization.

Clarification is also needed regarding the two-year time frame for tracking citations. When does it begin, end, etc.? Nothing described is clear.

Will there be an appeal process after each, but especially, the fourth citation? What does this appeal process look like?

What steps will the provider need to take in order to reinstate their license if it is revoked/suspended?

In conclusion: I object to much of the guidance being provided for many reasons, as stated above. The data shows there is approximately 91% compliance with the SIR reporting time frames in CHRIS already. There is no need for such severe consequences. We are ultimately here to meet the needs of the indivduals being served. If licenses are revoked/suspended, this will only hurt our most vulnerable population that we are supposed to be helping.

CommentID: 84171